Article Outline
The Institute of Medicine’s (IOM) June 2006 3-volume report on The Future of Emergency Care in the United States Heath System brought welcome national attention to the problems of crowding, ambulance diversions and inadequate preparation for disasters.
But in what may be a lesson in the Law of Unintended Consequences, the reports have also brought fresh attention to an issue that seemed settled: the difficult debate over how welcoming emergency medicine should be to those trained outside the specialty.
The decades-long dispute over defining emergency medicine specialists began practically when the young specialty did; emergency medicine’s formal recognition by the American Board of Medical Specialties came in 1979. The dispute intensified with the 1988 closing of the “practice track” that allowed physicians residency trained in other specialties to be grandfathered into board certification by the American Board of Emergency Medicine (ABEM).
The Debate Begins Anew
But the discussion appeared over as of October 2005, when the Second Circuit Court of Appeals dismissedDaniels v. American Board of Emergency Medicine, a 100-plaintiff suit brought by physicians seeking to reopen the practice track. With that suit’s dismissal, the definition of a specialist as someone residency trained and board certified in emergency medicine (or trained in another specialty and boarded in emergency medicine by 1988) seemed established.
But last summer’s IOM reports could open the argument again. A little-noticed chapter details the difficulties of supplying an adequate emergency department (ED) workforce, underlining the persistent mismatch between the needs of EDs and the number of emergency specialists medical education can supply.
The first report of the 3, “Hospital-Based Emergency Care: At the Breaking Point,” notes the differential: “Approximately 38% of practicing emergency department physicians are neither board certified nor residency trained in emergency medicine.” It adds that the mismatch will not soon be remedied: “In the absence of a large-scale expansion of training positions, [the supply of board certified emergency physicians] will not be sufficient for several decades.”
The report then raises an alternate yardstick by which to judge fitness to practice: assessment of “core competencies for all disciplines working in the [emergency department] … in accordance with the level of ED in which they practice, regardless of board certification.”
Opening the Door?
The mention of core competencies has electrified some physicians who feel disenfranchised by the closure of the grandfathering option and by the American College of Emergency Physicians’ (ACEP) decision to restrict 21st century membership to those who are residency trained and board prepared in emergency medicine. But Dr. John Prescott, an emergency specialist, member of the IOM reports’ core prepared and dean of the West Virginia University School of Medicine, said the mention of core competencies should be understood solely as a nod to difficult realities, not a rollback.
“We weren’t trying to sit on a fence,” he said. “We were asking ourselves, ‘How do we render care that is coordinated and is accountable and is regionalized and makes sense?’ If we waited until we had enough emergency medicine specialists before we provided emergency care, we would wait a long time.”
Nevertheless, he said, speaking as a report author and as a dean: “Do I believe that only emergency medicine physicians can render emergency care? Absolutely not. Do I believe residency trained, board certified physicians should be considered emergency medicine specialists? Yes, I do. That is not just semantics. If you’re going to be called an emergency medicine specialist, you need to go through the training and certification that goes along with it.”
Lessons from Other Specialties
To long-time members of the specialty, the argument over how to define a specialist will seem like reopening of old wounds. By accepting physicians who came into emergency medicine via the grandfather option, ABEM provided a home for emergency physicians who trained during the specialty’s earliest years. And emergency medicine was not alone in offering a “practice track.” Fourteen of the 24 recognized specialties at some point offered some form of experience-related grandfathering, beginning with ophthalmology in 1917 and extending to medical genetics, the specialty recognized after emergency medicine, in 1981, according to a 1996 analysis. Thirteen of the 14 closed after periods that ranged from 3 years to 27 years. Only one of those practice tracks, for preventive medicine, remains open 58 years after its creation, though it allows physicians trained outside the specialty to sit for certification in preventive medicine only if they graduated from medical school before 1984.
When emergency medicine closed its practice track, it left some physicians— primarily those who trained in other specialties but graduated too late to be grandfathered or came too late to the realization they preferred to practice emergency medicine— outside the big tent it had created.
