Should ABEM Offer More Subspecialty Certification?

[southerndoc]

The American Board of Emergency Medicine currently offers subspecialty certification in medical toxicology, sports medicine, pediatric EM, and hyperbaric medicine.

Do you think it's time for ABEM to offer certification in more subspecialties?

Specifically:
- Pre-hospital and Disaster Medicine
- Emergency Ultrasound
- Critical Care Medicine

What do you think?

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[Willamette]

Another sub-specialty that is being touted by some (see the current ACEP News) is Geriatric Emergency Medicine.


Willamette

 

[southerndoc]

Another sub-specialty that is being touted by some (see the current ACEP News) is Geriatric Emergency Medicine.


Willamette

Geriatric emergency medicine may be too new to offer subspecialty certification. It's only the second year that this fellowship has been offered, and as far as I know, it's only offered by two locations.

If anyone is interested in taking this further, I encourage you to write to ABEM and express your opinion.

The address is:

Board of Directors
American Board of Emergency Medicine
3000 Coolidge Road
East Lansing, MI 48823-6319

 

[docB]

The American Board of Emergency Medicine currently offers subspecialty certification in medical toxicology, sports medicine, pediatric EM, and hyperbaric medicine.

Do you think it's time for ABEM to offer certification in more subspecialties?

Specifically:
- Pre-hospital and Disaster Medicine
- Emergency Ultrasound
- Critical Care Medicine

What do you think?

I voted no. Here's why.
For EMS I don't think that this requires an academic fellowship or a board cert. EMS from the Physician level is primarily administration and education. I am not putting down EMS fellowships. I think they're great for those who want to be EMS directors (I considered doing one myself). I also don't think that the lack of a board cert for the fellowship diminishes the fellowship at all.

For US I think that it is a very specific area, not broad enough to require a cert. It is one modality, in one setting. It's valuable, no question. There are fellowships for it and those train EPs to use it well. However, I don't think it needs its own cert. I'm sure there are those who will disagree (Peski?). I also wonder (this is kind of aimed at Peski as well) if a cert would make the billing questions and the turf disputes between rads and EM worse and actually hinder the spread of EM US.

For Critical Care the last thing we want is to expand the role of EPs from care for the first few hours to the whole Critical Care admission. Taking on the whole admission as the CC doc is contrary to the basic mission of EM.

 

[southerndoc]

Simply offering these subspecialty certifications does not mean that they are required.

EMS - For rural systems, a fellowship is not needed. However, active large EMS agencies who are (a) active in research, (b) active in education through residencies, and (c) active in education through fellowships should have a subspecialty certified -- or credentialed -- person operating the system.

Ultrasound - This is probably the area that needs it the most! Individuals who take on ultrasound directorships, either in academic or rural settings, should be subspecialty certified/credentialed to ensure competency. Saying this is not needed is saying that board certification in emergency medicine is not needed.

Critical Care - This is primarily needed for those individuals who wish to pursue critical care medicine training. You mention that expanding the role of emergency medicine to involve critical care admissions is contrary to our basic mission. Whether we like it or not, many of us are taking care of critical care patients for prolonged periods of time. Sometimes the best care in the first few hours comes from those familiar with long-term care.

 

[docB]

Simply offering these subspecialty certifications does not mean that they are required.

of course.

EMS - For rural systems, a fellowship is not needed. However, active large EMS agencies who are (a) active in research, (b) active in education through residencies, and (c) active in education through fellowships should have a subspecialty certified -- or credentialed -- person operating the system.

I disagree. Especially in large, urban systems the directorship is primarily about administration if not outright politics. Education of EMTs does not require a fellowship trained or credentialed doc. Right now the vast majority of EMS training is done by veteran EMTs supervised by RNs. Just because someone is training fellows doesn't mean that they need to have a board cert. In fact, it's not even necessary for them to be fellowship trained themselves.

Ultrasound - This is probably the area that needs it the most! Individuals who take on ultrasound directorships, either in academic or rural settings, should be subspecialty certified/credentialed to ensure competency. Saying this is not needed is saying that board certification in emergency medicine is not needed.

Not sure how saying we don't need a subspecialty board for US equates to saying that EM doesn't need a board. US is a great tool but EM US does not have the breadth that a subspecialy board cert needs to exist. EM US just doesn't equal the scope of Tox or peds. Could an argument be made that US is similar to Sports or Hyperbarics? Maybe. It's the same argument that surgery is having about creating a subspecialty board for laparoscopic surgery. Now credentialing to ensure competency is fine but that's not the same as creating a whole new subspecialty board.

