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The great debate over allowing non-boarded EM physicians into ACEP is a battle that doesn’t make sense anymore. Here’s why ACEP needs to open its doors a little wider.

There has been a longstanding debate on what credential you need to be a member of ACEP. I completed my residency in EM in 1975 — before some of you were even born. I was ABEM certified in the first year certification was available. So I completely understand the angst associated with EM being recognized as a specialty. I have now been an ACEP member for about 35 years.

That being the said, I believe that ACEP members who want to limit inclusion to only EM-boarded physicians are making a huge mistake. I have heard all of the elitist arguments in favor of this model – and yes, I think the best way to learn EM is to take a residency. But there are simply too many compelling reasons why the College needs to open membership to all who practice emergency medicine.

Screen Shot 2014-05-27 at 6.41.43 PMThis sense of exclusivity ignores the fact that emergency medicine is now being practiced, and will always be practiced, by well-intended, sincere physicians who are not EM-trained. At least 10,000 (probably closer to 14,000) physicians practice emergency medicine without the EM board stamp of recognition. Many of these docs practice is rural environments, covering the ED at a local hospital. It is a bit of a slap in the face to exclude them from the club even though they’re showing up and doing the same work.

Then there is the fact that excluding non EM-boarded docs is hypocritical because we are readily and happily handing over EM duties to PAs and NPs, and welcoming them into the fold. Would it be better to have all EM-boarded physicians seeing every ED patient in the country? Probably. But, realistically, that’s never going to occur. I know large, multicontract groups where 30% of all patients are seen by PAs or NPs. So who is kidding whom? Why relegate our non-boarded brethren to second-class status when we readily admit the vital role of advanced practice providers?

We also need ALL emergency care physicians to be involved in ACEP for the sake of EM advocacy. It is not just about educational opportunities or e-mails and news updates. It’s about these physicians being needed to help carry the legislative advocacy ball. Although I don’t know the percentage of ACEP dues that are allocated for legislative advocacy, it is significant. And that doesn’t count the additional funds raised for the ACEP Foundation, which would also benefit from enlarging the rolls.

To look at it a different way, currently, EPs who are not ACEP members get all of the benefits of our extensive, expensive advocacy efforts without paying a dime. And that advocacy also is present on the state level. In my state chapter in California, I’ll bet that at least half of discretionary income goes to advocacy. And we, too, have a Foundation in which even more money can be spent for advocacy. Widening the net and getting more emergency medicine docs to pay dues just makes practical sense because they are benefiting from these initiatives.

I know that suggesting that all physicians who practice EM should be allowed membership in ACEP will ruffle feathers – especially at the residency level. But, honestly, the residency fight is over. Emergency medicine is recognized as a specialty; boarded EPs will get good jobs and non-boarded EPs are not going to replace boarded EPs. The fear that the American Academy of Emergency Medicine was going to siphon off all the boarded EPs if ACEP didn’t also mandate boards is largely behind us — ACEP and AAEM are at least cordial now. The contract management corporations don’t control ACEP, and the people on the ACEP Board are reasonable folks with no hidden agendas. It’s OK to open up a bit.

Let’s follow the lead of other medical societies. The majority of specialty societies allow some sort of membership for non-boarded physicians. Non-boarded physicians who are allowed into ACEP can become “affiliate” members, or what have you. They can be counted, or not counted, when determining the number of councilors from a state for the ACEP Council. (I would count them because they do provide care in settings in which EPs either are not available or choose not to practice and they have a great deal to offer the College.)

Finally, opening up the ACEP gates is the right thing to do because we need to provide more support to our colleagues working in rural areas. For decades, ACEP members who work in rural areas have bemoaned the lack of attention paid to this very important aspect of emergency care. Not every hospital has 24-hour CT scan access, ultrasound on demand, MRI capabilities and house staff and specialists available 24/7. In many ways, it is a lot harder working in the rural setting than in large hospitals. And when you look at who teaches at most conferences, you see that it’s the academics, the people with virtually no experience working in a resource-limited rural setting.

Take a look at these stats: According to a recent study (see below) of emergency department staffing in Iowa, only about 12% of EDs are staffed exclusively by boarded EPs. About 60% are staffed by family physicians and boarded EPs and about 28% are staffed by FPs only. The numbers have remained steady from 2008 to 2012. A similar study is underway in Wisconsin – and I bet it will produce similar results.

So, please, let’s have ACEP represent all of the physicians who provide emergency care. It makes practical, fiscal sense, and it’s the right thing to do.

