What Is An Emergency Physician?


What is an Emergency Physician?

There’s an old riddle. How many legs does a dog have if you call the tail a leg? The answer, of course, is four, because calling the tail a leg does not make it a leg.

Calling doctors who practice full-time emergency medicine something other than emergency physicians does not make them something other than emergency physicians.

Any doctor whose main job is to work full-time shifts in a hospital emergency department is, by definition, an emergency physician.

How in the world did we ever forget this simple fact?

Recently some have tried to characterize a portion of the EM workforce as being “family physicians who work in emergency medicine” and other similarly euphemistic titles.

Look, it’s really simple. We don’t need euphemisms adding confusion to an already tenuous medical system.

I am an emergency physician.

My sole medical practice is working full-time in hospital emergency departments.

I see the same patients that are seen by EMRT and/or ABEM-boarded docs.

I assume the same liability as that assumed by EMRT and/or ABEM-boarded docs.

I am held to the very same standards of care.

So, can we just forget all of this foolishness and get on with our work?

The discrimination against non-boarded and non-EMRT emergency physicians, both by hospitals and by ACEP is not only insulting, it is counterproductive.

Let’s give it a rest so we can all work together. We all have better things to do with our time and we owe much more to the patients who come to our ER’s.

Marlene

Marlene Buckler, MD, FACEP
www.StayOutOfMyER.com

  1. #1 by Sonny Saggar - July 5th, 2010 at 06:40

    The only reason such turf battles (in any profession) have ever existed is because of money. The fools at ACEP and AAEM (the latter being amongst the biggest dorks on the planet of North Korean leadership caliber) will quit their attacks once the pay for ER docs starts to fall again. Looking at the current marketplace, I am eagerly looking forward to more mid-levels in ERs so that hospitals will suddenly discover that they can drastically reduce their payroll costs. Just watch what’ll happen to the turf battle then. I look at the crazy comments by our Croisimodic brethren at AAEM and I laugh out loud. Go on. Hit the ‘Non-residency-trained docs’ with your best shot, ya big goofballs. Ha! Have a good life you grumpy old men. Actually, it would be more accurate to say “get a life” and “how about looking after your patients instead of your pocketbook, huh?” Just smile. Be happy. Enjoy life. Be good to everyone around you.

  2. #2 by John Newcomb - July 6th, 2010 at 00:20

    Marlene, Nice post. The fact is that ACEP cannot provide a definition of an Emergency Physician. It is well established that 1/3 of physicians practicing EM are not ABEM certified. The number of patients Non-ABEM physicians treat is not known, but is likely not less than 25% of all ED patients. CMS does not distinguish between the two in regards to reimbursement.

    Given the fact all EM physicians, regardless of Boards of Certification, are working under the same unfair rules not as applicable to our physicians colleagues in private practice, including but not limited to, EMTALA, increase in the uninsured, coercive contracts by hospitals, and balanced billing legislation for Non-par physicians popping up in state after state, wouldn’t we all (ABEM and Non-ABEM) be better off putting off the Board issue for now and come together to fight the greater threat to the livelihoods of all whose principle source of income is the practice of medicine in the ED (regardless of what you call the person providing the service). Wouldn’t we not also better serve those that are currently in EM residency programs by doing so?

    Emergency Physicians are under attack from all sides, there has never been a greater need for unity, less we all go down together.

  3. #3 by a specialist in emergency medicine - July 6th, 2010 at 01:30

    Excellent post. Too bad Dr. Saggar’s comment didn’t adopt the same tone. After a paragraph of insults and name-calling he has hypocrisy enough to advise us all to “Be good to everyone around you.”

    Just to put the record straight, AAEM has never objected to any physician working in any emergency department. Local hiring decisions are the purview of the hospital medical staff and the entity that employs the emergency physicians. What AAEM and those of us who are board certified in emergency medicine do object to is non-board certified physicians calling themselves board certified in emergency medicine. That’s all. You’re welcome to work anywhere that will hire you Dr. Saggar.

  4. #4 by Dr. JB - July 6th, 2010 at 10:09

    Specialist,

    NIce to see you carry the ABEM line on “We don’t object…” sadly that’s pretty far from the reality.

    More and more hospitals are requiring that we are board certified to work in their ED’s.

    What do I do as a non EMRT EP if my hospital changes it’s hiring policy and now wants me to be boarded as a condition to continue my employment? Or I decide to move and get a new job at the new location and they have such a requirement?

    What’s worse is that many of those doing the credentialing in the hospitals are ABEM boarded and hold your opinion, thus dissallowing employment to any EP who is non-ABEM boarded.

    So it comes down AAEM/ACEP/ABEM would rather see mid levels in ED’s rather than give in to logic and allow in either alternate boarded EP’s or non-emrt physicians in “their” ED’s.

  5. #5 by Sue Reagan - July 6th, 2010 at 11:52

    Sonny Sagar speaks the truth, and the truth oth hurt, dear Specialist. You will do better, if you re-read it , esp. regarding mid-level providers taking your job;otherwise one day, you will find out, the hard way.

