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In October, more than 250 emergency physicians gathered at the ACEP Council Meeting in Seattle. More than 30 resolutions were considered, debated and voted on. One dealt with the issue of Fellow status for a small group of physicians, many of whom helped found the specialty of emergency medicine.

Fellow status is a class of ACEP membership that was first established in 1982 to honor members who made a special contribution to the College and the specialty of emergency medicine. For the past 21 years the requirements have included active membership status for three continuous years, board certification by ABEM (AOBEM and ABP certification for pediatric emergency physicians were added later), and additional service to the specialty. In October, the Council created an alternate pathway to allow the specialty to honor the first wave of emergency physicians. The eligibility criteria for members using this pathway are considerably stricter and will apply only to a small number of our colleagues.

ACEP’s policy and position regarding residency training and board certification has not changed. It is the College’s position that, as of the year 2000, the only legitimate way to begin the practice of emergency medicine is through training in an emergency medicine residency program followed by ABEM or AOBEM certification.

There is a small subset of valued ACEP members who have spent untold hours advancing emergency medicine but who will never be eligible to sit for the ABEM exam. These individuals will eventually retire and leave the practice of emergency medicine to the next generation of board certified and residency trained emergency physicians. Their contributions have been very significant to the development of our specialty and they will continue to play an important role in our workforce for at least another decade. The College has been clear in its support of this group which is often referred to as legacy emergency physicians.

Since the changes were made that linked ACEP membership eligibility to residency training and board certification, many have questioned the rational for maintaining the ABEM requirement for Fellow status. They believed that this requirement prevented the College from appropriately honoring the career contributions of a number of legacy emergency physicians, including founders such as Dr. John Weigenstein and Dr. John Rupke.

Over the past two years, a group of concerned members used the democratic process within ACEP to call attention to this issue and offer a solution. Working with individual members, state chapters, sections, and through the ACEP Council, they pressed their message that providing an alternate route to Fellow status for this unique subset of members was the right thing to do.

Through the efforts of this group, consensus was reached between such diverse groups as the Emergency Medicine Residents’ Association, our young physician members, academicians, past ACEP leaders and others. In the end, the Council vote was nearly unanimous in favor of this alternate pathway to Fellow status.  

We look forward to honoring a small group of new Fellows who qualify under this alternate pathway at our 40th anniversary at Scientific Assembly in Chicago. It is the right time and the right place to recognize those physicians who have been so important to the development of our specialty.
 
Linda Lawrence, MD, is the current president of the American College of Emergency Physicians  (ACEP)
 

Comments   

# This is wrong for EMRobert McNamara, MD, FAAEM 2007-12-07 21:45
Elements of this justification statement deserve comment.
Rupke and Weigenstein and every other founder were eligible under the practice track providing they actually pulled ED clinical shifts. The practice track closed in 1988, they and 6 others founded ACEP in 1968. The "first wave" of EM entered EM well before 1983, so all of the founders of our specialty had ample opportunity to become certified and eligible under the old criteria for FACEP.

The following statement is equally problematic: "It is the College’s position that, as of the year 2000, the only legitimate way to begin the practice of emergency medicine is through training in an emergency medicine residency program followed by ABEM or AOBEM certification." How can this be said when to be a full member and now also to be a Fellow it just requires residency training and not passing the boards? The new criteria for FACEP allows for a "permanent loophole" of false legitimacy for those who cannot pass the test. Is it "not just the training but also the test"?

When a physician sees "Fellow of" whatever major specialty society it is assumed that board certification is a minimum requirement. I would bet that most hospital administrators and legislators assume that also. When a medical staff or administrator is asked to see the list of the new docs proposed by the contract group they will take comfort in having seen FACEP. Unless the hospital bylaws specifically require ABEM or AOBEM no one will be the wiser. Likewise, we will now have letters and testimony to legislative/reg ulatory bodies offered by BCEM and non-certified FACEPs regarding matters of importance to EM. This is critical right now as there is much current state level activity by the AAPS to make BCEM equivalent to ABEM and AOBEM. Were these forces part of the group of "concerned members" who drove this issue? Importantly, recognize that requiring national or state ACEP involvement for non-certified EM physicians to become Fellows will likely result in this group becoming more active in the organization. One can foresee unintended consequences as they rise in influence.

I am dismayed that EMRA supported this, to have the younger generation being complicit in cheapening the requirements to be a truly legitimate "EM specialist", something the title FACEP implies, is disheartening. To those of my fellow academics who you say supported this, I would ask them as to why take a step back when the true academic founders told us to always move forward? Certainly, no academic organization gave their blessing on this move.

Time will tell if this will be a "small group" as you promise. I argue that one is too many. This is a fundamental principle that has been tampered with. In the house of medicine, specialty society fellowship implies board certification. I for one will never accept the rationale put forth here.

Disclaimer: the above is my personal opinion, I do not speak for any organization in this matter. In fact, my bias as an academic chair is an exceedingly more important influence on this opinion than any other factor.
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# grunt docTimothy Donnelly MD 2007-12-11 15:53
FACEP status and board certification are not synonymous designations. Board certification is
under the conrol of ABEM an entity distinct from ACEP.

