Op-Ed

Op-Ed: The New Reality of Emergency Medicine and the Rise of Peri-Primary Care

As recently as the 1950s, the “emergency room” often consisted of nothing more than just that: a room in the hospital reserved for emergencies.

Staffed by rotating hospital physicians, residents, and, in some cases, medical students, the early emergency departments were conceived of as places only for the interim management of severe injuries and acute illnesses.1 Over the last century, the role of the ED has shifted rapidly from that of an isolated adjunctive to inpatient care to its current status as a lynchpin of hospital functioning. The ED now serves as the source of admission for more than half of hospitalized patients over age 65.2 During this time, the number of patients visiting EDs annually has skyrocketed, far outpacing the growth in US population.

Just as the number of overall ED visits has increased, so too has the number of ED encounters for “non-urgent” issues. Increasingly, EM physicians are tending to patients who have come in not for life-threatening injuries or illnesses, but for management of more chronic medical conditions. Elevated at-home blood pressures, mild asthma exacerbations, chronic headaches — all issues broadly considered to be the realm of primary care — are increasingly common causes of a trip to the ED.

The root of this trend is not fully understood, but is likely due to the combination of a variety of factors. For many without insurance, outpatient primary care is not easily accessible or is prohibitively expensive. At understaffed, underfunded free clinics, patients often have to wait hours to be seen for a 15-minute visit. Patients working multiple jobs, or those who cannot get time off without risking their employment, may not be able to make it to most clinics during normal office hours. Some simply feel that the ED “doc in a box” format better serves them when they are experiencing a minor aggravation but cannot find an available outpatient appointment for another three weeks.

Whatever the reasons, the general dialogue regarding this trend often maintains that these problems are outside the purview of an EM physician’s practice. While it may be true that many of these non-urgent issues would be better addressed by regular outpatient follow-up, EM physicians are already well-versed in adapting care to the reality of the patient in front of them. In the same way that EM physicians may alter prescriptions for different patients — IM haloperidol for a patient having trouble with oral psychiatric meds, or generic drug prescriptions when the brand name is not covered — so too may they adapt care according to the primary care status of their patients. If a patient has regular, easy access to ambulatory care, the management of their hypertensive meds may well be deferred to their PCP. But for a patient coming in for the third time with a BP of 180/120 and no established PCP, the EM physician who accepts his/her responsibility as a provider of peri-primary care is the one who is really going to save this patient’s life. Of course this ED peri-primary care will never, and should never, serve as a full substitute for regular access to primary care, but in the absence of any primary care, it is a critical alternative.

While it diverges from the more traditional understanding of EM, we should try to understand this ED primary care, or “peri-primary care,” not as an inconvenience but as the vital next phase in the ever-adapting field of EM. In the past 70 years, emergency medicine has grown from a limited non-specialty staffed by unequipped medical students and residents to a well-established, integral part of hospital functioning staffed by highly trained physicians. As the field continues to grow, so too will its purview.

We can reframe the responsibility of EM physicians so as to include not only acute, life-threatening emergencies, but also chronic conditions that can be equally as life-threatening. In the end, a patient with uncontrolled diabetes and no regular primary care faces equally as dangerous complications as the patient with acute frostbite. The time course may be different, but the outcome is still the same. Emergency medicine as a specialty was developed to handle acute emergencies, but as the field grows and ED utilization rates continue to rise, we would do well to expand our understanding of the purview of EM to include chronic emergencies as well.


References

  1. Zink BJ. Anyone, Anything, Anytime: A History of Emergency Medicine. Elsevier Health Sciences; 2005. https://play.google.com/store/books/details?id=bUImH2GeULAC.
  2. Greenwald PW, Estevez RM, Clark S, Stern ME, Rosen T, Flomenbaum N. The ED as the primary source of hospital admission for older (but not younger) adults. Am J Emerg Med. 2016;34(6):943-947.

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