Perhaps relevant:
Task Force Suggests Development of Emergency Medicine/Family Practice Residency Programs
Goal is to provide more residency trained emergency physicians in rural areas
ACEP News
December 2003
In an effort to improve the delivery of care in rural emergency departments, an ACEP task force recently made several new training proposals, including the possibility of creating a combined emergency medicine/family practice residency program.
The Emergency Medicine Rural Workforce Task Force presented the proposals to the ACEP Board of Directors in September. The Board approved the recommendations, and many of the suggestions have already been implemented.
After sponsoring a Rural Emergency Medicine Summit in late March, the Task Force developed several proposals that focus on ways that academic medical centers and emergency medicine organizations can support all providers of emergency medicine in rural areas, said John C. Moorhead, MD, chairman of the Task Force and former ACEP President.
In addition to the proposal of a combined residency program, the Task Force also suggested including rural exposure in residency programs, pursuing changes in federal laws to provide economic incentives for rural practice, and encouraging rural EDs to have a board certified, emergency medicine residency trained physician overseeing the department.
"It's part of the natural evolution of the specialty. Emergency medicine is still very young and our primary goal is to improve care to the patient." Dr. Moorhead said.
"The fact that residents are not migrating to rural areas, and other evidence from the workforce studies caused us to focus on rural emergency care. Clearly, patients in rural areas deserve high quality care and these recommendations are ways to continue to enhance care," he said.
Combined Residency Training
Workforce study results (published in the July 2002 edition of Annals of Emergency Medicine) have shown that the majority of rural emergency physicians are not residency trained in emergency medicine, and that most are non-specialists, largely primary care physicians.
While the specialty's ultimate goal continues to be staffing all emergency departments with board certified emergency physicians, Dr. Moorhead pointed out that there are several significant barriers to achieving this goal in rural areas, including recruitment and retention difficulties, clinical practice differences, and economic factors.
Because it is likely that family practitioners will continue to provide emergency care in many rural areas, "there has been interest from both specialties to see if an attractive combined residency model could be created," Dr. Moorhead said.
In a letter from the American Academy of Family Physicians (AAFP), President James C. Martin, MD, noted that their group discussed an emergency medicine/family practice combined residency program after the issue was broached at the Rural Summit.
"At that discussion, data from a recent survey of family medicine residency program directors was presented, which indicated more than 70 training programs interested in combined training with emergency medicine," Dr. Martin wrote. "Since then, the attractiveness of such combined training also has been reviewed with a number of medical student groups, with a notably positive response being found across the country, especially among those interested in rural practice settings."
A needs assessment to determine if there is similar interest among emergency medicine residency programs in combined training was being developed in late October in collaboration with the Council of Emergency Medicine Residency Directors (CORD). In addition, ACEP sponsored two representatives to work with AAFP to present findings to the American Board of Emergency Medicine (ABEM).
"If we can demonstrate an interest to ABEM, it will stimulate conversations between ABEM and Family Practice to see how a model of training can be delineated," Dr. Moorhead said.
Dr. Moorhead added that the proposed combined residency would involve more work than either single residency program, but ultimately would provide more specific training for physicians who choose to practice in rural emergency departments.
"If the perception is that this is a short cut, I don't see how that is possible," he said. "We are proposing a lengthening of the current training. Like pediatrics and internal medicine, it would be training specifically for both, and longer than if it was just one or the other."
Rural Residency Opportunities
The recommendations from the Task Force are meant, in part, to encourage migration of emergency medicine residency trained and board certified physicians to rural areas. One way to do that, the Task Force suggested, is through resident exposure to the rural emergency department environment.
"I think the rural emergency department has always been a concern because something we have not been able to do is move people out into the rural areas," said Mary Jo Wagner, MD, an ACEP member and Secretary/Treasurer of CORD's Board of Directors.
"There are lots of reasons why that happens. For one thing, we do not often provide opportunities for residents to learn about rural emergency departments because residencies aren't held in locations where they can prepare for the rural ED environment," she said, adding that "many of the residents who come from rural areas go back to practice there. If they had a choice, they may not choose a big city to do their residency."
The Task Force recommended that ACEP work with CORD, the Association of Academic Chairs of Emergency Medicine (AACEM) and the Society for Academic Emergency Medicine (SAEM) to encourage rural ED training.
Specifically, the Task Force suggested developing models of rural rotations for medical students and residents, providing/integrating rotation opportunities to rural sites (or as an optional elective) for emergency medicine residents, encouraging emergency medicine faculty to select residents interested in rural ED practice, and developing faculty educational programs and training pertinent to the unique characteristics of rural ED care.
Another Task Force recommendation was to request that the Residency Review Committee - Emergency Medicine revise its guidelines to add flexibility to the specialty program requirements. By late October, the RRC had made the suggested revisions.
Economic Incentives
Another way to bolster interest in rural emergency departments, the Task Force suggested, is to provide some economic incentives for board certified, emergency medicine residency trained physicians to move to rural areas.
Although most of the changes would have to be made by the federal government, the Task Force recommended that ACEP advocate for these changes.
"It all begins with staffing. We are looking at getting incentives for emergency physicians to go out to rural areas, and continuing education for those already practicing," Dr. Moorhead said.
One of the suggested avenues to pursue is a change in the requirements for rural graduate medical education (GME) funding through legislative and regulatory efforts, including funding for demonstration projects for rural emergency medicine residency rotations.
The Task Force also recommended exploring the reduction of medical debt load by including emergency medicine in loan forgiveness opportunities and obtaining tax credits for medical school loans for physicians practicing in rural areas.
Pursuing decreased liability expenses for rural EDs, including providing liability limitations for uncompensated EMTALA-mandated services under federal tort reform, as well as working to increase reimbursement for rural practice were also suggested.
Workforce and Distribution
The Task Force also recommended that ACEP identify ways to address the barriers that prevent emergency medicine residents from pursuing rural practice.
Encouraging rural EDs to have a board certified emergency physician manage or provide medical oversight of the rural ED, and possibly even revise current ACEP policies on the definition of a qualified emergency physician were also suggested by the Task Force.
"The proposal that all emergency departments be directed by a board certified emergency physician extends the guidelines and we believe will have a significant impact on rural emergency departments," Dr. Moorhead said. "It focuses on quality of care and continuous service improvement."
The Role of Other Organizations
Recognizing the value of the Emergency Medicine Residents' Association, the Task Force had considerable discussion about the role EMRA could play, Dr. Moorhead said.
Focusing on increasing resident awareness and education of rural emergency medicine practice, EMRA was asked to develop a database of all rural health electives for emergency medicine residents, to include information about rural emergency medicine practice during its activities and meetings, to include an article from the summit in EM Resident and to continue to increase its educational resources about rural emergency medicine on the EMRA Web site.
In addition to ACEP and EMRA, many other associations and organizations also contributed to the proposed recommendations during the summit: ABEM, SAEM, CORD, RRC-EM, AAFP, the National Rural Health Association, the Federal office of Rural Health Policy/HRSA, the National Rural Resource Center, ACEP's Section of Rural Emergency Medicine, and the Society of Emergency Medicine Physician Assistants.
"The Task Force gives us the opportunity to coordinate among all emergency medicine organizations.. It can take action and plan on behalf of the specialty and not any one organization," Dr. Moorhead said.