  6. #6 by a specialist in emergency medicine - July 7th, 2010 at 01:19

    I’m not for NPs/PAs taking any physician’s job, and I would much rather staff the fast track in my ED with a family practitioner than a NP or PA. However, neither I nor ABEM nor AAEM nor ACEP is responsible for the policy decisions of a local hospital’s medical staff, or for the hiring decisions of the local group staffing the ED (much less if the staffing entity is a corporate megagroup). All I ask is that physicians not call themselves board certified in emergency medicine unless they are indeed ABEM or AOBEM certified, and that emergency medicine abide by the same rules as all other specialties.

  7. #7 by a specialist in emergency medicine - July 7th, 2010 at 01:29

    “Sonny Sagar speaks the truth, and the truth oth hurt, dear Specialist. You will do better, if you re-read it…”

    OK. I reread it. “Fools…dorks…North Korean leadership caliber…Croisimodic (whatever that means)…goofballs…grumpy old men…”. That still seems hateful to me, and given his call for us to “Be good to everyone around you”, hypocritical. Reasonable people can disagree without personally attacking each other.

  8. #8 by Dr. JB - July 7th, 2010 at 10:55

    Specialist,

    Why is it so important to you that someone boarded by another certifying group not be allowed to call themselves “board Certified”?

    Other specialties allow those certified by non-ABMS/AOA boards to call themselves “Board Certified” Why does only EM have to abide by a different set of rules?

    You are showing a huge unfounded bias against those who chose to certify in EM with another organization.

  9. #9 by a specialist in emergency medicine - July 8th, 2010 at 21:56

    Because it is dishonest, especially when the “board” in question will grant certification in a specialty to physicians who haven’t completed a residency in THAT specialty. Every specialty requires residency training to qualify for board certification, as EM has for over 20 years now. I believe EM should abide by the SAME rules as other specialties, NOT the “different set of rules” you allege.

    The fact is that most states have no regulations regarding which physicians may call themselves board certified. Since I generally abhor government regulation, I personally have no problem with that. The minority of states that do have such regulations generally specify that “board certified” means certified by a board under the authority of ABMS or AOA. Since all those boards require residency training, I do oppose the efforts of BCEM/ABPS to get those states to recognize it as equivalent to ABMS/AOA boards.

    The public will make the reasonable assumption that “board certified” includes residency training in the SAME specialty as the certification, which is not true of BCEM, as opposed to all ABMS/AOA boards. BCEM is not equivalent to ABEM or AOBEM, and I believe that the states that regulate advertising of board certification should not regard them as equivalent. Florida unfortunately does, and at the moment so does Texas. I hope Texas will reverse that decision shortly.

  10. #10 by Dr. JB - July 9th, 2010 at 07:20

    Why is it dishonest just because a physician has taken a different route to board certification?

    Why should a physicians who has a residency in another field but who has worked in the ED for decades be denied access to certification because ABEM closed that track prematurely and that doctor can’t afford or feels the need to quit his job and move to take an ER residency?

    Until the times comes when all the EP’s are residency trained ( in about 40 years from now) that experience pathway will still need to available for the 40+% of non RT physicians practicing.

    And please, don’t go into the ” They can still work in the ED but without calling themselves board certified” the reality is that more and more hospitals are requiring certification of all their doctors for employment and excluding physicinas from employment when there is already a shortage makes no sense at all.

  11. #11 by samuel mark - July 9th, 2010 at 08:24

    There is so much of discrimination at work place lately agianst ABEM certified but not residency trained doctors.This is pathetic.we see intelligent but morally weak taking over.

  12. #12 by An Emergentologist - July 9th, 2010 at 11:15

    Tom Scaletta MD = a specialist in emergency medicine

  13. #13 by a specialist in emergency medicine - July 10th, 2010 at 01:29

    JB-
    It is dishonest because the “different route” you mention does not include residency training in emergency medicine, the specialty in which the “board certification” is being granted. ABEM did not close the practice track prematurely. It gave nine years of advance warning, more than any other new specialty since the 1950s. The people who created/founded the specialty had plenty of time to take board exams, and THEY are the reason for a practice track. After they have a chance to take boards, the proper path to board certification is through residency training. Those are the rules for every specialty, and if emergency medicine is a legitimate specialty it should follow those same rules.

    If a medical staff is requiring board certification for all its members, that is an issue to take up with the medical staff. If the hospital is unable to find board certified emergency physicians to staff the ED, however, I would expect this problem to take care of itself rather quickly, and be resolved in your favor. If the shortage of boarded emergency physicians is a bad as advertised, I would think you have little to fear.

    Samuel Mark-
    I agree with you, as do most of our colleagues. That’s why AAEM has policies against discrimination towards board certified emergency physicians who became certified via the practice track – the very people who founded our specialty. AAEM’s newsletter won’t even accept advertising from groups that don’t promise not to engage in such discrimination.

