The case for maintaining strict membership requirements for ACEP

The discussion on opening up ACEP membership to non–emergency medicine boarded physicians is not a new one, but it is one that is important to continue. When considering this issue, I feel it’s important to question why a non–emergency medicine boarded physician would want the ACEP affiliation in the first place. The answer is simple: the affiliation means something now more than ever.

When our specialty was in its infancy, there were no “emergency medicine” physicians. There were certainly people who worked in the emergency environment, however, who had the wisdom to recognize the need for something better. Those pioneers saw the need for specific emergency medicine training, and over time, the emergency room became the emergency department, and the specialty was born. Since that time, there has been a marked evolution of what is expected from the emergency department and of those who provide emergency care. We are now the gatekeepers to the hospital and the providers of the bulk of ambulatory care in this country. Certainly, this is a far cry from the emergency room of old.

Our founders had to “learn on the job,” as new doctors in emergency department roles, without the benefit of formal emergency medicine training, are still doing the same thing. Although this is still an unfortunate reality, I do not feel it is in the best interest of the College to support this method of meeting our patients’ needs by endorsing the individuals who did not train in emergency medicine. Emergency medicine training prepares us to work up complaints in a different manner. The ordering of our differential diagnosis is different. Our skill set for approaching problems is different. These differences matter—period. Just because physician shortages force us to accept non–emergency-trained physicians in emergency department roles does not mean that we should fail to recognize that emergency medicine is best practiced by emergency-trained physicians and that those who work in the emergency environment who lack our specialty training are markedly dissimilar from us. On-the-job training is no longer appropriate just as simply passing written and oral exams is insufficient to demonstrate knowledge. To state that ACEP needs to incorporate non–residency-trained physicians into emergency medicine discounts the effort, knowledge, and dedication of emergency medicine–trained residents. It also sets a dangerous standard for the care of our patients.

Non–emergency-trained physicians working in an emergency department often say, “I am an emergency physician who does the same work as you; I just don’t have the residency training.” Endorsing this mentality sends the wrong message. In our department, we have physician assistants and nurse practitioners working alongside us who also do “emergency physician” work; they work under our supervision while the non–emergency medicine boarded physicians work independently. Just because I set fractures in the emergency department, deliver babies, and interpret ECGs doesn’t make me an orthopedist, obstetrician, or cardiologist. Likewise, there is a distinction between being an emergency medicine physician and being a physician who practices emergency medicine.

To state that ACEP needs to incorporate non–residency-trained physicians into emergency medicine discounts the effort, knowledge, and dedication of emergency medicine–trained residents. It also sets a dangerous standard for the care of our patients.

Fortunately, we have reached a point where the medical community at large understands this distinction. Many hospitals already require emergency medicine–trained and –boarded physicians for staffing their departments, and when it comes to good jobs for our residents completing training, they are out there. Until we reach a point where there are enough emergency physicians available to fill every emergency department across the country, it is still necessary for non–emergency physicians to fill these positions in underserved areas. So why is it important that we continue to recognize the difference between “us” and “them”? And, more important, why not embrace them into our ranks?

If we allow non–emergency physicians the benefit of membership, what is it that they would hope to gain? They are already able to come to our conferences. They can receive our publications. They can publish in our journal. They already receive the benefits of our advocacy efforts even if they are not held to our standards. They will not provide a financial windfall to the College through their membership. The only reason to invite them is that we feel we need them at the table when we make decisions about the future of our specialty. I would argue, however, that we don’t.

Where the line must be drawn is the final remaining benefit that affiliation with the College would bring: a seat at the table. ACEP is recognized as the voice of emergency medicine, and our advocacy efforts put us in a position to make our voice heard when policies affecting us are being made. The important thing for us now is to make sure “our” message is the one being heard. No one is better equipped to determine the needs of our specialty than we are. No one is better able to develop clinical guidelines that we should follow than us.

Dr. Radtke is chair of the ACEP Young Physicians Section and a pediatric emergency physician at St. Joeseph’s Children’s Hospital in Tampa, Florida.