Finding the tent not big enough, the newly formed Board of Certification in Emergency Medicine began in 1987 to offer an alternative board exam (under the American Board of Physician Specialties) to physicians from other specialties who could prove they had worked 7,000 hours in emergency medicine, the same number of hours required under the grandfather track.
Finding the tent too big, the American Academy of Emergency Medicine (AAEM) formed in 1993 and defines a specialist only as one residency trained and board certified in emergency medicine. And the pendulum swung back once more with the 1993 founding of the Association of Emergency Physicians, which accepts all physicians practicing emergency medicine regardless of training or board status, and the 2006 founding of the United States Alliance of Emergency Medicine, which accepts physicians, nurses, and EMS workers.
Following the Fracture Lines
Behind the fracturing of the emergency physician corps among multiple organizations, each with a vision of what constitutes an authentic emergency specialist, lies the ultimate confounder: money. What ACEP calls “legacy emergency physicians”—those from another specialty who practice emergency medicine but are not boarded in it—contend that, as training and certification have grown in importance, their job opportunities have shrunk.
“Many of us couldn’t move jobs easily, because places advertising for new hires are almost always looking for residency trained, board certified emergency physicians,” said Dr. W. Anthony Gerard, a family physician who has worked in emergency medicine for more than 20 years and belongs to a practice that staffs the ED of Good Samaritan Hospital in Lebanon, PA.
Gerard is one of 3 coauthors, all family physicians and ACEP members, of an unpublished paper that calls for revisiting emergency medicine credentialing in light of the IOM report.
Out of concern for potential discrimination, ACEP last summer approved a policy statement supporting legacy emergency physicians that reads in part, “ACEP believes that the quality of care delivered by legacy emergency physicians should be a primary determinant of their hospital privileges and credentialing. … Legacy emergency physicians should not be forced out of the workforce solely on the basis of their board certification status.”
“We’re making a big mistake if we marginalize these folks … and prematurely remove them from the workforce,” said Dr. Brian Keaton, ACEP’s president and a principal author of the policy statement.
The census of those who may share these concerns is not trivial. There are approximately 10,000 physicians who work currently in emergency medicine but trained in other specialties and never grandfathered into certification, according to a 2002 workforce analysis that was the source of the IOM’s “38%” estimate.
Two-thirds of that group trained in either family medicine or internal medicine, the authors of the analysis found. Their specialty organizations have taken up the cause of their possible disenfranchisement. The American Academy of Family Physicians explicitly supports its members practicing emergency medicine under a core competencies concept.
“What we want for our members who practice emergency medicine and do a good job at it is for them not to be told that they are substandard physicians who have no place in the emergency department,” said Dr. Perry Pugno, the AAFP’s director of medical education, who was himself grandfathered into emergency medicine in the 1980s and ran a California trauma center.
Many states allow medical school graduates who have completed a 1-year internship to obtain a medical license for general practice, but all but the smaller, rural hospitals limit full privileges to residency trained physicians. In some areas, residency trained family practitioners perform cesarean sections and surgeries. A 1995 study published in the Journal of the American Board of Family Practice noted more than 2,000 family physicians perform cesarean sections in the United States. In a further blurring of the margins, it also noted general surgeons sometimes perform cesarean sections. Finally, even some “general practitioners,” presumably having completed only an internship, still perform the procedure, the study said.
The American College of Obstetricians and Gynecologists (ACOG) seems to have taken a stance similar to ACEP’s policy on legacy emergency physicians. In its Standards for Obstetric-Gynecologic Services, Seventh Edition, ACOG states: “Privileges should be granted on the basis of education, experience and demonstrated competence, not solely on the basis of board certification, fellowship in the American College of Obstetricians and Gynecologists, membership in other organizations or the physician’s rank or tenure.”
