Archive for the ‘Emergency Medicine’ Category

Am J Med Qual. 2010 Aug 17. [Epub ahead of print]

A National Study Examining Emergency Medicine Specialty Training and Quality Measures in the Emergency Department.

Mathews SC, Kelen GD, Pronovost PJ, Pham JC.

Johns Hopkins University School of Medicine, Baltimore, MD.

Abstract

The objective of this study was to measure the relationship between emergency medicine (EM) specialty training and quality measures in the emergency department (ED). Data were gathered from the 2003-2004 National Hospital Ambulatory Medical Care Survey. The outcome was proportion of patients with acute myocardial infarction (AMI), pneumonia (PNA), and long-bone fracture (LBF) who received recommended therapy. These measures were analyzed with respect to EM residency completion. Compared with EDs with more than 80% EM-trained physicians, EDs with fewer than 80% EM-trained physicians had similar rates of aspirin (43% vs 42%) and beta-blocker (26% vs 19%) use for AMI, appropriate antibiotics (78% vs 83%) and pulse oximetry (51% vs 55%) for PNA, and analgesia (85% vs 79%) for LBF. Additionally, a composite end point and an adjusted model showed no statistical difference across these measures. The proportion of residency-trained EM physicians did not affect the use of recommended treatment for AMI, PNA, and LBF.

PMID: 20716690 [PubMed – as supplied by publisher]

Full Text: EM Specialty Training and Quality Measures study

From the introduction of this paper:

“When patients present to the emergency department (ED) for care, they assume that they will be cared for by a physician qualified to diagnose and treat their ills. This trust is even more sacred in emergency settings because patients with emergent conditions generally do not have the opportunity to choose the location or provider who will render this care. For this reason, the American College of Emergency Physicians and the American Board of Emergency Medicine advocate specific training (ie, emergency medicine [EM] residency) for physicians who treat patients in EDs.

 Yet across the United States, only 69% of physicians who work in the ED are EM residency trained or EM board certified. Fewer than 40% of EDs have a majority of physicians with EM residency training, and only 1 state (Hawaii)adequate supply of EM-board-certified emergency physicians.

Although recent EM physicians are much more likely to be EM residency trained, this deficiency has been attributed  to at least 4 different causes: (1) overall shortage of EM-trained physicians; (2) because EM is a relatively young specialty, a significant proportion of the workforce is composed of so-called legacy emergency physicians (ie, those engaged in EM practice prior to the proliferation of EM specialty training programs); (3) the lower staff cost of hiring non-EM-trained physicians; and (4) the difficulty of recruiting specialty trained physicians to rural locations. This variability in training of ED physicians has elicited some controversy, but the impact of the differences in training on clinical outcomes has not been assessed. EM-trained physicians are less likely to have expensive malpractice claims against them compared with their non-EM-trained counterparts.

Whether specialty training when compared to care provided by generalists  leads to improved clinical outcomes for specific conditions has been reviewed more broadly in medicine, but not in the context of EM.

Because the Institute of Medicine’s 1999 report identified shortcomings in the quality of care in the US health system, there has been renewed emphasis on emphasis on identifying measures of quality and performance.

Treatment of acute myocardial infarction (AMI), pneumonia (PNA), and long bone fractures (LBFs) has been used to evaluate quality across EDs. These characteristics have been recognized as ED quality measures to varying extents. These measures evaluate the extent to which patients receive recommended therapies.”

Commentary:

Core Measures are a set of care processes developed by The Joint Commission, the nation’s predominant standards-setting and accrediting body in health care, to improve the quality of health care by implementing a national, standardized performance measurement system. The Core Measures were derived largely from a set of quality indicators defined by the Centers for Medicare and Medicaid Services (CMS). They have been shown to reduce the risk of complications, prevent recurrences and otherwise treat the majority of patients who come to a hospital for treatment of a condition or illness. Core Measures help hospitals improve the quality of patient care by focusing on the actual results of care.

This study was a national cross-sectional study of ED visits for 2003 through 2004 using the National Hospital Ambulatory Medical Care Survey (NHAMCS). The NHAMCS is administered by the Centers for Disease Control and Prevention’s NCHS and is endorsed by the Emergency Nurses Association, the Society for Academic Emergency Medicine, the American College of Emergency Physicians, and the American College of Osteopathic Emergency Physicians.  It is a national probability sample of visits to the EDs of non-governmental general and short-stay acute care hospitals located in the 50 states and the District of Columbia.

 As stated above, this study was performed using cross-sectional data culled from a national database of all 50 states, and is clearly of greater quality and inspires more confidence compared to the small studies often cited to support claims of the alleged superior skills of EM residency trained physicians over their experienced, non-EM residency trained ER colleagues ( AAEM: Board Certification, Articles on Quality of Care ). Aside from having small samples, these other studies  were performed with less stringent methodologies (mostly retrospective reviews)  performed in only one hospital or at most, compare one hospital with another, mostly examining the effects of the introduction of an ER residency training program, the results of which can not, by any stretch of the imagination, be extrapolated to demonstrate what the AAEM and ABEM claim, that EM residency trained physicians have significantly superior clinical outcomes compared with non-EM residency trained physicians.

This quality study shows otherwise. In the discussion, it is interesting to note that the authors are hesitant to state outright what their results show, namely that when looking at nationally defined clinical criteria, non-EM residency trained and EM residency trained physicians  give the same quality care.  Instead, they state that the measures they used

“may be too simple to demonstrate the value of EM physicians. Future efforts to assess the role of EM training in ED quality should focus more on measures that demonstrate the unique skills of EM-trained physicians.”

