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Hot Topic: Certification Of ER Doctors

Texas is at the center of a heated national battle over the training emergency physicians need in order to advertise themselves as “board certified.” Via the Houston Chronicle:

At stake is the welfare of patients requiring immediate medical attention. Leaders of the traditional board say allowing physicians without proper training to advertise themselves as board-certified would mislead the public. Leaders of the alternative board say the proposed rule change will undermine the ability of Texas’ rural hospitals to staff their emergency departments with board-certified ER physicians.

A final verdict may only come, given one board’s already delivered threat, in a court of law.

At stake also are the careers of a lot of practicing Emergency Physicians, many of whom I’m proud to call friends and colleagues. (And it’s not just docs at rural hospitals, they’re in nearly every ED in Texas, and your lesser state).  They practice high quality Emergency Medicine, and I have no qualms about the practice of those who are alternately boarded.

I’m a residency trained, BCEM doc, so I’m in the group that’s considered Board Certified by definition.  I’m also still in the minority in US ED’s.  The majority are ‘alternately trained’ docs, the vast majority of whom always wanted to practice EM but either there was no such training when they finished med school, or the few EM programs were full.

Most are FP or IM trained, have worked hard and have been and continue to be ED and hospital leaders.  Again, I’m proud to have them as friends and colleagues, and have no questions as to their abilities.  They’re not interested in practicing EM for a few years then establishing a private practice somewhere, they’re EM docs, who didn’t do EM residencies.

In an ideal world would I like all docs in the ED to be residency trained as a requirement?  Yes.  Is that at all practical?  Not unless you want to close a whole lot of ER’s across the country, and the rural ones (where there is arguably more need for an EM doc who knows what they’re about) would be the first to go.

EM is either the newest or the second newest specialty in medicine, and for a primer on the brief history of EM, look here, (and there appreciate the spirit and the gamble that made my specialty):

Unlike the residents of today, those physicians who pursued Emergency Medicine residency training in the early 1970′s faced an uncertain future. They had no opportunity to be certified by a specialty board, and had no guarantee their chosen field would persist. They were pioneers and mavericks in spirit and action.

Now, about the Board Certified thing…

The reason this is an issue is the recognition that physician credentials are important (they are), that it’s desirable for physicians to be Board Certified in their chosen specialty field (it is), and the public is becoming more sophisticated about who’s trained in what (good). The reason this is a problem is that as of now the only ‘officially approved’ path to Board Certification in EM is to complete a residency, as the ‘practice track’ to grandfather other-trained docs closed in 1988.  It had to close eventually, there would always be some people stuck no matter the chosen date, but it’s done.  (I now think it was closed too early, but that’s not under my control).  Every medical specialty has had the same issue, the conversion from docs who filled a need to specialty-trained specialists in their field.

In 1990 Texas had one EM residency, taking either 6 or 8 residents per year (3 year program) in El Paso.  Texas then had a population of nearly 17 million.  Most EM docs I know work hard, but that seems like a pretty steep workload for those 6-8 grads a year.  (There are now 8 residencies in Texas, with at least one more opening in 2011).

Therefore, Texas ED’s have been staffed (mostly) with other-trained docs who only wanted to practice Emergency Medicine.  A few did the then accepted thing of working ED shifts to supplement their income while they built a private practice then bowed out of the ED, but most didn’t.  Most worked, many ‘grandfathered’ into a specialty that literally developed as they practiced, and more and more residencies in EM started.

So, the practice track closed several years ago when there were nowhere near enough EM training programs for the demand.  These docs worked hard, but needed to demonstrate they were EM pros.  Enter the ABPS which provides Board Certification through an alternate pathway, thus they’re often referred to as ‘alternate boards’.  per their website:

must have practiced Emergency Medicine on a full-time basis for five (5) years AND accumulated a minimum of 7,000 hours in the practice of Emergency Medicine and maintained currency in ACLS, ATLS, and PALS.

In any career, if you’ve been able to do it for 5 years full time you’re good enough to be recognized as able to do it long-term.  Alternate boards are the only path open to anyone who practices EM but wasn’t grandfatherable in the late 80′s.

(My issue with alternate boards is those 5 years of independent practice as an EM doc without EM training, which I’m not a big fan of, but I cannot come up with a reasonable / workable alternative.)  (And stop it with the ‘they should go back and do an EM residency’: it’s economically unfeasible both for the residency and the doc, and that would cause a shortage of EM docs as they’d be a) in residency and b) taking slots from new med-school grads who also want to do EM).

I think Texas should accept ABPS Boarding of EP’s for the foreseeable future, with the recognition that in 10-20 years it’ll need to be re-addressed as the number of residency grads is able to take up the slack in US ED’s.  There should not be a permanent need for an alternate pathway to EM boarding.

Pragmatism and practicality aren’t dirty words, they’re how life is lived, and in the ED they’re how lives are saved.  Let’s keep our experienced Emergency Medicine physicians.

Update: reminded by the comments, the standard should be residency training in EM for anyone getting new Board Certification today.  The above argument applies, IMHO, only to those who are already alternately boarded (and yes, there’s another group that’s excluded…)

*This blog post was originally published at GruntDoc*


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