When a Colorado hospital last February asked the state to waive a requirement that emergency physicians be board certified in emergency medicine to practice in its trauma center, it's doubtful it expected the maelstrom that would result. The request, the first of its kind in the state, sparked controversy locally, statewide, and even nationally over what both sides call a matter of fairness.
The waiver was granted in November in the upper echelons of the Colorado Department of Public Health and Environment, even though the advisory State Emergency Medical and Trauma Services Advisory Council voted to turn it down. Although the one-year waiver allows two physicians to provide trauma care in St. Mary-Corwin Medical Center, a Level II trauma center, it also requires them to be monitored by another doctor during that period.
The story is complicated. When St. Mary-Corwin in Pueblo sought a Level II trauma designation in late 2004, the decision placed it in direct competition with Parkview Medical Center, which had been the city's only Level II trauma center since 2001. St. Mary-Corwin passed the American College of Surgeons review of its credentials, but soon after it received a green light for certification, a complaint was filed stating that two emergency physicians at the hospital lacked emergency medicine board certification. Responding to the state's inquiry in February, the hospital restricted the two doctors from providing trauma care and applied for a waiver for the two: Michael G. Silver, MD, who is board certified in internal medicine, and Kevin J. Weber, MD, who is board certified in family practice.
Southern Colorado Emergency Physicians Associates, the emergency medicine group that staffs the Parkview Medical Center emergency department, opposed the waiver, and among those writing letters in support of the waiver was Robert E. Suter, DO, MHA, then the president of the American College of Emergency Physicians.
That letter sparked outrage among the doctors of Southern Colorado Emergency Physicians Associates. “We were all pretty much astounded by Suter's letter,” said Chad A. Davis, MD. “It sounds like, ‘These people are ACEP members,’ and that's what ACEP is concerned about.”
His colleague, Thomas Greidanus, MD, said his group opposed the waiver because of concerns about setting a precedent. “There should be no exceptions to the state guidelines,” he said.
Rules are Rules
When Parkview sought its Level II status, Dr. Greidanus said, some of his group's physicians were not boarded in emergency medicine. The group and hospital chose to move those physicians to the hospital's fast track, which meant they met the rules.
“Our organization has done more for these things than any other in emergency medicine over the years.”
Dr. Greidanus attended the state committee meeting where the matter was discussed, noting that the council voted not to exempt these physicians from the policy.
He said, however, that the council is only advisory, and the department's executive director decided to grant the limited waiver. “There should not be exemptions to the state guidelines,” he said.
Dr. Weber, one of the physicians exempted by the waiver, said only representatives of Parkview testified against the waiver request. “When they testified against us at the state, it was for fairness issues,” he said. “They said they had to follow the rules, and we should as well.”
He said no one questioned his or Dr. Silver's competence, but because Parkview had to follow the rules, the physicians said they thought St. Mary-Corwin should as well. “It was a competition issue,” he said.
Dr. Weber said the department of health's executive director said waivers were meant to take special situations into account, allowing that there are exceptions to every rule. He and Dr. Silver, he said, were caught in the window of time that made it difficult for them to obtain board certification in emergency medicine.
They started practice shortly after 1985, and were not eligible to take the board examinations in emergency medicine. Few residency slots existed in emergency medicine at that time either, Dr. Weber said. Eliminating physicians like them from the practice of emergency medicine would mean losing a generation, said Dr. Silver.
“It was a competition issue.”
“Mike and I agree that today all emergency physicians beginning to practice should be residency trained and board certified,” Dr. Weber said. “But we also agree with ACEP's position that physicians who were in practice before the year 2000 and who are not residency trained and board certified should be able to finish their careers with dignity and respect.”
ACEP Helping Members
Drs. Weber and Silver said they had no problem with their trauma care being monitored for a year. “It rankled when I couldn't practice trauma care while applying for the waiver,” he said. “I'm happy as a clam. We give good care.”
Dr. Silver agreed, saying it doesn't bother him to have someone looking over his shoulder. “I think we should review everyone's care,” he said.
Both physicians expressed appreciation for ACEP's support of their request. Frederick C. Blum, MD, ACEP's current president, said the college's position was simple. “Two members asked us for help. We provided that help within our policy parameters. That's what we did. We are in support of board certification in general. Our actions in this have been portrayed by some as meaning we are not supportive of board certification and residency training. Nothing could be further from the truth,” he said.
“Our organization has done more for these things than any other in emergency medicine over the years. But we also understand that we currently have a workforce that is mixed with regard to training and will be that way for the near term until we can train enough people to meet the demands of the workplace. We certainly are not there yet.”
“I think we should review everyone's care.”
In his letter to the state, Dr. Suter said it was laudable that Colorado would like to have only board certified emergency physicians treating patients in trauma centers. “This is a commendable long-term goal, but presently some hospitals that would make excellent trauma centers are staffed in part by highly qualified, experienced emergency physicians who are not board certified but have been excellent members of their staff for many years,” he wrote. “ACEP recognizes that many excellent physicians who began practice in the 20th century are not board certified, and strongly believes that these physicians retain their ability to practice in their current practice settings. While we believe that all physicians entering practice in the 21st century should be residency trained in emergency medicine, this standard should not be applied to physicians who entered practice prior to 2000. We would ask that the state of Colorado take a similar approach in the application of its credentials requirements. … It is in consideration of both fairness and the public interest that we ask you to allow Dr. Weber and Dr. Silver to continue the unrestricted practice of emergency medicine that over the years has served their patients and their hospital so well.”
“There should be no exceptions to the state guidelines.”
But Southern Colorado Emergency Physicians Associates' Dr. Davis is not convinced. “ACEP says it values and upholds the principle of board certification, but this letter contradicts that,” he said.
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