The feds and 48 states don't require EDs to have 24/7 physician staffing. The ACEP Council recommended action to require continuous ED physician presence. Will legislation follow or is this just talk?
Is the "Gold Standard" mentioned several times in the article "EM Residency Trained Physicians," or just "Physicians" (of any specialty) as mentioned elsewhere in the article? Much of EM is already practiced by non-EM residency trained physicians, typically IM or FM, so this distinction isn't trivial and the two are hardly interchangeable. Also, it would help if the author could point to outcome data to support the article's argument.
- EM Residency Training + ABEM Boards is the gold standard. However, gold standard is not the same as a base-case legal requirement. The legal requirement (maybe except for remote frontier EDs) should be physician in the hospital/ED.
- Tony has written extensively on encouraging family physicians with EM expertise to staff rural EDs. Yes, that's not "gold standard", but it's significantly better than not having a doctor in the hospital. And my sense is that in rural areas, FM/EM might actually be ideal training for the type of "everything for everyone" care that would be required in those settings. A few of Tony's articles on the topic:
- There are not many studies of the quality of care delivered in EDs without physicians. It's a bit of a "studies of skydiving without parachutes" situation. Physician training - including family physicians - is so much more extensive than that of PAs and NPs that it's not really necessary to wait for large numbers of studies to conclude that a hospital should have a physician in-house. A few somewhat relevant studies:
Thank you! I'm curious about your (and the author's) thoughts on APPs in the ED supported by telemedicine? I'm thinking of a program based out of Univ. of Mississippi Medical Center that's been around for a couple decades now with EM Trained APPs at small ED's with real-time access to BCEM docs. As I understand it, the APPs are trained to do critical procedures (intubation, chest tubes, etc.) and the docs can oversee everything remotely, manage codes, etc. In a place like Mississippi, where there's hardly an abundance of physicians, this seems like a good compromise. And to hear them talk about it, they say their outcomes are good (compared to what exactly, I don't know, nor do I have any data to point to. . .)
Good question. This is a bit outside of my expertise. My sense is that EM is a very physical specialty. Remote emergency department doctoring doesn't work very well in my experience. I'd much rather have an in-person family physician than a tele-ED physician in my hospital (if those were the options).
I'm reading with interest the thoughtful posts & replies.
As a RT/BC EM physician of 31+ years, I've seen a spectacular transformation of Emergency Medicine
Long gone are the days where I had to "justify" my/our specialty to patients, professional colleagues, even to my own family members!
I also wish to celebrate and recognize our terrifically talented APP's. They are a tremendous "force multiplier" within the appropriate supervised ED settings.
I've also had a good share of working in several CAH's where I was continuously on call to an ED for up to 1 week, staying local but responding within < 10 mins to a call from the ED should I not be present.
My friend and fellow USAF Reservist EM physician started a staffing company based solely on CAH's across the US. He explained to me the specific funding the federal government provides to staff these rural/remote ED's full well knowing the challenges of finding/hiring docs in such remote areas.
This is a quick summary from Google AI on the question of physician funding for CAH's:
The federal government pays physicians in critical access hospitals (CAHs) in a few ways, including:
Standard Payment Method: Medicare pays CAHs 101% of reasonable costs for most outpatient services. Physicians or other qualified practitioners bill for their services under the Medicare Physician Fee Schedule (PFS).
Optional Payment Method: Medicare pays CAHs 115% of the allowable amount for outpatient services.
Method II Billing: Physicians and non-physician practitioners can reassign their billing rights to the CAH. Medicare pays the CAH for professional services using revenue codes (RC) 96X, 97X, or 98X.
CAHs are reimbursed differently than non-CAHs. For example, CAHs are paid based on the cost of providing services in most care settings, unlike other hospitals.
My concerns are -does the federal government no longer reimburse hospitals for physician coverage as the above indicates? If this is still true, I'm curious to how hospitals can justify NOT hiring physicians when the CAH's are reimbursed with the physician staffing model foremost in mind?
I also support the statement that a EM trained physician in the ER is the gold standard, fully understanding the realities of the economics of finding/retaining EM trained physicians. I guess the "silver standard" would be a non-EM trained physician but with demonstrable experience/skill to practice in such remote areas without much/any physical specialty back-up.
As far as "evidenced-based studies" regarding APP's staffing ED's, why following that logic is there not a push for APP's to perform surgery, or practice medical specialties in underserved areas? I'm sure the expectation from the public is that they have a right to be treated by a physician in a hospital/ED regardless of the setting if at all possible.
In closing, as an 25 yr Air Force veteran ED physician & flight surgeon, we had a saying when flying missions:
"Everyone want's to be in the right seat (Pilot or Aircraft Commander), but you must have the skills and training to sit there". What works for military aviation is very applicable to civilian medicine.
Physicians have a professional duty to care for our patients. Allow us to do so......
