Archive for January, 2009

from: Mass Gen Hospital Press Release:

MGH-led study supports the need for alternate staffing strategies


BOSTON – The number of physicians with board certification in emergency medicine is unlikely to meet the staffing needs of U.S. emergency departments in the foreseeable future, if ever; according to a study from a research team based at Massachusetts General Hospital (MGH). In the December issue of Academic Emergency Medicine, the investigators report finding that staffing every emergency department with board-certified emergency physicians does not appear to be feasible, given their projections for the field.

“Thousands of emergency departments are not currently staffed by physicians with this type of training,” explains Carlos Camargo, MD, DrPH, of the MGH Department of Emergency Medicine, who led the study. “We questioned whether staffing every department with residency-trained, board-certified emergency physicians – which some individuals have advocated for decades – was a realistic goal. So we set out to estimate emergency physician workforce needs, taking into account the diversity of hospitals across the country and projections about the future physician supply and demand.”

The researchers analyzed data from the 2005 National Emergency Department Inventories–USA database to determine the number of emergency departments in the country and their patient volumes. Based on the approximately 22,000 board-certified emergency physicians in practice and the 1,350 who became newly certified during 2005, the team developed three scenarios for physician supply, all of which assumed the same number of new board-certified physicians each year. The best-case scenario, which was intentionally unrealistic, assumed that no board-certified emergency physician died or retired; the worst case assumed an annual attrition rate of 12 percent; and the intermediate scenario assumed 2.5 percent attrition each year.

Having at least one board-certified emergency physician present in all U.S. hospital emergency departments at all times would require 40,000 physicians with such training, indicating that only 55 percent of 2005 demand was being met. Under the intermediate-scenario projection, it would not be possible to meet the goal until 2038, and under the worst-case scenario, the goal could never be met.
*** Even if no board-certified emergency physician ever died or retired, 100 percent staffing of all emergency departments with board-certified emergency physicians would not happen for more than a decade. ***

“The mismatch between the supply and demand for residency-trained, board-certified emergency physicians is a longstanding problem,” Camargo says. “The need for emergency services is large and growing; and even if existing programs graduated more physicians, there is little reason to think more of those graduates would move to the rural areas that are particularly short on physicians with this specialized training. We probably should explore alternatives, such as giving the family physicians who currently staff many U.S. emergency departments extra training in key emergency procedures. We might also increase our reliance on nurse practitioners and physicians assistants, who can help emergency physicians of any training background better handle the continually rising number of patients.” Camargo is an associate professor of Emergency Medicine at Harvard Medical School.

Co-authors of the Academic Emergency Medicine report are Janice Espinola, MPH; Ashley Sullivan, MS, MPH, and John Pearson, MGH Department of Emergency Medicine; Adit Ginde, MD, MPH, University of Colorado Denver School of Medicine; and Ayellete Singer, MA, and Adam Singer, MD, Stony Brook University Medical Center, New York.

THANK YOU! Now, who will step up and do something about it? It is obvious that the leadership of EM organizations are too preoccupied with protecting their turf, to care whether good emergency care is actually being delivered to the US population. Board certification, which has been used as a “merit badge” of quality, is instead being used to exclude other competent medical professionals from working in Emergency Departments regardless of the detrimental effects on communities.
It would seem that other agencies, perhaps the government (Health and Human Services?) or even the courts will have to come in and act, and their solutions will probably be something that the EM residency trained/ “board certified” docs will not like. But you know what? It will be their own fault for not seeing the big picture.

There are numerous physicians likely more skilled than those having completed a residency in emergency medicine, that could be absorbed in the ER workforce and fulfill the nations needs virtually instantaneously. Those docs are methodically being eliminated by restraints on trade that quite frankly echo the charges in ANTITRUST made by Daniel v. ABEM. Imagine, the powers that be would rather have a P.A. or a N.P. [nothing against the care provided by these practitioners] supervised by one residency trained ER physician, than have an experienced, higly trained ER physician certified by AAPS, who in some instances, trained the ER residency trained physician. Thus, this ER “residency” has become manna. But not so fast. The need for this residency was not called for unanimously, far from it. I heard it once said that life imitates art and that the TV show ER probably had more to do with legitimizing ER medicine than any politial sleight of hand that brought it about.

It has become obvious to me that this “ER residency” has been fought for tooth and nail and has become a holy grail so to speak. At the heart of things, the demigods in ER medicine sold the nation, or at least got it passed when no one was looking or even cared, on the need for a “residency” in ER medicine. Note that many specialties disagreed with such a need and opposed the creation of ER medicine as a separate specialty. Initially it was suggested it be a fellowship of general surgery, internal medicine or family practice. As such, training costs would be minimized and manpower issues would be less severe or there would be none. Saved money would be spent on improving 911 care so to speak so that out of hospital care would be improved and not as dismal as some reports now charge.

ER is not like general surgery where one would have to learn operations. So even cross training would not be a problem. Thus, if there was a national emergency there are many physicians that could walk into an emergency room and independently and successfully care for patients. Not so in surgery.

Yet still, the demigods, by attrition, or because of oppositon apathy, won the battle to create what was felt by important medical authorities to be, a relatively insignificant residency. And then the first thing they did was arbitrarily close their practice track eliminating thousands of excellent ER physicians/colleagues from the workforce, resulting in Daniel V. ABEM. I should say, Daniel v. ABEM 1, since the way the ER workforce is controlled by all the outsourced ER service providers [another issue], we will soon see much more litigation, and Daniel v. ABEM 2. We are already poised for a dramatic court case in AAPS V. NYSDOH, wherin AAPS is very likely to win under the legal standard that the NYSDOH lacked rational basis. You may know that under the legal theory of rational basis, States can legislate that a caveman may practice emergency medicine and win, but not so in this current AAPS case.

In AAPS V. NYSDOH case, really a natural outflow of Daniel 1, the opposers to the broader, more inclusive practice of emergency medicine, of course i mean, ABEM, ACEP, AAEM, AMA, ETC…have gone as far as to put their own grandfathered physicians on the line. Because in this case, the grandfathered physicians would have to be removed from the State’s website and unable to call themselves Board Certified in New York State. OR, they permit BCEM certified physicians to be listed on the website.

Dr. Collman in a recent rant on your site, is perfectly right. It is about patient care. And you are right in part, it isn’t a turf war, it is an attempt at monopolizing a market.

The United States would see dramatic reduction in costs, and I am certain an increase in quality of care if they open up the ER market and expand not shrink the workforce. This issue will need to be removed from the hands of physicians, especially those with strong self interest in eliminating equally qualified physicians. Let’s face it, ER medicine is such that just because a physician trained in ER medicine doesn’t make him better than a physician with practice experience that did not. The “residency” should not have gone forward.

Richard Davis ESQ.
Litigation Logistics

Disposable Doctors 1
Disposable Doctors 2
American Board of Physician Specialties
US Alliance of Emergency Medicine
Fighting to Level the Playing Field for AAPS docs in NY
News from AAPS vs. NY-DOH
Florida ACEP: “Only EM Residency Trained Docs Should Work in ERs”
Response to Florida ACEP