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.

There is no doubt that the best way to develop the skills to practice emergency medicine is through EM residency training and board certification.  However, unless there is a significant increase in the number of EM residency positions ACEP will never be able to accomplish its mission of advancing emergency care. In addition, non-EM certified physicians can benefit from resources such as educational opportunities and research endeavors that are aimed at their type of practice. ACEP’s advocacy resources can also empower them to champion emergency medicine in their communities. It is by enhancing the skills and supporting the work of all physicians who are able to demonstrate a dedication to emergency medicine that ACEP’s mission can be realized.

Whether or not these physicians are ACEP members, they are the backbone for emergency care in certain areas—they are part of the emergency medicine workforce.

They should be part of ACEP.

—Donald L. Lum MD FACEP
Chair, Emergency Medicine Workforce Section

I am a family medicine board certified fulltime, life-long legacy ER physician. I am also ER medical director and hospital chief of staff and facility ER director for our 54,000/ year high acuity ER. I am an ACEP, but not ABEM, member, as I have been excluded in spite of my lifelong work in a high acuity, high volume, and high intensity ER in Phoenix, Arizona. I’m confused by the discussion, as I am a non-ER boarded ACEP member (although I lack the ABEM pedigree) but certainly believe the association, not the college, represents all dedicated fulltime ER practitioners based upon quality of ER and acute or critical care expertise and skills, and support those with similar clinical competency being included in ACEP.

—Mark E. Sexton, MD
Phoenix, Arizona

Sorry, Dr. Radtke, but I have to vote for the big tent approach. I come to this position not by reading the words but by watching the actions of leadership.

I am one of those 30-year veterans of the early days. I boarded many years ago and have maintained my knowledge base. I am proud of our specialty and contribute to it in time, talent, and treasure.

I noticed over a decade ago that non-EM boarded physicians were claiming to be EM boarded by declaring EM as their specialty. (These same non-EM boarded physicians deliver babies but do not claim OB/GYN specialty.) These claims reside on state and federal sites, including members of Federation of State Medical Boards and the Centers for Medicare and Medicaid Services. The American Board of Medical Specialties is aware.

The claiming of boarding falsely has implications far beyond our specialty, of course. This is especially dangerous, as the sites hosting these claims are licensing and governmental. Communication with some of these boards has resulted in nothing, as our official bodies do not object.

Our ACEP has refused to take up the defense of our “trademark.” In this setting, how can we hold both positions? Anyone can claim to be EM boarded, using a governmental site. But our college would refuse membership to the same physicians who claim boards they don’t have.

The cognitive dissonance boggles the mind.

—Thomas Benzoni, DO, AOBEM, FACEP
Sioux City, Iowa

I read the pro and con arguments for opening ACEP to all physicians who work in EDs vs keeping membership to those who are actual emergency physicians. I understand the advantage of opening membership; it swells numbers. That has its advantages, but who are we as ACEP? Who are our colleagues?

40 years ago, it made sense to open the borders, if you will. However, we are now a recognized specialty. We have a body of knowledge that ostensibly represents our expertise. We have the advantage, in many hospitals, of not being required to maintain “merit badges” such as advanced cardiac life support, basic cardiac life support, advanced trauma life support, and the like. Why is that? Why do the non-EM docs who work in my ED occasionally have to maintain these certs and I don’t? Could it be because, as a board certified EM physician, it is recognized that I have earned the right to be called an emergency physician—a specialist in emergencies and resuscitation? Do general surgeons typically do cardiothoracic surgery or is a cardiothoracic specialist called in?

There was a time, not too long ago, when those who blazed the trail of EM for the rest of us had a window where they could sit for the American Board of Emergency Medicine/American Osteopathic Board of Emergency Medicine board and grandfather in. There was recognition that it was only fair to allow those who never had the chance to train formally in EM to join the ranks of the board certified. A couple of them I am honored to call my colleagues at my home shop, and they are great docs. However, that window closed in 1988. Now there is no excuse for not being residency trained. Board certified means something, doesn’t it? I understand that there are those who work in EDs full time and started after the window closed. I mean no disrespect to these great docs. However, at some point we have to decide what the future will look like. I suspect every new specialty goes through this transition.

When I was a medical student, I considered family medicine (FM) as a residency, but I wanted to be able to treat emergencies and keep up with the latest in life-saving techniques. My faculty and mentors in the family medicine world told me, “It’s OK, you can do an FM residency but still moonlight in the ED.” As I got closer to declaring my residency desires, I found by talking to more and more EM physicians that that advice was not entirely accurate. Sure, a family doc could moonlight in a small, rural ED. But if I wanted to treat trauma, overdoses, arrests, and higher acuity, EM was the only preparation that would get me there. I committed to my specialty. Why should those who did not commit to our pathway reap the benefits?

