Regarding Dr. Sonny Saggar's article, “The Dermatologist and the Magician,” I would like to pose some questions to the author. First, to quote Dr. Saggar, with a minor change (in brackets): “If a certain [nurse or medic] happens to have the right skills to be a fully functional and competent emergency physician, then what would be so wrong about letting him work in the ED?” Isn't it possible that a rare nurse or medic with lots of reading, observation, CME, and procedure practice in a morgue or vet hospital could acquire good emergency medicine skills? Why draw the line at dermatologists?
Secondly, he claims that there is no evidence that emergency-medicine-trained physicians perform better than non-emergency-medicine-trained physicians. However, AAEM lists several sources of evidence on its web site (www.aaem.org/boardcertification/quality.php). I suppose that he would reject this evidence for one reason or another. But what about the other side of this coin? Is there any evidence that physicians not trained in emergency medicine perform as well as those who were trained in emergency medicine? Is there evidence of equivalence, Dr. Saggar?
If there is no evidence of equivalence, then do we expect everyone just to assume equivalence? Wow, talk about sticking your intellectual neck out! Didn't he say in his editorial that evidence “should be a guiding principle?” And he compared this issue with the drug approval process. New drugs need to be proven to be at least equivalent (or not inferior) to existing drugs, not assumed to be equal because someone says so. Instead of complaining about no evidence or evidence he does not like, Dr. Saggar should do some of the studies he advocates. Assuming equivalent performance is intellectually dishonest.
The bigger point here is that residency training is a proxy for skill in that specialty. It is a useful, albeit imperfect, proxy, but it is the best we have. The average board certified dermatologist is assumed to be more skilled than a family physician who has decided to practice dermatology based on some on-the-job training, CME, and independent reading. When talking about groups of individuals, we can draw an analogous conclusion for emergency medicine.
Many would disagree with Dr. Saggar's assertion that hospitals' desire for residency trained and board certified EPs is just “marketing.” He says, “Let's let market forces rule.” Isn't a hospital's demand for emergency medicine residency trained and board certified EPs an example of market forces working? Or does he feel that hospital administrators and managers are just plain stupid and that their actions are uninformed and not in their institutions' best interest? Come on, Dr. Saggar! Is the market for EPs collectively so uninformed that such an aggregate result in a country of 300 million could come about on such a wide scale? I don't think so. The market will quickly weed out the poor decision-making that he attributes to hospital administrators if it really is inferior. More likely, hospitals know that having better EPs is in their best interest, and that a good proxy for what they want is represented by emergency medicine residency training and board certification in emergency medicine.
Mike Evans, MD
Los Angeles, CA
The authors are the principal investigators in the Olive View-UCLA Department of Emergency Medicine/Division of Infectious Diseases, and have been awarded a five-year, $9 million grant from the National Institutes of Health to study the use of off-patent antibiotics for treating uncomplicated skin and soft tissue infections. The study will be conducted at Olive View-UCLA, Johns Hopkins University, Maricopa Medical Center in Phoenix, Truman Medical Center and the University of Missouri in Kansas City, and Temple University Medical Center in Philadelphia.