Florida ACEP: “Only EM Trained Docs Should Be Working in ERs”

Posted: October 23, 2007 by Doc in Emergency Medicine, ER Docs
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(I am posting this “editorial” from the Floria ACEP EM Pulse mainly because when other physicians tried to respond to this piece in writing, they were informed that their letters would not be published. Therefore, in the interest of free speech and debate, I am offering this space as a forum to discuss the issues. Note: I put the phrases I found interesting in boldface, everything else is Dr. Graber’s.)

from EMpulse September / October 2007
Like it Or Not, The Future is Emergency Medicine Residency Training
by Mylissa Graber, MD, FACEP editor@fcep.org
VP, Florida College of Emergency Physicians

I find it so sad that there are still people that think that someone does not need to be residency trained in emergency medicine in order to begin a career in emergency medicine in today’s day and age. Not only do some physicians think that way, but they actively pursue
legislation to always keep that door open and belittle what all of us have worked so hard to develop: a quality,well-trained emergency medicine specialist, who has been rigorously drilled and tested on a specific skill set that makes them capable of working extremely effectively
in any emergency department, and ready for any emergency situation. Not only do these others continue to fight this, but they do it with half truths about what we are doing and what we are trying to accomplish.

As you all should know, this past year we submitted a bill in the state of Florida to require specialty-specific residency training in order to be recognized as Board Certified in the state of Florida on a go-forward basis,meaning that anyone who has already been recognized
as board certified would still be so, but that from this point on we will close the door to those training in other fields to pursue an emergency medicine career. ABEM closed its doors 20 years ago. ACEP closed its doors eight years ago, and still, even with that, we decided in
Florida that anyone recognized up to now, 2007 or when resubmitted next year in 2008, could still be recognized, but not past that. The bill specifically states that the Florida Board of Medicine could only recognize organizations that require emergency medicine residency training
to enter the specialty as of this year, which means that all AAPS would really have to do to be recognized and end this entire ridiculous continued struggle, would be to shut the door for new diplomats to only those who have completed an accredited emergency medicine residency
program. But instead of doing that, they choose to spend thousands and thousands of dollars to “defeat us” and to continue to push state-by-state to forever keep the door open to non-residency-trained physicians entering emergency medicine. Why?

Two sessions ago we attempted to submit this bill, and I met personally with certain key legislators who could pass the bill through, including one who had sponsored the AAPS bill that failed a few years before. Interestingly, when he heard what we were trying to do,
he agreed completely and said he would support us on this. We met with him several times after and he still gave his support. Then a lobbyist for the “other side,” who apparently had been away, and who had some sort of connection to this legislator, resurfaced and the next
thing we knew, the legislator withdrew his support and we were blocked from filing the bill. Why?
Recently I was talking to a colleague I used to work with, who unbeknownst to me is BCEM certified, not ABEM certified. I knew that he was not EM trained by his practice style, but assumed he had grandfathered in to ABEM and he had never told me otherwise until
recently. I had called him about something else and he told me how he heard about the bill I was pushing and that he had received correspondence from AAPS stating that they needed to fight this bill, because it would result in the loss of his job and the end of his career, etc. He
told me he donated several thousand dollars to help them fight this “cause.” Of course, I had a lot to say about that and was furious, especially because this was blatantly
false and I was upset that as a personal friend he never came to me to inquire about what was really going on. I explained to him that the bill we submitted was not retroactive and that anyone recognized or already practicing would be able to continue to do so, that this is only
about board certification and not employment, and that this was about the future workforce of emergency medicine, not the present, and that no one entering emergency medicine today should be residency trained in anything other than emergency medicine. His response: “Oh,
well I agree with you about that. That’s not what they said. Hmm, I will need to talk to them.” I told him he gave a huge amount of money – I wish we could foster that kind of contribution for any of our other issues -against something he didn’t even agree with, because he
was given false information. He told me he was going to follow up with them, but I haven’t heard anything since. So let’s look into this for a moment. Why would an organization rally up such support from their members based on inaccurate information? And why is it that they
require specialty specific residency training for almost every other specialty except emergency medicine? What is it that is driving them so? Well, a few years ago I visited their website and found out some interesting information.

The vast majority of the new diplomats, who sit for their boards, sit for the emergency medicine boards. It would seem that we may be their “cash cow” and we could easily surmise that if they close their doors to only EM residency-trained physicians, they may be losing significant money, so they potentially have a lot at stake financially. Sad, isn’t it, that it may not be about quality after all? Interestingly, I visited the site again, and you can no longer access this information. I guess they were afraid we might catch on. There is also another website bragging about their success at “defeating” the bill that we sponsored and announcing that they are suing the New York Board of Medicine, that thanks to that they can
continue to be recognized and it states on there that this will “open the door for non-ER trained, non-ABEM certified ER physicians to continue their careers and maintain
their livelihood.”

