Tuesday, May 1, 2007

Board Certification

EM news recently ran an article on their front page on the AAPS (American Association of Physician Specialties). The organization is suing the NY Dept. of Health because they are not listing physicians boarded by their organization on the NYDOH website.

The AAPS is an organization that will grant board certification to a specialty including Emergency Medicine. Obviously, board certification status is important since if affects the physicians ability to obtain hospital privileges, be eligible of certain types of malpractice insurance and compensation. Interestingly, the individual can become boarded without having completed a residency in EM.

The requirements according to the AAPS website and their boarding arm the ABPS (American Board of Physician Specialists) in short are as follows:

  • complete a residency in anesthesiology or a primary care specialty, or
  • be certified in a primary care specialty or anesthesiology by the ABPS
  • complete a 12 or 24 month emergency medicine graduate training program approved by BCM and have practiced emergency medicine full-time or five years, accumulating at least 7,000 hours of practice. The graduate course cannot be substituted for a primary care or anesthesiology residency.

The full page of requirements can be found here.

The AAPS even recognizes three different fellowship programs. In Memphis, Tennessee, family practice residents spend one year doing an EM fellowship and can then call themselves boarded certified EM physicians.

Are alarm bells going off? This alternate boarding organization could jeopardize EM-trained physicians in a number of ways. First, patient safety. Patients are best treated in the emergency department by EM-trained physicians. Tom Scaletta, president of AAEM (American Association of Emergency Medicine) summed up this point by stating, “The AAPS does not understand that the public want board certified specialists staffing their emergency departments.” Secondly, malpractice rates may increase. Allowing AAPS board certified physicians to be credentialed could potentially increase rates, as the insurance companies can easily look at a non EM-trained physician practicing in the ED as an increased risk. Finally, compensation. Physicians staffing an ED that are not boarded in EM usually bill at a lesser rate.

Fortunately, the AAEM and ACEP (American College of Emergency Physicians) are vehemently fighting the AAPS. They have won a suit in North Carolina against AAPS and are actively fighting to preserve Board Certification status for EM-trained physicians.

If this makes sense to you, I would encourage you to contact your state legislator and express your opinion. If it does not, I would welcome your response.

Post submitted by Mike Grinney, Resident in Emergency Medicine at Lincoln Hospital, New York City.

"SoapBox"
is a column designed for medically-related rantings. Whether it's a recently published article or the disgruntled clerk in your ED; this column allows the writer to express how he or she really feels.

10 comments:

Chris said...

You must certainly know that there are nowhere near enough ABEM-certified docs to fill all the ER positions in this country, and there won't be enough new EM grads to accomplish this for the foreseeable future, because of the large cluster of "Grandfathers" (those trained in other specialties who were once allowed to sit for the ABEM Boards)who became certified in the early 80's and who will be retiring soon. Nearly half of our current ABEM-boarded docs never trained in a EM residency.

So, if you truly believe in optimizing patient safety (as you claim), how do you propose we assure the competence of the non-ABEM docs who *must* be used in order to adequately staff our country's EDs? It seems to me that recognizing BCEM as an equivalent board alternative would be most reasonable. With that certification, the patient can be confident that his/her doc is competent, experienced and has completed training/testing requirements MORE RIGOROUS than the ABEM grandfathers.

I encourage readers to check out the ABPS website to appreciate the full extend of those requirements (which include 5 years of full-time practice in EM), rather than your truncated list.

EM Rez said...

Chris,

I am aware there are not nearly enough ABEM board certified doctors to staff the EDs in this country, nor will there be in the forseeable future. That is not the issue at stake. The issue is physicians presenting themselve as "Board Certified" in Emergency Medicine who have not completed an EM residency or who have not been "grandfathered" into the speciaty. Board Certified in Emergency Medicine means the physician has completed an accredited residency program in Emergency Medicine and passed both the written and oral boards. This needs to be distinguised from physicians who practice in the ED but have training in another field. The public has an understanding of residency training. Board certified in a specialty means that you were trained in that speciaty.

The reason "Grandfathering" into an ABEM certified position was that in 1970 there was one EM program and as of 2005 there are 135 programs.
There is no need to continue to "grandfather" physicians from other specialties any longer which is why ABEM no longer does so.

I do firmly believe that patients are best treated in the ED by board certified EM physicians. I also think this applies to every other field as well. If I am going to have a AAA repaired, I would want a board certified vascular surgeon to do it. If a family member needs to be resuscitated in the ED, I would want a board certified EM physician to do it. The specialty of Emergency Medicine exists for a clear reason, which is the body of knowledge and a skill set that is unique to Emergency Medicine.

I believe there should be a standard or method to assess the competence of non-ABEM docs who practice in the ED. Patient safety would likely benefit from a standard to measure competence of non-ABEM docs. However, they should not be granted board certification status in EM. The family practice doc that sees pediatric patients is not eligible to be boarded in pediatrics. The orthopaedic surgeon who does spine surgery does not present his/herself as board certified in neuro surgery. A physician that presents him/herself as board certified in Emergency Medicine but is not by the ABEM standards is fraudulent in my mind.

