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First, The News: 
ACEP members will now, under some circumstances, be able to put FACEP behind their name, even if they haven’t passed the certifying exams administered by ABEM or AOBEM. That was the decision reached by the Certification Section of the American College of Emergency Physicians and ratified by the ACEP Council at the October Scientific Assembly in Seattle. The criteria for fellowship status are more stringent for LEPs (non-ABEM/AOBEM certified or so-called ‘legacy emergency physicians’) than for ABEM certified members, explained John Newcomb, MD, co-chair of the Certification Section. “Specifically, it requires ten years of active involvement in EM as the physicians chief activity (rather than three), exclusive of training and it requires either active involvement in state ACEP or National ACEP plus two additional activities.  ABEM certified members can meet any three of ten approved activities (not necessarily related to support of the College).”
 
Next page: 
Opposing forces Sonny Saggar (USAEM) and Tom Scaletta (AAEM) square off on board certification and the significance of ACEP’s recent move towards open fellowship.
{mospagebreak} 
F.A.C.E.P.: What does it mean?
Opposing forces Sonny Saggar, MD, (USAEM) and Tom Scaletta, MD, (AAEM) square off on board certification and the significance of ACEP’s recent move towards open fellowship.
 
Free at last, free at last!
by Sonny Saggar, MD
President of the United States Alliance of Emergency Medicine (USAEM)
 
The passage of Resolution 11(07) by the American College of Emergency Physicians, on October 7th 2007, was as important to the specialty as granting universal suffrage was to women, and as abolishing slavery was to African-Americans. It is by no means the end of prejudice, as many have commented, but it is a start.
 
The prejudice has been going on arbitrarily against those physicians who had been unceremoniously excluded from the practice track for taking the ABEM, when many of their colleagues, who were perhaps only weeks or months less experienced but were somehow deemed ‘unqualified’ to be eligible to sit for their boards with ABEM. With no door open to ABEM, they either took no EM boards, or they took the equivalent board BCEM, as administered by another board certifying authority. Why do some folk not recognize BCEM, when BCEM diplomats and practice-track ABEM diplomats have exactly the same training and experience? They refuse to answer. The answer is self-preservation, a closed-shop mentality, and their infamous attempts to arbitrarily reduce the true number of emergency physicians, and thus increase their salaries by suddenly becoming a commodity in short-supply.

Just like a true feminist has nothing against men, or like a civil rights activist has nothing against Caucasians, those of us who have been campaigning for equality amongst those who have the same competency levels in our specialty, have nothing against those who are residency trained in emergency medicine. Many of these fine physicians, who did emergency medicine residency training, feel like we do, that the litmus test is in the ability, not in the curriculum vitae. As long as the physician has a medical license; as long as the physician knows how to manage an airway, a tPA requiring CVA, a STEMI, a child with meningitis, all the orthopedic emergencies, and so on, then it should not matter whether he completed his formative residency training in family practice, internal medicine or emergency medicine. The ability I am talking about is REAL and developed without the sheltered environment of a residency program attending looking over you; it is not practiced in a simulator as some would try to mislead you. It is developed in the real world.

Most authors of the textbooks, used as companion ‘bibles’ in emergency medicine residencies were written by physicians who completed training in family practice or internal medicine. Surely if there is an 800 pound gorilla in the room, there it is.

Let us sit down and reason together, with a good dose of civility and patience, the following questions:  How do we propose to staff every ED in one state, much less the entire country, with all emergency medicine residency trained (EM-RT) physicians? What method should we use to gauge or insure competency if you cannot staff every ED with EM-RT physicians? When do we expect to be able to staff every ED with all EM-RT physicians?What data are we using for our responses to the above?
 
I am aware that a certain organization, competing at any cost for members, and which was appropriately snubbed by ACEP when a merger was proposed earlier this year, will try to exploit the good judgment of ACEP (which has 6 times the membership population) by declaring that such an announcement of equality (the passing of Resolution 11) is unfair to the EMRT physician. It is not. This is like declaring that a confederate state/academy will not ratify the abolition of slavery, and so all the slave masters are welcome to do business there, and the slaves be damned, “because they’re just not proper citizens anyway”.
 