Should we extend membership in 2014? Well, perhaps.
Does the American College of Surgeons have non-surgeons as members? Doe the American College of Physicians have non–internal medicine docs in their membership? They do…as affiliate members only, according to their sites. I would be OK with ACEP allowing non-EM docs to join our membership, but as observers. If ACEP would extend affiliate membership to non-EM docs, I think that’s not unreasonable. However, it should be clear that such membership would never lead to Fellowship or voting privileges. These stipulations should be codified unambiguously. Otherwise, my vote is a resounding “no.”

If so many are concerned that there aren’t enough emergency physicians to man the rural EDs, maybe we need to increase the number of EM docs. Maybe the medical students that have interest in FM/IM and EM should consider committing to one specialty or do a dual residency.

I also would like to suggest a policy idea for ACEP to champion: Perhaps, if safety/quality is the big concern, as intimated by the “pro” article in this month’s ACEP Now, maybe there should be a rating system for EDs, like there are for trauma centers.

As an example, Level 1 would be an ED where the public knows that each and every physician working in that ED is a board-certified or board-eligible emergency medicine specialist. Level 2 would be where greater than, say, 80 percent of the physicians are EM boarded or eligible. Level 3 is an ER from the past where there may be good physicians working there, but they are not held out to the public as emergency physicians. Trauma goes to non trauma centers, but there is recognition that the more severe trauma should divert or be stabilized & transferred. Just a thought…

Respectfully,

—Larry Goldhahn, MD

What’s missing in this conversation is the topic of what the core skill is in emergency medicine. Consummate emergency physicians are masters of management as a whole, not just differential diagnosis or doing procedures. Leadership and management define the core of EM, but our residency programs and professional societies have so far not embraced this philosophy. Because we haven’t done so, we are a fractured specialty. We argue over who really is an EP and who deserves to be boarded without being clear on who we are to begin with.

If we embrace this philosophy and act on it, we will take our specialty to new heights as leaders in health care. It is something we sorely need in today’s health care climate.

I commented extensively on this in an article written last year: http://www.kevinmd.com/blog/2013/09/leadership-management-define-core-emergency-medicine.html.

—Anoop Kumar, MD

It would be helpful to recognize that ACEP is not solely a political organization advocating for those who are being trained by the current model. I believe it short sighted to assert that learning can only occur one way. Training is not the only way to create a mindset and approach to quality. I believe ACEP should be advocating for the physician on the front line at the critical access hospital who was trained as a family physician but felt the pull to do emergency medicine. Does ACEP become stronger by excluding that physician from membership or dialogue. To suggest that emergency medicine cannot be learned any way but the way I learned it is dangerous for our patients and our college. I suggest that those advocating an isolation position walk in the shoes of those they wish to exclude. Probably can’t be done in the halls of a big city academic institution.

—Ed Boudreau, DO, FACEP, FAAEM

I’m personally against allowing non-emergency medicine–certified physicians acceptance into the College.

Why can’t I get acceptance into the American College of Surgeons? Or Cardiology? There are plenty of regions throughout the country that are in need of specialists and the services that they provide. This is hardly a problem unique to ER and, pardon my sarcasm, a lousy reason to allow someone admission into what is supposed to be a crowning achievement.

I’m a pretty smart guy. I know my anatomy, I am procedurally adept, and I learn fast. Furthermore, all specialty books and procedures can be found online on YouTube. I can learn on the job just like anyone else. So why can’t I just start practicing?

What? You mean to tell me that even if I began practicing in some rural area where no specialist wants to go, performing successful cardiac caths, appendectomies, etc., I still wouldn’t be “accepted” into their college? Strange, that is.

The fact is all other specialties would (appropriately) scoff at the idea that I be accepted as an equal into their college without formal training. You can’t lower your standards just because there is a shortage of board-certified physicians—in any specialty. If we did, it would basically undermine everything our predecessors fought for (and we still do) in order to be considered something beyond simple triage monkeys. To do otherwise essentially says that anyone can do this job. And if that’s true, then why go through residency? And if you’re the hospital, why spend extra money on a “board-certified physician” when it’s own College states that non-emergency medicine–certified physicians have the same rights and privileges as those that are?

—Kurt Kaczander, DO
Laingsburg, Michigan

YES! Open membership to all those who practice EM.

