Scalpel comment on "Qualifications"

I started a blog comment, and it got to be a rant.  Rants are a blogger’s best friend, so here it is:

The original post begins:

I suppose I should finally admit something to all of you. I am considered by many to be unqualified for the work that I do. Whether I am capable is open to debate, but the fact that I am unqualified is an inarguable fact which is etched in stone to many people. Perhaps unqualified is too strong a word. A better term would be uncertified. Unfortunately, I will never be able to demonstrate whether or not I am capable to those who could certify me as “qualified” if they so desired. Let me explain.

My comment:

As any specialty initially flowers it is populated without regard to training or experience, especially when the specialty is so young as to have no idea what training or experience is needed. That’s been the pattern since medicine began, and will continue. Emergency medicine has been no different (anesthesia was the latest to go through this on a large scale, as I recall), but is the most recent.

The certification problem comes when the specialty matures, training standards are outlined and agreed upon, and residents are taken aboard to pursue the specialty. There is now a built-in schism between those who began, grew and advanced the specialty and those trained to do it, based on the training and skill standards learned the hard way (by the patients) but designed into the training of new grads.

So, initially residents are actually very well educated but only mildly experienced and a much larger cadre of wildly differently trained but variably experienced physicians exist in the ED’s. Initially (1970’s, EM is a Very Young Specialty) there were a few training programs, and thay had no hope of turning out the number of graduates needed to fill all the ED’s in America this year, or decade, but now (2006) there are finally enough programs to turn out trained, qualified Emergency Physicians for the ED’s. This conversion has taken some of the 70’s through today, and has been relatively quick by most medical training standards.

There was a pathway to EM board certification through the 80’s, to ‘grandfather in’ those who had done the ED work but had not the specialized training from residency. This pathway required a lot of practice (something like 10,000 hours, etc.), but was pursued by many. Again, like all specialties, the practice path eventually closed (after a couple of year’s warning; this closure resulted in a lawsuit against the American Board of Emergency Medicine, the ‘Daniels suit’ that was only finally dismissed last year).

And, inevitably, there are those caught between twixt-and-tween, those who decided a career in EM was for them but an EM residency wasn’t within reach, either due to prior training, or lack of opportunity, take your pick, and the practice track had closed. Unable to grandfather in and unable or unwilling to go back to training, and stuck, usually in the velvet handcuffs of income, they soldier on. If residency paid what practice did this wouldn’t be an issue, but it doesn’t, so it is. These physicians will hopefully finish their careers in the ED, usefully. They shouldn’t let their original board certifications expire (we just lost a good 70’s EP because he wasn’t Boarded in anything; a competing ED started a very big ‘all boarded’ PR campaign, and my colleague was forced elsewhere).

For the record, I’m a Fellow of both ACEP and AAEM, and believe all new-hires in any ED should be EM residency grads. The training and standards exist for a reason.


  1. I’m a Family Medicine resident who strongly considered EM, and I’m interested in hearing what you think about non-EM physicians seeing the non-critical patients in an ER. The hospital where I’m traning has a “Fast Track” area of it’s ER where all the URI’s, abscesses, simple fractures and lacerations, “my tooth hurts,” “something’s stuck in my eye,” vaginal discharge etc. are sent. This side of the ER is mostly staffed by Family Physicians (who are graduates of my program), and sometimes by Emergency Physicians.

    The shifts I’ve done in Fast Track during my ER rotation were the most fun I’ve had in residency. Sometimes a P.A. shift will open up, and residents jump at the opportunity to moonlight. The nurses and P.A.’s have expressed to me that the FP’s do a better job in Fast Track because of their speed and Peds experience. And of course, patients can be transferred down the hall if they are more sick than the triage nurse thought.

    What is your view on the role of non-EM physicians in an ER, seeing the simple stuff?

  2. Fortunately, not everyone agrees with you. Because of the transient nature of our work and the fact that many of us work at multiple facilities (either to supplement income or to broaden our practice experience) there exists a broad “good old boy” network in the sense that many of us know each other. That helps a bit. Plus the fact that many ABEM types just don’t want to bother with some of the smaller jobs. There’s still plenty of places to work.