I mentioned some of the requirements in my "truncated list". The full requirements are easliy accessed with a click of the mouse in my posting.

I do believe that there are many excellent physicians that practice in the ED who are not board certified in EM by the ABEM. No matter how caring or how competent they might be, if they have not met the ABEM standards for board certified, they should not be able to present themselves as board certified.

docwhisperer said...

I vehemently disagree. Chris, Thanks for your comment. I challenge anyone to prove that a newly board certified EM residency grad is "better" than an ER doc trained in IM/ FP/ or surgery who has worked in a busy ER for 10 years. What I find disgusting about the entire matter is how the new ABEM grads via AAEM are denigrating and undermining the ER docs who came before them and helped make the specialty what it is instead of working with them to help serve the public better, particularly in view of the recent IOM report (which states that the way things are going, it will be 30 years before there are enough ABEM certified ER docs to staff all the ERs in the country).
For anyone who's interested, I have several posts on this topic on my blog at:
http://docwhisperer.wordpress.com/2007/02/05/disposable-doctors-2-er-docs-fight-back-in-ny/
and
http://docwhisperer.wordpress.com/2007/06/04/not-so-disposable-doctors-progress-in-abps-ny-fight-and-others/
To all the non-ABEM ER docs, join ABPS in the fight against this injustice.

EM Rez said...

docwhisperer,

Your challenge to find a newly EM grad who is better than a non-EM trained doc who has worked in a busy ED for 10 years is flawed for a number of reasons. First, a large number if not the majority of non-EM trained docs do not work in busy EDs. Secondly, how many of the non-EM trained docs are have experience with difficult airways, toxic infants, chest tubes, TPA with stroke and the list goes on. Thirdly, the non-EM docs that are practicing in the ED are not trained in the unique body of knowledge that compromises Emergency Medicine. Is it ethical for a doc to learn on the job? Where is the surgeon getting training in stroke management? Where is the IM doc getting training in chest tube placement or caring for pediatrics? Thirdly, extending your line of reason that experience must count for something, why not let experienced CRNAs sit for the anestheisa boards? Why not let PAs or NPs with 10 years experience in a busy ED have the ability to be board certified in EM?

The public has an understanding of what a residency and specialty entails. Presenting oneself as boarded in a specialty, when one has not completely residency training in that field is fraudulent in my mind.

docwhisperer said...

It is presumptious to assume that just because a physician has not done a formal residency does not mean that he or she does not have the skill set to be competent at their job. Speaking as a physician in practice for over a decade, many of the current skills and knowledge I am currently applying I’ve learned “on the job” due to the fast pace of advancement of medical technology. To think that learning stops after residency training reveals a lack of understanding of real world practice.

I always thought that the purpose of board certification was to ensure that the physicians practicing in a specialty had the required knowledge and skill base to practice in that specialty. This is because that residency programs do not provide the level of exposure required to become skillful in certain areas. If finishing an ER residency training was all you needed to show that you were a competent ER doc, then why even have board certification at all?

If it were true that the ER residency trained docs are so superior to the career ER docs, then why not let the career ER docs take the board certification test? Oh, I forgot, they already did that when they grandfathered in all those guys in the nineties. I don’t think there was any difference then, and I doubt there is any difference now since ABEM and ABPS pretty much give the same test.

It all boils down to politics, with groups like the AAEM trying to artificially raise the salaries of board certified and residency trained ER docs by claiming “shortages” meanwhile ignoring the fact that by their actions, they are injuring the careers and livelihoods of experienced but non-ABEM ER docs and limiting the public’s access to traned physicians in underserved areas. For shame!

EM Rez said...

There is no other training other than an Emergency Medicine residency that can prepare onself adequately for work in the ER. You have not addressed whether you think training in another specialty prepares one for working in the ED. Do you think a residency in surgery, medicine etc. adequately prepares you for seeing pediatric patients? Knowledge can be obtained to most anything, but clinical skills need to be learned in a hands on fashion. How many chest tubes do you think someone with an IM background has done? Do you really think it is ethical for them to learn on the job? I surely hope many of the clinical skills you have learned were done in residency and not on the job due to advancements in “medical technology”. Your comment about learning stopping after residency is completely unsupported. Of course learning continues after residency and it should until the day one retires.

Nearly every specialty in medicine has a residency. All of the specialties also have boards to pass. Boards exist so to ensure residents have acquired the knowlege base and it acts as a standard to apply to all graduating residents. Boards do not adequately test for skill sets. One could read at length about intubation and know the correct answer for every exam question, but it certainly does not mean they have the “skill base” to perform one. I agree that residency programs “do not provide the level of exposure required to become skillful incertain areas” and these are residencies in surgery, medicine etc.