    Emergentologist-
    My name isn’t Tom. I choose not to post it because of the hateful vehemence I have heard from some of those who disagree with me. Several BCEM/ABPS people live nearby, and I prefer not to subject myself to the possibility of violence or vandalism, even if unlikely. I am quite capable of engaging in rational debate without personally attacking those I disagree with, but unfortunately that is not true of everyone. Just look at the first comment in this chain.

  14. #14 by Dr. J - July 10th, 2010 at 21:53

    Spec.EM.: You cannot say your name because there are non-ABEM-boarded people who live in your neighborhood and they might vandalize your house or cause you personal violence? WHAT? Are you serious? Are you intoxicated?
    You have every right to give yourself a pseudonym, but please don’t invoke that sort of ridiculous strawman. Have you ever had fisticuffs with another physician? Even after a heated argument? I doubt it.
    Non-boarded Er-docs are not boarded by the taliban. They mainly went to normal medical schools and follow the same sort of of ethics as you. Socially they are the exact same as you. I forgot all of the potentially compelling points you made in your post immediately after reading the final histrionic paragraph. There is no reason to think that anyone would be violent towards you except perhaps any rhetoric teacher you may have had in high school.

  15. #15 by a specialist in emergency medicine - July 11th, 2010 at 02:07

    Dr. J-

    I hope you are right, but given the level of rhetoric I have been subjected to on this topic, both in previous posts at this website and in other forums, I choose not to take the risk.

    “You have every right to give yourself a pseudonym…” I appreciate your understanding, but many of those on the BCEM/ABPS side of this arguement don’t agree. In another comment string currently posted on this website, I am called a coward for using a pseudonym. Why would anyone care about who I am, as opposed to the validity of my arguments, unless they were more interested in personal attacks than a rational debate? It is a small step emotionally/psychologically from verbal abuse to physical violence. In fact, it is rare for violence NOT to be preceded by insults and name-calling. Those activities get the attacker psychologically ready for violence. So, I try to reason with those on what I believe is the wrong side of this issue, and the wrong side of history, and I choose not to reveal my identity.

  16. #16 by a specialist in emergency medicine - July 11th, 2010 at 02:09

    I almost forgot: does anybody want to resume the argument or have we beaten this topic to death?

  17. #17 by An Emergentologist - July 11th, 2010 at 11:50

    Emergency Medicine News:
    July 2010 – Volume 32 – Issue 7 – p 19
    doi: 10.1097/01.EEM.0000383982.00485.06
    Letters
    ‘Dr. Scaletta’s Nasty Comments’
    Hirsch, Evan MD
    Free Access
    Author Information

    Pasadena, CA

    Editor:

    I am one of those full-time emergency physicians caught up to some extent in the middle of this ongoing battle between ABEM and those doctors who, like myself, did not do a residency in emergency medicine, for whatever reason. I am family practice residency trained and boarded (and recertified), and I also applied for and passed the AAPS emergency medicine certification requirements. I have worked full-time in emergency medicine for almost 10 years. Consequently, I am always somewhat interested in the articles in your publication about the issues related to who is considered qualified to work in the nation’s EDs.

    Reading the current article, I am shocked by the sheer nastiness of Dr. Tom Scaletta’s comments. (“These are programs where people who didn’t get into emergency medicine residencies end up. If you want to water down the quality, that’s a great way to do it. As for these physicians, did they suddenly have an epiphany after a couple of years, and decide they had made a mistake in their choice of specialty?”) (“EM Fellowships for FPs: Bane or Boon?” EMN 2010;32[5]:1.) I can only assume that they are accurate and in context. I have several books upon which Dr. Scaletta’s name appears as an author or editor. I respected his contributions highly, but his comments are so insulting, it is difficult to imagine that any respected professional could utter them to another professional. So much hostility, intentionally demeaning! I wonder if he is one of those narcissistic peacocks we all suffered through during our training, who believes he is always right and that everyone else is a fool.

    Although I feel no reason to defend my career path, I will nevertheless briefly describe it. I went to a highly regarded public medical school on a scholarship. My MCAT score was 70. I had a 4.0 average in my major, and achieved honors throughout my collegiate and medical education. I didn’t simply not get into an emergency medicine residency! I chose family medicine for many reasons: variety, the emphasis on relationships, and because I felt it was what being a doctor was all about. Also, the institution I attended promoted family practice very highly; many of the best medical students chose it, along with pediatrics.

    Remarkably, as a medical student, I had no exposure to emergency medicine as a specialty other than glimpses while admitting patients to other services. In my residency, I realized I made a mistake based on my lack of knowledge about the specialty and, yes, about myself. I would not call it an “epiphany,” as Dr. Scaletta so derisively describes, but it was something I realized over time.

    I loved my first ED rotation (and achieved an “honors” grade), and started moonlighting in urgent care and then in a rural ED in my second year of residency. I could have attempted to switch residencies, and, in fact, I regret that I did not. However, I turned 30 my first year in medical school, and was eager to finish my training. Regrettably, I have never worked in family medicine. By temperament and skill, I am much more suited to emergency medicine, which I greatly enjoy. I am appreciated by my patients, co-workers, and colleagues.