1: BOARD-CERTIFIED EMERGENCY 

PHYSICIANS COMPRISE A MINORITY OF THE EMERGENCY DEPARTMENT
WORKFORCE IN IOWA Groth, H., et al, West J Emerg Med 14(2):186, March 2013

BACKGROUND: It has been estimated that family physicians (FPs) provide nearly one-third of emergency care, particularly in rural areas where 42% of EDs are located. A three-fold increase has also been reported from 1993 to 2005 in the proportion of ED visits managed by PAs and NPs.

METHODS: These multicentered authors, coordinated at the University of Virginia, surveyed the administrators of all 119 Iowa hospitals with EDs in 2008 and 2012 regarding ED staffing patterns. The response rate was 100%.

RESULTS: There were no significant differences between 2008 and 2012 regarding the percentage of EDs that were staffed with board-certified emergency physicians (EPs) only (12.6% and 11.8%, respectively), a combination of EPs and FPs (63% and 60.5%), or FPs only (22.7% plus 1.7% staffed with IM residents vs. 27.7%). However, there was a significant increase in the percentage of EDs with solo staffing by PAs and NPs for at least part of the week (38.7% vs. 60.5%). In 2012, the mean population of communities supporting exclusive ED staffing by EPs was just under 85,000. Reasons for staffing with FPs most commonly included low availability of EPs, low patient census and satisfaction with the care provided by FPs, while reasons cited for staffing with EPs included high availability of EPs and patient census, and the quality of care provided by EPs. Low salaries and low physician availability were often cited as reasons for hiring PAs and NPs for solo ED coverage.

CONCLUSIONS: Physician staffing of Iowa EDs did not change substantially between 2008 and 2012, but there was a significant increase in staffing by advanced practice providers (APPs). Without ED coverage by FPs, it would not be possible to provide emergency care for large areas of the state. 17 references (This email address is being protected from spambots. You need JavaScript enabled to view it. – no reprints) (PMID: 23599868)

Copyright 2014 by Emergency Medical Abstracts – All Rights Reserved           4/14 - #12

Richard Bukata, MD
Editor of Emergency Medical Abstracts (www.ccme.org)

 

Comments   

# M.D.William Hardman 2014-05-28 15:11
Excellent, clear thoughts as usual. Rick, keep up the good work!
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# RE: ACEP, Open Wide the GatesMichael LeWitt 2014-05-28 15:13
One can join various groups without being board certified. AAEM requires board certification for fellowship, ACEP does not in every instance; fellowship allows one to vote for officers in the organization. ABEM requires that all of its candidates for the Board be residency trained, excluding those of a certain age who did not have access to residencies, but often were among the first faculty of residencies. Groucho Marx didn't want to be part of any club that wanted him as a member.

The same argument about advocacy could be said of the AMA, state and county medical societies as well. I suppose the plight of doctors would be worse if we didn't have someone to advocate for us, but I have never seen such discouragement among my colleagues as I feel now.
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# ACEP Past PresidentLarry A. Bedard, MD 2014-05-28 15:33
Rick,

Just because a family practitioner sets Colles Fractures in a rural community doesn't make him/her an Orthopedic Surgeon. A FP who delivers babies in a rural area is not on Obstetrician.

Virtually all specialities use physician extenders, PAs, NPs, etc.

Just because a cast tech applies a cast for an Orthopedist doesn't make them an Orthopedic surgeon.

Rick you need to provide information on which professional physician societies have affiliate and associate members. Does the American College of Cardiology allow paramedics, who perform more CPR than virtually any cardiologist as affiliate members.