What “unique skills”? The authors themselves admit that they chose these measures based on quality studies endorsed by professional societies.  What the authors may be hesitant to acknowledge due to the controversy currently raging in the EM community, is that there is no significant difference in quality between EM residency trained physicians and experienced non-EM residency trained physicians, certainly not enough to warrant paying non-EM residency trained physicians much less and removing their much needed presence in the ERs.

 

 

Friday, November 12, 2010
ACEP, ABEM, AOBEM, and AAPS Should Work Together
Editor:
I would like to comment on the article, “NY, OK Thwart AAPS Quest for Certification Recognition.” (EMN 2010;32[9]:1) http://journals.lww.com/em-news/Fulltext/2010/09000/Breaking_News__NY,_OK_Thwart_AAPS_Quest_for.2.aspx

I have been a practiced-trained emergency physician for more than 20 years, having just missed the ABEM window to sit for the boards. I sat for the American Board of Physician Specialties exams in emergency medicine in 1995, and have since re-certified. I am the medical director for a rural ED in North Carolina.

I am continually amazed at the emotion evoked by this subject, especially by residency trained emergency physicians. Are physicians like me taking jobs from the residency trained doctors? I can’t get one of you to even look at my ED; you prefer referral centers and a significantly higher number of patients. There is a crisis out here, and you guys are concerned about advertising? Where are these advertisements? As fellow physicians interested in patient care, wouldn’t you prefer that the rural emergency physicians calling you at least proved their competence in emergency medicine in some credible way? Go ahead, and blow your horn about your residency training; you deserve it. It is a great sacrifice you endured, and it made most of you better emergency physicians, much more so than the testing you do at a computer after a weeklong class.

But take a look outside your bubble of medical center meccas at the shambles that is rural health care secondary to a massive physician shortage. Our ED volume is growing exponentially as primary care disintegrates, and the economics require more physician extenders with less supervision. Wouldn’t it be nice if ACEP, ABEM, AOBEM, and AAPS could come together to show this country that we recognize the problem, that together we are going to ensure that they receive the best possible care no matter what ED they walk into, and that the physician they shake hands with is supported by his peers in the profession?

Meanwhile, I will continue working in the environment I have grown accustomed to and now prefer with the knowledge that there will always be work for me until the day I retire because no one is beating down our doors for a job. Someday soon, no one will want my job unless we work together.

Scott L. Korn, DO
Rutherfordton, NC

ER doctors settle squabble on certification

By TODD ACKERMAN
HOUSTON CHRONICLE

Oct. 29, 2010, 10:52PM

AUSTIN — In a matter that competing camps of doctors warned would affect the welfare of patients, Texas’ medical regulatory agency Friday changed its rules to prevent future emergency physicians from advertising themselves as board-certified if they haven’t completed supervised training in the specialty.

But the Texas Medical Board also put in place a compromise grandfathering in those emergency doctors certified before Sept. 1, 2010, by an alternative association that substitutes ER experience for residency training. The association includes about 175 doctors in Texas.

“I can’t predict the future effect this rule change will have, but the intent has nothing to do with whom hospitals employ,” said Texas Medical Board Chairwoman Dr. Melinda McMichael, refuting the alternative association’s claim it would lead to hospitals requiring ER doctors be board-certified. “It’s strictly about advertising.”

Board-certified?

The board’s 12-6 vote ends a yearlong battle that pitted emergency doctors against one another. Traditionally certified doctors said allowing physicians without proper training to advertise themselves as board-certified would mislead the public.

Doctors certified by the alternative association said the rule change would cost some of them their jobs and rob the state of some manpower it relies on to staff emergency departments, particularly those in the state’s rural areas.

Neither side was happy with the compromise.

The fight’s primary combatants are the American Board of Medical Specialties, a 76-year-old association that in 1988 began requiring emergency doctors, a relatively new specialty at the time, to do a three-year residency; and the American Board of Physician Specialties, a younger association that in 1989 began certifying doctors who never did an emergency medicine residency but had worked in an ER five or more years.

The meeting drew national attention to a conflict now spreading to other states. One observer called Texas a bellwether for the rest of the U.S. Another predicted the war will last another generation.

For two hours, a packed house of mostly doctors took turns testifying, occasionally emotionally, before the state regulatory agency. It was the fourth such public hearing .

Shortage of physicians

“I’d love to have some residency-trained emergency doctors in my department, but another year went by and I’m still not seeing any,” said Dr. Daniel Garza of Cleveland. “We need another plan to provide the doctors we’re short on. This is that other plan.”

Dr. Otto Marquez, a Dallas-area emergency physician, said “the board should be protecting patients, not taking sides in a turf war.” Accusing the ABMS of trying to kill the ABPS, he said the board has gotten in “the middle of a food fight that’s been going on for 20 years.”

Dr. Sandy Schneider, president of the American College of Emergency Physicians, denied the issue puts the jobs of doctors who haven’t completed an emergency residency at risk, noting that many doctors practice in ERs and are not board certified.

The rule changes must be published in the Texas Register before they become effective and can be enforced. Medical board officials said that would probably be in December or January.

Bruce Catton, the American Board of Physician Specialties’ director of governmental affairs, said it will be two weeks to a month before the association decides on its next step but didn’t rule out legal action.

The association sued in 2007, alleging the New York Department of Health was illegally barring its physicians from listing themselves as board certified online.

Practice Track Needed Till EP Shortage Ends
Editor:
I am a board certified diplomate of the American Board of Physicians Specialties (ABPS). I have practiced emergency medicine for the past 20 years. I have never seen this type of idiocy in any profession other than medicine. (EMN 2010;32[9]:1.) We fight each other as if we are foreign countries. We have the fight of our lives trying to save our way of life as it is with all the Medicare cuts and insurance companies targeting us by cutting our salaries and reimbursements for their own profits.