If experience counts for so much, why not let NPs or PAs sit for the boards if they have “practiced for over a decade”. Just because they have not done a formal residency “does not mean he or she does not have the skill set to be competent at their job.”

I find it interesting that ABEM and ABPS give “pretty much the same test”. Now that is presumptuous! (unless you have taken both tests several times or write questions for both the exams). How can you make that conclusion?

I agree that this issue largely does boil down to politics. ABPS is trying to dilute the specialty of Emergency Medicine by creating their own board certification process. ABEM already exists and is recognized nationwide. Just because a physician chooses not to practice in the residency in which they were trained is not reason to create another set of boards. There is no shame in trying to maintain the integrity of a specialty.

docwhisperer said...

You seem to be confused regarding the comparisons being made. The ABPS diplomates are IM/ FM/ Surgery grads who have WORKED IN ERs FOR 10-15 YEARS, not new grads which you seem to be comparing with the new EM residency grads.
The IM/ Surgery residency itself does not prepare docs to see kids, it is the 10-15 years of having worked in the ER and seeing thousands of kids that does. I also argue that the EM residency by itself does not sufficiently prepare one to see children, otherwise why is there a special Pediatric ER specialty (which is a fellowship, not a residency). And what about the FM grads who already see kids?
Your other points are the same tired argument espoused by the minions of AAEM (American Academy of Emergency Medicine), which thankfully are not shared by other ER organizations. (see the ACEP position statement, “The Role of Legacy EM Physicians in the 21st Century”
link: http://www.acep.org/webportal/PracticeResources/PolicyStatements/certcred/legacyep.htm )
which specifically states
” ACEP acknowledges that legacy emergency physicians, by virtue of their primary training and emergency medicine practice experience, play an important role in the current emergency medicine workforce and patient care safety net.

ACEP supports the efforts of legacy emergency physicians who seek additional training and continuing medical education to enhance their ability to provide high quality patient care.

ACEP believes that the quality of care delivered by legacy emergency physicians should be a primary determinant of their hospital privileges and credentialing. Legacy emergency physicians should be subject to the same quality standards as ABEM/AOBEM certified emergency physicians. Legacy emergency physicians should not be forced out of the workforce solely on the basis of their board certification status.”

I find it interesting that your concept of maintaining the integrity of a specialty involves excluding the very people who helped create that specialty in the first place. We live in sad times for medicine indeed.

Anonymous said...

Does anyone know of actual DATA that patients treated by EM residency- trained Docs have better outcomes than those treated by IM/FP docs with a great deal of ED experience?
As an IM resident, I know that I can manage many medical problems just as well or better than EM trained docs, and could easily match them if given the opportunity to do a one year fellowship in EM (trauma, ortho, peds, OB).I believe IM and FP docs haven't fought hard enough to maintain our practice rights in the ED.

Michael said...

Anonymous,

There is data that Residency Trained EM docs are sued less the ED than non EM trained docs. See article.
Emergency Medicine News:Volume 23(2)February 2001p 35-39
This has of course translated into lower malpractice rates for EM trained docs. Maybe EM docs just have better bedside manner, but I doubt it. I will let the reader draw his/her own conclusion.


I find it interesting that you think IM docs have a "right" to practice in the ED. Do EM docs have a "right" to practice internal medicine? I certainly don't think so. I agree that IM docs can manage medical problems well in the ED. The problem with that line of reasoning is that the ED is not a medical office. It is a place where anything can come through the door, not just medical complaints. I wonder how the parents of a lethargic 2 year old would feel about an IM trained doc seeing their child in the ED. I think the answer is obvious. I feel it is unethical to learn on the job without supervision. Hence, IM docs should not be allowed to see pediatric, ortho, trauma, etc cases, unless being supervised by a doc with experience in that area. Sounds kind of like a residency doesn't it?

EM has a unique body of knowledge and that is why the residency exists. If you want to practice in the ED, I encourage you to apply for a residency. If not, I hope you would limit your scope of practice strictly to medical complaints.

Anonymous said...

If I may interject,

As a f/t ed doc for 14 yrs and triple boarded in IM/Pulm/CC,
the arguements I've read each have merit. The EM trained docs want a pure certification and they deserve so. Docs like me are finding jobs to be less available due to the lack of EM training and certification and are searching for a way to prove our worth without diluting the certificate.

There are EM trained docs who cant diagnose costochondritis in a 20 y/o female without an ekg/d-dimer/cxr and cta of the chest/ because thier training teaches "admit all chest pains".
Alternatively the non Em trained docs can come from a wide array of backgrounds and do present a confusing approach to work-ups and are very likely to have had very little exposure in trauma situations and probably less adept at ortho/peds/and ob.

The best and exremely unlikely solution is to make EM a subspecialty of Medicine with rotations through the non IM areas.
This would greatly reduce over testing in the ED due to the "cook book" approach I too often see.

In summary, the IM trained doc searches for the most common diagnosis and the EM doc searches for the most dangerous. Unification of these programs would definitely find common ground.