Last month, Rick Bukata suggested that ACEP open its gates to non-boarded EPs. This would be an insult to EM residencies, and would set our specialty back decades.
Last month’s editorial by Dr. Rick Bukata re-ignited the debate over the role of board certification in emergency medicine. The American Academy of Emergency Medicine’s (AAEM) position has not changed in our 21 years of existence — you must be board certified to become a full-voting member and fellow of AAEM — period. AAEM has no control over how other EM organizations classify their members. However, we feel a call for other organizations to open their membership up to non-board-certified physicians is a step in the wrong direction. Since AAEM’s inception, supporting the value of board certification has always be a core part of our mission.
The first emergency medicine (EM) residency began 44 years ago. It has now been 38 years since the American Board of Emergency Medicine (ABEM) was incorporated. Progress in EM, as well as any other specialty, demands rising standards that evolve into formal training being the only legitimate route to certification. By the time ABEM closed the practice track in 1988, after a 10 year grace period, there were enough excellent training programs that a practice track no longer made sense for our evolving specialty. We are now at the point that the practice track was closed before many of our EM residents had even been born. We have had more than 100 EM residency programs for twenty years now. Today, there are at least 209 EM residencies (allopathic and osteopathic), graduating in excess of 2,000 residents a year. It has been 24 years since Dr. Gregory Daniel sued the American Board of Emergency Medicine (ABEM) for restraint of trade, seeking to re-open the practice track — the suit was dismissed in 2005 after 15 years of litigation. At a certain point, a specialty needs to move on — I feel we are well past this point.
Twenty-six years after the practice track has closed, it doesn’t make sense to look for ways to offer additional legitimacy to non-boarded emergency physicians. In 2014, it is not fair to patients when unsupervised physicians “learn on the job.” I’ve worked with and trained physicians from other specialties who took the difficult step of completing a second residency in emergency medicine, and ultimately becoming ABEM or AOBEM board certified. Each expressed how surprised they were about how much they didn’t know and how much of a better physician they became.
We realize it is highly inappropriate for an emergency physician to perform outside their scope of practice, such as by performing a cardiac catheterization or a hip replacement. Why should we encourage physicians trained in other specialties, who had not completed the board certification pathway while it was open, to be emergency physicians? By doing so, we would essentially say that emergency medicine residency training does not have any value, and that the more than 2,000 physicians who enter emergency medicine residency training each year are wasting their time. This undermines the entire construct of specialty-specific residency training that has clearly become the standard across all specialties. Becoming an emergency medicine specialist is a lifelong process, and emergency medicine residency training under the supervision of board certified emergency medicine faculty is the cornerstone of that process. If it is acceptable to learn unsupervised on the job, why have residencies in any medical or surgical specialty at all? AAEM’ s White Paper on The Value of Board Certification and Residency Training in Emergency Medicine concluded that “there is clear evidence in the literature that supports that board certification and residency training in EM improves the quality of care provided to patients in the nation’s EDs.” (The White Paper can be viewed at aaem.org.)
Proponents of non-board certified physicians in emergency medicine often argue that these physicians have significantly more training than a PA or NP. I certainly agree with this assessment; however, that ignores the supervision aspect (although supervision of physician extenders is subpar in many EDs and should be improved). On the other hand, it would be highly unusual for a non-boarded physician to be practicing under the supervision of another physician.
For years, I’ve repeatedly heard that we have a critical need for non-certified physicians in our EDs, as the demand far outweighs the supply of board-certified emergency physicians, and this imbalance may never be resolved during our careers. I’ve heard this argument countless times to justify the expansion of opportunities for non-board certified emergency physicians. In 2014, this simply isn’t true anymore. As of November 2012, there were 41,479 emergency physicians in the U.S. (source: Kaiser Family Foundation). Between 2000 and 2010, the number of emergency physicians increased by 44.6%, more than any other specialty (source: AAMC 2012 Physician Specialty Data Book). As of December 31, 2013, there were 31,154 emergency physicians currently board certified by ABEM (source: ABEM) and 3,280 board certified by AOBEM (source: AOBEM). In addition, if we assume it will take on average two years for a board-eligible residency graduate to become board certified, there are likely about 4,000 board-eligible EM residency-trained physicians. Looking at this data, it appears that the 38,000+ board-certified/eligible physicians now comprise more than 90% of the EM physician workforce. Far more emergency medicine residents graduate each year (over 2,000) than it takes to replace retiring emergency physicians (typically about 1.7% attrition, so around 700 physicians), and many EM residencies are created or expanded each year. Soon there will be more board certified/eligible physicians than there are emergency physician practice opportunities, particularly in urban/suburban areas.
In Dr. Bukata’s article he correctly points out that in many rural areas, it is very difficult to recruit board-certified emergency physicians. I expect that these difficulties will abate somewhat as the number of emergency physicians desiring urban/suburban jobs eventually exceeds the number of these opportunities available. In addition, efforts should be undertaken to make rural EM opportunities more attractive to new residency graduates (i.e., rural EM rotations). However, I do not think rural emergency physician shortages are a good rationale for increasing legitimacy for non-boarded emergency physicians. Note that shortages of neurosurgeons, ophthalmologists, neurologists, and others are also common in many rural areas. However, we do not see their professional organizations responding to these shortages by opening up membership to non-BC/BE physicians. The shortages in many areas for many specialties are significantly more acute than in EM — however we do not see emergency physicians being recruited to practice as neurosurgeons in these areas. In many rural areas, the primary care shortage is more acute than that of emergency medicine, yet we have a paradox where many of the primary care trained physicians instead practice in the ED.
I recognize that non-BC/BE physicians have the right to practice in any emergency department, assuming the hospital is willing to grant clinical privileges. However, 26 years after the practice track has closed, at a time when we have virtually enough BC/BE emergency physicians to staff all of our EDs, we should not be encouraging anything less than the gold standard of board certification. Opening up membership to non-BC/BE physicians sends the wrong message and is a step in the wrong direction.
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