I don’t think the American College of Emergency Physicians and all the powers-that-be have the patients’ best interests at heart. These people are self-serving and self-absorbed. Their interest is to keep salaries very high for residency trained emergency physicians. These residency trained physicians will never go to underserved areas where they are needed; they will remain around the cultural centers, commanding higher salaries and enjoying the amenities of city living. The underserved areas will continue to suffer, and have a lack of or diminished physician services.

The newly residency trained doctor will not want to work the long laborious night shifts or odd hours, and most likely will not want to work more than the usual work week when the hospital is in a pinch. The hospital will find itself still turning to even more expensive locums coverage. This is what ACEP and its companions want because who will most likely be the locums owner and provider? Probably the same residency trained doctors group or some similar type of arrangement.

These are some of the reasons that ACEP and its companions want to rule out ABPS, family, and internal medicine doctors from working in emergency departments. I don’t think it has a lot to do with training or the ability to work an emergency department at all. I don’t think you can tell a hospital administrator with confidence that a doctor just out of residency is more capable of working in an emergency department than a 20-year veteran emergency physician who has worked more than 4,000 hours a year for 20 years in an emergency department.

I have nothing against residency training. If a practitioner knows when he finishes medical school that emergency medicine is the field that he wants to pursue, then go into an emergency medicine residency. But, like most things in life, nothing is perfect. We finish medical school, chose our paths, and for whatever reasons decide that something else may be more attractive than what we chose. So maybe we find one of those small hospitals that will allow doctors residency trained in something other than emergency medicine to work in the emergency department because of need and because they cannot find a board certified residency trained emergency physician at any price who wants to come to Timbuktu to practice mistake-free medicine because we all know residency trained doctors never get sued and never make mistakes.

No one in emergency medicine wants a practice track, but it is still needed, and as long as there are not enough residency trained physicians to cover our emergency departments, some hospitals will have to use internists or family practitioners to cover their departments. The way to ensure that these physicians have the knowledge of emergency medicine is to offer them certification. If a family practitioner or internist wants to work in the emergency department, ABPS or some other entity should offer testing before the doctor ever works in the emergency department. Maybe an airway clinic or some type of anesthesia course also should be offered prior to the physician working in the emergency department. This would better serve the public and better ensure patient safety than fighting over certification, which only boils down to a fight over money.

My message to ACEP is this: When you can tell me that state regulations will allow your residency trained doctors to drop their malpractice insurance because they are so perfect, I will believe that only residency trained doctors should be in emergency departments. We all have to carry malpractice, which means that the public doesn’t believe in any of us, so to better protect them and ourselves, why don’t we unite and develop solutions that include all of us? There is enough room at the table; visits keep going up, and people keep coming. Let’s quit acting like wolves and pigs, and act like humans who can talk and work things out, and come up with solutions instead these turf battles.

John Stanton, DO
Horsham, PA

COMMENT:

“I have never seen this type of idiocy in any profession other than medicine.”

Thank you for your letter, Dr. Stanton. I would venture to add that not only has “this type of idiocy” not been seen in any other profession except medicine, but the level of  abuse and vituperation hurled mainly by AAEM (see Dr. Scaletta’s Nasty Comments)  over the decades since ABEM  prematurely and mistakenly closed its practice track, even in medicine, can only be found in the specialty of Emergency Medicine, much to its eternal shame.

“Turf wars” occur between specialties on a regular basis. Even now, radiologists and emergency physicians battle over who is qualified to do ultrasounds in the ER;  plastic surgeons, ENTs, and ophthalmologists argue over who is best qualified to do eye lifts; Dermatologists and cosmetic surgeons maintain that they should be the only ones who should do botox and restylane injections, the list is endless.

However,  most of these other “turf wars” have been conducted in semi-civilized, collegial discourse between specialty groups without resorting to demeaning, occasionally libelous speech which has been the hallmark of the rhetoric of AAEM and its minions.

And instead of healing the rift and seeking solutions for ALL ER physicians, not just the ABEM certified,  ACEP has exacerbated the divide by siding with AAEM, making non-EM residency trained physicians like Dr. Stanton even more disenfranchised. This is a failure of leadership and policy that can only be described as tragic.

Fortunately, the American Academy of Family Physicians has stepped into the void left by ACEP and has been more proactive in advocating for the significant number of its members who do practice Emergency Medicine. They also have enough foresight to offer solutions to the EP shortage in the rural areas by sanctioning EM fellowships, which of course, the EM leadership is fighting tooth and nail.  (see: EM Fellowships for FPs: Bane or Boon?)

Let us hope that the bullying tactics of AAEM and ACEP do not win the day. The only way to combat this would be to support ABPS and AAFP in its efforts, such as during the Texas Medical Board meeting.

LINKS:

GruntDoc

“Affirmed”!

and with that, the NY Appellate Court, seemingly sealed the dismissal of ABPS’s suit against NY-DOH, forcing a possible showdown before the U.S. Supreme Court.

The Appellate Court, gave short shrift to the strong arguments made by ABPS’s lawyer, Mr. Michael Sussman, easily finding for NY State, without reasoning or gravitas.  

Not that the Court needed a reason. You see, actions by this or any state, wherein the regulation(s) involve health education and welfare and not race, gender or nationality, gets subject to a legal analysis called, “rational basis”. And DW wants you to know that “rational” is used loosely, we mean really loosely, we mean even, irrationally.