    Unfortunately, Dr. Scaletta seems to feel that a broad and contemptuous brush is appropriate. In my career, I have found that colleagues vary in degrees of competency, compassion, and interpersonal skills across all specialties. Part of my skill set in the ED is knowing with whom I am consulting and evaluating them to the best of my ability on an individual basis, sometimes a superbly skilled interventional cardiologist with a lousy bedside manner is best for my patient. It is a pity that Dr. Scaletta is so hasty in his obnoxious and broadly insulting conclusions. It does little justice to the complexities of human life to which we all sincerely and honorably chose to dedicate our working lives.

    Evan Hirsch MD

    Pasadena, CA

    © 2010 Lippincott Williams & Wilkins, Inc.
    Article Outline

  18. #18 by An Emergentologist - July 12th, 2010 at 09:41

    Emergency Medicine News:
    July 2010 – Volume 32 – Issue 7 – p 5
    doi: 10.1097/01.EEM.0000383975.34550.fa
    Letters
    ‘Same Old, Same Old’
    Cartaxo, Ken MD
    Free Access
    Collapse Box
    Author Information

    Kinnelon, NJ

    Editor:

    Same old, same old. Dr. Tom Scaletta’s opinion is the same self-serving attitude that ABEM took more than 20 years ago by closing the practice track in 1988. (“EM Fellowships for FPs: Bane or Boon?” EMN 2010;32[5]:1.) Here we are 22 years later, and the problem is only getting worse. Dr. Scaletta and ABEM care little about the physician shortage in emergency medicine or providing the best care for the public. They are more interested in creating a monopoly and protecting their turf by limiting the number of board certified physicians, allowing them to cherry-pick the best ED jobs, leaving the rest of the hospitals, communities, and the public to fend for themselves staffing their EDs any way they can.

    Dr. Scaletta is ok with nurse practitioners and physician assitants attending to ED patients but not primary care doctors. As this problem worsens, Dr. Scaletta and ABEM will be content with their success in keeping control and monopoly over the practice of emergency medicine. As more hospitals require board certification to work in the ED, where will they come from? I guess we should be thankful for BCEM; at least it is providing one solution to the problem.

    Ken Cartaxo, MD

    Kinnelon, NJ

    © 2010 Lippincott Williams & Wilkins, Inc.
    Article Outline

  19. #19 by Dr. J - July 12th, 2010 at 15:14

    Spec.EM: I agree that this is an argument to be discussed in a rational way and eventually decided on the basis of the arguments and evidence. I am outside the argument as I live in Canada where there are at least 4 recognized tracks to the practice of emergency medicine, but watching with interest as there is recent resumption of interest in developing a singular approach in my country.
    In my previous post I complained that you had made a fallacious argument, and unfortunately in your response you have made another one (because violence is often proceeded by threats, violence will follow threats which is a form of post ergo hoc propter hoc, or in medical terms a correlation vs. causation argument). Again it is in response to a side issue of using a pseudonym, which everyone uses on the internet anyways and needs no real defense. Calling you ‘a coward’ is an ad hominem attack and should be dismissed in kind.
    I mention this because these logic problems make it difficult to read and follow the debate because these fallacies are often intermingled in posts which actually contain rational arguments for either side…

  20. #20 by a specialist in emergency medicine - July 13th, 2010 at 00:03

    Dr. J-

    All good points, except that you have set up a straw man. I never claimed that violence inevitably follows verbal abuse. I just said I preferred not to post my name in order to avoid even the possibility of violence, no matter how remote. I agree completely with your most important point: if we stuck to the issues and avoided personal attacks, these distractions would not arise.

  21. #21 by An Emergentologist - July 13th, 2010 at 13:03

    Emergency Medicine News:
    July 2010 – Volume 32 – Issue 7 – p 8, 18
    doi: 10.1097/01.EEM.0000383979.54742.9e
    Letters
    Focus on Patient Care, Not Turf Wars
    Gerard, W Anthony MD; Bullock, Kim MD; Staufffer, Arlen MD
    Free Access
    Collapse Box
    Author Information

    Members, AAFP Special Interest Group-Emergency Medicine Perry Pugno, MD Director, Medical Education, AAFP

    Editor:

    The article in the May issue “EM Fellowships for FPs: Bane or Boon?” was excellent. (2010;32[5]:1.) Thanks to Ruth SoRelle for her excellent reporting.

