ER Docs Need a Clearer Path to Outpatient Primary Care

Nishant Gogna, DO


December 29, 2022

It was 2 PM on a sunny and humid day, 1 hour before my 8-hour shift was over in the emergency department (ED) at the community hospital that I was rotating through. It was part of my fourth-year emergency medicine (EM) clerkship. Not that I would have noticed the weather, save for the few seconds the sliding door to the ED would open periodically, as if on its own cadence, with the sounds of stomping boots and a rolling gurney making its way through.

We were busy. At this particular hospital, I was told, EM volume is already up 35% this year compared with last year, and bed holds had been hitting new highs each week.

One more hour until my shift is over and a poor soul will take over my computer, seat, and the chaos.

I took a glance at the electronic health record again, seeing whether there was anything I could do to discharge any of the patients to relieve some of the strain. Knee pain, toe pain, headache/migraine, shoulder pain, elevated blood pressure. Although it's true that any of these listed complaints could have emergent etiologies, the truth was that all of these patients were here owing to exacerbations of chronic issues. And yet most, if not all, of these patients had been here for nearly 8 hours, some even longer, waiting for treatment and exacerbating an already busy ED.

"I don't understand. Couldn't these patients have sought care outpatient with their PCP? It would have been a lot cheaper and faster." I asked. A seasoned ED physician, bald, graying, and whom I had just met today and hadn't spoken to much until this very moment, turned to me and said, "We have become the dumping ground for primary care complaints."

'Go to the ER'

"PCPs are already too busy," the physician continued. "It's just easier to say, 'Go to the ED. They'll take care of it.'"

He continued, "In my 30 years of practicing, emergency medicine has changed so much. When I first started in the 1980s, I was only seeing emergencies, and it was fun. Now, 80% of my patients are primary care complaints. These days, I am more of a primary care physician than an emergency physician."

Hmmm, I thought. Was this physician burned out and jaded? Quite possibly. Was this change the physician experienced throughout his career more likely attributed to a capitalist-run, profit-driven healthcare system and its cohort of underinsured and noninsured citizens? Certainly. I'm only a fourth-year medical student, so my view of the situation is no doubt limited.

But something he said definitely rang my bell: I'm more of a primary care physician than an emergency physician. That is an argument I can consider. Whether it is due to poorly designed reimbursement schedules or the state of America's profit-driven healthcare system, there is no doubt that these days, emergency physicians are in fact seeing a lot of primary care complaints, which effectively makes these physicians double as PCPs on a daily basis.

I let this thought ruminate on my drive home, along with how there's a such a huge demand for PCPs, resulting in it taking up to 3 months to get an appointment with one. That's crazy, and I understand the need to come to the ED where you'll (hopefully) be seen the same day.

I also ruminated on how emergency physicians have the highest rate of burnout among all the specialties, with no career recourse afterward. Either you're part of the hospital machine complex, or you're out. Practicing EM for nearly 30 years is apparently a rarity these days. Most emergency physicians last 5 years, 10 years tops, and then are so burned out that they retire to pursue a life outside of medicine (real estate seems to be popular). But this is a shame.

Emergency Docs Exiting Medicine

Emergency physicians have seen a ton of wildly different pathologies and have treated a variety of different conditions, including conditions usually reserved for primary care. To let knowledgeable, experienced emergency physicians just exit medicine, with no recourse to further contribute to this country's health system outside of the hospital machine, is a travesty in its own right.

I ruminated further on the American College of Emergency Physicians (ACEP) 2021 report on the EM physician workforce, which stated that there is projected to be an oversupply of emergency physicians by 2030, leaving thousands of them out of work. No doubt that report has left an impact on the volume of residency applications into EM in 2021. No one wants to go through residency and be unemployed at the end of it.

And finally, I ruminated on the sheer volume of patients visiting EDs across the country. Patient volumes are up, wait times in general are up, wait times in the ED are up, and bed holds to get admitted are hitting highs across the country each week. The deluge of patients visiting the ED is not getting better, and it's only likely to get worse as the population ages.

It's time to offer emergency physicians a path to outpatient primary care.

Now before I get hung for this suggestion ("I went into EM precisely not to do outpatient care!"), hear me out: Such a path should be offered via a 1-year accelerated fellowship and will allow emergency physicians to practice outpatient primary care medicine independently. And although working in urgent care centers is already an option, the opportunity to own and operate their own primary care practice should also exist.

In my humble opinion, by offering such a path, the following objectives could be accomplished:

Alleviate the pressure on primary care medicine in the US. It's no secret that the United States needs more primary care physicians. Allowing emergency physicians who got burnt out by hospital life an alternative way to serve their community and country via outpatient primary care would greatly alleviate the pressure on the need for PCPs today.

Provide an alternative career path for emergency physicians.

We would be doing a disservice if we don't offer emergency physicians a way to revive their burnout and utilize their skill set in a post-ED life. Outpatient primary care is the perfect way to do this, and it's a win-win-win on several fronts: We need more outpatient physicians, they need an opportunity to flex their knowledge in an alternative setting.

Solve the "ACEP" problem. The ACEP report scared medical students away from applying to residency in EM. Who wants to go through 3 years of residency only to be unemployed at the end of it? By offering a path to outpatient primary care, we can offer an important and viable path for those emergency physicians who would be unemployed to continue to practice medicine and serve the community, thereby alleviating concern about an oversupply.

For better or for worse, because of the state of healthcare today, ED physicians have been exposed to a myriad of primary care concerns, all of which have prepared them for a career as an outpatient PCP. By offering such a path, we can provide more flexibility for an emergency physician's career, help alleviate the primary care shortage affecting the United States, and serve our community and country in new and helpful ways.

Nishant Gogna is a fourth-year osteopathic medical student at Philadelphia College of Osteopathic Medicine Georgia and is pursuing a career in emergency medicine.


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