Here is what occurred;

(1) New York has a physician website that lists doctors as emergency medicine board certified IF they did a residency in emergency medicine,  no problem there,

(2) an organization called ABEM [The American Board of Emergency Medicine, owned by the American Medical Association] lobbied New York to list MDs with its certification as board certified, whether or not they had done a residency in emergency medicine.

(3) the ABPS [American Board of Physician Specialties, certifies experienced ER doctors who have done residencies such as surgery, family practice and internal medicine AND have at least 5 years experience in emergency medicine practice, not owned by the AMA, having a patient first position] sued  because except for the emergency medicine residency requirement, their ER doctors meet and exceed the criteria, permitting the ABEM non ER residency trained to be able to advertise themselves as board certified.

(4) ABPS contended that if the ABEM/AMA doctor did not do a residency s/he should not be listed on the State’s website following the rule. But that if such a doctor certified by its competitor could be listed, then ABPS doctors should be listed as well.

(5) It is even simpler, ABPS said there should be a site where all ER docs should be listed, and in fact the State could list the certifying board, and whether or not an emergency medicine residency was done. ABPS believes that the best ER docs are residency trained in a relevant specialty and experienced with more than five years practice and does not accept the AMA tenet that three (3) years of emergency medicine is enough. Some hospitals agree and have even added another 4th year. However, that still does not trump greater than 5 years of experience.

 A simple and rational argument; if the rule says, you have to be emergency medicine trained to be board certified in new york, ABPS argued, then why are non emergency trained ER docs listed as certified. Was it simply because they had grandfathered certification by the AMA?

All that seems simple enough. And yet, the courts in New York, ruled against the ABPS    essentially aiding and abetting the business of the AMA/ABEM, on the basis that New York’s action was “rational”- The sort of irrational technicality that only lawyers and judges can understand. the sort of irrationality that allows criminals to get away with their crime(s).

DW asks, when did New York get into the business of aiding and abetting bad actors who seek to destroy competitor organizations with complete disregard for patient welfare issues, such as adequate access to Emergency Care?

DW has learned that there are hospitals in upstate New York, that don’t have and cannot recruit any ER doctors. Moreover, superior ABPS ER physicians are excluded from the Emergency Medicine workforce because of the AMA’s predatory action; now assisted by the state.  

DW wonders who the Court would prefer seeing if they had an emergency: a physician trained in a relevant specialty e.g. surgery, medicine, family practice, anesthesiology, pediatrics, with at least 5 years experience as an ER attending such as the ABPS certified physicians; OR, a physician who only completed a three (3) year residency in emergency medicine but was certified by the ABEM/AMA. If the court is confused, ask the patients in Upstate New York, or indeed throughout the state.

PATIENTS PREFER EXPERIENCED AND EXPERT PHYSICIANS, THAT’S JUST COMMON SENSE. 
Unfortunately, as we all know “common sense” isn’t so common, and as it turns out, in NY state, “rational” isn’t rational either.
INCIDENTALLY, A RECENT NATIONAL STUDY HAS SHOWN THAT EM RESIDENCY TRAINING DOES NOT IMPROVE QUALITY OF CARE.  (see EM Residency Training and Quality Measures)

What were the judges thinking? CLEARLY, THEY WEREN’T THINKING FOR THEMSELVES BUT MERELY CHOSE TO LISTEN TO AMA/ABEM TO THE DETRIMENT OF THE PEOPLE OF NEW YORK.

ABPS Pressures Texas to Endorse Its EM Board Certification
By Polly Ross Hughes
 
An emotional battle over which emergency physicians should be allowed to advertise their board certification in Texas shows no sign of a quick resolution.
 
After more than two hours of contentious testimony in June, the Texas Medical Board postponed a decision, deciding to tinker more with hard-fought wording in a key certification rule. “We’re not going to make everybody happy. We have no delusional thinking there,” said Board President Irwin E. Zeitler Jr., DO, after the board’s latest attempt at compromise wording failed to satisfy either faction.
 ***
At stake is whether some 175 Texas emergency physicians will be allowed to continue advertising themselves as board certified by the American Board of Physician Specialties (ABPS), the certifying arm of Tampa, FL-based American Association of Physician Specialists (AAPS). Opponents argued that ABPS requirements for emergency medicine don’t rise to the level they called the “gold standard” set by the American Board of Medical Specialties (ABMS): completing a supervised three-year residency before candidates are allowed to sit for a board exam.
***
 
“This really boils down to an argument between these two groups. They each want us to do what they want,” Dr. Zeitler said. “I would remind the board this is really a rule about advertising, and you have to do what is right for the citizens of Texas.”
 
AAPS, however, is strongly encouraging the Texas board to see the issue its way: Its lawyer, Joseph M. Nixon, sent the Texas Medical Board a letter on March 29 warning that “several legal issues will arise” if the board ultimately bars practice-track emergency physicians from advertising certification through ABPS and its subspecialty group, the Board of Certification in Emergency Medicine (BCEM). (Read Mr. Nixon’s letter to the Texas Medical Board on EM-News.com: http://bit.ly/NixonTMB.)
 
That’s no idle threat. The association filed suit against the New York Department of Health in December 2006, claiming the state agency illegally prohibited physicians certified by ABPS from advertising themselves as board certified. (http://bit.ly/NYdoh.) A federal district court granted New York summary judgment last September, finding “no genuine issue of material fact.” AAPS has appealed that decision. (Read the summary judgment on EM-News.com: http://bit.ly/NYJudgment.)
 
Emergency physicians opposing AAPS told the Texas Medical Board at its June meeting that ABPS’s alternate certification for emergency medicine misleads the public, calling it “disingenuous” and “fraudulent.”
 