    It is certainly true that this is a volatile issue in emergency medicine, but this does not have to continue to be the case. There are some important issues to clarify about AAFP’s position on family physicians in emergency medicine. Unfortunately, Dr. Tom Scaletta’s biased opinions are prototypical for the kind of protectionism and internal focus that is common for some emergency medicine leaders. This may be part of the reason that emergency medicine has not developed the kind of cooperative approach to workforce issues that was recommended in the Institute of Medicine report. (“Hospital Based Emergency Care: At the Breaking Point?” June 13, 2006; http://bit.ly/IOMbreakingPoint.) But has emergency medicine matured enough to move beyond the turf wars that are part of its adolescence? (“Board Certification: Competency vs. Competition,” EMN 1993;15[6]:1; “Daniel vs. ABEM: The Debate Rages On,” EMN 1994;16[6]:1.)

    AAFP’s support for EM fellowships is neither new nor is it part of a plan to subvert the ABMS process for training emergency physicians. The combined ABEM-ABFM programs were initiated by an AAFP taskforce, and created through a collaborative approach with ACEP and ABEM. The AAFP web site lists EM fellowships to help meet workforce needs that residency trained EPs have failed to meet. (Ann Emerg Med 2001;38[3]:323.) The EM fellowship programs are supported by private institutions, and are designed to provide additional emergency medicine training for family physicians, many of whom practice in rural areas where there are few, if any, EM-residency trained EPs. AAFP’s support for fellowships in EM is just one aspect of a longstanding position that supports the role of family physicians in providing emergency care. (Texas J Rural Health 2000;18[2]:34, and “Equipping Family Physicians for the 21st Century” [AAFP Position Paper]; http://bit.ly/AAFPequip.)

    The concept of fellowships for emergency medicine and family practice is well established but often controversial under ABMS guidelines. If EM fellowships for family physicians are controversial, it is not because of quality issues. Many fellowships also exist for emergency physicians that do not lead to ABMS certification. (“Resident President’s Message: Fellowship Opportunities in Emergency Medicine,” [AAEM]; http://www.medscape.com/viewarticle/586572 [Medscape registration required].)

    AAFP does not have “a plan of its own,” and its support for family physicians who provide emergency care is not a threat to the specialty of emergency medicine. Just as AAFP has defended family physicians who want obstetrical privileges without claiming to be obstetricians, family physicians recognize that residency trained emergency physicians are the true specialists. But the dream of an exclusive, residency trained, emergency medicine boarded workforce needs to be rooted in the realism of the current health care system and its specific challenges. The evidence for a workforce shortage is clear for the unforeseeable future (Ann Emerg Med 2009;54[3]:349), and family physicians will continue to be essential in providing emergency care in many areas. (Am Fam Physician 2006;73[7]:1163.)

    We believe that the focus of AAFP and ACEP should be on improving the care of emergency patients, and should not continue to involve turf wars and protectionism. Emergency medicine leaders need to heed the mandates of the IOM report, and to “adopt the cooperative approaches to scope of practice issues that characterize a mature medical specialty.” (Ann Emerg Med 2007;50[5]:622.)

    W. Anthony Gerard, MD Kim Bullock, MD Arlen Staufffer, MD

    Members, AAFP Special Interest Group-Emergency Medicine Perry Pugno, MD Director, Medical Education, AAFP

    © 2010 Lippincott Williams & Wilkins, Inc.
    Article Outline

  22. #22 by An Emergentologist - July 13th, 2010 at 13:07

    Emergency Medicine News:
    July 2010 – Volume 32 – Issue 7 – p 8, 18
    doi: 10.1097/01.EEM.0000383979.54742.9e
    Letters
    Focus on Patient Care, Not Turf Wars
    Gerard, W Anthony MD; Bullock, Kim MD; Staufffer, Arlen MD
    Free Access
    Collapse Box
    Author Information

    Members, AAFP Special Interest Group-Emergency Medicine Perry Pugno, MD Director, Medical Education, AAFP

    Editor:

    The article in the May issue “EM Fellowships for FPs: Bane or Boon?” was excellent. (2010;32[5]:1.) Thanks to Ruth SoRelle for her excellent reporting.

    It is certainly true that this is a volatile issue in emergency medicine, but this does not have to continue to be the case. There are some important issues to clarify about AAFP’s position on family physicians in emergency medicine. Unfortunately, Dr. Tom Scaletta’s biased opinions are prototypical for the kind of protectionism and internal focus that is common for some emergency medicine leaders. This may be part of the reason that emergency medicine has not developed the kind of cooperative approach to workforce issues that was recommended in the Institute of Medicine report. (“Hospital Based Emergency Care: At the Breaking Point?” June 13, 2006; But has emergency medicine matured enough to move beyond the turf wars that are part of its adolescence? (“Board Certification: Competency vs. Competition,” EMN 1993;15[6]:1; “Daniel vs. ABEM: The Debate Rages On,” EMN 1994;16[6]:1.)