Critical Care - This is primarily needed for those individuals who wish to pursue critical care medicine training. You mention that expanding the role of emergency medicine to involve critical care admissions is contrary to our basic mission. Whether we like it or not, many of us are taking care of critical care patients for prolonged periods of time. Sometimes the best care in the first few hours comes from those familiar with long-term care.

Is the argument that we are boarding these pts in the ER so we might as well create a subspecialty to deal with it or is it that training in CC will make more effective EPs? I'd say that if we're holding pts too long we should fight those battles with the hospitals rather than train to deal with the situation they've dumped on us. If the argument is that training in CC would make a better EP then you could say that about any specialty such as surgery, neurology or OB/GYN but we don't want subspecialty boards for those. I can see how the idea of a CC board would be interesting if someone is thinking they might want to switch over to inpt stuff in the future. I agree that CC is important but should it really be a pathway from EM?

 

[southerndoc]

The keyword is subspecialty certification, not specialty certification. Nobody is proposing the creation of a new certifying board. ABEM would administer the EMS, ultrasound, and CCM subspecialty certifications, much like internal medicine administers critical care subspecialty certifications.

You hit my point exactly: why should hyperbaric medicine and sports medicine require subspecialty certification, yet the others do not? Ultrasound is definitely technical and challenging enough that we should ensure competency, and subspecialty certification is the way to go. Likewise, EMS and critical care should be subspecialty certifications as well.

With regards to neurology, OB/gyn, etc., if these fellowships develop and areas become concentrated enough, then yes, there should be subspecialty certifications available for those as well. However, at the present moment, there is no need for it. I foresee geriatric medicine being the first of this batch of subspecialty certifications.

It seems that the majority of voters are in agreement. ABEM should offer subspecialty certification in EMS, ultrasound, and critical care medicine. It is one way we can advance emergency medicine.

 

[Jeff698]

I disagree. Especially in large, urban systems the directorship is primarily about administration if not outright politics. Education of EMTs does not require a fellowship trained or credentialed doc. Right now the vast majority of EMS training is done by veteran EMTs supervised by RNs.

Slightly off the topic, but I disagree that this is what a well-trained EMS medical director will/should be doing. Certainly politics is a large part, but the root of their job is the absolute responsibility for the system's clinical practice. To truly carry out this responsibility, they have to be very involved in initial training, CE, direct clinical oversight (yes, as in, in the field) and the QI process.

Whether this requires fellowship training or not, I'm not sure. I tend to think it does but haven't completely made up my mind yet.

Another issue about training. At least in the three states I've been involved with training, RNs are rarely involved. While there are some outliers (I can think of only one in Texas), most initial training is done these days by paramedics. As the dept. chair of our college paramedic program, I wasn't very happy about this. I'm a firm believer that we need MUCH more physician involvement in paramedic education. I might add, that's why I went to medical school.

Sorry for the topic-jacking.

Take care,
Jeff

 

[swaamedic]

perhaps someone should re-post the poll with the 3 seperate specialties individually.

I do not feel that EMS needs to be boarded but just an emphasis, however CC should be to be on a level playing field with the IM/AN/Surgery docs who complete a similar fellowship.

 

[southerndoc]

perhaps someone should re-post the poll with the 3 seperate specialties individually.

I do not feel that EMS needs to be boarded but just an emphasis, however CC should be to be on a level playing field with the IM/AN/Surgery docs who complete a similar fellowship.

One of the ways we can advance our profession is to have subspecialty certification.

Swaamedic, what about ultrasound?

 

[peksi]

However, I don't think it needs its own cert. I'm sure there are those who will disagree (Peski?). I also wonder (this is kind of aimed at Peski as well) if a cert would make the billing questions and the turf disputes between rads and EM worse and actually hinder the spread of EM US.