    Heck, my own facility even advertises that our doctors are board eligible or board certified. They just don’t say in what specialty or specify if we’ve recertified.

  3. Scalpel,
    Sorry about not being clear in my last two sentences; I mean what I wrote but it’s a little more nuanced than that (and I don’t like the word nuanced).

    What I meant to say was “New EM doc hires should be EM residency grads or be one of these very-experienced physicians with different training, not a new grad from another residency path”. I’m not in any way for a ‘purge’ of non-residency grads from ED’s, that wouldn’t make any sense from a fairness or manpower standpoint.

    Eventually this will be taken care of by hospital credentials committes, and I don’t envy them that shift of targets (and by eventually I’m talking 20+ years). In the mean time, I enjoy working with my differently-trained colleagues in the ED.

  4. Matt, Hmm. I think if you come to an ED you should be seen by an EM specialist, whether it’s for your stubbed toe or whatever.

    (In a perfect world these cases wouldn’t be in an ED anyway, they’d be taken care of in a primary care office, where they belong).

    This doesn’t mean I’d be unpleasant about any such arrangement, but I have a cautionary tale: I also work in an ED that dissolved its FT in order to get more beds for the main ED, which was good for the patients (the paradox of FT triage is that you can be too sick to be seen quickly, but the stubbed toe can be seen immediately).

    Anyway, this ED now has more beds but the same staff, primary care trained who are now expected to see everything, including the sicker patients. They aren’t happy about it, they’re uncomfortable with it, but it’s that or go elsewhere. Interesting development.

  5. I appreciate the clarification, and I agree with you to a point. Though the patients are sicker, it’s actually easier (and safer) for someone coming from an alternative specialty to start practice in a major academic ED with lots of backup as opposed to a more rural ED without the ability to call a specialty resident consult to help fill in some of the knowledge/procedure gaps. A big academic place is more likely to have a “pedi ER” for example, or in-house anesthesia backup for tough intubations.

    Unfortunately, it is becoming the other way around, despite the persistence of the manpower deficit for residency-trained/boarded ER docs. Smaller, more isolated ERs are the ones more likely to accept alternatively-trained physicians. And that is the fault of ACEP/ABEM. They closed the practice track too early, and their policies (while beneficial to the specialty in the long-term) are compromising patient care in the short term.

  6. Scalpel,
    we’re on the same side here, and thanks for letting me clarify.

    It’s undoubtedly true that residency trained docs aren’t taking the jobs they’d be best at, the rural ones without good backup, for exactly the reasons you’ve outlined. (Ditto the PA’s, remember the justification as a need for help in the hinterlands? Some do (TundraPA springs to mind) but most like living with amenities like the rest of us).

    But, I don’t get how reopening the practice track would fix the staffing of ED’s with alternately trained docs. Can you explain that assertion?

  7. Extending the practice track is simply the right thing to do until there are enough residency-trained EM docs, but that wouldn’t necessarily homogenize them to all EDs. My beef with ABEM closing the practice track too early is separate from my beef with their other restrictive policies.

    When ACEP’s official policy states that “At a minimum, those applying for privileges as emergency physicians should be eligible for ACEP membership” (meaning residency training or ABEM certification), you have to admit that this is designed to weed out even very experienced ER docs who happen to move or change jobs. How fair is that? If that recommendation were followed by all facilities, then that would mean that currently practicing ER docs must keep their current position forever or find another profession.

    These exclusionary policies are being primarily followed only in the larger/academic centers, reducing the ability of alternatively-trained would-be ER docs to obtain further experience prior to the time when those of us are eventually forced to the smaller centers.

  8. Scalpel,
    I was reading the application for ACEP membership, and wonder if there’s not an ‘in’ for you (emphasis added)

    PLEASE NOTE : Applicants for Active Membership
    must be board certified in emergency medicine by
    the American Board of Emergency Medicine (ABEM),
    American Osteopathic Board of Emeregency Medicine
    (AOBEM), or in pediatric emergency medicine by the
    American Board of Pediatrics (ABP), or be residency
    trained in emergency medicine, or completed a
    subspecialty training program in emergency medicine,
    or meet eligibility requirements for membership prior
    to January 1, 2000.