    AAFP’s support for EM fellowships is neither new nor is it part of a plan to subvert the ABMS process for training emergency physicians. The combined ABEM-ABFM programs were initiated by an AAFP taskforce, and created through a collaborative approach with ACEP and ABEM. The AAFP web site lists EM fellowships to help meet workforce needs that residency trained EPs have failed to meet. (Ann Emerg Med 2001;38[3]:323.) The EM fellowship programs are supported by private institutions, and are designed to provide additional emergency medicine training for family physicians, many of whom practice in rural areas where there are few, if any, EM-residency trained EPs. AAFP’s support for fellowships in EM is just one aspect of a longstanding position that supports the role of family physicians in providing emergency care. (Texas J Rural Health 2000;18[2]:34, and “Equipping Family Physicians for the 21st Century” [AAFP Position Paper];

    The concept of fellowships for emergency medicine and family practice is well established but often controversial under ABMS guidelines. If EM fellowships for family physicians are controversial, it is not because of quality issues. Many fellowships also exist for emergency physicians that do not lead to ABMS certification. (“Resident President’s Message: Fellowship Opportunities in Emergency Medicine,” [AAEM];

    AAFP does not have “a plan of its own,” and its support for family physicians who provide emergency care is not a threat to the specialty of emergency medicine. Just as AAFP has defended family physicians who want obstetrical privileges without claiming to be obstetricians, family physicians recognize that residency trained emergency physicians are the true specialists. But the dream of an exclusive, residency trained, emergency medicine boarded workforce needs to be rooted in the realism of the current health care system and its specific challenges. The evidence for a workforce shortage is clear for the unforeseeable future (Ann Emerg Med 2009;54[3]:349), and family physicians will continue to be essential in providing emergency care in many areas. (Am Fam Physician 2006;73[7]:1163.)

    We believe that the focus of AAFP and ACEP should be on improving the care of emergency patients, and should not continue to involve turf wars and protectionism. Emergency medicine leaders need to heed the mandates of the IOM report, and to “adopt the cooperative approaches to scope of practice issues that characterize a mature medical specialty.” (Ann Emerg Med 2007;50[5]:622.)

    W. Anthony Gerard, MD Kim Bullock, MD Arlen Staufffer, MD

    Members, AAFP Special Interest Group-Emergency Medicine Perry Pugno, MD Director, Medical Education, AAFP

    © 2010 Lippincott Williams & Wilkins, Inc.
    Article Outline

  23. #23 by Dr. JB - July 14th, 2010 at 14:05

    So how is it residency trumps practical work experience?

    I would contend that as a veteran EP, I am more than qualified to practice in the ED and earn a board certification based on that experience than a newly certified doctor just three years from his/her residency.

    To say MY certification is “dis-honest” is denying the reality of the real world.

    Emergency Medicine News:
    February 2010 – Volume 32 – Issue 2 – p 5, 24, 25, 26
    doi: 10.1097/01.EEM.0000368072.75863.28
    Viewpoint

    We’re Failing Our Residents: Training ED Docs for the Real World
    Welch, Shari J. MD; Hellstern, Ronald A. MD; Seay, Timothy MD; Lyman, John L. MD; John, David P. MD