Dr. John Rupke, one of the founders of ACEP, spoke during the deliberations in Seattle, at the ACEP Scientific Assembly. It is important to be aware that ABEM was founded by ACEP, not by AAEM or any other pretender to the House of EM. Dr. Rupke once supported Board Certification in ABEM as a requirement for FACEP. He admitted to making a mistake in Ref. Comm. Hearings and that that mistake was in tying Fellowship in ACEP with ABEM certification.

He stated he made the bar too high for FACEP. At that time all that was required for FACEP was ACEP membership and ABEM certification. He did not have the foresight to see that this would someday pit EP against EP within ACEP. He was not involved in the closure of the ABEM practice track.

Let’s assume for the sake of argument, that the Gold Standard of the future is emergency medicine residency training. There are no good people or bad people in this debate. There are only those living in the present reality (ACEP) and there are other organizations living with some delusions. We must do what is best for our patients first, not what is best for our salaries by arbitrarily making announcements that lead to the erroneous conclusion that there is a shortage of emergency physicians. This is an artificial and deliberate deceit. Finally, an organization should work hard for the betterment of ALL its members and their charges – our patients. Unfortunately some have seen fit to spend the bulk of their members’ dues money on futile legal battles challenging free enterprise and the American way of life. There is no other valid emergency medicine organization for physicians other than the American College of Physicians.

I am proud to be a member of the only professional organization that continues to defend all emergency physician specialists, regardless of their curriculum vitae, who have demonstrated proven ability in the field, not in a sheltered academic fishbowl.
 
We must defend our standards
by Tom Scaletta, MD
President of the American Academy of Emergency Medicine (AAEM)
 
AAEM defends the public expectation that emergency medical care ought to be delivered by a specialist in emergency medicine defined as a physician with ABEM/AOBEM certification (or eligibility). Since the practice track closed two decades ago, becoming board eligible requires completion of an approved emergency medicine residency program. Self-learning emergency medicine is past history. Board certification is a non-negotiable prerequisite for AAEM fellowship. Certainly, it would be a disservice to the public and disrespectful to those who achieved legitimate board certification for AAEM to abandon this position.

Acceptance into an emergency medicine residency is a privilege for those at the top of their medical school class and believed to be psychologically and physically suited to rigors of our profession. Accredited emergency medicine training programs carefully select candidates and then provide
direct training over the course of several years to assure each is ready for independent practice upon graduation. This process is highly effective. If one discovers a passion for practicing emergency medicine after completing another program, the solution is to reapply and retrain.

The AAEM website lists several research articles, covering trauma, cardiology, and airway management, that conclude formal emergency medicine training improves safety. Thus, it is no surprise that emergency medicine liability insurance providers demonstrate a significant risk reduction with ABEM/AOBEM certified physicians.
 
The founders of emergency medicine, those who essentially “created” the specialty, deserve our deep gratitude. They introduced emergency medicine training programs and made plenty available by the time the practice track closed. In fact, our highest honors include the David K. Wagner Award and Peter Rosen Award, who’s namesakes are such leaders. AAEM does not discriminate against those certified via the ABEM/AOBEM practice track even though we will not reconsider this pathway.
 
AAPS advocates promote their alternative board using the argument that there is an undersupply of emergency physicians. They convey concern that low-volume, rural emergency rooms cannot generally attract a full complement of ABEM/AOBEM certified physicians. AAEM recognizes that certain regions may lack emergency medicine specialists as well as other specialists. Certainly a primary care physician willing to cover the emergency department may be a second tier option.
 
Even though the fifteen-year-long Daniels suit, filed on behalf of those adversely affected by ABEM’s decision to close the practice track, was dismissed last year, relentless challenges by the AAPS continue. Though they failed to be recognized in Florida (Senate bill derailed in 2005) and North Carolina (rejected by the Board of Medicine in 2006), this year the AAPS wants to take the New York Department of Health to court because the AAPS alternative board is not acknowledged on a public website.
 