***
 
“The problem with the rule as it’s currently written is it creates apparent equivalency between those who did a supervised training program and those who have work experience,” said Patrick Crocker, DO, the chairman of the Texas Medical Board committee charged with hashing out a new certification rule. “You’ve got the American Board of Medical Specialists, the Board of Osteopathic Specialists, the Texas Medical Association, and everyone on [that] side saying, ‘It’s time that ends … for there to be a legitimate specialty of emergency medicine.’”
 
***
 
Traditional certifying boards recognized by name in the Texas Medical Board rule — ABMS, the Bureau of Osteopathic Specialists, and the American Board of Oral and Maxillofacial Surgery — took notice, and soon the full board began holding a string of meetings bent on rewording rule 164.4. The rule’s latest proposed version, which met resistance on both sides of the warring factions in June, is set to undergo another round of revisions. While doctors with ABPS emergency medicine certification feared losing their right to advertise outright, doctors with ABMS board certification said the remaining vague language in the rule could open up new loopholes for ABPS to slip through.
 
Otto Marquez, MD, couched the issue for ABPS doctors as one of job security. “Forty percent of the emergency doctors in the state of Texas are not ABMS board [certified] in emergency medicine,” he said, adding that he has practiced emergency medicine in Dallas for 18 years. “My hospital advertises that I’m board certified [in emergency medicine]. The day the board changes that rule, I lose my job. It will affect my future patients. Leaving the rule the way it is benefits the patients of Texas. Changing this rule hurts the patients of Texas.”
 
Board President Dr. Zeitler called that logic “flawed” because the Texas Medical Board merely decides which doctors can advertise they are board certified. Each hospital’s medical staff, on the other hand, sets rules on which emergency doctors can practice at that hospital.
 
While it seems like a simple advertising rule, I really believe we can be disenfranchised by it because we could be fired so easily,” countered Mike Fawcett, MD, who has ABPS certification in emergency medicine.
 
If the Texas Medical Board does not allow ABPS practice-track physicians to advertise their board certification, argued AAPS attorney Nixon, it should exclude physicians certified by the ABMS practice track before it was closed in 1988. “Today, approximately 45 percent of ABMS EM board certified physicians are ‘grandfathered,’ meaning they did not complete a[n] AGCME residency in emergency medicine,” Mr. Nixon wrote in a May 26 email to Ms. Robinson, the board’s executive director. During the board’s June meeting, he said, “[C]riticisms that are launched against ABPS’s pathway are valid if they are valid against 45 percent of the ABMS physicians.”
 
Debra G. Perina, MD, the president of the American Board of Emergency Medicine, said, however, that only 19 percent of the board’s current members were board certified through the practice track. “Eighty-one percent of ABEM’s 26,665 active diplomates completed a residency in emergency medicine,” she said.
 
The problem with AAPS’s argument, said Dr. Crocker, is that every new medical specialty, in order to establish itself, has an early but limited period in which doctors can become certified through a practice track. The difference, in the case of ABPS, is “they want to extend that forever.”
 
Angela Gardner, MD, the president of the American College of Emergency Physicians, said the Texas Medical Board is ultimately responsible for the health and welfare of the people of Texas, and setting criteria for board certification is a legitimate part of that duty. “I believe that the public expects a certain level of training when they hear the words ‘board certified,’” she said. “You simply cannot say that practicing and taking a board exam from an alternative board is equal to doing a residency in emergency medicine, not in the year 2010.”
Full article on EM News
COMMENTARY:
It should be noted that the ACEP President Dr. Angela Gardner herself and a significant number of the ACEP leadership have not finished an Emergency Medicine residency. If they claim that Texas ER physicians can not advertise themselves as “board certified” simply because they did not do an EM residency, then Dr. Gardner and the members of the ACEP leadership who did “primary care residencies” similar to the 40% of Texas ER physicians they are attempting to disenfranchise, should also not claim they are “board certified”. If we’re talking honesty and truthfulness, then it should go both ways.
 
– How did EM residency become a “gold standard” anyway, and what does that even mean?  There are no studies demonstrating that EM residency trained ER docs have better outcomes than experienced ER physicians who did primary care residencies. In countries like Canada, both EM residency trained and Family Medicine physicians can be considered “board certified” in Emergency Medicine.  
 
– Another fact glossed over in this article is that after more than 20 years,  the EM residency track has failed to provide enough ER physicians to staff the nation’s ERs (Camargo 2008) at least till 2038, if ever.  There is no other “legitimate specialty” where 45% of the services are provided by physicians who did not do residency/ fellowship training in that particular field 20 years after that specialty was introduced.   This statistic clearly shows that Emergency Medicine is not like other “specialties”  and
demonstrates the failure of the EM residency track approach in addressing the problem of providing Emergency services to meet the population’s rapidly growing demand.
Rather than a specialty, Emergency Medicine is really an “area/ field of expertise” like Primary Care where serivces are provided by physicians from multiple disciplines.  
-ABPS attempts to address the Emergency Care staffing needs, particularly of  rural populations who are underserved by ABEM certified physicians. If ABMS/ ACEP were truly concerned about protecting the citizens of Texas and other states, then they should worry more about providing access to good Emergency Care than protecting their turf and worrying about who calls themselves “board certified”.
As promised, this site received and now posts the letter ( ABMS letter to SenCoffee) from Kevin Weiss MD, CEO of ABMS, opposing the Oklahoma Medical Boards final approval for ABPS diplomats to advertise their board certification. On November 18, 2009 a public hearing to recognize the ABPS as another pathway to ‘Board Certification’ for the purpose of physicians advertising their credentials to the public was granted.
 
