Editor’s Note: In the April 2008 issue of FCEP EM-Pulse, editor-in-chief Dr. Mylissa Graber wrote ” Our issue (board certification) basically got ‘hijacked’ by a small group of physicians and one Senator who turned the issue into something it is not,… It was one of the most appalling displays of deceit I have seen by a group of doctors who have been practicing for 20-plus years, who would in no way be impacted by this legislation, unless of course they work directly for AAPS,…”)
Comment on EM Pulse Editorial April 2008
We have been following the medico-legal issues raised by the in-fighting in emergency medicine for some time now; occasionally with amusement, but almost always with disappointment and gravitas. We find Dr. Graber’s recent editorial (see above), given her ascension to the position of vice president of the Florida College of Emergency Physicians [FCEP], sadly disappointing, and intemperate. We would hope that a physician at her level would strive to end the divisiveness that prevents the unification of emergency medicine, in order to provide excellent cost effective emergency care for Floridians and citizens of the United States. To that end, we felt compelled to address many of the issues raised by Dr. Graber.
The American Board of Physician Specialties [ABPS] certifies physicians in Emergency Medicine through BCEM, their Board of Certification in Emergency Medicine. BCEM certified physicians have completed residencies in a primary care specialty and practiced in an ER for at least five years, logging no less than 7,000 consecutive hours. This stringent and exacting qualification criteria mirrors the exact requirements for ABEM (American Board of Emergency Medicine) “grandfathered” diplomates (medical professionals who have not done a residency in emergency medicine, yet who according to ABEM criteria meet the requirements to be Board Certified emergency medicine practitioners).
BCEM certified physicians have not completed a residency in emergency medicine, similar to their ABEM certified “grandfathered” colleagues. Thus, when Dr. Graber and Florida College of Emergency Physicians [FCEP] lobbies the legislature to define a board certified physician as one that has completed a residency in emergency medicine and certified by ABEM, Dr. Graber in effect seeks to eliminate all non residency trained ER physicians from the workplace. Dr. Graber seems willing to destroy the careers of ER physician members of her own organization in order to push for what she believes to be the gold standard, EM residency trained physicians. Why? Many individual BCEM certified physicians have been practicing emergency medicine for upwards of thirty (30) years. Surely Dr. Graber would not suggest in her current position, that new residency trained physicians replace senior experienced attending physicians. Or would she?
Notwithstanding Dr. Graber and FCEP/ACEP’s efforts, Florida’s Board of Medicine has evaluated and approved BCEM credentials, permitting BCEM diplomates to represent themselves as Board Certified in Florida. The only difference between BCEM and ABEM certified physicians is BCEM’s commitment to certifying physicians skilled in Emergency Medicine from all relevant disciplines, including but not limited to Emergency Medicine residency training.
The American College of Emergency Physicians [ACEP], and the Florida College of Emergency Physicians [FCEP],important organizations that purport to represent all emergency medicine physicians, really only support ABEM certified, residency trained ER physicians. ACEP’s position has created sedimentary layering and artificial lines of medical skill demarcation among all other emergency medicine physicians, including their own ABEM “grandfathered”, non ER residency trained physicians.
Dr. Mylissa Graber, vice-president of FCEP, has propagandized against AAPS (American Association of Physician Specialists) in recent editorials in FCEP’s EM-Pulse newsletter, of which Dr. Graber is editor-in-chief. Dr. Graber launched a seemingly vituperous and potentially libelous attacks against AAPS, chanting the ACEP party line, that only EM residency trained physicians are competent to practice Emergency Medicine. Dr. Graber has never stated what she expects non-EM residency trained physicians, including those grandfathered by her own organization to do, if Dr. Graber and FCEP are successful.
BCEM certified, non emergency medicine residency trained physicians have been rejected from numerous hospitals because they did not do a residency in emergency medicine. These doctors are limited in where they can live, by virtue of restrictions on where they can work. Even Frederick Blum MD, past ACEP president, admitted that he himself was a victim of this restraint of trade. While holding ABEM certification, he still could not work in many hospitals because he was not residency trained. Thus, Dr. Blum, in a letter to the ACEP certification section concluded:
“I understand why many of you sought certification with BCEM. In your position I would have done the very same thing. I will support your right to do so and your rights as members [of ACEP]….and your ability to practice unfettered.” It is unfortunate that Dr. Graber and FCEP do not share this understanding. Instead, they engage in short-sighted and self-interested efforts to eliminate highly skilled competitor ER physicians from the market place by numerous attempts to eviscerate the law that the State of Florida has put in place to allow these skilled physicians to practice Emergency medicine.
