Archive for the ‘ER Docs’ 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.


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.”


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
I would like to comment on the article, “NY, OK Thwart AAPS Quest for Certification Recognition.” (EMN 2010;32[9]:1),_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

Practice Track Needed Till EP Shortage Ends
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


“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.




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.

Unfortunately, as we all know “common sense” isn’t so common, and as it turns out, in NY state, “rational” isn’t rational either.


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.


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 (

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









Published: September 15, 2008
in the New York Times

A vast majority of emergency room patients are discharged without understanding the treatment they received or how to care for themselves once they get home, researchers say. And that can lead to medication errors and serious complications that can send them right back to the hospital.

Patient Comprehension of Emergency Department Care and Instructions: Are Patients Aware of When They Do Not Understand? (Annals of Emergency Medicine)
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In a new study, researchers followed 140 English-speaking patients discharged from emergency departments in two Michigan hospitals and measured their understanding in four areas — their diagnosis, their E.R. treatment, instructions for their at-home care and warning signs of when to return to the hospital.
The study, published online in July by the Annals of Emergency Medicine, found that 78 percent of patients did not understand at least one area and about half did not understand two or more areas. The greatest confusion surrounded home care — instructions about things like medications, rest, wound care and when to have a follow-up visit with a doctor.

“We’re finding that people are just not prepared for self-care, and that’s what is bringing them back,” said Dr. Eric Coleman, director of the Care Transitions Program at the University of Colorado, who was not involved in the study.

The researchers described a woman in her 20s who went to the emergency room with abdominal pain. After extensive testing, doctors there diagnosed pelvic inflammatory disease, a sexually transmitted infection.

But when interviewed by a researcher, the woman said that she was not aware of any diagnosis, that she did not realize she had been sent home with an antibiotic (she took only the pain medication she was given), and that she did not know she should abstain from sex, tell her partner or have follow-up care.

“The risk is that she could become more seriously ill,” said one of the authors, Dr. Kirsten G. Engel, a clinical instructor at Northwestern University. “It’s a significant risk to her fertility, and she could pass it to her partner.”

Dr. Paul M. Schyve, senior vice president of the Joint Commission, the main organization that accredits hospitals, said: “This study showed that this is much more common than you think. It’s not the rare patient.”

Similar results have been found for patients leaving hospitals, not just emergency rooms. And experts say they help explain why about 18 percent of Medicare patients discharged from a hospital are readmitted within 30 days.

Doctors and patients say that with hospitals pressed to see more patients faster, patients get less attention. “When I start my shift, I know what I’d like to accomplish, but by the end of the shift, my main concern is that nobody dies, and the other things become less important,” said Dr. Michael S. Radeos, research director in the department of emergency medicine at New York Hospital Medical Center of Queens.

Jaleh Teymourian Brahms of Millburn, N.J., ended up in the emergency room after falling face down on a street in Manhattan. “I had pavement embedded in my face and two chipped front teeth,” she said.

After being examined for broken bones (there were none), she waited four hours before she was discharged, with bits of pavement still embedded in her face. Ms. Teymourian Brahms said she received no instructions about how to care for her face. Her dentist had to pick the tar and gravel out with a dental tool, then instructed her on how to clean her face and to keep it moist with an antibacterial ointment.

“I risked a nasty infection had I not seen him,” she said.

Everything is exaggerated in the emergency department. Doctors are harried, they have little time to go over complicated information and they do not know the patients. Most patients are anxious, upset and not likely to be thinking clearly.

“These factors do not make for the best environment for someone to absorb information,” Dr. Engel said.

The problem is particularly acute when it comes to drugs. A patient-education program used in 130 health delivery systems across the country found that about 40 percent of patients 65 or older have a medication error after they leave the hospital. A 2006 report by the Institute of Medicine found that doctors and nurses were contributing to these errors by not providing information in an effective way.

“The physician’s ability to predict whether a patient understands isn’t as good as can be,” said Dr. Rade B. Vukmir, an emergency physician at the University of Pittsburgh and spokesman for the American College of Emergency Physicians.

In the past, patients who did not follow discharge instructions were often labeled noncompliant. “Now, it’s being called health illiteracy,” Dr. Coleman said, adding that as many as half of all patients are considered to lack the ability to process and understand basic health information that they need to make decisions.

But the patient is only part of the equation, he continued; doctors are notoriously inept at communicating to patients.

The new study found that people were not aware of what they did not understand, suggesting that simply asking a patient if he understands is not enough.

“We’re good at saying, ‘Here’s the information, any questions?,’ ” Dr. Coleman said, “and the person nods his head, but they don’t get it.”