I still do not understand what they are talking about.The physicians who have been so vocal and intricately involved in their activism and responsible for getting the Florida Board of Medicine to recognize them are far from unemployed. In fact, some of them are leaders of the
community and even directors of the ERs, own groups, etc. One I know of who is very vocal is retired, not even practicing anymore. I’m sorry that 20 years ago they missed the deadline for sitting for the ABEM boards or chose not to because they didn’t think it would matter, but there had to be a cut-off somewhere, and the natural attrition of these physicians needs to take place. The doctor who I know is in absolutely no danger of losing his job.

There are non-EM-trained physicians all over the state that are working in emergency departments and have been for 10, 20, 30 years who have very secure jobs, but
emergency medicine has become very complex, so it is inappropriate for physicians currently training in other specialties to use these alternate routes to enter emergency
medicine and call themselves board certified emergency physicians without doing the appropriate emergency medicine training. The learn-on-the-job approach
with no formal supervision or training is not only antiquated, but in today’s day and age potentially harmful and definitely unfair to our patients.
As the non-EM-trained physicians retire, they should naturally be replaced with
residency-trained emergency physicians. The argument that we will never fill all emergency departments with EM-trained physicians is a ridiculous one. More and more programs are opening up and more and more EM trained physicians are entering the field and several that I know personally have left the academic and urban world to go to some of the underserved and less-populated areas to live and practice. Even so, if a physician who is a family practice doctor chooses to work in these areas in the ED, that is fine, but s/he is still a family practice doctor,not an emergency physician and there is no shame in that.
Just don’t misrepresent who you are.
In the same way,when I do a pelvic exam, I do not tell the patient I am a gynecologist, and when I put in a chest tube, I do not say I am a cardiothoracic surgeon. I’m an emergency physician and I am proud of that. You should be proud of your specialty too.
This fight is not over and we will continue to pursue residency training in EM as the only appropriate pathway into emergency medicine today, but it is time for the emergency medicine residency-trained docs to stop sitting on the sidelines and join this fight. We need your
support too. Don’t assume we’re going to fix the problem and that we will naturally prevail. We need to make our voices heard. Contribute to FLACPAC, write articles,
come to EM Days and visit your legislators at home to push this issue. Feel free to contact me and I’ll put you on a list of people who want to help and let you know how you can get involved. We don’t expect you to give thousands of dollars, but every little bit helps. When you
send your checks to FLACPAC, write residency training on the “for” line. We need to spark the same passion for the importance of residency training in emergency medicine board certification as these other physicians have in undermining our progress. Like it or not, residency training
in emergency medicine is the future. It’s just a matter of time.

Response to Florida ACEP: “No Correlation Between Doctors WhoFailed to Meet Standard of Care and Board Certification”

Supply of Board Certified Emergency Physicians Unlikely to Meet Projected Needs Across the US

American Board of Physician Specialties (ABPS)

Disposable Doctors 2: ER docs fight back in NY

Not So Disposable Doctors
Florida to Say, “Bye bye Grandpa!”
Disposable Doctors 1

An ER Doc’s Top Ten List

  1. Jim Meade MD BCEM says:

    Thanks for the opportunity to comment on the above. I asked Dr Graber for an opportunity to respond to the above and was told that I could, but it would not be printed.
    I have had contribution published by her as a Letter to the Editor, about this matter, which I would like to submit to this site. How can I sent this as an attachment?

    Jim Meade

  2. […] and Board Certification The following is an eloquent response to the EM Pulse Editorial “Like it or Not, The Future is Emergency Medicine Residency Training” BCEM vs. ABEM controversy: “Why Can’t We All Just Get Along?” by James Meade, […]

  3. I personally dont see how this point could be debated. Dr. Graber makes excellent points regarding the necessity of emergency room training within a dedicated certification body to practice in that environment.

    I do not have sufficient ER training to perform adequately in that environment, and I completely accept that. It would be irresponsible for collegues to be placed in that position when they fully know that our other peers are better-suited to fill those roles.

    As a non-retroactive measure, who could be against that??

  4. docwhisperer says:

    Dr. Graber and AAEM makes the assumption which despite vigorous debate, has yet to be proved, namely that non- EM trained, ER physicians who have worked in the ER for 10-15 years (the “legacy physicians”, as they have been labeled), are not as proficient or competent as the newly-graduated residency trained, ABEM board certified physicians.
    This is a critical point since these legacy physicians, despite having served in the same capacity for over a decade, now have their careers and income seriously threatened because they are not EM residency trained and ABEM certified. To understand these issues better, see previous posts:



  5. Rob Hill says:

    …What a poorly composed, whiney and painfully redudant rant… If the argument was so apparent and obvious, there would be none. …As an ER physician. I am disappointed at to hear such an incoherant voice supposing to represent an intelligent discourse on the value of EM training. Please explain your point of view.