It is also my understanding that to remain a Fellow of the College continued ACEP membership is required.
If you are not a member of ACEP you should not be
refering to yourself as FACEP.

These elegible physicians must all show contribution to Emergency Medicine as z specialty as well as participation in, and support of the American College
of Emergency Physcisns. This measure recognizes the contributions of these individuals over many years.

ACEP is meant to be an organization in support of Emergency Medicine as a specialty. It has never
purported that its membership is or should be confined
to residency trained board certified physicians.

The youngest grandfathered physician designated FACEP
is in his 50's. This is a small group getting smaller. The number of practicing ED physicians
that enterd after closure of the practice track is
also small and getting smaller.
If you are residency trained and Board certified
proudly proudly designate yourself BCABEM, but do not
denigrate FACEP.

Timothy Donnelly MD
Reply
# M.D.Michael Nestor 2007-12-12 03:06
I think ACEP president Linda Lawrence said it quite correctly and succinctly that the college's new policy on fellowship is aimed at "a small subset of valued ACEP Members". These were the legacy physicians that gave credibility and respectability to our specialty before it was official recognised. Most of them invested years in another residency, even if not emergency specialty. Embrace them or tolerate them for the little time they will be fellows.
Reply
# From whence comes the tension?Ken Solis 2007-12-13 15:28
As an ER doc (okay, I'm "only" BCEM certified) with a master's in bioethics, I remain puzzled that the discourse about the legitimacy of "alternate or practice-based boards," FACEP qualifications, etc., ignores the very reason why physicians like me exist in the first place. There are NOT enough residency trained physicians to meet the demand and will not be for probably many years. When I began ER practice 22 years ago, rural ER's in Wisconsin, at least, were converting to full-time coverage at a very rapid pace. Even dermatology residents were moonlighting in ER’s then (and still do in various areas of the country). Even now, according to IOM, about 40% of physicians in ER's are not residency trained. This is but one special circumstance that ER medicine labors under - a vast shortage of formally trained specialists, with increasing patient census. Of course, we also provide a critical societal service, we're open 24/7/365, provide near universal access to health care (though not universal health care), etc.

Given the tension of too much demand meets too little supply, there seems to be several options for dealing with the reality at hand and its attendant constraints. The option that I experience and read about is a significant contingent of emergency medicine leadership seeking to devalue and marginalize those with qualifications and experience similar to mine, but still doing a great job (e.g., I’ve been offered a job everywhere I've gone during my current stint as a locums doc). By devaluing and marginalizing BCEM, the profession steals away the impetus many non-residency trained ER physicians might have to be certain they have and ultimately prove their competence in ER medicine (please allow that BCEM testing just might be as tough as ABEM’s as some who have taken both tests claim). Yes, I understand the desire for the specialty to be respected by the conservative house of medicine. However, priority must be given to meeting the ER medical needs of society – and the attendant status and respect that SOCIETY in turn gives. Understand that the ultimate goal of status and respect for the profession and its practitioners is not to enhance our self-esteem or set up a pecking order, rather its aim is to gain or maintain the trust that society must have in us so that they will come to us with their problems, tell us their health-related secrets, disrobe for an examination, etc.


I would propose a second option to devaluing and marginalizing physicians like me that would if anything, enhance the status and respect of ER physicians have in society in general, and must have precedence over status that might be compromised within the house of medicine. This option essentially states that until there are enough ER residency trained physicians to cover societal needs, patients will see a similarly certifiably qualified ER physician whether they are seen at a university teaching hospital, or a low volume rural ER. Because ER residency programs require large resources and time to matriculate its specialists, alternative paths like BCEM which requires completion of a primary care specialty residency 5 years, 7,000 hours ER experience, OR F.P. residency 1 year emergency fellowship 1 year experience, should be recognized as legitimate and embraced as a current necessity.


Eventually, when there are enough residency-train ed ER physicians to fill even the lower volume, lesser paying positions, "practice-based " boarded physicians like me will undoubtedly fade away, just like the founders of ER medicine. In the mean time, it's what you bring to the bedside that matters. Let's work together to make sure that what is brought to the bedside is competent to excellent regardless of the path that took the ER physician there.
Reply
# President Georgia College of Emergency PhysiciansMaureen Olson 2007-12-16 13:39
This does not appear to be well thought out at this stage. We have received multiple request already for letter of recommendations many by people who we have never heard of and who list attendance to a conference as involvement. If the intent was to honor a few deserving souls then perhaps the best approach is for all applicants to go through ACEP first and if the ACEP screening committee feels they may be a worthy candidate then contact the state chapters. Since it appears ACEP had a few specific doctors in mind why not award them an honorary FACEP- HFACEP-and let it go at that? The resolution put no qualifiers in place and no uniform guidelines to be followed so each state could set a different standard. This leaves the field of candidates much broader and harder to define. Shouldn't the implementation of this resolution be delayed until a clearer more specfic set of standard guidelines are developed by ACEP? Do the individual state chapters have a role in this if ACEP already knows which physicians they feel should receive this honor? Without stringent, specific, uniform guidelines FACEP will become meaningless.
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