    So, were you eligible on the practice track before 2000?

  9. I’m not sure what the eligibility requirements for ACEP membership were prior to 2000, so I have no idea who they are trying to include with that statement. I probably had 8,000 hours of full-time ER shifts by that date.

    In the current situation, being a member of ACEP wouldn’t really benefit me much anyway, and I can’t see paying dues to an organization that doesn’t have my best interests at heart.

  10. I’d guess it’s the 7K hours and 60 months of practice cited at the bottom of this page.

  11. Actually, they were less restrictive than that, I just discovered:

    “Qualifications for active membership prior to January 1, 2000 were fairly simple: The active members of the College shall be physicians who devote a significant portion of their medical endeavors to emergency medicine.

    In essence, if a physician was employed as an emergency physician prior to January 1, 2000, that physician is eligible to join. Obviously this change provides opportunities the college hasn’t had during the past five years.


    I’ll have to reconsider my position, I guess.

  12. Well, it looks like I have had some misconceptions about ACEP, and I appreciate your bringing them to my attention. ACEP supports physicians like myself who began the practice of emergency medicine prior to the 21st century, according to their legacy page.

    I can find no reason to disagree with any of their policies, and I appreciate their support. Now I’ll have to cough up the $515 to join them, I guess. I just renewed my Annals subscription, too. Bummer.

    Thanks, GD.

  13. It’s been my pleasure. This doesn’t fix the Board Certification problem, but being an ACEP Fellow would help come job-switching time.

  14. You know you’re warped when the word legacy makes this pop to mind:

    Hoover: Kent is a legacy, Otter. His brother was a ’59, Fred Dorfman.
    Flounder: He said legacies usually get asked to pledge automatically.
    Otter: Oh, well, usually. Unless the pledge in question turns out to be a real closet-case.
    Otter, Boon: Like Fred.

    maybe it’s just me, or that I’ve been up all night.

  15. For the record, I’m a Fellow of both ACEP and AAEM, and believe all new-hires in any ED should be EM residency grads. The training and standards exist for a reason.

    Why do you belong to both, rather than either one? I’m just curious, particularly when I just finished reading (with a grain of salt, mind you) “The Rape of Emergency Medicine” from the AAEM web page.

    By the way, the new HTML buttons seem to work just fine. :)

  16. It would appear from my cursory review of the AAEM site that they are less hospitable toward legacy docs than ACEP. Am I reading them correctly?

  17. Geordon,
    I’m a member of ACEP because they’re the “Big Tent” organization of EM. I’m a member of AAEM becuase they’re more supportive of the individual docs, having gone to bat for several individual EM docs and at least one group over unfair contract issues.

    Which brings me to answer Scalpel’s question, and the answer is that while AAEM is not hostile toward legacy docs in the ED, they want to make residency training / ABEM/ABOEM certification the standard, and as soon as possible. I think their aim is ultimately correct, but their timeline is somewhat short.

    Plus, I cannot see a reason (if eligible) to be a member of one and not the other.

  18. All I saw on the AAEM site was them repeatedly saying “the standard is board certification.” Although they admit that there is a shortage of boarded docs, they don’t even give a polite nod to those of us who aren’t.

    Now obviously I’ve been wrong before, and recently, so correct me if I’m wrong. But it sure doesn’t seem like they are going to bat for me or my leprous brethren. Ignoring us is the same as shutting us out, and my previous statement applies to them: why would I give them money if they want to exclude me from work?

  19. You shouldn’t give them any money. Their primary interest is the residency trained, BC EP.

    You are being shut out in that you cannot join AAEM, correct. I don’t know if they’d go to bat for you or not, frankly, I don’t know the gritty details of the cases they’ve been involved in.

  20. Fortunately, it looks like I’m not eligible anyway. I’d forgotten how expensive all these societies are.

  21. Hi, Our hospital has had to deal with this issue on an up close and personal level for the community and the medical staff. If you read my post “Disposable Doctors” on you’ll see where I, my colleagues, and our patients stand. ACEP allows the non-ER trained and non-ABEM certified docs to join, but they are treat them like second class stepchildren and they do not advocate on their behalf at all. So save your money Scalpel!