Last month, Rick Bukata suggested that ACEP open its gates to non-boarded EPs. This would be an insult to EM residencies, and would set our specialty back decades.
Last month’s editorial by Dr. Rick Bukata re-ignited the debate over the role of board certification in emergency medicine. The American Academy of Emergency Medicine’s (AAEM) position has not changed in our 21 years of existence — you must be board certified to become a full-voting member and fellow of AAEM — period. AAEM has no control over how other EM organizations classify their members. However, we feel a call for other organizations to open their membership up to non-board-certified physicians is a step in the wrong direction. Since AAEM’s inception, supporting the value of board certification has always be a core part of our mission.
The first emergency medicine (EM) residency began 44 years ago. It has now been 38 years since the American Board of Emergency Medicine (ABEM) was incorporated. Progress in EM, as well as any other specialty, demands rising standards that evolve into formal training being the only legitimate route to certification. By the time ABEM closed the practice track in 1988, after a 10 year grace period, there were enough excellent training programs that a practice track no longer made sense for our evolving specialty. We are now at the point that the practice track was closed before many of our EM residents had even been born. We have had more than 100 EM residency programs for twenty years now. Today, there are at least 209 EM residencies (allopathic and osteopathic), graduating in excess of 2,000 residents a year. It has been 24 years since Dr. Gregory Daniel sued the American Board of Emergency Medicine (ABEM) for restraint of trade, seeking to re-open the practice track — the suit was dismissed in 2005 after 15 years of litigation. At a certain point, a specialty needs to move on — I feel we are well past this point.
Twenty-six years after the practice track has closed, it doesn’t make sense to look for ways to offer additional legitimacy to non-boarded emergency physicians. In 2014, it is not fair to patients when unsupervised physicians “learn on the job.” I’ve worked with and trained physicians from other specialties who took the difficult step of completing a second residency in emergency medicine, and ultimately becoming ABEM or AOBEM board certified. Each expressed how surprised they were about how much they didn’t know and how much of a better physician they became.
We realize it is highly inappropriate for an emergency physician to perform outside their scope of practice, such as by performing a cardiac catheterization or a hip replacement. Why should we encourage physicians trained in other specialties, who had not completed the board certification pathway while it was open, to be emergency physicians? By doing so, we would essentially say that emergency medicine residency training does not have any value, and that the more than 2,000 physicians who enter emergency medicine residency training each year are wasting their time. This undermines the entire construct of specialty-specific residency training that has clearly become the standard across all specialties. Becoming an emergency medicine specialist is a lifelong process, and emergency medicine residency training under the supervision of board certified emergency medicine faculty is the cornerstone of that process. If it is acceptable to learn unsupervised on the job, why have residencies in any medical or surgical specialty at all? AAEM’ s White Paper on The Value of Board Certification and Residency Training in Emergency Medicine concluded that “there is clear evidence in the literature that supports that board certification and residency training in EM improves the quality of care provided to patients in the nation’s EDs.” (The White Paper can be viewed at aaem.org.)
Proponents of non-board certified physicians in emergency medicine often argue that these physicians have significantly more training than a PA or NP. I certainly agree with this assessment; however, that ignores the supervision aspect (although supervision of physician extenders is subpar in many EDs and should be improved). On the other hand, it would be highly unusual for a non-boarded physician to be practicing under the supervision of another physician.
For years, I’ve repeatedly heard that we have a critical need for non-certified physicians in our EDs, as the demand far outweighs the supply of board-certified emergency physicians, and this imbalance may never be resolved during our careers. I’ve heard this argument countless times to justify the expansion of opportunities for non-board certified emergency physicians. In 2014, this simply isn’t true anymore. As of November 2012, there were 41,479 emergency physicians in the U.S. (source: Kaiser Family Foundation). Between 2000 and 2010, the number of emergency physicians increased by 44.6%, more than any other specialty (source: AAMC 2012 Physician Specialty Data Book). As of December 31, 2013, there were 31,154 emergency physicians currently board certified by ABEM (source: ABEM) and 3,280 board certified by AOBEM (source: AOBEM). In addition, if we assume it will take on average two years for a board-eligible residency graduate to become board certified, there are likely about 4,000 board-eligible EM residency-trained physicians. Looking at this data, it appears that the 38,000+ board-certified/eligible physicians now comprise more than 90% of the EM physician workforce. Far more emergency medicine residents graduate each year (over 2,000) than it takes to replace retiring emergency physicians (typically about 1.7% attrition, so around 700 physicians), and many EM residencies are created or expanded each year. Soon there will be more board certified/eligible physicians than there are emergency physician practice opportunities, particularly in urban/suburban areas.
