If at least 40 percent of physicians who staff emergency departments in the United States did not complete an emergency medicine residency and are not certified by the American Board of Emergency Medicine or the American Board of Osteopathic Emergency Medicine, should they receive at least some training for their task?
Many in emergency medicine say no, that the only path is through an emergency medicine residency. But does that leave the public to be treated by physicians who are less well trained? And if the specialty allows anything other than an emergency medicine residency, does that devalue the specialty?
By now, everyone knows about last year's study that found the supply of emergency physicians wasn't meeting the demand. Not only did the researchers determine that there were only enough EPs to meet 55 percent of the workforce need, they said it was unlikely that demand would be met in the next 20 years. And worse, the study theorized, supply may never meet demand. (Acad Emerg Med 2009;16:1014, reported in EMN 2009;31:1; http://bit.ly/EPsupply.)
No more volatile issue exists in emergency medicine, and despite decades of infighting, emergency physicians are no closer to an answer. The American Academy of Family Practice, meanwhile, has forged ahead with a plan of its own, listing five one-year emergency medicine fellowships open to family practitioners on its web site. The programs are funded by private groups and institutions, and are designed to provide emergency medicine training for primary care doctors who want to work in emergency departments.
Tom Scaletta, MD, a past president's council representative for the American Academy of the Emergency Medicine, is adamant that such fellowship programs are bad medicine. “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?”
Dr. Scaletta also discounted the findings of the Academic Emergency Medicine study, saying that the increased number of urgent care centers has consolidated emergency care in EDs and nonurgent care in clinics, reducing the need for emergency physicians. “There's a general notion that there are not enough [board certified, residency trained] emergency physicians. However, we are increasing the number of midlevel practitioners and scribes,” he said, noting that those practitioners increase the productivity of a single emergency physician in the emergency department. “I am supportive of nurse practitioners independently staffing rural emergency departments. That's fine with me. That's not what this is all about. Nurses are moving things forward. I'm a big fan of that. We don't need as many emergency physicians. It's one person's guess that we will be short of them.”
On the other side is Ronald A. Hellstern, MD, an independent practice management consultant who stopped practicing emergency medicine in 2000. “I think the reason all these alternative boards have focused on emergency medicine as a growth opportunity is that emergency medicine has failed to take a big-tent approach. Forty percent of emergency physicians practicing in emergency departments won't be ABEM-boarded,” he said. “Hospitals and the public need some degree of assurance that these physicians have some level of emergency medicine competence.” And he added that they need more emergency medicine training than is provided in a family practice or internal medicine residency.
He disagreed that this devalues the specialty. “ABEM certification will continue to be the gold standard,” he said.
The stance that only those certified by ABEM or ABOEM could be members of professional organizations such as the American Academy of Emergency Medicine and the American College of Emergency Physicians “ignores the needs of non-ABEM physicians by denying them specialty society membership,” Dr. Hellstern said. “In medicine, one best promotes one's own interest by promoting the best interest of the patient. Denying 40 percent of physicians practicing emergency medicine a professional home does not do that. Are we a trade association dedicated exclusively to board certified emergency physicians or a true specialty society dedicated to our patients? I'd rather be a member of a professional society than a trade association.”
Dr. Hellstern proposed that one of the specialty societies create a new kind of membership, and that the societies look at the one-year emergency medicine fellowships as a alternate means to ensure that physicians can practice emergency medicine competently, more than someone who only completed a primary care residency but less than ABEM or ABOEM certification. “I don't see how that diminishes ABEM certification at all.”
Currently, many physicians practicing emergency medicine are excluded from ACEP membership, he said. “With supply not projected to meet demand in the foreseeable future, just standing on the sidelines, and throwing rocks is not the answer,” said Dr. Hellstern. “The right answer is to get involved. Establishing another level of membership would help because it would provide non-board certified physicians practicing emergency medicine with the information flow that would be of value to them.”
He said the current competing status of ACEP and AAEM as professional societies does not help the specialty. “They use the argument that competition is good,” he said, but noted that nonprofit advocacy groups need strength in numbers. “What would it take to give up the fight, and let us combine energies?”
Perry Pugno, MD, MPH, the director of medical education for the American Academy of Family Physicians, said his group supports board certification through the American Board of Family Medicine, which is affiliated with the American Board of Medical Specialties. “We don't endorse the American Board of Physician Specialties certification program, but with the caveat that in some jurisdictions, people cannot get privileges without a piece of paper that says certification.”
The emergency medicine fellowships for primary care specialists are listed in the AAFP fellowship directory. (www.aafp.org/fellowships/other.html.) Dr. Pugno said private groups and institutions can offer fellowships not accredited by the Accreditation Council for Graduate Medical Education if they wish, noting that many fellowships are not ACGME-accredited. “What the graduates of the fellowship get is a piece of paper from the institution saying they have a year of additional training. The AAFP does not endorse them. The academy is not a certifying body,” he said.
“In the majority of situations, family practitioners are more than adequately qualified to work in emergency departments. It could be argued that family doctors are better prepared to staff emergency departments in rural and remote communities. Our position is that especially for rural and remote communities, family doctors are the work force, and we support that community. We've been trying to collaborate with our emergency medicine colleagues for years.”
Dr. Pugno said there has been progress on that front with at least one dual-accredited program for family practice and emergency medicine at Christiana Care in Wilmington, DE. “There may be another in the pipeline,” he said.
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