What's going on at Univ. of Washington/Harborview?

The following is an email that AAEM sent out on February 25 regarding the same.

The American Academy of Emergency Medicine (AAEM) strongly agrees with and stands by the principle that emergency physicians must be trained by specialists in the field of emergency medicine. This tenant is the bedrock for graduate medical training in all recognized specialties. The special requirements of the RRC-EM (Residency Review Committee in Emergency Medicine) of the Accreditation Council for Graduate Medical Education (ACGME) clearly state in sections 3.a and b:

3. Qualifications of the physician faculty are as follows:
a. The physician faculty must possess the requisite specialty expertise and competence in clinical care and teaching abilities, as well as documented educational and administrative abilities and experience in their field.
b. The physician faculty must be certified in the specialty by the American Board of Emergency Medicine or possess qualifications judged to be acceptable by the RRC. This standard applies to all core physician program faculty and to other attending staff hired to provide resident supervision in any emergency department where emergency medicine residents rotate.

Every institution that trains emergency medicine residents must meet this standard. Harborview is no exception. While the approach used at the Harborview Medical Center affiliated with the University of Washington may have been the best practice thirty years ago (before there were board certified emergency physicians), it is viewed as a dinosaur by the current standards of training. We sincerely doubt that anyone would debate the appropriateness of having surgeons teaching internal medicine to internists. The public should be equally dismayed at the thought of surgeons teaching emergency medicine to emergency physicians. Hiring a few board certified emergency physicians is an inadequate solution.

While the AAEM recognizes the many contributions to emergency care and emergency medical services (EMS) systems at Harborview, it is clearly time for the University of Washington School of Medicine to recognize that every academic training center in Emergency Medicine must first and foremost meet the basic requirements of the RRC-EM (part of the Accreditation Council for Graduate Medical Education). The ACGME is the accrediting body that is deemed to be the best and only standard for residency training accreditation by all our US academic institutions, including Harborview, for all specialty training programs.

Finally, the absence of onsite emergency specialist supervision represents a suboptimal means of training at an institution otherwise known as an educational leader. Broad awareness of this problem will also impact the institution's ability to recruit new faculty talent and the best residents. Without a solid training program in emergency medicine, the provision of qualified and adequately prepared emergency physicians for the citizens of Washington and other states served by the University of Washington's WWAMI out-reach program (Washington, Wyoming, Alaska, Montana, Idaho) will suffer.

The AAEM feels that it is time for a change at Harborview. As a teaching institution, it has a clear obligation to meet every specialty's requirements for graduate medical education. While the institution and its medical director have made contributions to emergency practice, training in emergency medicine continues to suffer. It is time for emergency medicine at the University of Washington's Harborview Medical Center to enter the 21st century.


AAEM
555 East Wells Street
Suite 1100
Milwaukee, WI 53202
[email protected]

When I interviewed there, we were informed about this ongoing situation up front. We were told that if it continued to be a problem, they'd start sending their residents to Oakland for their trauma months. Apparently, they used to do this back in the day. I, too, would be interested in hearing from any current residents at Madigan/UW about their experiences at Harborview.

So is the issue that the faculty isn't EM trained or is it that they aren't EM boarded? I would think that Copass and the rest of his generation would have at least grandfathered in back in the day.

I have to say though that if they are still lavaging everybody that doesn't speak highly of their currency. We've had good evidence for a while that lavage makes no difference in outcomes except for a small subset of patients and has clear and significant complications. If you are at a an academic center and lavage everyone its not good enough to say, " I don't think we are hurting anyone." You pretty much have to say, " I've decided I don't believe in evidence based practice or I don't read"

AAEM should have sent their email before the rank list due day, for all those applying to UW.

hello23 said:

AAEM should have sent their email before the rank list due day, for all those applying to UW.

Click to expand...

No, by all accounts UW has been very upfront about this issue with applicants. If ACEP and AAEM would have sent the e-mail prior to the match, the overall effect would have magnified the problems UW has, as having to scramble a number of residents would have a chilling effect on future classes; which works against everyone's goal. ACEP, EMRA, AAEM and the ACGME are all primarily interested in changing the experience at Harborview (note: not the whole UW residency) to a more positive one. Trashing a match class wouldn't help things.

- H

I disagree. My interview last year made some mention of a few problems at harborview, but I was not aware the serious nature of the issues. There were lots of reasons I didn't end up there (there side and mine) but I had no idea they had been seriously sanctioned by the RRC.

Additionally, this is one of the few programs that offers very little in resident contact during the interview process (supervised luncheon, no pre-interview event). There is very little time for candid talk.