    The 154 emergency medicine residencies in this country provide training in very large, even ultra-large, teaching hospitals with a focus on tertiary care. According to data accrued from the SAEM Residency Program catalog, the majority of residents are trained in programs in high-volume teaching hospital EDs that are Level I trauma centers. Often children’s hospital rotations are added to round out the pediatric experience. Less than 20 percent of emergency medicine programs have rotations in medium-volume community hospital EDs (with less than 40,000 visits) without trauma designation, and in these programs the average time spent at the community hospital location is three months.
    Dr. Welch is a fello…
    Image ToolsResidents training in large urban centers typically see more than 200 patients a day. They have access to all subspecialty care, typically available 24 hours a day. Residents have around-the-clock access to angioplasty, interventional radiology, hand surgeons, neurosurgeons, and plastic surgeons. Most practice emergency medicine with cardiologists and neurologists in the building or a short phone call away. Decision-making is shared, and occurs with a relative surplus of information and opinions and in a milieu of shared risk.
    In reality, though, these very large and highly-specialized EDs with Level I trauma comprise less than five percent of U.S. EDs, according to the American College of Surgeons. The average ED is in a community hospital, and sees fewer than 100 patients a day. This community hospital ED will likely not be designated a Level I trauma center, and the practicing physician will have to make decisions on complicated patients without all of the resources and consultants available at a tertiary care medical center. He will have to make these decisions alone. Given that most graduating emergency medicine residents will practice in such a setting, we should ask ourselves is this the best we can do? Does the current training model best prepare the emergency medicine resident for the kind of practice he will enter?
    Though rarely acknowledged, our residency programs train physicians in some of the most inefficient EDs in the land. Relative value units of emergency medicine work per hour in the teaching hospital setting is typically half that seen in private practice. And residents train in a culture where customer service is an unaffordable luxury amid the chaos of the typical academic ED. According to data from the Emergency Department Benchmarking Alliance and Press Ganey, the large urban tertiary care and teaching hospital EDs have the slowest throughput times, the highest left-without-being-seen percentages, low patient satisfaction scores, and high complaint ratios. If emergency medicine residents have never seen emergency medicine practiced in an operationally efficient department with a strong customer service commitment, how will they know how to practice in such an environment? Or more importantly, how will they know how to develop such an environment wherever they practice? The new emergency physician entering practice will immediately find himself confronted with the expectation that he provide highly efficient and patient-satisfying emergency care, though he has had little training in those concepts and skills. Perhaps this is in part why nearly 50 percent of new graduates do not survive their initial practice choice for even five years. Perhaps they simply are not sufficiently prepared to deal successfully with the realities of the community emergency medicine practice.
    It is also worth noting that our residencies train physicians in elements and strategies of care that probably are going to be less relevant to their future practices than they anticipate. Though emergency medicine residents will train in facilities with an emphasis on trauma care, for example, few will actually practice in departments where those skills are commonplace. Their training has them fixated on many procedures and technologies that will be largely irrelevant when they enter practice. (When was the last time you put in a chest tube? Be honest!)
    This fixation is at the cost of other important skills in difficult medical diagnoses. Though rigorously trained in trauma, the newly practicing physician likely will have many more cases of atypical chest pain and “weak and dizzy” than trauma resuscitations. While bedside ultrasound is uniformly taught to emergency medicine residents, according to a 2006 Yale University survey only 19 percent of non-teaching community hospitals have ED bedside ultrasound available 24 hours a day. Despite the emphasis on this training regarding technology, storing images, and documentation requirements, only 16 percent are billing for this service. This is yet another example of the mismatch between training and practice reality.
    Residents at tertiary care centers admit more than 25 percent of the patients they see, and have the luxury of observing patients for longer periods of time in dedicated areas, not to mention that waits and delays of greater magnitude are tolerated in these tertiary care settings. Meanwhile, according to Centers for Disease Control and Prevention data, the typical community ED will admit only 12.8 percent of the patients who present for evaluation. It is likely this community ED will not have an observation area or a clinical decision area. Decisions on patients with complicated and difficult medical symptoms will bedevil the new physician who discovers that waiting patients are dissatisfied patients. He finds himself on the clock, and that clock has fewer minutes than he was allowed in training.
    Teaching hospitals provide a disproportionate amount of underfunded and charity care by volume. These safety net patients have nowhere else to go and so will tolerate greater waits and delays without leaving. On the other hand, community hospital patients are more likely to be adequately insured, and have higher service quality expectations. When they leave an ED without being seen (the ultimate patient complaint), they are taking their funding with them. When they leave with their expectations unmet, they will share this negative experience with others in the community. The resident who was oblivious to these issues in training will now find himself meeting his medical director for breakfast the morning after a well-heeled patient or board member complains about his service to hospital administration. The new physician has to cope with an abrupt and steep learning curve, with many unexpected realities such as:
    ▪ The patients are not as sick as the ones they treated in training hospitals, and the admission rate is much lower.
    ▪ There are fewer procedures and more psychosocial dilemmas.
    ▪ There are complex cases, but consultations are not nearly as available as they were in training.
    ▪ Time constraints color every activity.
    ▪ Patient expectations are much greater.
    ▪ Physicians are expected to generate that high starting salary they were given and then some.

    Another gap between residency training and the real world involves leadership and management training. Though most residents will leave their programs with certification in ATLS (many at the instructor level) and in ultrasound skills, very few will have leadership or management training. But consider the stark reality that every ED will need a medical director and one or more assistant directors. This reality is quantifiable, and far outstrips the need for ATLS instructors and ultrasound practitioners. Keeping the group’s ED contract depends much more on leadership and management skills than on clinical skills. Emergency medicine interacts with virtually all of the specialties in the hospital practice environment as well as government agencies like the Joint Commission, CMS, state and local governments, and the community and public health systems. As hospital-based providers, emergency physicians must know how to relate with and gain the support of the administrative side of health care. Yet we continue to graduate physicians with no proper training in health care management and few of the leadership skills necessary for working in a health system that is increasingly organized around team care and team management.
    Many larger physician groups have begun providing extra training to their physicians to help fill these gaps in training. At EMP, for example, the Patient Satisfaction Academy was developed to train physicians in service quality, and it has been highly successful. EMP also developed a Scholars program to build leadership skills. The Schumacher Group, Emergency Service Partners, EPMG, and Premier also offer in-house training of physicians in areas that residency training seems to neglect. CEP America has an administrative fellowship, a Leadership Academy, and utilizes the Studer Group approach to improve nonclinical skills for physicians. With increasing contractual demands from hospitals for measurable emergency department patient satisfaction, smaller groups may outsource this training to entities like the Institute for Healthcare Communication. Other groups send their directors for emergency medicine leadership and management training to ACEP’s Emergency Department Directors Academy for formal certification as an ED medical director.
    If we were in charge, what changes would we make to train emergency physicians for the real world? First, a much stronger commitment to getting community hospital experience for the residents would go a long way in remedying the mismatches. We believe that residents should complete as much as a third of their training in a setting more analogous to their future practice environments. This time in the real community hospital trenches allows residents to get a glimpse of the differences in the realities of practice between a community hospital and the tertiary care center. Secondly, the educational role of clinical affiliate faculty members from the community should be expanded to provide resident exposure to typical community hospital administrative issues such as leadership, negotiation and conflict management, patient satisfaction, documentation and billing, and risk and operations management. Third, the academic emergency medicine anti-business bias should be replaced with the realization that no emergency medicine practice can survive or prosper without sound business leadership and management skills. These abilities are not typically necessary in the world of academic emergency medicine, but they are imperative in the rest of the practice world.
    Recognizing deficiencies in training in areas such as practice leadership, service quality and operations, and practice management is the first step toward fixing them. An excellent next step might be for residency program directors and faculty to survey the recent graduates of their programs to find the answers to questions like: What is the one aspect of your new position you feel least prepared to deal with? What didn’t we teach you that we should have?
    Today’s emergency medicine resident graduates his program with an impeccable knowledge base and a set of world-class technical skills. He won’t misstep as a practitioner for lack of factual knowledge or mastery of procedural skills. Yet he is still likely to flounder in the community ED for lack of other proficiencies. Town and gown could fix this easily by working more closely together.