I think the membership criteria is fine just the way it is. After all we are the american College of EMERGENCY PHYSICIANS.
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# RE: ACEP, Open Wide the GatesEliezer Basse, M.D. 2014-05-28 15:59
I agree whole heartedly with Dr. Bukata and congratulate him for having the fortitude to bring up this sensitive subject. As a Fellow of the American College of Emergency Medicine, I have always wondered why the College would turn away colleagues who practice our specialty even though they did not complete an EM residency. Let's not forget that most of the fathers of EM were trained in other specialties before committing their careers to EM and developing it as a specialty.
It is time for ACEP to become all encompassing and obtain the support of all those who practice the specialty.
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# RE: ACEP, Open Wide the GatesCarol Nieroda M.D. 2014-05-28 16:11
I am one of those non-board certified emergency physicians who now practices in a rural area. I have been practicing Emergency Medicine since the early 1980's, sometimes part-time and sometimes full time sometime in rural areas and sometimes in urban centers. When I did my residency, emergency medicine residences did not exist. My medical training is long and complex. I was board certified in general surgery with a speciality in surgical oncology for many years. During some of this time I continued to do part-time Emergency Medicine. I worked for several years at the NCi in the Laboratory of Tumor Biology and Immunology a great teaching and learning environment. Several years ago I was invited to join an Internal Medicine practice on a part-time basis of two days a week. I assume that my general medical knowledge was sufficient, since I still see my patients on a weekly basis and they are very loyal to me. To keep my skills and knowledge up to date I have taken the Internal Medicine Board Review Course given by Harvard every 3-4 years. I have taken the Emergency Medicine Board Review Course, which you support, every 3 -4 years. I have completed the Lifelong Learning and Self-Assessment Study Series every year since the early 2000's as well as hundreds of other hours of continuing education both in emergency medicine and internal medicine. In my internal medicine office, teach second year medical student from Georgetown University the principles of physical examination and interviewing their first live patients ( a big jump from the cadavers they have previously examined). At my surgical oncology research position, I teach residents and fellows how to write a scientific/clin ical paper, many of which have been in a variety of peer-reviewed national and international periodicals. I oversee physicians' assistants and nurse practitioners. I see the young physicians (not just emergency medicine trained) coming out of residency or just having passed their boards and I find it somewhat discouraging when I see how much they think they know, when in reality, they have only begun to not only the facts of medicine and medical treatment, but also what medicine is all about. It is a whole lot harder to be working in an emergency room without a CT scanner, an MRI, or an US available, especially when you know that one of these tests might save a life. It is much easier to call the trauma team or all the cath lab. A bit of a slap in the face to be excluded from the elitist club? Saying I agree is an understatement.
With respect, but sincerely,
Carol A. Nieroda, MD
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# Non- boarded ED Physicianfmiyares 2014-05-28 17:09
I agree wholeheartedly with Dr. Bukata. Having attended some of his conferences in Las Vegas, NV I see the number of non-boarded physicians nurse practitioners physician assistants all sitting there with me attending is excellent lectures. I'm trained as a general internist but I've been practicing emergency medicine mostly in rural critical access hospitals and he's right it is a lot more difficult to practice in this setting. Having been trained at Cook County Hospital and working in their emergency department as a resident as well as a senior medical resident moonlighting, I know the big difference between having back up and not having back up and it sucks! I know that I can do as well as a job in a tertiary hospital in Chicago just like I do in rural Wisconsin or rural Illinois. It is refreshing to hear Dr. Bukata's astute comments again.
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# Past PresRichard Stennes 2014-05-28 17:30
Rick, I absolutely agree and always have.
I work in a hospital in rural minnesota where we have 1 to 3 providers working daily including nurse practioners. My objective when I started staffing in 1992 was to place boarded EP's there. Even now with a pay package in the area of the 90 percentile, we have 2 ABEM certified EP's. The rest are FP. I am a believer in the value of EM training and certification. But what is a primary function of ACEP on behalf of its members....and all others who do EM but are not allowed to help carry the water? Get money, and promote legislatively those things that further the cause of EM and more commonly prevent those things that are bad for EM. There is strength in numbers. Put all those folks you reference into our boat and let them help row the boat.
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# RE: ACEP, Open Wide the GatesLee Dudley 2014-05-28 17:42
Affiliate status for primary care boarded physician that have soley practiced Emergency Medicine for more than five years in a level III or higher environment, I feel would still be insulting. To those physicians who are primary care boarded and have completed a recognized EM fellowship should upon their completion be recognized fully by the organization and eligible for fellow status. Accepting primary care boarded EM practicing physicians as affiliates or as full members eligible for fellow status doesn't negate a hospitals preference to higher soley EM residency trained physician. ACEP is not a certifying board and should encompass all those that competently work in the capacity of an EM physician. If wondering, I am EM/IM trained and boarded.
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# ED Medical DirectorJames Bell, MD 2014-05-28 19:09
Thank you for your kind words Dr. Bukata.
I'm an FP by certification (1982) and an "ER" doc by practice (68,000+ hrs). I joined ACEP years ago but took a break from the elitism. Rejoined since. By default I became Medical Director of our ED 10+ years ago and have accomplished my goal; all of my full-time physicians are ABEM residency trained and board certified. I reckon the ranks of ACEP will become purer when I age out if not first ousted.
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# Open the gates is NOT the message ACEP should SendCraig Smith 2014-05-28 20:01