Raising and maintaining the quality bar is a public expectation in professions that have many lives at risk. Imagine the notion that someone who has mastered Microsoft Flight Simulator ought to be interchangeable with an FAA-certified commercial pilot. It’s inconceivable. I am proud to serve a professional organization that continues to defend ABEM/AOBEM certification as today’s standard.
 
 
 
 
 
 

Comments   

# Sorry to see ACEP lowering its standardJim Mensching, DO, FACEP 2007-11-07 03:57
As a member of both organizations (ACEP/AAEM) and a residency-train ed EM physician, I find Sonny Saggar's comments condescending and insulting -and yes, you DO have a major chip on your shoulder when it comes to residency-train ed physicians, Dr. Saggar. The practice track has been closed for 2 decades, and ABEM didn't keep it a secret as to when it would close. The "ability" he describes - "learned" without benefit of EM residency training - sets our profession back to the days when ER physicians were perceived as screw-ups who couldn't find a "real job" in medicine. I am dealing with the last vestiges of that older generation of physicians in all specialties, who are thankfully being replaced by a generation of physicians who appreciate the overall quality and benefit of residency-train ed EM because they've worked with them as part of a team during their training. "Proven ability in the field?" What arrogance! How many patients are put at risk for you to develop your "abilities" presumably without supervision? After all you didn't train "in a sheltered academic fishbowl." I was supervised, not sheltered in my residency and read those "bibles" of EM. By the way, I think those authors are ABEM boarded. This is the 21t century and like it or not, residency training - for ALL specialties - is the standard. Otherwise our specialty is cheapened. Shame on ACEP for participating in the cheapening.
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# The Bottom Line.Andy Walker, MD, FAAEM 2007-11-07 08:35
The bottom line is this: either emergency medicine is a legitimate specialty or not. If it is then it should play by the same rules as all other specialties. This means that after it is established the practice track to board certification ("grandfatherin g in") is closed and the successful completion of residency training IN EMERGENCY MEDICINE is required before one can sit for board exams. If emergency medicine is not a legitimate specialty then the correct action is to abolish it, not to let anybody trained in any specialty practice it and then pretend that it really is a legitimate specialty anyway. Intellectual honesty requires that emergency medicine either abide by the rules or be abolished.
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# Thank you ACEP!Daniel Combs 2007-11-07 08:40
As a new EM graduate, I no longer have to wrestle over whether I should support both ACEP and AAEM. I don't yet know whether I will continue to support ACEP, but I can say for certain that I would not feel guilty about supporting AAEM exclusively.

As for additional comments, Dr. Mensching pretty much knocked it over the center field wall, but I'll add just a few additional thoughts. I was already board certified in both Internal Medicine and Pediatrics when I chose to return to residency in EM. Although I could have chosen to practice emergency medicine with dual boards in IM/Peds, I sensed that there was a unique skill set that would serve me, and more importantly, my patients, by acquiring board certification in EM. I feel that conviction even more strongly now after completing my EM training. I can say with confidence that emergency physicians, internists, and pediatricians all approach patients very differently. There are skills that EP's must have that are not taught in IM or peds training.

Dr. Saggar seems to believe that this is a fairness issue. The first thing that comes to mind is that life's not always fair. However, the one thing that jumped out at me from his editorial is that he seems to endorse the idea that one should be allowed to gain experience without supervision in the real world. Wow. So let me get this straight. Dr. Saggar is the president of USAEM which promotes the IOM concept. The IOM issued one of it's most influential reports which has driven considerable debate within the entire healthcare system over how best to promote patient safety. And yet he endorses the practice (in the truest sense of the word) of emergency medicine without supervision so that he and others can gain experience. I believe that he is saying the residency training doesn't matter as long as you have the skills to do your job. By logical extension, we really wouldn't need to do anything more than an internship if we happen to be particularly gifted at this whole medicine thing. However, he specifically cites EM, FP, and IM as potential routes to practicing emergency medicine which suggests that some training beyond internship is warranted. Does it really matter at all which residency you do? Can a radiologist do our job? How about a pathologist? Apparently as long as they can intubate, they're good to go.

