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EMERGENCY MEDICINE WORKFORCE
EMERGENCY MEDICINE WORKFORCE
When the ideals of academia and the profit-driven goals of some hospitals unwittingly adversely affect quality of medical care it is time to take a second look.
In Florida, as in many other states of the Union, Emergency Medicine has evolved to a point where the training of doctors is coming under increasing scrutiny. While it is prudent to continually evaluate and improve all medical specialties there are times when a path that appears attractive may, in fact, lead to an undesirable destination.
For those of you unfamiliar with the history of Emergency Medicine (EM) I will give a short historical account.
Compared to other medical specialties EM is fairly new, having started in its present form back in the 1970's. Because of the many hospital Emergency Rooms (ER's) serving the vast population of this country the academic residency programs have thus far been unable to keep up with workforce demands. It will be several years before there are enough residency-trained docs to fill the positions currently available.
At its inception the American Board of Emergency Medicine (ABEM), the main (though not the only) examining board for the specialty, wisely provided two distinct tracks for board certification, the residency-trained and the practice tracks. Realizing that doctors who learned emergency medicine by actually practicing it were equally as well equipped as those who attended a residency program ABEM granted board certification to both groups of examinees.
Unfortunately, due to errors in judgment about the length of time it would take to fill all the available jobs with residency-trained physicians, ABEM closed its practice track in 1988. Since that time the only avenue for achieving board certification with ABEM is to complete a residency in emergency medicine and then sit the exams.
This would be all well and good were it not for the fact that if we were today to depend on only residency-trained EM doctors to man the current workforce many ER's would have to close their doors. There simply are not enough to go around. Though residency training should be the preferred path, as it is for other specialties, and though even practice-trained EM doctors acknowledge this, the reality of the situation is the current shortage of such doctors.
Because hospitals like to advertise to the public that all on their medical staff are board certified and because these hospitals contract with EM groups/companies to staff their ER's, many "legacy physicians", a term that will be explained shortly, now find themselves being discriminated against when it comes to keeping their present jobs and/or seeking new ones.
I am one of these doctors. You can learn more about the path I took by reading "Dr. B's Bio" on this website.
One of the results of hospitals' rush to squeeze out non-boarded doctors is that a young inexperienced graduate of a residency program will be hired instead of a seasoned proven competent EM physician.
The American College of Emergency Physicians (ACEP), the main (but not the only) professional association representing emergency doctors in the USA, and comprised of both boarded and non-boarded emergency specialists, has come out with policy statements in support of "legacy physicians", those non-boarded doctors practicing before the twenty first century. The text of one of these policies follows.
As mentioned previously, though hospitals like to limit their medical staff privileges to only board certified physicians, there is a Medicare regulation forbidding such behavior.
According to The Code of Federal Regulations, Chapter IV, Sec. 482.12,a,7 under participation: governing body, medicare receiving facilities are prohibited from discriminating against physicians on the basis of board certification, board eligibility or membership in any group or club. Any hospital found to be discriminating in such a manner, either by policy or in practice, is subject to immediate action by the Office of the Inspector General (OIG) and can have its medicare reimbursement withheld if it fails to comply. Such an action could effectively shut down a hospital.
This regulation was enacted in an effort to prevent restraint of trade within the world of medicine and to protect the public by allowing competent doctors to attain hospital privileges. In spite of this, and some state statutes which basically serve the same purpose, hospitals regularly discriminate against my colleagues and me. When one is busy saving lives and trying to swim against the tide of prejudice, little energy is left for fighting a system that perpetuates such unfair treatment.
Two other points are worth raising here.
One is the fact that there is no clinical evidence to show that practice-trained, non-boarded EM doctors are less competent or get sued more often than their residency-trained board certified counterparts.
Another is the topic of the increasing numbers of physician extenders used in emergency rooms in this country. Physician assistants (PA's) and nurse practitioners (NP's) are in many cases replacing doctors in these settings. Because it is cheaper for hospitals and ER companies to pay PA's and NP's, their numbers in ER's are growing.
While it could be argued that PA's and NP's serve a legitimate role in emergency rooms, I would say that when they actually replace doctors, and when patients are discharged from the ER having never seen a doctor, I think we need to ask ourselves what we as a society really want. It is ironic that some of the very hospitals that refuse me a job in their ER's will have some patients being seen by only PA's and NP's. These extenders apparently are qualified to be evaluating and treating patients but I am not!
Where is the logic in this?
It has nothing to do with logic or quality of care and has everything to do with money. The system has begun to put at increasing risk the very people it is sworn to protect.
The medical safety net has holes in it and we, the American public, are at risk of falling through.
So the next time you go to an ER expecting to be cared for by a competent experienced emergency medicine specialist you might get lucky. But there is no guarantee.
What do you want for yourself and your loved ones?
Marlene Buckler, MD, FACEP www.StayOutOfMyER.com
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