Older patients are particularly vulnerable. “They have the kinds of communication barriers we might expect, with vision and hearing problems,” said Dr. Susan N. Hastings, an instructor in geriatrics at Duke. The hectic environment of the emergency department can be particularly stressful for them.

Until recently, poor communication was largely ignored by hospitals. “Just a few years ago, there were subtle incentives for hospitals to not get involved in this area, because of financial gains when people come back,” Dr. Coleman said.

But hospitals are now being forced to face their communication inadequacies. “We’ve raised the bar of what’s expected of hospitals,” said Dr. Schyve, of the Joint Commission. At the same time, the Medicare Payment Advisory Commission, a government agency that advises Congress on Medicare issues, has recommended a policy change that would reduce payments to hospital with excessive readmission rates. It has also asked Medicare to allow hospitals to reward physicians who help lower readmission rates.

Experts in doctor-patient communication recommend a “teach back” approach, in which the patient, preferably accompanied by a relative, friend or caregiver, has to repeat the instructions back to the doctor.

“No matter what you put in writing, what diagrams you have, you really can’t be confident that patients understand what they should be doing unless you have them repeat it back to you,” Dr. Schyve said.

Dr. Vukmir, of the emergency physicians’ group, recommends a “dual discharge” approach: the physician talks to the patient about the results, treatment plan and follow-up care. Then a nurse follows up with computerized discharge instructions.

But Dr. Coleman believes this is not enough. “A third of people over 55 have impaired executive cognitive function,” he said, adding that such patients might understand their medications and know when to take them, but fail to follow through.

He recommends that hospitals coach patients on self-management skills before discharge. Patients need to ask questions, he said. Hospitals should make follow-up calls and visits to patients, a costly endeavor but potentially less expensive than getting reduced Medicare payments if readmission rates are high.

“Hospitals need to have some accountability for the no-care zone, the period between when you leave the emergency department or hospital and when you get into your primary care setting,” Dr. Coleman said. “They should be available for 72 hours.”

We have decided to conduct an informal, completely unscientific survey to answer the question,
“How many non-Emergency medicine (EM) residency trained ER physicians have had their ER career/ livelihood terminated or seriously limited due to lack of EM residency training?
Post and be counted, you don’t have to use your real name, just give us
your work setting (urban/ suburban/ rural),
-years in ER practice,
original specialty training, and
-if you’d like to tell us something about your circumstances, it would be greatly appreciated.
If you want to solve a problem, you have to get a good look at it.

Links: Disposable Doctors
Disposable Doctors 2
Fighting to Level the Playing Field for ABPS in NY
Not So Disposable Doctors
News From AAPS vs. NY-DOH
Florida to Say “Bye-Bye Grandpa!”
Florida ACEP: “Only EM Residency Trained Docs Should be Working in ERs”
FCEP: Whose Side are You Really On?
Response to Florida ACEP: “No Correlation Between Doctors Who Failed to Meet Standard of Care and Board Certification”

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

AAPS vs. NYS-DOH Update
Fighting to Level the Playing Field for AAPS Docs in NY
Florida to Say “Bye-Bye Grandpa!”
Honoring a Legacy or Opening a Loophole (EM News)


For years, ABMS/ABEM/ACEP/AAEM have sought to eliminate competition from ABPS board certified physicians. In New York State, they seem to have tricked the DOH (Department of Health) into accepting their version of the facts: that only residency trained ER physicians are qualified to practice emergency medicine. Unfortunately, by so doing they may have also stripped board certification in Emergency Medicine from their grandfathered members, who are NOT residency trained in ER medicine.

In their rush to exclude competition from ABPS certified physicians from the practice of Emergency Medicine, ABMS/ABEM/ACEP/AAEM should have heeded the advice in the Proverbs of Solomon, regarding wisdom, or the common prudence, that everything cuts two ways!

ABMS/ABEM/ACEP/AAEM lobbied NYS- DOH to list only ABEM residency trained physicians on their website as being board certified in Emergency Medicine [].
ABPS sought the same privilege but were repeatedly, irrationally and arbitrarily denied. After being unfairly denied on multiple occasions, ABPS finally brought suit against the NYSDOH under Equal Protection, seeking to have ABPS certified physicians listed on the NYSDOH website as board certified, as other boards have successfully done in other states. (see ABCS case)

This 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 basis and ABPS’s reluctance to share their world view, that the only way to practice emergency medicine is after a residency in that specialty.

In other words, why can’t ABPS just keep quiet and allow ABMS/ABEM/ACEP/AAEM to continue their monopoly of Emergency Medicine?