In Dr. Bukata’s article he correctly points out that in many rural areas, it is very difficult to recruit board-certified emergency physicians. I expect that these difficulties will abate somewhat as the number of emergency physicians desiring urban/suburban jobs eventually exceeds the number of these opportunities available. In addition, efforts should be undertaken to make rural EM opportunities more attractive to new residency graduates (i.e., rural EM rotations). However, I do not think rural emergency physician shortages are a good rationale for increasing legitimacy for non-boarded emergency physicians. Note that shortages of neurosurgeons, ophthalmologists, neurologists, and others are also common in many rural areas. However, we do not see their professional organizations responding to these shortages by opening up membership to non-BC/BE physicians. The shortages in many areas for many specialties are significantly more acute than in EM — however we do not see emergency physicians being recruited to practice as neurosurgeons in these areas. In many rural areas, the primary care shortage is more acute than that of emergency medicine, yet we have a paradox where many of the primary care trained physicians instead practice in the ED.
I recognize that non-BC/BE physicians have the right to practice in any emergency department, assuming the hospital is willing to grant clinical privileges. However, 26 years after the practice track has closed, at a time when we have virtually enough BC/BE emergency physicians to staff all of our EDs, we should not be encouraging anything less than the gold standard of board certification. Opening up membership to non-BC/BE physicians sends the wrong message and is a step in the wrong direction.
Quite right! If EM is a legitimate specialty it must play by the same rules as all other specialties: a practice track to board certification that is open for several years after the specialty is recognized, and that is then closed forever. If EM is not a legitimate specialty it should be disbanded, along with all EM residencies. So, which will it be?
I fully understand the need for board certified ER physicians to protect their hard earned identity. As a family physician with a career-long affinity to emergency medicine, and as a DO now in the final quartile of my career, protecting one’s identity and purpose has long been ingrained. I am one of the physicians in the Iowa referenced study. Graduating in 1984 with six figure debt at 19% interest. My practice path, by necessity, was the most direct possible. I was by far the most aggressive “moonlighter” during my residency, great experience now practically outlawed, covering both urban and mainly rural hospital ERs practically every free weekend to support my young family. Now at 55, I really don’t have a horse in this race, yet I remain interested and read your periodicals every month. Many, like me were caught just beyond the arbitrary deadline of practice pathways. I have been, for several decades, medical director for my critical access hospital, and medical director for our level 4 trauma center, and medical director for every ambulance system in my county. I would love to give that to a board certified ER doc, but none care to venture out this far. I have seen it all and I am fairly certain, save the new ultrasound modalities, have done it all. I have performed C-section during a trauma code, countless intubations, many chest tubes, surgical airways, and complex traumas and lacerations galore. I get Christmas cards from patients I have defibrillated and provided fibrinolysis to. I love the career I have had in rural family (and dare I say emergency) medicine and I will be forever thankful to the ER physicians who have taught me. My ER career through my alternative pathway has given me much affinity for procedural medicine, in the past month I have performed: 2 vasectomies, 10 colonoscopies (8 with polypectomies), 2 large volume thoracentesis, one paracentesis, 4 esophagogastroduodenoscopies (one with esophageal dilatation). As you may observe, all of the above were actually scheduled, along with 525 office patients, but the point is the confidence was forged in the emergency room. There are many of us out here in the boondocks, and we pose no threat to the value and prestige of board certified Emergency docs. After scoring in the 99th percentile on the emergency medicine section of the Family Practice Recertification Boards, I appealed to the American Osteopathic Emergency Medicine Board to allow me to join your brotherhood. I presented my tens of thousands logged hours in the ER, my directorships, my procedural experience, my decades of affiliate faculty status teaching ACLS and PALS all over the state – the board was unimpressed and pointed out to me what I already knew, the pathway closed I think in 1988. Please don’t fear the exclusiveness of your specialty, the door is tight shut, even on the leaky DO side. I salute those rebels in your ranks that reduce fractures, I teach my students and physician assistants to do the same. I plan on taking one of your emergency ultrasound courses, if you will allow a non-certified person to pollute your ranks. I particular like reading your rants on radiologists protecting their turf, because turf protection has essentially destroyed the teaching of family medicine as I know it. I respect metro and urban ER physicians, but ponder, for a moment, what it is like to be the only physician available in 2500 square miles with a measly population of 25,000. Bad things happen out here too, and we are a little lonely.