The problem with Dr. Weiss’s letter was (1)  it was sent AFTER approval was granted by the Oklahoma Medical Board, AND  (2) after receiving the letter it seems that Senator Coffee contacted influential board member(s) per Dr. Kevin Weiss’s influence, and as a result, the Board overturned their properly considered approval of ABPS  and (3) Dr. Weiss’s ABMS’ letter is filled with propaganda and mischaracterizations, which Senator Coffee obviously did not take the time to check out. 
 
This conduct is, at the very least unethical, and possibly actionable, on multiple levels and a response from the Oklahoma Medical Board, Senator Glenn Coffee and ABMS and ABPS to clarify this issue would be much appreciated.
 
 
Board tampering and misconduct are alleged to have occurred during this period by virtue of interference with the medical board’s decision by parties who are not members of the board.
  LINK:

ABMS letter to SenCoffee

ABMS Resorts to State Board Tampering Part 1

In April 2010, the Oklahoma State Medical Board approved an amendment to the Oklahoma Administrative code which would have allowed diplomates of the American Board of Physician Specialties (ABPS) to advertise themselves as “board certified” in their medical specialty.  It has come to this site’s attention that Kevin Weiss, CEO of the American Board of Medical Specialties (ABMS), ABPS’ chief competitor, contacted Oklahoma State Senator Glenn Coffee and influenced him to block this amendment in the state legislature.  Upon information and belief, and after consultation with counsel, it has become evident that such an action is improper and unlawful, and may constitute first amendment and ethical violations, particularly on the part of the senator. 

Such behavior by the leaders of ABMS is more reminiscent of the actions of corrupt  political bosses, or more recently, CEOs of Exxon and Bear Stearns than the head of a medical specialty certification organization that purports to have the public’s interests at heart. 

This is not the first time that ABPS efforts’ to seek recognition for its diplomates have been blocked via questionable means by organizations who perceive ABPS as a threat.  ABPS certification is recognized in states such as Florida and Texas, and in both states, the American College of Emergency Physicians (ACEP), which is supposed to represent ALL Emergency physicians, and not solely those with Emergency Medicine residency training who comprise barely half of the currently practicing EM physician workforce, have made repeated attempts to influence these state medical boards to withdraw their recognition of ABPS board certification. 

In the face of an impending ER physician shortage, it would seem that ACEP, instead of opposing ABPS, should be welcoming and aiding its initiative to provide experienced and skilled ER physicians to the public. It is the utmost hypocrisy and symptomatic of how out of touch they are from real world realities, for the ACEP leadership to continue to proclaim that Emergency medicine residency training is a “gold standard” for ER physicians when a significant number of both ACEP leaders and members are not EM residency trained.  As one of the many comments made on this topic on the ACEP website noted, the ACEP stand on EM residency training is not a “gold standard”, it’s a double standard.

We will be posting Dr. Weiss’ letter to Senator Coffee in full on this site when it becomes available shortly.  At that time, we invite ABMS, ACEP and ABPS to comment.

LINKS:

ABMS Resorts to State Board Tampering Part 2

from EM NEWS: AAPS Ramping Up Campaign for Recognition

Texas Recognizes ABPS Certification

ACEP Releases Statement on Texas Medical Board Action

News from  AAPS vs. NYDOH

Response to Florida ACEP: No Correlation Between Doctors Who Fail to Meet Standard of Care and Board Certification

Florida ACEP: Only EM Trained Doctors Should be Working in ERs

Disposable Doctors 2: ER Docs Fight Back in NY

(from Emergency Medicine News Volume XXXI, Number 2 February 2009)

 By Ruth SoRelle, MPH

 

 

 

 

 

A recruiting letter from Team- Health has raised the hackles of leaders in Vanderbilt University Medical Center’s emergency medicine residency program, and has even drawn a demur from the president of the American College of Emergency Physicians.“It was sent out by one of those big agencies,” said Keith Wrenn, MD, the director of the emergency medicine residency program at Vanderbilt University School of Medicine in Nashville. “By recruiting people who have not been trained in emergency medicine, they are undermining the whole board certification process.”

 

 

 

In the letter that began “Dear Primary Care Resident,” Dr. Dukes wrote: “Physicians who are trained in primary care specialties such as Family Practice and Internal Medicine are in a position to take advantage of the opportunities available in Emergency Medicine.” He noted that only 1,100 doctors graduate from emergency medicine residencies in the United States each year, a number that falls short of meeting the demand.

“Therefore, primary care physicians will be needed in the foreseeable future to staff the nation’s Emergency Departments,” Dr. Dukes wrote. “ECC’s experience over the past 27 years reveals that Primary Care trained physicians are well equipped to perform superbly in the Emergency Department,” noting that they have the “people skills”needed to “get along with patients, hospital staff, and attending physicians.”

The letter continued: “We have immediate opportunities available in several of our departments for Primary Care Residents to work directly with an experienced Emergency Medicine Physician. Residents are compensated while receiving on the job training.”

David Lawhorn, MD, the president of the Tennessee chapter of American Academy of Emergency Medicine, did not dispute that more emergency physicians are needed, and he said the number of emergency medicine residency slots should be examined. “But he said one of the significant differences between primary care and emergency medicine is that primary care physicians begin to lose many of their procedural skills, such as intubations or central lines, due to the demands of the office-based practice. “It is in these critical care areas that the emergency medicine-trained physician stands out and performs confidently, knowledgeably, and routinely. In the United States today, we are like a hybrid of primary care, office surgery, and critical care intensivist. It is clearly very disheartening for the trained emergency medicine physician who loses his emergency medicine job to someone trained in another specialty,” Dr. Lawhorn said.