Ok I'll chime in...sorry... was chillin by the pool, busting a killer tan with my kids (30 sunblock of course!). As one of the first folks fellowship trained in EM US I can honestly see and have discussed this issue at very high levels in organized medicine and EM...should EM US have an ABEM/AOBEM Subspecialty Certification....my answer is that it just might or maybe I should say it just might have to! ( I know, bad grammer)

First of all, Critical Care will likely get the nod as it should, since many of their Fellowship spots in CC IM/Surgery/and Gas now accept EM graduates. So that is a no $#@%ing brainer. Gunner and his folks on the critical care side are working this hard, and I think as the emphasis on CC management in many states move to up front ED care, then CC will get the ABEM and ABMS nod,i feel it truely is just a matter of time


The issue that ABEM and the ABMS looks at is as follws: Is there a sufficient descrete set of "skills and or knowledge" that would justify the classification of a subspecialty...this is NOT even to say if it could pass the ABMS specialty votes. Now we can argue about this, but there are many, NO EM US folks who say; EM US at programs with highly developed training and research could (many of us are told by folks who HAVE been through the process in establishing TOX, Sports Med etc) COULD hit all the marks on the scorecard that ABEM and ABMS would have.

I do have some concerns as well about a "perception" that other specialties may have that if one is NOT thus ABEM EM US Boarded, then they should not do US or bill....that's part of the question right? The real issue is that many other specialties, OB/GYN, Surgery and yes even to some degree radiology now recognize the level of organization that EM has specific to EM US and training and we are viewed by many outside of EM as the Model for clinican use and education of bedside US. But would a subboard hinder billing and growth...in short i don't think so...emphasize the "think" part.

-My thought on that is that this is very similar to aspects of EM such as pediatrics, you need not be Peds EM boarded to treat children emergently, but from a residency program or a departmental/hospital standpoint, it is great to have a ABEM Peds Boarded EM doc on staff as an internal expert. From a payment standpoint i do not see that a subboard would be a problem, CMS does not adress most billing based on board certification, but rather hospital credentialing and state liscences. So I cannot specifically see from a billing standpoint how this would have a negative impact on the no EM US Boarded EP. The real issue is will we NEED some kind of national credential/board in EM US to protect our billing potential...and the answer is that we may based on some current discussions on Capital Hill with MEDPAC and CMS!

Now is such an argument enough to warrent ABEM in EM US....well regardless of your specific stance this same discussion IS occurring at some very high levels and we have not decided on an absolute plan of action, but it is being discussed by many in EM, EM US and with some past and present ABEM BOD members as well as others in EM who have blazed the path for other EM Subspecialties! Phew that was a lot....must go. Need JAVA!

The opinions here are those of "peski" and not to be considered endorsed by ACEP, SAEM, AAEM, AIUM, EMRA, AAEM-RES,AMA,Christiana Care, NAEMSP or my MOM!

Paul

 

[southerndoc]

My proposal is truly academic. I do not want to see the subspecialty certification used for billing purposes. I won't to see ultrasound fellowship directors, residency ultrasound gurus, and ultrasound directors of community ED's subspecialty certified.

 

[peksi]

The issue isn't always what we want, but what the overall results of the actions would be. I'm not saying that this won't or should not happen, but every action has an equal and "potentially" opposite reaction, I am certainly someone willing to act. And though I agree with your intent for some litmus for those running or training residents in EM US we cannot assume that their would not be some potential for "collateral damage" for lack of a better term in the community. Presumtions that there is "no downside" to any potential policy is again niave and potentially dangerous..my issue is that there needs to be clear agreement into any potential policy change or movement in EM US for the community pit doc . that is what this trechnology is intended to assist the most the pit doc and their patients. If there are potential negative reactions there needs to be some plan in organized EM, EM US and medicine to address this, and i think we want to have flushed this out BEFORE the documents and full proposals would be layed out, or BEFORE I personally would support such an open move. I do think there is some merit and as i have said such discussions are occuring. Again my opions only

Paul

 

[southerndoc]

I just found out that NAEMSP is going to push for subspecialty certification in EMS medical direction. This is on the agenda of the president-elect of NAEMSP.

I also found out that AOBEM offers EMS subspecialty certification. Interesting!

Looks like 80% of respondents thought that ABEM should offer subspecialty certification in at least some of the subspecialties of emergency medicine. Let's try to advocate for this to happen.

 

[FoughtFyr]

I just found out that NAEMSP is going to push for subspecialty certification in EMS medical direction. This is on the agenda of the president-elect of NAEMSP.