So, our specialties cannot overlap?
I am not Internal Medicine trained yet have cared for adults and geriatric patients my entire career. I would wager even BETTER in many cases. I am not a pediatrician but ditto the above.
Family medicine implies that we provide all levels of service for our patients. Acute and chronic care.
Before EM residencies, ERs were staffed with internists and GPs who chose this practice environment. Before such a thing as an emergency physician was identified.
I don’t think i should be identified as a board certified EM FP but perhaps a lesser qualification certifying an exceptional level of experience and skill. Perhaps a CAQ as there is for Geriatrics and Sports Med.
we all make each other better…which is the goal of course…!
Wow that is my story almost exactly. Actually I’m not sure that EM is a valid specialty. It seems to be more of a protector if the treasure. Should the treasure change (probably won’t ) we will see how quickly the protectorate abandons EM as a specialty. I already see board certified EM docs delving into areas outside their “specialty” strangely they demonstrate no shame at not being “certified”……
I don’t have a horse in this race as a rural medical sub specialists. I do know that it has been virtually impossible to find ER boarded docs where I work. What I see here is once again a cluelessness by an ivory tower doc who hasn’t practiced in rural America. Dr Bukata, if you can’t tell the difference between the shortage of other sub specialties in rural America which have the luxury of waiting ( and going or being transferred to a larger center) those that need a Boarded ER doc, then you are really missing the point. I suggest you spend more time outside of the UT system.
During my first job out of residency, I worked in a hospital that was mostly staffed by FM trained physicians. There is a very real difference in the approach that an EM trained physician and an FM trained physician has not only to the patient but also to managing work flow in a department when things get busy. I have to agree with AAEM’s stance: I don’t think that approving membership of our professional societies to physicians trained in other fields would be beneficial to our specialty.
At the same time, I realize that rural departments are going to not going to be able to attract boarded emergency physicians to work there. Part of the problem is location – a young, possibly single, residency graduate is probably not going to want to live in a town of 10,000-20,000. The other issue is pay. Many rural jobs are independent contract positions and pay 90 or 100 an hour. Someone carrying 200,000 in student loan debt which has likely grown over the course of residency simply cannot take a job at such a rate and make ends meet. Keep in mind that a family medicine physician who moves to such a town and practices in a clinic with some ED coverage is eligible for loan repayment. His health insurance and other benefits are paid for by the hospital. The emergency medicine trained doctor who is a 1099 contract employee is eligible for none of these things. I have tried to make the numbers work at three rural hospitals but the reality is that they don’t if you are writing a $4,000-$5,000 a month check for your student loan payments, health insurance, and disability insurance…and that is without putting a roof over your head, food on the table, or saving for your children’s education or retirement.
Finally, a real threat to our field – to both boarded and non boarded physicians who work in emergency departments – is the rise of the nursing physician. DNPs who have never gone to medical school are starting to fill jobs in rural EDs. Their training courses are short, relatively inexpensive, and they can afford to work for what rural departments are willing to pay.
Rather than focusing on the certificate that hangs on the wall, I propose that AAEM and AAFP work together to restructure family medicine training to provide for a rural EM track. A family medicine physician interested in this could combine low OB volume (20 deliveries) with expanded EM experience during training.
In the end we may have to settle for a future where all EDs are at staffed by physicians with some degree of relevant training before we end up in a future where rural departments aren’t staffed by physicians at all.