I seriously doubt there is some grand conspiracy by AAEM to restrict board certified EP's for the sake of salary. I personally know FP's and internists working in ED's in Indiana who make salaries that would make the EP's in San Diego weep. There used to be a provision that if you had completed residency training in both pediatrics and emergency medicine, you could sit for the pediatric EM subspecialty board. They closed that track and now you must complete a fellowship in pediatric EM as the exclusive route to certification as a pediatric EM specialist. To whom may I address my grievance? Are those pediatric EP's just trying to restrict the competition to preserve their outrageous salaries?


The future is board certification. Period. Board certification is what the American Board of Medical Specialties says it is. Is anyone aware of any "alternative" boards for Dermatology? The pay is great, the lifestyle is great, and getting into that residency is so darn competitive. Perhaps we could just make up our own board for those of us who have learned dermatology in our free time. Seriously - how difficult could dermatology be? Lotions, steroids, biopsy if you aren't sure what it is. Does anyone think this makes sense? Of course not. Actually, come to think of it, I spend a lot of time each day looking at radiographic studies. Perhaps after a few years I can call myself a radiologist. I cut and paste the following directly from the ACEP website regarding the significance of "FACEP."

The designation highlights your board certification and underscores your commitment to emergency medicine.

Apparently not any longer.

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# BCEM is NOT equivalent to residency trainingMark Reiter 2007-11-07 09:30
Dr. Saggar asks, "Why do some folk not recognize BCEM, when BCEM diplomats and practice-track ABEM diplomats have exactly the same training and experience? They refuse to answer."

I'll answer - BCEM does NOT have "exactly the same training" - my 3 years of supervised emergency medicine residency training is not equivalent to submitting case reports and gaining unsupervised practice experience.

Non-EM residency experience simply doesn’t cut it; there are too many gaps in training. Most FP residents have minimal critical care, surgical, trauma, and procedural experience, surgery residents have limited medical, pediatric, and OB/GYN experience, IM residents have minimal surgical, trauma, pediatric, orthopedic, and OB/GYN experience, and so on. These residents have limited exposure to the breadth of patients seen in the ED, managing patient flow, and many ED procedures such as LPs, vaginal deliveries, procedural sedation, etc.

Many non-residency trained BCEM physicians are outstanding doctors. However, at the end of the day, we should be doing what is in the best interest of our patients. It takes supervised experience to become a good emergency physician. It is not fair to patients when unsupervised physicians “learn on the job.” I’d imagine many BCEM physicians performed their first (or second or third) chest tube, vaginal delivery, difficult airway, etc. without supervision, which has the potential for disastrous outcomes. How do you fix mistakes when you don’t know what you did wrong?

The ABEM practice track has been closed for ~ 20 years and needs to stay closed; it’s hard to believe this is still an issue. It’s ludicrous to believe that my colleagues in surgery, cardiology, OB/GYN, etc. would ever agree that I should be considered for board certification in their specialty by virtue of an EM residency, practice experience, and a test.
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# Who dies while you learn?Gregory Schneider 2007-11-08 09:20
Here is a question for all of us who practice emergency medicine. Where were you when you successfully intubated your first patient? Was it your first attempt? Your second? If you failed, did the patient die or was someone with more experience ready to take over and save that life? I can remember missing my first few attempts at intubation, but fortunately for my patients my failures occurred within the “sheltered environment of a residency program.”

I asked my wife, who completed a residency in internal medicine, how many meconium deliveries she had attended during her training. I don’t need to tell you the answer. She never placed an umbilical line or resuscitated a premature infant, either. She never performed procedural sedation on a child with a complex laceration. Despite taking care of adult patients throughout her training, she never performed a cricothyrotomy, cracked a chest, or even placed a chest tube. She never reduced a dislocated hip, shoulder, or elbow.

For those who have completed residency in specialties other than emergency medicine, had you performed all of these procedures before you worked your first ED shift alone? Did you disclose to the patient that even though you have read about floating a pacer, that you hadn’t ever done one “in the real world”. If you missed a few intubations when you were a novice, learning EM “in the real world”, did you disclose that information to the families of the deceased? Were they understanding and supportive of you developing your skills on them without backup or supervision?