The back-and-forth over what constitutes a true emergency medicine specialist finds another parallel, resembling the dispute over qualifications between neurosurgeons and the subset of trauma surgeons who place themselves in the emerging subspecialty of acute care surgery. Acute care surgeons view their scope of practice as reaching beyond trauma surgery to surgical critical care and emergency general surgery, including emergency neurosurgical conditions—raising staunch opposition from neurosurgeons.
Proponents of acute care surgeons performing neurosurgical procedures “focus only on the technical part of the procedures” and ignore depth of training and experience, said Dr. Alex Valadka, professor and vice chairman Department of Neurosurgery at University of Texas Medical School at Houston and a spokesman for the American Association of Neurological Surgeons. That group issued a November 2006 position statement opposing performance of emergency neurosurgical procedures by anyone other than a neurosurgeon, a position similar to that taken by the AAEM regarding emergency physicians.
A Shortage of Supply
The concerns raised in the Institute of Medicine reports make the continuing argument over defining an emergency specialist freshly relevant—to the care of patients, and also to the robustness of the emergency medical network the report calls for.
Residency training will not supply enough specialists to meet the demand for emergency physicians for 30 years, according to a paper presented at the 2004 annual meeting of the Society for Academic Emergency Medicine. The imbalance is worst in rural areas, the IOM reports found. Emergency medicine residents cluster in urban teaching hospitals; rural hospitals serve 21% of Americans, but only 12% of residency trained emergency physicians work in those hospitals, down from 15% in 1997.
“Although, ideally, all EDs would be staffed by residency trained, board certified emergency physicians, this is highly unlikely to occur in the near to middle term, if ever. Therefore alternative staffing models must be developed,” the hospital-based care report said.
Legacy physicians contend they fill the gaps that the specialty of emergency medicine cannot cover.
“I couldn’t get a [residency trained emergency specialist] to work here; they wouldn’t do it for the money we pay, and we don’t train them for this setting,” said Dr. Jeff Bates, a pediatrician and internist who is ED medical director and director of trauma at Lavaca Medical Center in Hallettsville, TX, and is president of the Association of Emergency Physicians.
Emergency medicine residents naturally disagree. “To minimize the importance of staffing emergency departments with residency trained, board certified emergency medical physicians would be going in the wrong direction,” said Dr. Aisha Liferidge, president of the Emergency Medicine Residents’ Association. The organization has called for loan repayment assistance to create incentives for rural work; a fall 2006 survey of its members showed 74% interested in rural emergency medicine and 87.5% willing to practice in rural areas if loan repayment were offered.
Legacy physicians contend they are inappropriately considered a second-best option, hired only when trained and boarded specialists are not available. But Dr. William Strudwick, residency trained and boarded in emergency medicine and ED director at Providence Hospital in Washington, DC, has no lack of emergency specialist applicants because Washington is a desirable place to live. Yet he still hires outside of the ABEM pool to staff his community hospital, hard-pressed by the closing of DC General Hospital 6 years ago.
“It’s not a workforce shortage issue that gets me using family physicians and internal medicine trained physicians in my department,” he said. “You want to make sure your department is staffed as efficiently as possible. I would say 60% of what we do is ambulatory medicine—office-type urgent care—and who is better to do that than family practitioners or internists trained in primary care?”
The Legacy Generation
The contentious debate over authenticity is unlikely to be solved anytime soon— may not be solved, in fact, before the retirement of the legacy generation makes the issue moot.
Prescott, the medical school dean and member of the IOM committee, said: “There is plenty of room to develop skill sets in others who are not defined as emergency physicians, so that they can render emergency care. … I am less concerned about what specialty an individual is in than whether or not they follow well-established guidelines and provide good quality care.”
Legacy emergency physicians say that, if the process of reexamining the training and distribution of the emergency workforce neglects their contributions, emergency care will be poorer for it.
“The practice of emergency medicine varies quite a bit between urban, suburban and rural ERs,” Gerard said. “The IOM is clearly saying there needs to be an effort to look at emergency medicine with those workforce issues in mind.”
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