With all due respect to Dr. Reiter, I agree with Joe: he truly is an “ivory-tower” doc without a clue to the realities of working in some suburban and rural ED’s. His article is well-written and taken, but this hubristic attitude only serves to lessen the view that most people have of ivory-tower docs… all “knowledge” but less compassion. I agree with Old Mil. My former residency does exactly that, provide for CAQ in ER with an additional year of ER only experience. It wasn’t available during my residency, but the administrators were talking about it. Dr. Meeker’s response reflects my sentiments.
Prior to the year 2000, all that was needed to be an ACEP member was an MD/DO degree and an interest in EM.
How many of the current members of ACEP are not boarded?
Im a close second to Dr. meeker 10 years his junior but have been the medical director in a shop in central Iowa in my hometown seeing a volume near 20k a year. I went through traditional family practice residency at a time when the hospital system I trained in needed residents to staff all of the rural ER’s they “gobbled up” and also at a time when the rules governing how many hours one could moonlight/work were relaxed. And so I worked sometimes 3 weekends a month moonlighting and I thrived in that environment. Now I am a member of ACEP but only because I was grandfathered in but after more than 15 years of full time ER practice here I can state flatly several irrefutable truths:
1. We manage critically ill patients in rural Iowa too.
2. I cant pay you as much money as the urban ER per hour and so if you are EM board certified with all of your elitism you probably dont want to come work with me. This is evidenced by 15 years of failed recruitment attempts for an ER board certified partner.
3. I crave continuing education in the field in which I practice. Because I could not get this I was forced to seek board certification through the American Board of Physician Specialists. Now at least all of my CME efforts are geared toward skills I employ and love and not say learniing which statin or oral hypoglycemic to initiate.
4. Dr Bukata was arguing for membership in ACEP, and somehow you seem to confuse this with board certification through the ABEM. I dont see how inviting all comers to participate in the wonderful learning opportunirties and advocacy of ACEP treads upon the prestigious status of being board certified through the ABEM. Yes I understand the blathering about not validating people to work in ER’s who are not ER board certified but brother what is your reality? Dr. Bukata speaks to the truth of the world as it is. You can graduate a gazillion ER board certified docs, but if I cant pay them as much in a rural ER, they arent coming here.
Finally, you dont want me in your elite group, I understand. Its a nifty cloak of guarded determination to wear in an urban setting. Now imagine you are the patient in an auto accident traveling through the countryside near my town. Are you nervous? Don’t be because despite your obstacles we find ways to access cutting edge emergency medical information, its just a shame we couldnt all collaborate through ACEP to accomplish this goal.
Thank you for engaging your readership in a discussion of whether it may be reasonable to “increase legitimacy” to committed practicing emergency physicians who did not complete a residency. This is a matter of critical strategic importance to the US EM workforce and the patients we serve.
The analogy of EPs doing angiography or neurosurgery is flawed since nearly the entire body of EM is comprised of work that was and is done by other types of doctors. Everyday EM is an amalgamation of work that might be done by other doctors, if it were efficient to have a doctor of every type waiting in the ED. EPs do provide care daily to patients with both cardiology and neurosurgery problems, but there is no reason to train them in angiography or craniotomy. Low volume, high complexity, or costly procedures fail to provide utility in the hands of EPs and thus are unlikely to become part of the EM body of knowledge.
The argument that there exist sufficient EM RT doctors to staff the US fails given the strikingly unequal distribution of their talents in the US. This is not a challenge that market forces will address as long as there are financial and lifestyle incentives to support the misdistribution of talent. The majority of expert thinking on the future of the EM workforce projects a significant shortage of EPs.
The structure of a multi-tier system of providers divided along the lines of residency and boards guarantees the continued existence of these incentives and might be viewed as a self-serving function of professional bodies. A system to stratify physicians by talent or skillset, rather than by a certification for which only some may apply, would allow progress towards assuring a skillful EM workforce. Those who completed a residency should excel. Published, transparent data would allow the market to determine the actual value of residency versus other pathways in creating excellent EPs. For example, disaster planning or toxicology skills are likely best used in more urban centers or those influencing treatment of many toxicology cases such as a poison center.