—Saul F. Weinstein, MD, FACS
Jacksonville, Florida

I do not think that we should allow nonboarded physicians to be members of ACEP. I am not a member of the College of Surgeons or any other specialty because I am not a surgeon or any other specialist. Do we think that EM board certification stands for nothing? Why have it if it means nothing? Start another group called doctors who staff EDs if you want every licensed physician to join. Emergency medicine is a specialty and should be maintained as one, and our College should be just that—our College.

—Charlene A. Doyle, MD
Johnson City, Tennessee

The major reason to consider opening ACEP membership to non-boarded physicians is that it is best for the specialty and for our patients. The editorials by Dr. Smith and Dr. Radtke are both articulate and rational. They both wisely recognize that the issue is not about board certification, it’s about membership. Debates over board certification are part of our past and shouldn’t affect this issue.^1,2 In the early years of our specialty’s development, there may have been reason to be paranoid about our scope of practice, but we should now be proactive about what is best for the specialty and for our patients.

The question is not what is best for me or you or for these physicians. (They don’t care. I can say this for certain because I am, or at least was, one of them.)³ Most see ACEP—and all other EM professional organizations—as self-serving and self-protecting. But if ACEP wants to do what is best for our specialty, and for ED patients, there are compelling reasons to reopen membership.

Dr. Radtke correctly identifies that “there is a distinction between being an emergency medicine physician and being a physician who practices emergency medicine.” (Bold added for emphasis.) Emergency physicians who are residency trained in EM are true specialists in EM. Maybe we need new terminology to make this clear, but most physicians, and certainly most patients, care less about titles than competence. For example, rural EDs are still dependent on physicians who trained in family medicine, and many of these physicians are family physicians who provide emergency care who don’t care about a title. They think of ACEP as an elitist organization. Dividing the workforce of EM into categories of us and them is not a new idea, and it is part of the reason that the history of EM included a stage where there was intense controversy over who was an emergency physician.

Emergency medicine has expanding scopes of practice, many of which include on-the-job training (eg, critical care, hospitalist medicine, palliative care, urgent care, etc.). But the phrase “on the job training” is a dysphemism that minimizes many important issues in medical education. Lifelong learning is crucial for all physicians, and unlike the pioneers of EM in the 1970s, many of whom did not complete a residency, the majority of non-ABEM-boarded EP’s are residency trained in other specialties.

Both Dr. Smith and Dr. Radtke alluded to the workforce data that compel us toward more evidence-based workforce policies. The 2006 Institute of Medicine report on EM made it clear that more collaboration with other specialties was essential to meeting rural EM needs. Physicians who provide care in rural EDs make up a small percentage of the workforce but are almost completely excluded from mainstream EM (academic and organizational). “Improved access to high-quality emergency care for all acutely ill or injured patients across the entire United States” needs to be our goal.⁴

EM is now a well-recognized specialty, and adolescent angst about “turf wars” should be part of our past. As our specialty evolves to include broader scopes of practice, we need all physicians who provide emergency care to be part of our organization. As Rick Bukata recently wrote: “We need ALL emergency care physicians to be involved in ACEP for the sake of EM advocacy…Let’s follow the lead of other medical societies…[that] allow some sort of membership for non-boarded physicians. It’s also the right thing to do because we need to provide more support to our colleagues working in rural areas…It makes practical, fiscal sense, and it’s the right thing to do.”⁵

What is best for our patients or for the specialty? Dr. Radtke is correct that the financial benefit of open College membership will be minimal. But can we afford to exclude colleagues who work alongside us for the sake of our values and commitment to representing all emergency physicians? And, most important, our patients (in the EDs of the entire United States, including rural areas)? Dr. Smith is right in stating that “we shouldn’t invite them to join, we should ask them to join.”

—W. Anthony Gerard, MD, FACEP
Elizabethtown, Pennsylvania 
 

References

1. Sciammarella J, Gerard WA. The credentialing debate: on the outside of the house of emergency medicine looking in. Ann Emerg Med. 1994;24:293-295.
2. Wicher JA, Cummings I, Gerard T. On credentials and manpower in emergency medicine. Ann Emerg Med. 1993;22:1492-1496.
3. Bullock KA, Gerard WA, Stauffer AR. The emergency medicine workforce and the IOM report: embrace the legacy generation. Ann Emerg Med. 2007;50:622–623.
4. Ginde AA, Rao M, Simon EL, et al. Regionalization of emergency care future directions and research: workforce issues. Acad Emerg Med. 2010;17:1286-1296.
5. Bukata R. ACEP, open wide the gates. Emergency Physicians Monthly. Available at http://www.epmonthly.com/features/current-features/acep-open-wide-the-gates. Accessed September 2, 2014.