According to Dr. Saggar, anyone who graduates from medical school, reads Tintinalli, and works in an ER can consider himself fully competent. If I open an office and read Harrison’s can I call myself board certified in internal medicine and family practice? After all, it’s just managing hypertension and diabetes, right?

Residency training exists for a reason. The founding fathers of our field felt that the skill set necessary for competency in the ED should be developed during specialized training. That is the rationale for EM residency training today. It is also the reason why the practice track was closed 20 years ago.
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# ER doc in Rural AmericaJeff Bates 2007-11-08 15:08
Thank you Sonny for your honesty while living in the real world. Is is real true that the Average U.S. ER volume is 17,000 visits a year? and a third of the ERs are
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# FACEP for LPs Is Inappropriate Fodder for Debate on BoardsJohn J. Rogers 2007-11-08 18:14
Although I am a member of the ACEP Certification Section and USAEM, my comments now are purely my personal views. Granting Fellowship to current legacy physician members of ACEP is an internal ACEP membership issue. It is not a statement about the prudence of non board certified physicians working as emergency physicians. It only recognizes the contribuions of current ACEP members to the college, their state chapters or to emergency medicine as a whole. Using the inner workings of ACEP on the issue of Fellowship to fuel the debate regarding board certification as a requisite to practice as an emergency physician is inappropriate.
John Rogers MD
Chair Elect ACEP Certification Section
Secretary, USAEM
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# "No Correlation between Doctors Who Failed Standard of Care and Board Certification"docwhisperer 2007-11-08 20:15
For those interested, I refer you to Dr. Meade's excellent letter on www.docwhisperer.wordpress.com
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# Merit Badges of Emergency MedicineLes Lenning, MD, FACEP 2007-11-12 07:37
When I finished residency in emergency medicine, I realized there are many different practice locations with different requirements for employment. In larger volume facilities, ABEM certification is usually required. In more rural settings, it is difficult to attract such candidates yet there is a need for emergency services.

In order to find someone as qualified as possible for rural facilities, the merit badges of ACLS, ATLS, and PALS certifications are often required. Now, FACEP has become another merit badge which in no way certifies that someone is trained or qualified to practice medicine of any kind, but simply that they have met the qualifications of the college.

If FACEP were to mean anything related to qualifying ability or certification, then using the shortage of ABEM certified physicians as an excuse to broaden membership is absurd. Imagine if other specialties like ENT, neurosurgery, surgery and OB/GYN decide to add liason members to recognize the shortage of residency-train ed or board certified specialists in rural areas. Would American College of Obstetricians and Gynecologists offer FACOG status to midwives due to the shortage of physicians in many areas?

There are many physicians assistants who have the same experience and abilty of our new fellows but are discriminated against because of their degree. Maybe someday they too can experience the liberation Dr. Saggar compares to the abolition of slavery and womens sufferage.
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# M.D.George Belkowski 2007-11-12 18:17
I would agree that FACEP designation confers no certain qualifications to perform a particular job in Emergency Medicine. It simply designates a dedication to the specialty. The problem is that many in Emergency Medicine contend that in 10-15 years there will be enough BC/Res. trained physicians to fill the job positions in this country so that another practice track or certification path is unnecessary. I contend that there will always be a deficiency of EM physicians especially in rural areas and that a recognized and required EM board exam is a way to ensure at least a certain level of basic EM knowledge.
This I think would raise the bar of the entire specialty instead of miring it in these other disputes.
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# MD< FAAEM, Chairman Emergency Medicine, St. Elizabeth Medcial CenterDavid Levy 2007-11-13 15:13
I agree with Doctor Sager and would go even further. Not even the Holocaust or slavery was a more flagrant violation of human rights. This ACEP decision is the most important ruling since Brown versus the Board of Education. In fact I think there should be a constitutional amendment or maybe redraft the Decleration of Independence to read:
Life, liberty, pursuit of happiness and Board Certification in Emergency Medicine. Is there a petition could sign?
David Levy
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# Attending PhysicianLisa Moreno-Walton, MD, MS, FACEP 2007-11-17 17:59
As woman and a minority, I strongly object to Dr. Sagger using us to advance his position. Being disenfranchised or a slave as a result of one's gender or race means that one is abused and is not individually empowered to change one's condition. Wanting to be Board Certified in Emergency Medicine without having to do a residency is a personal preference, and refusing to do the requisite residency is a choice. It is an insult that Dr. Saggar should dare to equate the inability of those who will not do an EM residency to obtain EM Board Certification with the horrendous suffering of African Americans who lived under slavery. There simply is no comparison.