EM governing bodies might improve US health by approaching the EM workforce from a position of patient-centricity. Such an approach would include more efforts to assure the highest quality of all practicing EM doctors, rather than a subset who should be the best trained fraction in the first place by having completed a residency. It would also include broader efforts towards inclusion and skill building for those who did not choose EM residency but have ultimately joined the ranks of dedicated doctors providing the best care they are able in whatever size and type of facility that they work in.
Bravo Mark Reiter! I am one of those trained physicians from “other specialities” (mine was FM) who took it upon myself to complete a second residency in EM to insure that I had the training to make me a skilled, and most importantly, confident rural EM physician. It wasn’t easy – it took me three years of going through the Match to finally secure a position but it was worth it – even at the tender age of 47.
I completed my first residency in FM in 2008. I did a full three years at an unopposed program that had heralded itself as the program that could prepare its residents to practice in rural ED’s in Rocky Mountain West. This may have been the case twenty years ago but current FM programs – abd mine in particular – are highly focused on clinic (and if you are really unlucky OB). There isn’t time built into the programs for a thorough EM rotation and forget about learning how to manage critically ill patients in the ICU. We only got three mornings a week in the ICU because we had to be in clinic in the afternoon to satisfy the enormous amount of clinic hours necessary to graduate.
I was fortunate to have found an EM program that was willing to take me and I received six-months credit so I only had to do 2 1/2 years. Now, the ABEM will give a full year’s worth of credit so any there is no excuse for any FM, IM, Peds who wants to do a second residency in EM not to do it. It is worth it as an investment in your future. The jobs are better, the pay is better, but the important thing is that you will be a better EM physician. Please do not interpret that to mean that the FP’s who are practicing in rural ED’s are not good – these people were trained in a different era and they have learned from years of experience. This experience cannot be learned in a good majority of today’s FM residency programs.
Last point: there are a lot of rural Critical Access hospitals, in the West at least, who appreciate the value of having EM residency trained BE/BC physicians. I work in a small town in Montana and five out six of our ED physicians are BE/BC in EM. We have Pts coming from bigger towns miles away to see us because of the quality of care that they know they will receive in the ED. This is a huge source of revenue and pride for the hospital.
I am an FP with 10 years ER work experience. I have been excluded from a number of good positions due to my Board Certification being in FM instead of EM. About 4 years ago I called several EM Residency programs and I was told I could not have an EM residency position because I had been out of residency for over 7 years and the Federal Govt would not pay any residency program for me to be “residency trained.” Apparently the US govt pays money to residency programs to train us. I thought they were paid from all the work we did for so little pay..of course I went through residency before the 80 hour work week..we calculated from our pay to be $3.00/hr! So what residency program let you in? I would like to invest in my security as an EM physician, the training so I don’t end up a physician who is unable to find a job. For those of us who are trying to comply with the requirement we be residency trained – they should make residency positions available to us.
That last point- The opposite is true. Patients have no idea who they are seeing, FM or EM certified or even a midlevel. I know patients have no clue. As far as patients traveling further to get better emergency care… what kind of emergencies are these? It can be a point of pride for the hopsital, but advertising can only increase revenue so much. The more likely reason pts travel far… there is no other options. They aren’t driving by other ER’s for the purpose of getting an ER trained doc. This is coming from an ER trained doc.
I am having a tremendous struggle understanding your logic with all due respect. Are the rural populations a second hand citizens that only are allowed to be seen by a second hand ED physicians?. Who, out of the all ABEM would practice in rural Texas or New Mexico? . Wound’t it be better to have everyone to be on the same page from the credentialing and knowledge standpoint equal across the board. Is this issue about us and our pride of being ABEM or it’s about people. Think about it.
Residencies are only as valuable as the people taking them. They are made to make sure the most incompetent student is maximally trained. They are not made for elite students who can learn things faster and simply perform better. They do not evaluate, desire, courage, work ethic and the mental strength it takes to be a good ER doc. Why not just let not boarded EM doctors take the test. What are they scared of? If you have the experience and can pass the test without a residency, your likely to have those aforementioned traits, and if you can do that, you are also likely to be more competent then a recent residency grad who just had the training wheels taken off. Competency should be the goal, not EBEM authority.