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