From the Medical Editor in Chief: This is an important issue for our College, worthy of our attention and discussion. The ACEP Council has previously considered alternative membership categories for physicians practicing emergency medicine who do not meet the current membership criteria. In the past, such resolutions were not adopted but were not unanimously rejected either. I have spoken to several emergency physicians on both sides of this issue. It appears that it is time to continue this discussion. The following is the first formal submission I have received on the topic. It is published not as an endorsement of the position but as the beginning of a very important discussion. I certainly don’t know what the right answer is, but I hope through this discussion we will find clarity. Agree? Disagree? Either way, we want your input.
Send your comments to acepnow@acep.org.
—Kevin M. Klauer, DO, EJD, FACEP

When the same question continues to be asked, this might mean that the answers lacked solutions.

I have advocated for an expanded ACEP membership since day one. The argument has failed based primarily on “exclusivity in the club.”

Although recognizing residency training and board certification in emergency medicine as the standard is important, the masses seem to disregard the fact that vast numbers of physicians working as emergency physicians have no EM training but receive all of the educational and financial benefits that ACEP and the American Medical Association (AMA) provide for them.

Imagine our membership and lobbying numbers if we somehow included these physicians as members of ACEP in some unique category.

Historical Perspective

I joined ACEP in the early 1970s. In California, we needed a mechanism to go to Sacramento to lobby for money for Medi-Cal; Bill O’Riordan, Walt Edwards, I, and others did just that.

We realized early on that our efforts would require more sophistication, like the big boys in Sacramento, and so CAL/ACEP hired a lobbyist, Jim Randlett. Often, our legislative efforts did not bear fruit, but they did stop some bad things from happening—a continued theme today.

We also realized that money talks (and bullshit walks) and that a political action committee (PAC) would be necessary to prompt legislators to listen more closely, and so EMPAC was formed.

John McDade, president in about 1975, asked me to assume the chair of the Government Finance Committee during the Nexus 75 meeting in Palm Springs. I started marching on Washington, DC, with our part-time lobbyist, Terry Schmidt, again looking for money in some direct or indirect fashion.

Jack Wood of Wood, Lucksinger, and Epstein in Houston was one of the nation’s recognized experts in Medicare rules and reimbursement and was retained to accompany me to the Medicare offices in Baltimore to look for improved reimbursement. We won.

During the winter ACEP Symposium meeting in Bermuda in the ’70s, the option for independent contractor status for emergency physicians was being contested. I asked the Board for $20,000 to march on Washington, and we prevailed. This was a money issue, and this recurrent theme continues in present time.

It became apparent that our efforts to protect the practice of emergency medicine and the interests of emergency physicians needed full-time lobbying, and the College opened its own office in Washington.

We realized that a good message couldn’t reach the ears, hearts, and minds of legislators without numbers and money. This was the birth of NEMPAC.

What was, and remains, largely unknown to most physicians is the incredible effect that the Relative Value Scale Update Committee (RUC) of the AMA has on directing money to emergency medicine. Mike Bishop, MD, FACEP, and others before him have represented EM at the RUC and have done an outstanding job.

As ACEP president, I was at the Reagan White House for the signing of EMTALA into law in 1986. In theory, EMTALA was to protect patient access to emergency care. The net effect to us has been more patients, and that means more opportunity.

We passed a law in California that precluded nonemergency physicians from testifying against emergency physicians in medical-malpractice cases. This was an effort to reduce risk and malpractice costs—again, a money issue.

The EM Landscape Today

One must ask who has benefited from all of these efforts. Arguably, society has as we have improved emergency care immensely, but more specifically, all physicians (and advanced practice providers) who work in emergency medicine have benefitted. Of note, in approximately 40 percent of visits to California EDs, patients are reportedly seen by physician assistants (PAs). They are clearly practicing EM and are not physicians, but PAs do a fine job and are a permanent piece of our workforce.

My experience suggests that, at least outside of major metropolitan areas, most emergency care is delivered by non–EM-trained physicians. Interestingly, they all have the benefits provided by ACEP but contribute nothing when it comes to “carrying the water” on regulatory and legislative matters. Freeloaders? I don’t think so. We’ve refused their help and their participation.

I work in a rural Minnesota ED with up to three physicians and a nurse practitioner on duty at many times. I started staffing my hometown ED in 1992, with the objective of staffing it with residency-trained emergency physicians. Even today, with a pay scale at the 90th percentile, there are only two American Board of Emergency Medicine–certified physicians working there. The rest are family practice trained and do a wonderful job. They may not possess all the knowledge of those trained in EM in recent years, but this situation illustrates two points: there is an ongoing shortage of residency-trained emergency physicians in rural America, and emergency care is delivered effectively every day by those not trained in emergency medicine.

Imagine our membership and lobbying numbers if we somehow included these physicians as members of ACEP in some unique category. We have many sections within ACEP, but they don’t add numbers or dollars because existing members are the only pool for section membership. A new section/category could be a substantive portion of ACEP membership. When Washington or Sacramento looks out on the horizon and sees a bigger group of physicians all rowing the boat together, our strength and influence will be notably enhanced while ACEP’s mission of continuing to improve emergency care will be more completely actualized.

We are recognized as a big player in the house of medicine as evidenced by the recent election of an emergency physician, Steven Stack, MD, FACEP, as president-elect of the AMA.

Any fear that we would lose what we have achieved by adding members who practice our specialty but are not EM trained is no longer applicable, in my opinion. Quite the contrary, I think our stature and effectiveness would grow.

As a past president, I’m often silent on such issues as I watch the College and specialty grow and develop. It’s time to break the silence. I ask that you consider my thoughts carefully as we move into the future as an established, well-respected specialty. We are only benefited by strength in numbers.

Dr. Stennes was ACEP president from 1985 to 1986.