Is the "Gold Standard" mentioned several times in the article "EM Residency Trained Physicians," or just "Physicians" (of any specialty) as mentioned elsewhere in the article? Much of EM is already practiced by non-EM residency trained physicians, typically IM or FM, so this distinction isn't trivial and the two are hardly interchangeable. Also, it would help if the author could point to outcome data to support the article's argument.
Hi Greg,
Kudos on your work with NewGen EM!
A few thoughts:
- EM Residency Training + ABEM Boards is the gold standard. However, gold standard is not the same as a base-case legal requirement. The legal requirement (maybe except for remote frontier EDs) should be physician in the hospital/ED.
- Tony has written extensively on encouraging family physicians with EM expertise to staff rural EDs. Yes, that's not "gold standard", but it's significantly better than not having a doctor in the hospital. And my sense is that in rural areas, FM/EM might actually be ideal training for the type of "everything for everyone" care that would be required in those settings. A few of Tony's articles on the topic:
https://www.jabfm.org/content/jabfp/34/6/1221.full.pdf
https://www.jabfm.org/content/jabfp/34/6/1265.full.pdf
https://www.jabfm.org/content/jabfp/32/3/292.full.pdf
- There are not many studies of the quality of care delivered in EDs without physicians. It's a bit of a "studies of skydiving without parachutes" situation. Physician training - including family physicians - is so much more extensive than that of PAs and NPs that it's not really necessary to wait for large numbers of studies to conclude that a hospital should have a physician in-house. A few somewhat relevant studies:
https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs
https://healthpolicy.fsi.stanford.edu/news/productivity-professions-evidence-emergency-department
Thank you! I'm curious about your (and the author's) thoughts on APPs in the ED supported by telemedicine? I'm thinking of a program based out of Univ. of Mississippi Medical Center that's been around for a couple decades now with EM Trained APPs at small ED's with real-time access to BCEM docs. As I understand it, the APPs are trained to do critical procedures (intubation, chest tubes, etc.) and the docs can oversee everything remotely, manage codes, etc. In a place like Mississippi, where there's hardly an abundance of physicians, this seems like a good compromise. And to hear them talk about it, they say their outcomes are good (compared to what exactly, I don't know, nor do I have any data to point to. . .)
Good question. This is a bit outside of my expertise. My sense is that EM is a very physical specialty. Remote emergency department doctoring doesn't work very well in my experience. I'd much rather have an in-person family physician than a tele-ED physician in my hospital (if those were the options).
Good afternoon all!
I'm reading with interest the thoughtful posts & replies.
As a RT/BC EM physician of 31+ years, I've seen a spectacular transformation of Emergency Medicine
Long gone are the days where I had to "justify" my/our specialty to patients, professional colleagues, even to my own family members!
I also wish to celebrate and recognize our terrifically talented APP's. They are a tremendous "force multiplier" within the appropriate supervised ED settings.
I've also had a good share of working in several CAH's where I was continuously on call to an ED for up to 1 week, staying local but responding within < 10 mins to a call from the ED should I not be present.
My friend and fellow USAF Reservist EM physician started a staffing company based solely on CAH's across the US. He explained to me the specific funding the federal government provides to staff these rural/remote ED's full well knowing the challenges of finding/hiring docs in such remote areas.
This is a quick summary from Google AI on the question of physician funding for CAH's:
The federal government pays physicians in critical access hospitals (CAHs) in a few ways, including:
Standard Payment Method: Medicare pays CAHs 101% of reasonable costs for most outpatient services. Physicians or other qualified practitioners bill for their services under the Medicare Physician Fee Schedule (PFS).
Optional Payment Method: Medicare pays CAHs 115% of the allowable amount for outpatient services.
Method II Billing: Physicians and non-physician practitioners can reassign their billing rights to the CAH. Medicare pays the CAH for professional services using revenue codes (RC) 96X, 97X, or 98X.
CAHs are reimbursed differently than non-CAHs. For example, CAHs are paid based on the cost of providing services in most care settings, unlike other hospitals.
My concerns are -does the federal government no longer reimburse hospitals for physician coverage as the above indicates? If this is still true, I'm curious to how hospitals can justify NOT hiring physicians when the CAH's are reimbursed with the physician staffing model foremost in mind?
I also support the statement that a EM trained physician in the ER is the gold standard, fully understanding the realities of the economics of finding/retaining EM trained physicians. I guess the "silver standard" would be a non-EM trained physician but with demonstrable experience/skill to practice in such remote areas without much/any physical specialty back-up.
As far as "evidenced-based studies" regarding APP's staffing ED's, why following that logic is there not a push for APP's to perform surgery, or practice medical specialties in underserved areas? I'm sure the expectation from the public is that they have a right to be treated by a physician in a hospital/ED regardless of the setting if at all possible.
In closing, as an 25 yr Air Force veteran ED physician & flight surgeon, we had a saying when flying missions:
"Everyone want's to be in the right seat (Pilot or Aircraft Commander), but you must have the skills and training to sit there". What works for military aviation is very applicable to civilian medicine.
Physicians have a professional duty to care for our patients. Allow us to do so......
Doc BG