Merit Badge Certifications and CME

…or, death by a thousand CME’s…

The Big Trend at my joint is Chasing Certifications. Yes, we’re a Trauma Center, and those that were here during that pursuit recall the extraordinary efforts (and monies) expended in that effort. Trauma Center Accreditation requires, inexplicably, ATLS certification of all the Trauma docs and EM docs who work in the hospital, plus semiannual ‘Trauma CME’. The ONLY thing that makes this even semi-tolerable is that the pain is pretty agnostic – the Trauma Surgeons have to jump through the same hoops, but it’s still terrifically annoying. (Why is it annoying? Because ATLS wasn’t meant for Board Certified EM docs working in Trauma Centers, it was meant for those practitioners who see trauma infrequently, and for whom it is a frightening novelty. Also, there hasn’t been anything significantly new in the EM practice of Trauma since RSI.) Finally, I had this training in residency, as did every residency trained, board certified EM doc.

Now, we’re being treated to the latest, a ‘Chest Pain Center Certification’. They want a set number of CME hours entailing Cardiac topics, and it’s Time to Draw the Line. Not that I’m against cardiac treatment or education, and if there’s a specialty that has an active journal set, it’s Cardiology. Unfortunately, this is a slippery slope, and it’s truly insulting to professionals in EM. Cards wants 10 hours a year of Cardiology CME (Trauma wants about 7 a year), so now 17 of my 25 state-required CME hours would be claimed. Nevermind I’m about to go to ACEP and would have a heck of a time finding 10 hours of cardiology specific programs to attend, and what would I miss while trying to attend cards CME primarily? The Trauma CME?

This isn’t a straw dog, this is reality, and here’s where the dog bites: our joint wants A Lot Of Certifications, and next is Stroke Center. Now add in another 7 – 10 hours of Required CME for Neurology, and you can see where this is headed: I’m going to have to quit my job to go all to the conferences to keep my job. This would be in addition to the EMCC required by my Board. And, what’s to keep every single specialty from laying on a requirement on the ED for all the docs to have ‘CME in our field’? None, at this rate.

So, here’s how I see it, and how I think it should be presented: I’m a professional, I am well trained and keep up with the literature (my board makes sure of it, yearly). I have to have 25 hours a year (minimum) of CME to keep my State licensure, just like every Physician on staff, and there’s the every two year Medical Staff reappointments to make sure we’re keeping up our end of the bargain. That should be plenty of assurance, and all the numbers required to fulfill any medical staff obligation.

Merit Badges make sense for Boy Scouts, but not for EM Professionals. Before you balk, consider your specialty and a requirement for 10 hours of EM CME a year…

AAEM statement on ACLS
AAEM statement on ATLS
Update 2-27: (via commenter Darren)
ACEP Statement on merit badges and specified CME


  1. Grunt,

    It’s a liability thing, don’t you get it?

    If you get sued for a patient who has a bad outcome after a resuscitation, how’s it gonna look if your ATLS has expired?



  2. Sorry, Flea, but I think you missed GruntDoc’s point. I don’t read his quibble as being with maintaining ATLS and ACLS certification (each of which just requires a one day re-test), but with the additional CME hours BEYOND certification.

  3. Actually, I’m against ALL merit badge courses as requirements for residency trained, Board Certified Emergency Physicians. Should you desire to take one of these courses, terrific! Just don’t waste my time by requiring a two day course on a subject I’ve been well trained in a 4 year residency education.

  4. Oops,

    I didn’t read carefully.

    Thanks, Lisa,


  5. All can say is, Amen brother!

  6. We took on the herculean task of getting ACLS/ATLS dropped from our credentialing requirements where we work. It took some politicking, and a lot of time feeling like we were tilting at windmills, but we did succeed.

    I wonder, how many hospitals still do require ACLS for ED docs? It pretty much felt like we were the only ones leading this particular charge.

  7. Gruntdoc, I have used the ACEP letter
    with regard to “merit badge medicine” to get hospitals to drop the requirements that we have every “advanced-take-up-your-weekend” course there is. So far it has worked. I have not seen much substantial change in the ATLS or ACLS curriculum in some time I keep up by reading the new recs in “Circulation”. The idea that other specialties should dictate our curriculum is BS. If Flea admits patients with chest pain or stroke should he also have all this additional CME as dictated per he Cardiologist or Neurologist? Keep up the good fight!

  8. >Just don’t waste my time by requiring a two day course on a subject I’ve been well trained in a 4 year residency education.

    Amen, especially with a course original designed and marketed for rural doctors (GPs and “moonlighters”) in the mid-west dealing with tractor injuries.

    Healthcare is entrenched with those that carve-out and create cottage industries for themselves.

    Fortunately, ACEP/AAEM statements on merit badges have worked fine for the last 10+ years.

    If you think ACLS really works — just go to any code on any hospital floor and you’ll be amazed at all those “ACLS certified” folks and the pervasive screw-ups. If you don’t use it — you loose it very quickly.