As Dr. James Meade, Florida physician and lifetime member of ACEP wrote in response to Dr. Graber’s earlier editorial:
“The continuing controversy over board certification ABEM v BCEM is counterproductive and serves no good purpose. I find it baffling since we all have the same goals: to improve the practice of emergency medicine.
Furthermore, the Florida Board of Medicine after a 3 year study, decided that The American Association of Physician Specialists (which includes the Board of Certification in Emergency Medicine) is a legitimate and bona fide organization and should be granted approval as a specialty recognizing agency… The Florida decision has since been unsuccessfully challenged on five (5) separate occasions by ACEP/FCEP and its allies, even though the composition of the Florida Board of Medicine has almost completely changed during that period.”
Dr. Meade went on to state that ACEP/FCEP have resorted to other tactics, such as writing language into statutes that would have the effect of undoing and undermining the legislative intent of the Florida Medical Board e.g. the requirement that EMS medical directors be emergency medicine residency trained. A hearing before an administrative law judge recently reaffirmed the original decision of the Florida Board of Medicine
Relentless and undaunted, in March 2008, FCEP resubmitted yet another bill, in the hopes of subverting the original decision of the Florida Medical Board. This time, after another fair and unbiased hearing in the Florida Legislature’s Health Regulations committee, FCEP was forced to withdraw the bill after hearing testimony that revealed its many embarrassingly obvious flaws. Yet, Dr. Graber insists that the bill did not fail, and ominously points out that “Time is on our side.”
Dr. Graber in her editorial, accused the doctors that testified against her/FCEP’s bill in Tallahassee, Florida, of being on AAPS’s payroll. However, this writer found that the only people who were remunerated by AAPS was their contract lobbyist in Tallahassee and an AAPS national government affairs manager, both of whom were in attendance at the meeting and neither of whom testified. The doctors who spoke were volunteers who received no compensation and whose only motives were to speak the truth and improve the practice of Emergency Medicine. I wonder if as vice-president of FCEP, whether Dr. Mylissa Graber’s trip to Tallahassee was paid for by FCEP, and if so, are the FCEP members who are not ABEM certified aware that their dues are being spent on trips supporting a bill that effectively discriminates against them and essentially restricts their livelihood and careers?
Dr. Graber further asserts that “…emergency medicine has become very complex…”. Has it really become so complex that it necessitates the exclusion of qualified doctors from the practice of emergency medicine?
So, what the issue comes down to is this; FCEP’s many efforts, including bill writing, is not about quality of care or the future of emergency medicine. If so, there would have been a rather convincing and statistically substantive argument posited. Rather, it appears that its efforts are protectionist in nature and only supported by the Florida College of Emergency Physicians [FCEP].
AAPS is in business to certify physicians expert in emergency medicine to provide the highest level of care to the citizens of every State, not limit the market place to a few physicians who as a matter of timing, had full access to residency programs in emergency medicine, and who, without competition, would be able to fix higher costs for their services. AAPS also recognizes those physicians trained in other relevant fields, with many years of experience in Emergency Medicine. Thus providing for the nation, a larger talent pool of expert emergency physicians that would control costs, and minimize physician shortage in Emergency Medicine.
Dr. Graber’s editorial entitled “Time is on Our Side” poses far more questions than it answers. The big question is, whose side is Dr. Graber and the restrictive special interest organization FCEP really on? Certainly not on the side of patients, Florida residents whose access to quality emergency care would be curtailed by their bill, and not their own FCEP members without ABEM certification and a residency in Emergency Medicine.
Perhaps Dr. Graber should take a lesson from New York, where AAPS was forced to bring suit against the New York State Department of Health [DOH], after years of unreasonable and unlawful attacks against them by New York ACEP and its allies. It seems that in New York, ACEP and its allies misrepresented AAPS to the NYSDOH and got the DOH to irrationally exclude ABPS as a legitimate Board. Thus, in New York, BCEM certified physicians have been unable to refer to themselves as board certified. I suspect, like Florida, New York will settle and include ABPS as a legitimate board.
Time may not be on Dr. Graber’s side if the NYS-DOH settles or goes to trial and loses. Certainly, all organizations upon which New York relied in excluding BCEM physicians would be called upon to testify as to their reasons for blackballing AAPS, perhaps Dr. Graber herself could give up some of the time that is on her side. That said, it is perhaps later than Dr. Graber thinks, and it would be wonderful if she had a change of heart and approached this issue in a manner befitting her office for the good of Florida and the nation.
Richard E. Davis, JD.
Director, Litigation Logistics
Special consultant, PUMAMD