Didn’t Daniels [Daniels v. ABEM] lose his case asserting monopolistic practice in Emergency Medicine by ABMS/ABEM/ACEP/AAEM? Not exactly. Daniels lost, but not on the merits.
Daniels was not dismissed on the merits. The error in the Daniels case was, when asked what he was seeking he said he wanted to practice emergency medicine, and if ABEM let him take their test then he would be able to practice. Simple enough, right? Daniels knew that ABMS/ABEM/ACEP/AAEM were lobbying so that for him to practice ER medicine, he had to join their group. He knew, that ABPS would face constant attack, notwithstanding the equivalency of their examination and certification process. That’s just the way it was and is.

But how could Daniels sue ABEM because ABEM won’t let him join them?

If what Daniels said was true and ABMS/ABEM were unlawful monopolizers, then a monopoly existed and he was being economically excluded. The court said, you can’t come to us to help you join a group you claim are unlawful monopolizers under the Sherman antitrust act. We the court, can’t help you join the monopolizers. Dismissed.

But what has occurred in NY is not much different.

Daniels should have joined ABPS and obtained their certification. His practice would have been impeded as well, since hospitals do not consider ABPS board certification and New York State won’t list ABPS as a legitimate board, because, ABMS/ABEM/ACEP/AAEM have lobbied to get NY State to help them eliminate their competitors.

New York listened and will not list a physician not residency trained in ER medicine as board certified on its website. This is inconsistent, since NY lists all the grandfathered ABEM certified physicians who definitely did not do residencies in ER medicine, as board certified.
ABPS cried “Foul!”

Of course, what’s interesting is that if the training was so unique, then any physician not trained in EM, would fail tests of the subject matter. But we know that’s not so…since ABEM grandfathered physicians have managed to do just that, and Daniels and many other excluded physicians are certainly no different in training from the physicians permitted grandfather status from an arbitrary closure of the practice track in EM.

In fact, all of the certified ABPS physicians are convinced they would also pass the ABEM board examination, just like their grand-fathered colleagues. Dwight Collman [ABEM certified], arguably the best ER Board Preparer in the country, did not do a residency in ER medicine. No one doubts his fund of knowledge nor his likely skill in the actual practice of EM.

And of course, what’s so wrong about using NY State to burden ABPS under the guise of jurisprudence or concern for the patient even if the relationship between the means and the ends are irrational? The fact that NY State ends up protecting ABEM/ABMS/ACEP/AAEM from economic competitors, though not a legitimate government purpose, well, that’s alright too, ABMS/ABEM/ACEP/AAEM knows best! Since the legal standard of review would be “rational basis” it seems that ABMS/ABEM/ACEP/AAEM took their chances. Anything can be deemed rational and many courts have found rationality when there was none.

The deck stacked in their favor, ABMS/ABEM/ACEP/AAEM pressed on in lockstep, with their self righteous, strong arm tactics, oblivious to cogent arguments against their positions from the State, who quite frankly, never investigated. What ABMS/ABEM/ACEP/AAEM/NYSDOH forget is that “rational basis” also cuts two ways and ab initio, does not mean abdication of judicial review.

If, as it is said, “Nothing cleanses like daylight”, then ABPS’s contention that its
certified member physicians are under unfair attack by unlawful discrimination, and that ABMS/ABEM/ACEP/AAEM have enlisted the State as aider and abettor in their attempt to destroy ABPS appears to be true.

Under the current NYSDOH rules, only ER residency trained and ABEM certified physicians can list themselves as board certified on the NY Physician Profile website.
( The website defines “board certification” as:
“If a doctor is Board Certified, this means that he or she had graduated from medical school; completed residency (training in a hospital); trained under supervision in a specialty, and passed an exam given by a medical specialty board.”

That’s right. Under this rule, ABMS/ACEP/ABEM/AAEM, seeking to eliminate ABPS competition, also strips board certification in New York from ABEM grandfathered physicians, not residency trained in Emergency Medicine

Technically, those grandfathered physicians cannot promote themselves in NY State as “Board certified” because they did not do an EM residency. Also, on applications to hospitals that ask for Board Certified physicians, they are as precluded as are ABPS physicians from getting those jobs, although we all know they are just as qualified.

Should the NYSDOH de-list ABEM certified non ER residency trained as not being board certified? ABPS does not think so. To their credit, ABPS does not seek to disenfranchise ABEM grandfathered physicians, but regards them highly, and would be happy to provide them with a new home in AAPS [American Association of Physician Specialists]. All they seek is for their own certified physicians to be treated fairly.

Fighting to “Level the Playing Field” for ABPS Docs in NY

Hear! Hear! Judge Decides NY AAPS Case Goes Forward

Disposable Doctors 2: ER Docs Fight Back in NY