Yet he acknowledged Dr. Dukes’ dilemma. “It is absolutely true that we in the United States will need physicians other than EM residency-trained physicians to continue to staff emergency departments across the country for several years to come. Even if EM residency programs were able … to fill all the slots, the problem would still exist with the many, many rural hospitals,” he said. “I suspect that ECC of TeamHealth has a significant number of these small rural EDs with which they have contracted to provide services, and thus put themselves in a position to fill the EM slots with any viable physician they can find.”

The reluctance of many emergency medicine-trained physicians to work with contract management groups also constrains supply, Dr. Lawhorn said. He noted that the letter implied contract management’s difficulty in filling EM slots with residency trained, board certified emergency specialists, adding that this will persist because of the contract management companies’ “necessary strategy for survival of getting the contract first and then figuring out how to fill the positions needed for coverage.”

But beyond the recruitment message of the letter is a bigger issue for the future of emergency medicine, Dr. Lawhorn said. “It is so close and obvious that it can be hard to see. Step back a bit, and you will see a large corporation in the business of selling the highest quality, lowest cost emergency care to the hospitals with which they contract. And now they are looking to other specialties to fulfill that role. What other board specialty in the United States has large business-run corporations that sell themselves as the leaders in that specialty that then turn around and recruit the residents from other specialties to fill their needs so that they can maintain contracts and keep their revenue streams?” Dr. Dukes said he sees no proble with recruiting primary care residents.“If you look at emergency medicine, what makes an emergency physician? A core of knowledge and technical skills,” he said. “I think these physicians have been proven to do as good a job as anyone in the emergency department. For these physicians to start in emergency medicine, they need to have the ability to work in the department along with another experienced physician. Once they get trained in family practice or internal medicine, they need some orientation in an emergency department along with training in advanced life support and other programs to work a solo shift. The letter was for primary care residents to offer them a position as a second physician usually working in the fast track alongside an experienced emergency physician.”Acknowledging that a Dec. 2, 2008, Institute of Medicine report (http://www.iom.edu/cms/3809/48553/60449.

aspx) on residency hours would include moonlighting in the numbers of hours resident is allowed to work, Dr. Dukes said ECC is open in its dealings with residency programs. “We usually take a few people in the third year with the knowledge of the program director. We also work with some physicians in emergency medicine fellowships,” he said.

Dr. Dukes said he recognized the controversy over this issue in emergency medicine. “I know AAEM does not recognize the AAPS board,” he said. “That is kind of bad. How are we ever going to get board certified physicians in all these hospitals if they are not graduating enough emergency medicine-trained physicians each year? For physicians who don’t have the same training but have excellent training in primary care and are doing the same rotations as emergency residents, how can they get certified?”

Dr. Wrenn of the Vanderbilt residency program said Dr. Dukes is seeking to employ physicians who completed primary care training but now want to practice another specialty. Such people can seek retraining and board certification through the American Board of Emergency Medicine, he said, although no federal funds support it.

 

“I am not sure as a specialty that we have done the best we can to send emergency physicians to the rural areas,” said Dr. Wrenn, also the vice chairman and a professor of emergency medicine at Vanderbilt. “We need to address that, but it needs to be addressed by board certified people, not those who have not been trained.”

Excerpt from AAPS letter to EM News:

BCEM, along with Team Health and others, recognizes that there are too few emergency medicine residency trained physicians to meet the growing needs of our nation’s communities, particularly rural emergency departments. The 1,100 physicians who graduate from Emergency Medicine residencies each year in the U.S. falls short of meeting the need which exists…

AAPS’ Board of Certification in Emergency Medicine (BCEM) provides primary care residency trained physicians practicing full time in Emergency Medicine, a valid and critical option to demonstrate that they can perform confidently, knowledgeably and safely.  BCEM has certified and recertified thousands of well qualified Primary Care residency trained physicians working in Emergency Medicine. BCEM Diplomates continue to increase in numbers…

At no time is BCEM’s option to board certification in Emergency Medicine designed to diminish Emergency Medicine residency training. Instead, BCEM’s focus is to provide a legitimate and recognized option for Primary Care residency trained physicians to demonstrate competency and to become certified in the specialty of Emergency Medicine.

BCEM has, and continues to, welcome the opportunity to meet and discuss effective methods that EM residency trained and non-EM residency trained physicians, including Primary Care residency trained physicians, can employ and engage to work together to provide care to the Moms, Dads, and families who present themselves each year to our nation’s ERs..”

Robert J. Geller, D.O., FAAEP

Chairman, BCEM

 Link: Supply of Board Certified EM Physicians Unlikely to Meet Country’s   Needs

 

 

 

 

 

 

 

 

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Misconceptions in the Emergency Medicine community regarding the now legendary case of “Daniel, et al. vs. ABEM” have been running rampant. Chief among these are:
1. that Dr. Daniel and AAPS were working together in this case
2. that the end of the Daniel case vindicates ABEM and that no antitrust violation occurred
3. that the end of the Daniel case means that for now and the future, only EM residency trained physicians can practice Emergency Medicine