The research article regarding Iowa staffing should reiterate the fact that there is a physician shortage. If ACEP were to relax the standard, our specialty would basically be saying that residency training in this specialty doesn't mean much. The non boarded physician was trained in his or her specialty to workup complaints in a different manner. The differential diagnosis order is different. We are TRAINED to think a certain way when working up a complaint. When I was a resident, I would fly to small hospitals and pick up patients that were completely mismanaged by these non trained physicians. Should ACEP give a rubber stamp, legitimizing their care?
I have also worked with non boarded doctors, as well as NPs and PAs. The one difference: PAs and NPs report to the board certified doctor. The non boarded physician works independently.
Regarding the statement of jobs. Many emergency medicine residents get good jobs when finishing residency because the hospital mandates "Board Certified, Residency trained".
There is a reason for this If ACEP changes the standard; What will be the incentive for hospitals to continue to hire in this fashion? Afterall, isn't it cheaper to hire a family practice doctor to moonlight in the ER?
Bottom line: Just because I am good at reading EKGs and managing chest pain, does not qualify me to become a cardiologist. Same is true for someone wanting to practice emergency medicine.
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# Family Doc hereJJ 2014-06-27 04:08
Having recently finished family practice residency and spending my 3rd year locum tenens ER I can say I haven't had trouble diagnosing emergencies and treating. A lot of the difference is procedural hands on experience that if one wants can be picked up on rotations such as ICU and EM spending extra time. Eventually you can get good at these procedures and do them just like everyone else. General surgeons taught me chest tubes during my surgery rotations. We get a lot of acute ER type stuff in the clinic we send to the ER for further management since it is an emergency. I've had my fair share of trauma situations and after going after specific "ER Type Procedures" in residency I can do central lines, incubate just like everyone else. Heck, I was even trained in csections. Don't forget family docs ran the ER's back in the day and for the properly trained family docs in residency with an ER interest I don't believe there is a gap in quality care as a lot of the principles overlap with what family docs encounter during their training. Since ER is a specialty you will always be regarded as the experts but family docs see and treat a lot of the same issues in residency. We might see an emergency on the inpatient floor such as acute chest pain just like it shows up at the ER floor.
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# MDKevin Holcombe 2014-05-28 21:37
Well put! Nuff said!
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# RE: ACEP, Open Wide the GatesMartin I Herman 2014-05-29 02:22
I agree with Dick.
I also would say the battle for Pediatric Emergency Medicine specialty recognition is still going full force. I can't get the administrators here in Northwest FLorida to understand that there is a magnitude of difference between EM docs taking care of kids and PEM docs doing so. Whether you train as EM-Peds, Med- Peds, Peds- PEM, or EM- PEM fellowship, that brings more to the exam room than a doc who has not spent the time in training..
Sure open up ACEP to anyone practicing EM or PEM
I would keep the boards issue separate. Seems to me there is always a difference between what the advocacy groups agenda should be and what the certifying boards agendas should be..
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# MDRuss Hartung 2014-05-29 10:05
Rick, Thanks for suggesting some sanity. I have been practicing full-time emergency medicine for nearly 30 years in high-volume EDs - not just in some rural ED but in 50,000 volume trauma centers where the next hospital is an hour away. I did a residency in Internal Medicine and on stayed afterward on as Chief Resident but have only done emergency medicine throughout my career. I was the Associate Director, EMS Director and QA Director in several EDs. I was course director for ACLS and PALS for 15 years. The glaring irony is that there are EDs where I can't get a job - yet in these same EDs 40% of the patients are seen only by a PA or NP who have never even been to med school or done ANY residency. One of the threats to our specialty, and to medicine in general, is not from people like me - it is the fact that physician "assistants" are becoming physician "replacements" in many clinical settings. I AM an emergency physician, and more than deserve the same considerations enjoyed by physicians who, as they come out of residency, are looking to me (the older, experienced doctor) for advice and guidance.
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# RE: ACEP, Open Wide the GatesZia Hashemi, MD 2014-05-30 01:21
It is sad in a the most democratic country in the world, Non-Residency Trained ED Physicians are not allowed to take the same tests and prove that they are as capable as others.
But the true fact is money! Hospitals has to run their system by cheap labor force, the residents! They are afraid they have to hire expensive Dr.s if this myth of residency training be exposed.
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# Attending EPWilliam Bell, MD 2014-05-30 01:27
I am a member of ACEP because I have been practicing in EM for over 15 years. I am also a FP boarded, Emergency Physician practicing for in a suburban and rural setting. I applaud this article. I pay my dues every year, and contribute to the PAC for the good of emergency medicine. As with AAFP and ABFM, ACEP is becoming too closely entwined with ABEM. The boards are not very democratic or responsive to the folks they certify, and are constantly looking to demand more of their requirements on your time and money. Stay independent and open.
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# MD, FAAEM, EX-FACEPMIGUEL A HERRERA,MD, 2014-05-30 01:55
RICK, ACEP CUT ME OFF AS A FELLOW IN 1992
NOT RESIDENCY TRAINED,NOT GOOD ENOUGH FOR THEM.ALSO WAS BOARD CERTIFIED IN SURGERY...ABEM CERTIFIED IN 82, RECERT IN 92, 02 AHD 2012...I WAS UNFAIRLY TERMINATED...TH EY DONT WANT OUR ILK,NOT WORTHY...I WAS SHOCKED, THEN JOINED AAEM... WHAT A DIFFERENCE...
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# Emergency PhysicianEmil Soleyman 2014-05-30 19:35
Emergency medicine is best practiced by emergency physicians who are residency trained as because of advances in knowledge and breadth. "On the job" training is no longer appropriate and neither is passing written and oral exams sufficient to demonstrate knowledge. To state that ACEP and emergency medicine need to incorporate non-residency trained EPs discounts the effort, knowledge, and dedication of EM trained residents while also being dangerous for patient care.