I had lunch with the head of ABEM at the last SAEM conference. The long and short of the conversation on additional subspecialities (brought up by all of the residents at the table) was "it ain't gonna happen". They have already looked at the issue of EMS direction and the board has decided (multiple times apparently) that there is not a discrete body of additional knowledge or skill required. (Note: I do not agree with this, I am merely repeating it!) Critical care has possibilities, but the IM board has recently refused to work with anyone else. He told us that they have considered going to the surgery and/or anesthesia oards but fear entanglement in litigation (but they haven't ruled it out). Other that have been considered in the past include environmental medicine (no interest) and occupational medicine (again, no interest). another interesting point in the discussion was the bizare EM / peds rules (that a five year EM/Peds grad can only be boarded in EM/Peds and EM, not peds, EM/Peds, and EM). He said that battle has already been "fought and lost".

- H

 

[Apollyon]

another interesting point in the discussion was the bizare EM / peds rules (that a five year EM/Peds grad can only be boarded in EM/Peds and EM, not peds, EM/Peds, and EM). He said that battle has already been "fought and lost".

- H

Do you mean to say the EM/Peds people can be boared in EM and peds, but not Peds EM? That's how I know it, and I think you were trying to say.

 

[southerndoc]

I had lunch with the head of ABEM at the last SAEM conference. The long and short of the conversation on additional subspecialities (brought up by all of the residents at the table) was "it ain't gonna happen". They have already looked at the issue of EMS direction and the board has decided (multiple times apparently) that there is not a discrete body of additional knowledge or skill required.

If NAEMSP is going to test and pay for development of testing, then ABEM will more than likely allow it. The fact that the chair of ABMS is an emergency physician makes it more likely that ABMS will approve any ABEM supported subspecialty certification.

I am just passing along what is on the president-elect's agenda. Usually he accomplishes what goals he sets, so we'll see how this turns out.

 

[southerndoc]

Just to revive an old thread...

The Institute of Medicine's report on emergency medicine has recommended subspecialty certification in pre-hospital and disaster medicine. The National Association of EMS Physicians will be working toward obtaining this.

I wonder what other subspecialties will follow?

 

[bulgethetwine]

of course.


I disagree. Especially in large, urban systems the directorship is primarily about administration if not outright politics. Education of EMTs does not require a fellowship trained or credentialed doc. Right now the vast majority of EMS training is done by veteran EMTs supervised by RNs. Just because someone is training fellows doesn't mean that they need to have a board cert. In fact, it's not even necessary for them to be fellowship trained themselves.


Not sure how saying we don't need a subspecialty board for US equates to saying that EM doesn't need a board. US is a great tool but EM US does not have the breadth that a subspecialy board cert needs to exist. EM US just doesn't equal the scope of Tox or peds. Could an argument be made that US is similar to Sports or Hyperbarics? Maybe. It's the same argument that surgery is having about creating a subspecialty board for laparoscopic surgery. Now credentialing to ensure competency is fine but that's not the same as creating a whole new subspecialty board.


Is the argument that we are boarding these pts in the ER so we might as well create a subspecialty to deal with it or is it that training in CC will make more effective EPs? I'd say that if we're holding pts too long we should fight those battles with the hospitals rather than train to deal with the situation they've dumped on us. If the argument is that training in CC would make a better EP then you could say that about any specialty such as surgery, neurology or OB/GYN but we don't want subspecialty boards for those. I can see how the idea of a CC board would be interesting if someone is thinking they might want to switch over to inpt stuff in the future. I agree that CC is important but should it really be a pathway from EM?

Re: Critical Care

I think the argument should be that man EPs would like to work a specific amount of time in the units. For instance, I would love to work 8-12 weeks per year as an attending. Ergo, specialty certification would facilitate this job search.

 

[FoughtFyr]

The American Board of Emergency Medicine currently offers subspecialty certification in medical toxicology, sports medicine, pediatric EM, and hyperbaric medicine.

Do you think it's time for ABEM to offer certification in more subspecialties?

Specifically:
- Pre-hospital and Disaster Medicine
- Emergency Ultrasound
- Critical Care Medicine

What do you think?

Umm, palliative medicine is now an ABEM certification. WTF?!? Hospice before EMS?!?

http://www.abem.org/public/portal/alias_0_Rainbow/lang__en-US/tabID__3799/DesktopDefault.aspx

- H

 

[Bent Aub]

Umm, palliative medicine is now an ABEM certification. WTF?!? Hospice before EMS?!?

http://www.abem.org/public/portal/alias_0_Rainbow/lang__en-US/tabID__3799/DesktopDefault.aspx

- H

I thought the point of hospice was to keep them OUT of the ED.