  9. You have my sincere and heartfelt sympathy. After years of repeating the same damned tests and covering the same damned material for institutional certification, I am sick and tired of it as well.

    But that isn’t going to change the minds of the special interest groups that push this stuff; as it has been pointed out there is money to be made in pushing this stuff on practitioners.

    We aren’t going to get out from this – it makes them money, and they figure all it costs us is time. Like we’ve got a lot of it to spare…

  10. Dr. Dagny T. says:

    GruntDoc, you are soooo right! As a surgeon at a Level II trauma center, I tried to avoid this by becoming an ATLS instructor. But I didn’t feel the need to be an ACLS instructor, didn’t have the time, anyway. Yet, at our hospital, I have to be credentialed in ATLS and ACLS and PALS … I feel nauseated with all this alphabet soup!

  11. You have forgotten to add the state-required CME courses on things like HIV and communicable diseases, child and elder abuse, methamphetamine abuse, HIPAA, drug interactions, workmen’s compensation and any of a number of other CME requirements imposed on doctors at the behest of special interests, not least of whom are the private companies that then sell the required CME courses at a hefty fee.

    I think I ought to impose a surcharge for state-mandated CME courses outside my practice specialty, just to bring home the point that this stuff costs time and money and delivers very little value in exchange. Naming names of state legislators who seem particularly swayed by these schemes and providing addresses and phone numbers of their offices would have to be part of the package.

  12. What exactly is going to be taught in 10 hrs of cardiology, which in all of medical school, residency, and just being on the job daily did not cover?
    Are these courses for learning the latest and greatest?

  13. The scary thing is that the CE burden will continue to increase (and not just in medicine, I’d wager)…and increase…and increase…after all, what organization would voluntarily “decrease” the amount of importance and influence that it wields over members?

  14. This touches on one of my aggravations about all this CME.
    It’s turned into an ever-increasingly expensive industry, fired by these regulatory presumptions that you cannot learn anything on your own anymore. But all you have to do is show up for the CME at some expensive resort and the presumption is that if you spent all that money you must have learned something.
    And it seems that many of those who feel this is so important are those who get free trips and honoraria to teach the courses. So I’m supposed to learn from this “expert” in something who may be on a faculty somewhere, but has just been out of training for a few years.

  15. Another thing, which has only just occurred to me, is that once we’re “Chest Pain Center” accredited, it’s not going to change a thing in what we do.

    We already see CP, our door-to-balloon times are very good, etc.

    This is about Marketing with a capital M, and it’s about ‘we jerk the string, you dance’. That’s what’s galling me about this.

  16. Re: “This is about Marketing with a capital M, and it’s about ‘we jerk the string, you dance’.”

    Definatly. And who eventually pays the costs? The patients do. Debates in Washington and pushes for a national health program so that everyone can afford health care looks rediculous.
    Instead of streamlining (responsibly…recycling exam gloves wouldn’t be wise, me don’t thinks) health care and making it as affordable as possible, more programs are added.
    I think if a doctor, or nurse, or even the janitor has a past showing he/she knows what she’s doing and is taking very good care of their patients then a badge or a certifcate won’t matter.
    Well, unless someone has no idea of how to pick out art but needs office walls decorated with *something*, then maybe it matters to them.

  17. The people that create these courses and lobby for them to be made mandatory are the real benefactors. Wouldn’t they be unhappy if evidence-based medicine methodologies were brought to bear on the efficacy of such courses?

    I seriously doubt that their proliferation has been shown to improve patient outcomes in any demonstrable ways.

    I’ve written a little about this before here.

    I’m all for making things better but I think more thought needs to go into making substantive changes in the way we do business. These little rules all add to the “hidden” costs of healthcare and detract from our enjoyment of our profession.


  18. By the way, I didn’t mean to imply that courses like ATLS or ACLS are not important. I’m only criticizing the manner in which they’re made mandatory. As the GruntDoc has noted, that’s what needs to be thought out better!


  19. Docs are the same as anyone else– they need continuing ed. Too often you guys think you are above the standards. I have worked in the medical field for many years and I can tell you– doctors who don’t keep their education up-to-date abound and are not in the best interest of the patient. Come down to earth and get with the program. You are worth it.

  20. To the poster above. No one here is against continuing ed. We are against mandatory continuing ed propagated by others with an “agenda”, or mandatory ed that we already know. Would you have me waste my time with merit badges at expense of improving knowledge and skills in other important areas??

  21. Hey! We nurses have merit badges, too! Most are not required, but at my most certified state, I have BLS, ACLS,PALS,TNCC,NRP, ENCC and now I can take ATLS and of course I can sit for the CEN exam which costs a lot and pays me nothing extra except for an ego boost and more letters on my nametag!

    Granted, it’s not the same as your situation, I just never thought of them as “merit badges” before and that is hilarious!


  1. symtym says:

    Merit Badges

    Excellent discussion on the "to be detestable" subject on merit badge CMEs over on GruntDoc, see "Merit Badge Certifications and CME"