Physician greeters? ED managers weigh pros, cons

A growing number of ED managers have begun using ED physicians as "greeters" — placing them in triage as the first provider to see patients. With the creation of a "door-to-doc" time of virtually zero, the patient satisfaction benefits are obvious. Proponents also argue that this strategy can improve flow as well.

However, support for this approach is far from universal. "This is a workaround for places like California that have [required] nursing ratios and staff shortages, and no beds or hallway spaces to bring patients back into," argues Loren A. Johnson, MD, FACEP, chief medical officer of Sutter Emergency Medical Associates, an emergency physician medical group and medical director of the ED at Sutter Davis Hospital, both in Davis, CA. "I’m personally leery," he says. "Why can’t you bring patients back into a private room, a real treatment space, where you can theoretically do a good job and better meet patient expectations?"

Johnson recognizes that the use of physicians at triage "is becoming more and more prevalent," he says.

One of the obstacles to universal acceptance of this new model is that triage has never achieved a high level of standardization in the U.S., he says.

Still, the advantages of this approach are clear to many ED managers, including Charles F. Pattavina, MD, clinical assistant professor of emergency medicine at Brown Medical School and attending emergency physician at The Miriam Hospital, both in Providence, RI. "The general idea is that you get a much better assessment and start the ball rolling on work-up," he says.

A lot of emergency physicians don’t like the idea of conventional triage because it causes a bottleneck, he says. "Even if you have two triage nurses, you still have a variable number of patients coming in, so you can end up with a backup in the waiting room," he says.

With a physician at triage, the doctors can see the people who otherwise would be "stuck" and, he hopes, eliminate the bottleneck, Pattavina says. Ideally, such a setup "would be great, because the more simple cases could be dealt with right then and there," he adds.

Johnson says he understands the rationale for physician greeters. "Triage, as it has traditionally been practiced, is not an MSE [medical screening exam]," he says.

"Having the physician at triage is a way to improve the efficiency in overcrowded EDs, so that in essence, it’s moving the fast-track a notch higher," Johnson says. You could call it a super fast-track, he adds. "You do the MSE for urgent care patients and speed work-ups for more complex patients even before they are brought back to the work-up area."

So why does he still object to this approach? "It’s true this is a relative patient satisfier and an efficiency response," he says, "but you have to ask the question: Is this really an enhancement to the quality of care we should be providing as part of emergency medicine?"

Pattavina recognizes the strategy does have its limitations. "You couldn’t have a physician alone [at triage] because they would be consumed with these minor cases," he says. "And you generally need a nurse to do some of the things docs are not trained to do."

Having a physician in triage also would be expensive, Pattavina says, "and there would have to be enough triage volume to support that."

Ironically, however, if your ED did have that much volume, "the physician would not be able to triage every patient," he says. Recognizing the drawbacks, however, Pattavina still concludes that having a physician in triage can shorten the time of the visit.

As for the patient satisfaction benefit of seeing a physician almost immediately, it may not be quite the benefit it might have been a few years ago, he says. "People in less urgent care areas have gotten used to the idea that they may see a physician extender, so there’s more acceptance of that reality."