Before explaining why these are misconceptions, let us first read what actually happened in “Daniel et al. vs. ABEM”
(Excerpted from “Antitrust: Emergency Medicine Physicians Lack Standing to Bring Antitrust Action” by Sarah Gasper in American Journal of Law and Medicine)
Background:
Dr. Gregory Daniel and 175 other named plaintiffs, along with approximately 14,000 members of the proposed plaintiff class were physicians who currently practice or who have practiced emergency medicine and who would be eligible to take the ABEM exam if the practice track still existed.18 Plaintiffs alleged that by closing the practice track and placing a premium on ABEM certification, ABEM, CORD, numerous hospitals, and various individuals associated with these organizations unlawfully restrained trade and monopolized the market for ABEM-certified and ABEM-eligible physicians.19 Specifically, plaintiffs argued that the defendants conspired to limit the pool of eligible applicants, thus creating an artificial shortage of ABEM-certified and ABEM-eligible physicians, with the end goal of demanding super-competitive pay.20 While other boards certify physicians in emergency medicine,21 the plaintiffs asserted that the ABEM certification is the most prestigious, that some hospitals only hire ABEM-certified physicians, and that some hospitals base compensation and promotion decisions on ABEM certification. As a result, plaintiffs asserted they receive “substantially less remuneration than ABEM-certified physicians” and that they continue to suffer loss of income.23 Furthermore, plaintiffs assert that they have been denied positions solely by reason of not being ABEM-certified or ABEM-eligible and that some were discharged, demoted, and assigned to undesirable work situations due to the lack of ABEM certification.24 Finally, plaintiffs claimed that CORD had a specific interest in keeping the formal residency training as the required path to ABEM certification.25

Court Decision:
In declaring that the plaintiffs lacked antitrust standing, the Court noted that even if a private party is injured by a violation of antitrust laws, the party must still have standing to bring a claim.37 The Court identified four relevant factors for determining antitrust standing38 and focused on two: the alleged antitrust injury and efficient enforcement of these claims.39 The plaintiffs here alleged financial injury due to ABEM restricting the number of eligible physicians that take the certification exam, which in turn limits the number of such doctors and allows the certified doctors to charge higher costs.40 However, as the Court summarized, the plaintiffs’ “theory of injury is not simply that ABEM-certified doctors command supercompetitive remuneration; their injury is the inability to do likewise.”41 The plaintiffs did not attempt to remove the residency track requirement, nor did they allege that they would have received the same pay but for ABEM’s domination of the market.42 Rather, the plaintiffs sued “only to restore-temporarily-the practice track as an alternative to residency training so that they can qualify for the ABEM exam, after which they are satisfied to have the certification door shut on any other test applicants.”43 The Court noted that the plaintiffs could not state an antitrust injury “when their purpose is to join the cartel rather than disband it.”44
In addition, the Court noted that even if the plaintiffs did have a viable antitrust injury, these plaintiffs are not the best enforcers for the alleged antitrust violation.45 As the District Court below found, these plaintiffs “have no natural economic self-interest in reducing the cost of emergency medical care.” 46 The Court emphasized that the relief pursued by the plaintiffs here is to gain entry into an exclusive arrangement that they otherwise seek to maintain in order to share in the supercompetitive remuneration allegedly made possible by ABEM exclusivity.47 Furthermore, the Court noted that both the individual emergency care patients, who rarely choose their emergency doctors, and the hospitals, who act both as consumers who pay for the emergency care and as suppliers of the residency training, are an unrealistic class of plaintiffs.48 On the other hand, the government and private health care insurers, who compensate hospitals for most emergency care, do have a direct and undivided economic interest in reducing the costs of emergency medical care as well as the necessary legal sophistication to challenge an antitrust violation.49 Ultimately the Court concluded that health care insurers would be the best enforcer of this antitrust challenge.50

Judge Katzmann concurred in part and dissented in part with the majority’s holding. While he agreed with the majority’s conclusions on personal jurisdiction, he believed plaintiffs had antitrust standing and would thus transfer the case.51 Katzmann found plaintiffs allegations sufficient to “allege losses stemming from a competition-reducing aspect or effect of the defendant’s behavior” because they allege that the defendants unreasonably restrained them from competing in the ABEM-certified market of physicians and consequently, the plaintiffs suffered financial losses.52 In addition, he argued that the plaintiffs’ remedy would actually benefit consumers because an increase in the number of ABEM-certified doctors could result in lower salaries for those doctors in general and thus lower costs for the consumers.53 Katzmann also disagreed with the majority’s conclusion that plaintiffs only want the practice track to be an option temporarily, indicating that the plaintiffs stated that they wanted the exam to be open to all class members, who, presently or with passage of time, would meet the practice track criteria.54 In sum, the plaintiffs did not seek to earn “super-competitive” wages, nor was their request for relief “inconsistent with their allegations that (1) prohibiting practice-track physicians from taking the certification exam is illegally anti-competitive and (2) the plaintiffs have suffered antitrust injury as a consequence.”55

***While this case does not rule affirmatively either way as to the allegation that closing the practice track was an antitrust violation,the second Circuit speculates that health care insurers, and not doctors, would be efficient enforcers of such an allegation.

It should be obvious from the above that misconception #1, that “Dr. Daniel was working with AAPS in the case” is completely untrue. In fact, AAPS had absolutely nothing to do with “Daniel et al. vs. ABEM”. Statements made by persons such as Dr. Antoine Kazzi, former president of the California Chapter and AAEM Board Director in EM News (“AAEM: Board Certification Under Attack in Florida” Emergency Medicine News:Volume 26(9)September 2004pp 1,46) and others stating this association reveal at the very least careless ignorance of the facts.
Misconception #2:
It should also be clear from the above that the decision in “Daniel et al. vs. ABEM” in no way, shape, or form vindicates ABEM’s actions. In fact, the decision states that upon reviewing the evidence, ABEM may very well be guilty of antitrust violations, however health care insurers, and not doctors should be the ones who should bring that claim to court. Judge Katzmann, who dissented in the opinion, argued that the plaintiffs’ remedy (allowing career EM physicians to take the ABEM certification exam) would actually benefit consumers because an increase in the number of ABEM-certified doctors could result in lower salaries for those doctors in general and thus lower costs for the consumers.

Misconception #3
that the end of the Daniel case means that for now and the future, only EM residency trained physicians can practice Emergency Medicine