Dr. Bukata states that "emergency medicine is now being practiced, and will always be practiced, by well-intended, sincere physicians who are not EM-trained" but fails to acknowledge the fact emergency medicine is best practiced by emergency residency trained physicians. While others may work in the ED as physicians, they are markedly dissimilar to those who are residency trained.

Dr. Bukata is setting up a straw man argument when he states that emergency physicians are "readily and happily handing over EM duties to PAs and NPs" and then goes onto to state that "EPs who are not ACEP members get all of the benefits of our extensive, expensive advocacy efforts without paying a dime". Emergency physicians who employ PAs and NPs in the ED are using them to see fast track patients (urgent care) and have close oversight of their activities while non-EM trained physicians see all comers. While non-EM boarded physicians benefit from our advocacy, they are also held to the same standard of care as EM-boarded physicians while not enjoying the benefits of residency -- a risky proposition.

"The majority of specialty societies allow some sort of membership for non-boarded physicians" is incorrect:

* AAFP (American Academy of Family Physicians) does not allow an affiliate membership and requires all fellows to be family medicine residency trained
* ACS (American College of Surgeons) allows affiliate members but whose benefits include Online access to the Journal of the American College of Surgeons (JACS), The weekly electronic newsletter ACS NewsScope and insurance / travel benefits.
* ACP (American College of Physicians) allows physician affiliate membership but "Physician Affiliate members are not eligible to vote, hold office, sit on a committee that does not have seats for non-members, or attain Fellowship in ACP."

As a residency trained EP resident, I am vehemently against opening up our physician organizations to non-EM boarded physicians and non-physician affiliates. Board certification is the only way forward to gain fellowship. AAFP, ACS, or ACP do not allow non-physician to gain fellowship positions in their organizations or have the ability to vote.

Why should emergency medicine as a specialty back away from this requirement? Why do we de-value our training and assume that other non-EM trained physicians do "just as good a job" as EM trained physicians? How often do you see EM-only trained physicians masquerading as family or internal medicine physicians or surgeons?
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# Family Medicine Boarded EM docJames 2014-07-13 16:00
I've been practicing EM for 15 years, in moderate to high-volume ED's, in a suburban setting. I have never been terminated from a position nor have I been reprimanded for any mistakes in my short career. I graduated from a FM residency that was the only residency in a 700 bed hospital, with a 60,000 visit per year ER---staffed by high-quality docs all of whom were FM docs. I take offense to your comments that I am "masquerading" as an ER doc. I will say without question that I give high-quality emergency care to every patient that I encounter. My ED director (who is EM boarded) once told me that he would hire me many times over some of his EM-boarded colleagues. Who are you or anyone else to tell me that I am providing substandard care? Have you seen me practice? To make a blanket statement that all non-EM trained docs give substandard care speaks volumes about your hubristic attitude. That kind of attitude just serves to damage the reputation of all doctors. It also speaks volumes about the elitist attitude of ACEP. THANK YOU DR. BUTAKA FOR YOUR EXCELLENT ARTICLE.
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# ACEP member since 1971Pam Bensen, MD FACEP 2014-05-31 20:02
Each year that the ACEP Council debated closing ACEP membership to non-boarded emergency physician, I stood at the microphone to plead for open membership for my colleagues in Maine and all rural areas. I only lost once. Perhaps, had Dr. Bukata spoken this eloquently, rather than me with my well worn speech about the dearth of EM trained physicians applying for rural jobs, ACEP would have remained wide-open, as it should be! Thanks Rick for once again telling it like it should be!
Pam
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