If any physician wishes to be Board Certified in Emergency Medicine, s/he can, as a free person, do what I and many of my colleagues have done: Do an EM residency, in mid-life and at mid-career. Once you do the residency, you realize how very important it is to be supervised and to learn how to practice the important and life-saving work of Emergency Medicine in a competent and evidence based fashion. And no, Dr. Saggar, it is not enough to be able to intubate competently. As I tell my residents, you need to know who to intubate, when it is the right time in the clinical course to intubate, why you are intubating rather than using other adjuncts for oxygenation and ventilation support, what you will accomplish during the time that the patient is intubated, and how you will accomplish it.

We say we want to give our patients the best. We must hold ourselves, then, to the highest standards.
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# Program Director of Emergency Medicine and FORMER FACEPBenson Yeh 2007-11-17 19:57
This issue has ramifications that go beyond just ACEP. The fellowship status in a group of specialists (read Emergentologist ) is a benchmark of ABEM board status and additional qualities (i.e. being an administrator within a Department). The crux of the problem lies in the defence of Emergency Medicine as a specialty. Since this revision, ACEP cannot refuse any physician who qualifies for FACEP status. Thus AAPS (BCEM) 'boarded' physicians can now apply for fellow status. ACEP will be torn by having members who are neither ABEM certified nor residency trained in EM. In fact, this move potentially strengthens those who have already challenged in court the notion thatt EM is a specialty. I, for one, do not want my representative body to take this stance. I have already contacted ACEP via their President, President-Elect , etc to remove me from their list of FACEP and ACEP membership altogether.

In my opinion, this move by ACEP has weakened Emergency Medicine as a specialty, and considering all the negative replies by my residents, will resonate for the future.

Signed,
Benson Yeh, M.D.
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# What is best for the patient?Sonny Saggar 2007-11-25 09:26
The emotions at work here are quite telling. As we are all aware, the litmus test when deciding how to manage a patient in the ER is "what would I do if he/she was my spouse/child/pa rent?" and then do exactly the same thing.

A similar test applies here, with a couple of questions: "what will I do when my spouse/child/pa rent goes to the ER with a life-threatenin g emergency and the only doctor available is NOT residency trained in EM?" Are you going to refuse care? We know that residency training is simply one feature of what makes a good physician. There are many, many other aspects and requirements.

I have never knocked residency training in EM, any more than I have criticized the need to be polite to your patients. Yes, it's a VERY GOOD thing to be, but there's more, and it's NOT the only way. It's as simple as that.

The other test is this. Surely what is good for the patients in America, is what our profession should seek to achieve. With 60 million people having no insurance. With W telling everyone to go to the ER. With overcrowding and overboarding, the last thing we need is a turf war that results in an artificial decrease in the number of available COMPETENT emergency physicians.

This is NOT the time to make access to an emergency physician even harder. People are quite literally dying because of this, and if access to an ER doc affected someone close to you, then you would certainly agree with me.

However, since supply and demand controls price, a reduction in the number of doctors will quite simply result in an increase in pay for those who remain. Will it make their lives better in any other way, except financially?

When people are too shy to say they simply want more pay, they hide behind conjured up theories about 'defending our standards' and 'protecting the patients' and other whining comments, which everyone knows to be nothing more than dung.

I believe that all those who are residency TRAINED in FP or IM or Surgery, but who have had years of experience as an emergency physician, and have saved countless lives and continue to be not just vital, but indispensible, to their communities, have EVERY RIGHT to continue to call themselves emergency medicine specialists.

AAEM has continues to challenge what is good for the patients. But if you are EM residency trained and care more for your pay than you do for your patients, then please join AAEM. They will welcome you with open arms.

AAEM has challenged American free enterprise, by suing TeamHealth in a futile effort to pretend to do something useful with its members annual dues.

