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.
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).