Our pro-con on “The Big Tent of Emergency Medicine,” which examined the benefits and drawbacks of requiring certification in emergency medicine for ACEP membership, drew an overwhelming response from readers. Here are just a few of the letters we received.

Email acepnow@acep.org with your thoughts to keep the debate going!

I am glad that ACEP Now is publicizing the membership issue for non-EM certified physicians, because the Emergency Medicine Workforce Section leaders continue the hope that ACEP may once again represent all physicians who practice emergency medicine in this country.  Indeed, this was the case in 1999. This is a good time to revisit that cut-off as the same workforce issues continue 15 years later into the new millennium.

This time period reveals two critical realities: the rural/urban disparities in resources for emergency care and the persistence of a hybrid workforce.  In the pro article, Dr. Williams points to the patients and the public—small town, rural, and remote communities—who are served by these physicians. In the con article, Dr. Radtke considers that, while these physicians who work in emergency care without EM specialty training are “dissimilar,” they continue to be needed to work in underserved areas. We would agree with both points.  Relative lack of hospital resources in low volume EDs—access to specialists, distance to tertiary care and ICU care—results in even greater reliance on these physicians for evaluation and management for serious medical problems and trauma stabilization. Non-EM certified physicians continue to be a fact of life for the foreseeable future. Yes, these physicians are dissimilar in that they have often come out of a primary care residency path, which includes a variable number of obstetrics, internal medicine, pediatrics, and ICU, as well as ED, rotations.  They share a different perspective, as they often practice in small town, rural, remote, and critical access hospitals with challenges in limited hospital resources, pay, and recruitment. Nonetheless, if you or I were to suffer a major trauma or illness while on vacation in any of these areas, we would depend on that common core of ED knowledge and skills to protect our airway, maintain our circulation, and stabilize our injuries/conditions prior to timely transfer to a level one trauma or tertiary care center.

Let us be clear about who these non-members are: physicians who did not complete an emergency medicine residency or obtain American Board of Emergency Medicine board certification but began to devote a significant amount of their professional time in the practice of emergency medicine after December 31, 1999. This cohort, age 29–43, by and large, is replacing older physicians who are retiring in smaller community, rural, remote, and critical access hospital EDs throughout the country. The issues raised about the training, education and skills of physicians practicing in these EDs rightly must continue to occupy not only ACEP’s scrutiny but also its advocacy and resources. Their work in resource challenged areas can lead to a fruitful dialogue about innovative ED care teams and regional approaches to emergency care. Our section leaders are resolutely committed to providing a place—including membership—for this physician cohort to participate in ACEP. The EM Workforce Section continues to examine the state of the workforce and the role that non-EM certified physicians and advanced practice providers play at present and into the future.