AAEM proposed a merger with ACEP, but was flatly spurned.

AAEM is known throughout the specialty as a clown outfit, that gives away free memberships to bolster its numbers, and then claims to make policy statements on those members' behalves. AAEM has one-seventh the [PAID] membership of ACEP. One-tenth, if you only include paying members of AAEM in the numerator.

FOR THE RECORD, I DO SUPPORT RESIDENCY TRAINING IN EMERGENCY MEDICINE. I JUST BELIEVE THERE ARE OTHER WAYS TO TRAIN. THAT'S ALL. NOTHING MORE. IF Y'ALL CAN ACCEPT THAT.

Finally, I hold no office or position within ACEP, and my views are strictly my own, and not representative of any organization, I may be a member of, or affiliated with.
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# Trickery and SubversionTom Scaletta 2007-11-25 15:44
The definition of EM specialist must not be diluted. Not every ED in the US has an ABEM/AOBEM physician around-the-cloc k and so second tier options must be discussed and arranged. This is analogous to other specialty that are periodically in short demand due to geographic challenges, unaffordable liability insurance or untenable practice environments.

The AAEM-TH suit concerns the corporate practice of medicine, fee-splitting and protecting physician roghts. Our Unity Proposal sought to join forces on Capital Hill and bring state members together. Our free medical student memberships number a few hundred interested in pursuing an EM residency. And, NONE of these issues have to do with the one being discussed.

Are you using ACEP’s FACEP criteria modification to advance your subversive goal of AAPS/BCEM legitimization? Are you bashing AAEM because of our solid stance against this effort?
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# Don't Confuse the Issuesdocwhisperer 2007-11-25 21:09
There are 3 issues discussed in this thread which have gotten all tangled up:
1. Awarding F.A.C.E.P. to Emergency Medicine physicians who have been deemed worthy by ACEP regardless of EM residency training/ certification status.- This is a decision by ACEP, as Dr. Rogers stated, recognizing service to the organization and should not be mixed up in the following 2 issues.
ACEP is supposed to represent all 38,000 ER physicians in the US, including the 13,000 who are not EM trained or ABEM certified.
2. Establishing Standards for EM- this is the "ABEM/ EM residency training vs. BCEM/ legacy physicians" argument, I do not see why these 2 groups should be in opposition (why are they?). I would think that everyone would want good standard of care be provided in the ER regardless of who is providing it.

3. Workforce Realities- If you read Dr. Meade's article (www.docwhisperer.wordpress.com), there will not be enough ABEM/ EM residency trained physicians for the next decade or so. So, until then, whaddaya do? Do you follow the solutions provided for the nursing shortage and recruit doctors from other countries? (which has its own issues) Do you (again like the nursing situation) expand mid-levels in the ER (which again has issues)? or do you utilize the ER docs who are not EM residency trained but have extensive ER experience and make sure they are up to par?