  24. #24 by Greg Owens M.D. - July 16th, 2010 at 08:16

    Greg Henry MD, ACEP Past President , once said that 50% of what we learn in Residency is WRONG and it is up to us to figure out which 50%.

  25. #25 by An Emergentologist - July 16th, 2010 at 08:47

    Emergency Medicine News:

    Wednesday, July 07, 2010
    ‘We’re in the ED, Like It or Not’ by Jerry Allison, MD

    Editor:
    I appreciate the continued attention that EMN is giving to this topic. (“EM Fellowships: Bane or Boon?” EMN 2010;32[5]:1; see link below.) I don’t know what it is going to take to convince the skeptics that there may be alternative pathways to practicing competent emergency medicine other than a residency in emergency medicine. The first step is to overcome the ignorance and hypocrisy characterized by Dr. Tom Scaletta.

    If the stats cited in this article are accurate, ABEM-certified emergency physicians account for only 60 percent of practicing EPs. Of those, what percentage is primary care residency trained, and what percentage is grandfathered? There are numerous emergency physicians who were not emergency medicine residency trained.

    General practice and family medicine are not the same; it is the American Academy of Family Physicians and the American Board of Family Medicine. We are a specialty of residency trained family physicians that practices family medicine. Semantics or perception, you decide, but our academic training is broader than any specialty, and it is closest to emergency medicine. While not all family physicians should or want to practice emergency medicine, there are numerous examples of outstanding family physicians practicing hospital, intensive care, and emergency medicine. As good educators know, there are numerous factors that affect one’s ability to acquire knowledge and skill.

    Dr. Scaletta contends that we are not allowed to change our mind about the type of practice we choose. That’s a pretty bold statement. I know many outstanding BCEM doctors who started as surgeons, internists, and family physicians. Dr. Scaletta does not think primary care physicians with four years of medical school and three years of residency (and five years of emergency medicine practice and written AAPS board exams) are any more competent to practice emergency medicine than NPs and PAs (and we do appreciate them). That speaks to his credibility.

    While I am disappointed with AAFP for giving in to a five-year combined emergency medicine-family medicine program (four years is totally adequate), I commend those physicians who chose an emergency medicine fellowship to improve their competency.

    Finally, where is the evidence? In this era of evidence-based medicine, this reeks of eminence. While I agree that residency in emergency medicine is ideal, who can say it is the only pathway when 60 percent of emergency physicians have made the journey, almost half of EDs are staffed with BCEM physicians, we cannot keep up with the demand, and the knowledge and skill set is able to be acquired by other means?

    Let’s work together to find solutions that are in the best interest of all involved, especially the patient. Tomorrow, we are all back in the ED whether you like it or not.

    Jerry Allison, MD
    Sacramento, CA

  26. #26 by Greg Owens M.D. - July 16th, 2010 at 09:55

    ” in Canada where there are at least 4 recognized tracks to the practice of emergency medicine”

    Could it be that in Canada they are more concerned with the public welfare and EM workforce issues than in protecting Guilds and turf?

    Shame on you ACEP and ABMS.

  27. #27 by Dr. JB - July 16th, 2010 at 13:14

    Strange that most medical boards will recognize a Canadian Dr, regardless of path and do their best to stop BCEM/ABPS…..

  28. #28 by Jane - July 19th, 2010 at 15:30

    I’m just a tech in an ED…but I deal with everybody. I’ve seen Drs with many letters after their names who were narcissistic knuckleheads and PAs who were amazing.

    Buddha says Attachment leads to suffering.
    Stop suffering and do no harm. Be in the moment. Work. Go home. Enjoy the fruits of your labor, your life and strive to always be better. Your professionalism, demeanor and compassion are what everyone around you notices, remembers and blesses you for. If those things don’t matter to you, maybe you are in the wrong profession.

(will not be published)

  1. No trackbacks yet.