This month’s issue of EP Monthly reveals the results of an interesting survey about the opinions of emergency physicians regarding ACLS and BLS cards, which are so often required for hospital credentialing. From a total of 769 respondents, 80% of whom were board certified in emergency medicine and 75% certified in ACLS, the majority felt the educational value of ACLS was low. Most felt if offered little or no improvement in patient care.
Why do we object?
After years of residency training and days of grueling written and oral boards, many EPs find ACLS and BLS to be kindergarten-level courses. The classes address an aspect of clinical practice that we handle on an almost daily basis. When somebody from The Joint Commission asks for your updated ACLS card, but ignores your board certification, it is at very least out of order in importance and frankly insulting to the effort required to obtain the latter. Certainly, ABEM and AAEM agree on this and both organizations have position statements indicating that ACLS or ATLS certification should not be required of board certified Emergency Physicians.
The philosophical objection to these certifications stems from the idea that any collection of weekend courses – ACLS, ATLS, ABLS, ALSO, NALS, PALS, or APLS – could actually prepare the student as well as years of residency training. No one objects to those attending these courses; they are simply attempting to further their education. The objection is that they represent a piecemeal approach to a global training objective. ACLS might prepare a generalist for a 50-year- old man with a STEMI and V-Tach. And ATLS might prepare the same generalist for a 28-year-old in a roll-over MVC with a pelvic fracture and a left hemo-pneumothorax. What’s more, all the various courses could be taken in about three weeks. But would that be equivalent to the lessons learned by several years of supervised training and education? If so, why bother with EM residency training at all?
Some feel that an emphasis on these courses is a threat to the job security of residency-trained EPs. With a manpower shortage in EM, which isn’t going away anytime soon, employers attempt to use the “merit badges” as a mini-fellowship route into the specialty for non-emergency physicians. And since the employer can rationalize paying non-EM boarded physicians less, there is profit motive to encourage this route. Board certified EPs fear that if weekend courses are used to “qualify” non-emergency medicine trained physicians, then demand for residency training will go down.
A further objection to “the cards” is who is involved in generating the content. Having left the conjoint aspect of ABEM certification behind, EPs are loathe to return to the day where non-emergency medicine physicians (and nurses) are having a say in how we must practice. At least EPs are now involved in determining the content of ACLS. But other cards, such as ATLS, have little or no input from emergency medicine. Designation as a trauma center requires providers have up-to-date ATLS training and certification that is exclusively the purview of the American College of Surgeons-Committee on Trauma. One could confidently say that no other specialty would allow ACEP to set mandatory training standards for a diagnosis that fell within their training and practice
How did we get here?
Emergency medicine is a young specialty with a history of conjoint supervision. As we have developed, both surgeons and internists have felt the authority to monitor our activities. But there are also outside forces, most of which boil down to money. The American Heart Association made approximately $20 million in program fees in 2009 and $46.5 million in sales of educational materials, much of it from EPs
The real problem is value
After the insult of outsiders running, requiring and profiting from these programs, we still must confront the deepest issue in these courses: efficacy. Unfortunately, many of the recommendations and guidelines contained in the courses appear to have little support in the literature. None of the ACLS cardiac arrest drug recommendations have compelling evidence that they do anything to promote neurologically intact survivorship. Moreover, several of the recommendations seemingly gained prominence due to input from the pharmaceutical industry. Amiodarone became the antiarrythmic of choice nearly overnight and the evidence to support its use is weak at best. The huge stroke chapter seems to cater to emergent tPA-based treatment of acute stroke despite the fact that scientific controversy continues regarding this issue. Lawsuits have been mounted against EPs both for giving tPA and for failing to give tPA. In 2009, the AHA accepted over $17 million from pharmaceutical companies and device manufacturers. This does little to reassure EPs that the standards are purely evidence based.
ACLS-EP: A compromise?
Recently the AHA introduced a new course for “experienced providers.” While it is intended for “seasoned ACLS providers who wish to renew their provider status,” it is still 9 to 10 hours long, according to the AHA web site. This kind of thing makes many of us feel that the AHA still doesn’t get it. It’s insulting. It works against the stability and stature of our specialty. Yet, we still sit through the classes. Many of us, including the authors of this article, even serve as instructors.
In the end, we put up with the cards because we don’t want to rock the boat just as we are climbing aboard. Most EPs have done the math and realize that when you are being credentialed for a new job, you don’t really want to cause problems at the medical staff office. So instead, you present an up-to-date AHA ACLS card and move on.
Dr. Shoenberger is the associate program director of the LAC+USC residency and holds an appointment as associate professor of clinical emergency medicine at the Keck School of Medicine.