Please discuss the issues separately and dispassionately . All the vitriol and rhetoric is entertaining and probably satisfying to some, but doesn't provide any real answers.
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# In reply to "Don't confuse the issues".Andy Walker, MD, FAAEM 2007-11-27 21:02
Docwhisperer is right about confusing the issues. Let's seperate them and keep things sipmple
1) If ACEP wants to allow non-board certified doctors
to become fellows of its organization and put
"FACEP" behind their names, that is ACEP's
business, not mine or anybody else's who isn't a
member.
2) On ABEM (a legitimate board recognized by the
American Board of Medical Specialties) vs. BCEM
(not recognized by the ABMS), either emergency
medicine is a legitimate specialty just like
other, older specialties or it is not (see "The
Bottom Line" above). If it is not it should be
abolished. If it is it should follow the same
rules as other specialties, which now means
completion of a residency in emergency medicine
before taking board exams.
3) On the manpower issue and the shortage of board
certified emergency physicians in rural areas:
nobody is advocating a law barring non-boarded
ER docs from working in emergency departments.
They are and will remain free to work in any
hospital willing to employ them. I am saying
that we shouldn't reopen the practice track to
board certification to them just because they
want it. The practice track was open for
years after its planned closure was announced,
just like all other specialties. We should play
by the same rules as all other specialties,
assuming we considers ourselves to be the
practioners of a legitimate medical specialty.
Denying board certification to some of the
doctors who work in emergency depts. does not
create an artificial shortage of emergency
physicians. It just means, as it has for years,
that successful completion of a residency in
emergency medicine is now required to sit for
board exams. You DO NOT have to be board
certified to work in an ED! You DO (and should)
have to be board certified to call yourself
"board certified".
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# FACEP - where is this going?Daniel Combs 2007-12-02 22:32
I'm confused as to what Dr. Saggar wants. He says the emotions on this thread are "quite telling".....of what I'm not sure. He also suggests that this is just a start.....again , of what I'm not sure. I think it is important to understand that the standard of board certification is less an internal matter to emergency physicians, but rather a standard that is driven by those outside the house of medicine. We are being asked to offer more accountability for the services we provide - not just in EM, but in every discipline. However, Dr. Saggar seems to think this new fellowship track is the first step toward something - again, I'm not sure what. Does he want FP's working at level 1 trauma centers? That seems to be the logical extension of his argument. Nobody argues that a small, rural ED is better off closed than being served by a competent FP. Dr. Saggar certainly has strong feelings on this issue even if his expression of these feelings is sometimes contrary to fact. I offer the following taken from his own blog:

"AAEM has long argued (with their "it's not the test, it's the training" wailing) that only a physician who has completed an EM residency can be considered an EM specialist. This explained their support for FCEP's annual [failed] bill to outlaw the designation of EM specialist to all those who are not residency trained in EM.

Those who have grandfathered in ABEM would be wise to abandon their loyalty to AAEM, chiefly because you are nothing more than a source of revenue for them. AAEM has no interest in protecting grandfathered ABEM physicians. If they did, then why are you so limited in your employment opportunities? Why do all the ads in AAEM-backed publications advertise for residency-train ed emergency physicians? This EXCLUDES the Grandfathered ABEM physicians.

Only ACEP, which has taken the position of protecting the Legacy Emergency Physicians, and USAEM, which welcomes all emergency physicians of whatever cloth, will protect you. AAEM has never taken the initiative to protect those emergency physicians who did not do an EM residency. This includes people like Professor Judith Tintinalli, and the past-president of ACEP, Dr. Rick Blum, amongst many other noted people in our specialty.

I know AAEM has long been considered full of "crazies", and this by rather eminent leaders in EM, but I think it's high time we put these so-called "crazies" back into the correct observational wing from whence they came. AAEM's recent president, played war games with American Emergency Medicine, and then went off home to Lebanon, to start a residency program!"
- Dr. Sonny Saggar, www.erdocworking.com, May 19, 2007

Not that we'd want facts to get in the way of this discussion, but I now offer the following taken directly from the AAEM website:

AAEM Calls for Non-Discriminat ion Between Practice Track and Residency Trained EM Physicians
The following position statement was approved by the AAEM Board of Directors on March 9, 2000:

"The American Academy of Emergency Medicine asserts that board certification through ABEM or AOBEM is recognized as the standard that establishes competence in the diagnosis and management of conditions in Emergency Medicine.

"The restriction of employment or access to fellowship training programs for board certified emergency physicians based upon a requirement of prior Emergency Medicine residency training is improper. The Academy asserts that equality of status between residency trained and practice track physicians is established by board certification, and equity of both educational and professional opportunities should follow."
- excerpt from the Position Statements of AAEM at www.aaem.org

Based on my reading of that statement, I suspect that Dr. Tintinalli would pass muster. She's ABEM certified, and as a past president of ABEM, I would assume she believes in the value of ABEM certification.

Yes, it's true that ACEP as an organization may offer Fellowship status to anyone they wish whether some of us believe that to be wise or not. However, my own personal communication with the leaders of ACEP makes it very clear that this fellowship change was intended to honor a very select, limited number of physicians who have demonstrated an extended and appreciated service to the college. The tone of Dr. Saggar's editorial suggests that he sees something else in the move. I simply ask: Where does Dr. Saggar want this to lead?
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