  6. docwhisperer says:

    I agree Dr. Hill.
    If you would like to make your comments known directly to Dr. Graber, please address them to the Florida chapter of the American College of Emergency Physicians of which she is Vice President through editor@fcep.org

  7. […] issue has been contentiously argued. ACEP officials such as Dr. Melissa Graber and Dr. Carol Rogala have vehemently castigated ABPS for filing this suit, asserting their lack of […]

  8. […] 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 […]

  9. […] of Emergency Medicine News from AAPS vs. NY-DOH Possibly related posts: (automatically generated)Florida ACEP: “Only EM Trained Docs Should Be Working in ERs”Alternate Staffing Strategies Required To Supply Sufficient Board-Certified…The Uninsured […]

  10. […] Florida ACEP: Only EM Trained Doctors Should be Working in ERs […]

  11. Robin Rothrock MD says:

    I am a Board Certified Family Med Physician who has practiced only Emergency Medicine for the last 6.5 years. My Data Bank is clear and I have not past or pending lawsuits. I enjoy EM work and do not want to do anything else. Dr. Graber statement “the bill we submitted was not retroactive and that anyone recognized or already practicing would be able to continue to do so, that this is only about board certification and not employment, and that this was about the future workforce of emergency medicine, not the present, and that no one entering emergency medicine today should be residency trained in anything other than emergency medicine.” is totally false. She has no idea what any non-ABEM ER doc’s qualifications are…she only knows she was trained for 3 years in an ABEM residency and therefore her ego tells her she is better and more qualified than all non-ABEM Boarded doctors. She has not idea how rigorous our training was nor how much we furthered our knowledge of Emerg. Medicine by our pure desire and love of the field. Her above statement is false because ABEM “is” seeking to keep all other doctors who are non-ABEM boarded from working in any ER. It really should be the other way around. We docs with experience should not allow any ABEM boarded doc in the ER unsupervised with nothing less 5 years experience on top of their 3 year residency time. There is a lot to know about EM work and my experience with ABEM boarded docs are they are not equiped with enough knowledge to run and ER by themselves straight out of residency. Dr. Graber and her ABEM friends seem to be more concerned with tooting their little horns about how special they are they will give each other certificates to prove it. What I have noticed is that they refuse to let anyone else take the same testing that they say proves they are qualified to be the only doctors in the ER. They have successfully lobbied most hospitals to “only accept ABEM Boarded docs in their ER’s..and yes it has cost thousands of non-ABEM Boarded docs their jobs and they can not just go down the street and get another job. She and ABEM are not concerned with the patients..the studies already prove there is no difference in outcome or treatment received by an ABEM boarded doc as compaired to a more experienced doctor with a different board certification. Instead, their focus seems to be solely about “how they should be recognized for their Board Certification”…okay, we see you, we hear you, but you aren’t any more special or better trained than the rest of us. ABEM Boarded docs should spend more time focusing on their patients than trying to monopolize all ER’s in the U.S. And, it is a “MONOPOLY”..which is illegal. They further create this monopoly by setting up self serving rules to not even allow docs like myself to re-enter the their special residency programs to be “trained the ABEM WAY.” Yes, in the beginning I thought, fine…I will try to comply with what they want..but they told me..”you can’t go back through residency, once you are out for 7 years you can not go back to residency.” So what are we docs supposed to do who have no other work experience than EM work. There is a doctor shortage after all..but ABEM doesn’t care about the patients who need doctors…even in a shortage of care, they still prefer the patients go without medical care at the expense of their propaganda. This is a monopoly for them to tell all other specialties, especially all of us in Family Medicine and Internal Medicine , that we can not work in the ER, WHEN WE ALL KNOW THAT 98% OF PATIENTS WHO COME INTO ALL ER’S HAS A PRIMARY CARE COMPLAINT. So they are trying to tell us we can’t practice what we are trained in that specifice building…That is against the law..period. They are also trying to tell Surgeons they can’t work in an ER when ATLS , required for any doc to work in the ER is a certification from “THE AMERICAN COLLEGE OF SURGEONS!” This is a monopoly and we should fight it and even penalize the hospitals who refuse to let us work because we are Board Certified by another Board. If there is a certification that has to be met, then all specialties should be allowed to sit for it..for the simple fact that we have the right to work in what is 98% predominantly a primary care setting..and patients have the right to be treated in a timely manner and receive affordable care. I can’t tell you how many recruiters tell me “Well you are Family Medicine so we don’t have to pay you as much as an ABEM doctor.” How insulting, and I always tell them “then pay the ABEM docs what you are trying to pay me.. because I don’t get to say..no I am not going to see that patient give that one to the ABEM doc. I have to see everything that walks through that door, so all docs deserve equal pay who work in the ER, you can not discriminate. Do not let ABEM or these agencies convince you of their self serving propaganda. If you do, that will be only the beginning. And by the way I have 5 years of residency training..which should make me more qualified straight out of residency than an ABEM with only 3 years.

  12. Doc says:

    I agree 1000% with everything you just said. There are 12,000 non-ABEM ER docs who share similar frustrations, but have yet to channel their sentiments into any action to change the situation.
    The American Association of Physician Specialists (http://www.aapsus.org ) has been fighting ABEM and ACEP in multiple states, most recently Texas and OK. The American College of Family Physicians has a special interest group in Emergency Medicine but I am not aware of any current actions to advocate for FPs like yourself practicing EM.

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