I'm not a resident but I am a MS4 that just finished ER at Harborview. UW residents train at Harborview in the ER for 1-2 months per year. The rest of the time they are at Madigan (with ER docs), UW (with ER docs), Childrens (with ER docs) or off service. While at Harborview they are on one of two services. On Trauma they are either the intern or the "trauma doc" (R2 or R3) that runs trauma and other surgical problems with Surgical attendings in-house for real badness. It is a LOT of responsibility. You supervise 2-3 interns and 2 med students (who function more like interns). Trauma doc is also a rotation for Gen surg R2's. On medicine, the are the "medic one" doc. There is a medic one attending in the ER at all times that helps and supervises the med students. They are internists, most having just finished medicine residency at UW, but a few have been there for years.

It works this way basically cause Copass wants it to. He is an amazing man who basically created modern EMS (especially pre-hospital defibrillation in the 70's) but everyone cringes at stuff like lavaging for overdoses. It functions surprisingly well but I know my ER resident friends hate it and my ER applicant friends didn't even consider staying. To be fair though, it is only ~4 months over three years so to say that they are not being trained by ER docs is somewhat disingenious.

BTW---What also is up is Mt. St. Helen's. It is currently spewing a plume of ash and steam.

I wasn't implying that what anyone on this forum said was disingenious. Just the politicos pushing for change.

FoughtFyr said:

No, by all accounts UW has been very upfront about this issue with applicants. If ACEP and AAEM would have sent the e-mail prior to the match, the overall effect would have magnified the problems UW has, as having to scramble a number of residents would have a chilling effect on future classes; which works against everyone's goal. ACEP, EMRA, AAEM and the ACGME are all primarily interested in changing the experience at Harborview (note: not the whole UW residency) to a more positive one. Trashing a match class wouldn't help things.

- H

Click to expand...

This argument depends on the angle you are taking.

RRC was created to ensure the standards of all training programs and to protect the residents... If RRC finds that UW have a problem, applicants this year should know about it and make an fully educated decision about its ranking. I am talking about a very important decision making in one's career.

The goal to make UW better might be the goal of these authorities. But it is not my goal, nor most applicants' goal... Chilling effect of scrambling the whole class? I think applicant will definitely worry a lot more about the chilling effect of finding a job or finishing the residency if they match at UW and UW lose its accredication. Again, that's why there is RRC.

Sometimes it's better to trash the whole thing in order to build a whole new thing from scratch....

hello23 said:

This argument depends on the angle you are taking.

RRC was created to ensure the standards of all training programs and to protect the residents... If RRC finds that UW have a problem, applicants this year should know about it and make an fully educated decision about its ranking. I am talking about a very important decision making in one's career.

Click to expand...

And the RRC did not take action. We are discussing the ACEP/AAEM mailings. And BTW, the UW program has taken action to address RRC concerns. Remember, almost every program gets "dinged" on something in the RRC review. Some things are minor, some major - this is really major, but the RRC did not pull the accreditation or even place them on probation. And there has been a response - "Officials with Harborview said they plan to hire several board-certified emergency physicians by mid-2006 in hopes of satisfying the ACGME requirement to maintain their national accreditation."

hello23 said:

The goal to make UW better might be the goal of these authorities. But it is not my goal, nor most applicants' goal... Chilling effect of scrambling the whole class? I think applicant will definitely worry a lot more about the chilling effect of finding a job or finishing the residency if they match at UW and UW lose its accredication. Again, that's why there is RRC.

Sometimes it's better to trash the whole thing in order to build a whole new thing from scratch....

Click to expand...

Let's be clear on what is going on. There are multiple sites for training the UW program's residents. Harborview is only one of them. Harborview is the only level one trauma center in the area and is home to "Medic One" - arguably one of the country's most outstanding EMS programs. Now, Harborview's ED, as is the case with many "old school" institutions, is staffed by trauma surgeons and internists. That needs to change if they are to continue training EPs, especially given the complexity of EM practice today.

BUT, the UW program is a long established program with a very strong reputation. Its graduates have gone on to many successes, both regionally and nationally. And before we get too bent out of shape, realize that other programs are (somewhat) similarly organized. For instance, Cook County Hospital has split trauma apart from their main ED. Like Harborview, when EM residents do a trauma month at CC, they work with surgeons, not EPs.

So, the problem at Harborview comes in the "medicine" months UW's EM residents spend there. These represent less than 10% of the residency by time. For that you want to "trash the whole thing in order to build a whole new thing from scratch" at one of the birthplaces of EMS? Talk about throwing out the baby with the bathwater.

- H

Don't get too worked up, even if you have any connection with UW. If you think UW has strong reputation, and this and that, then good for you, and I hope there is more people who will agree with you, well at least in WA..but wait, my friend in UW told me that almost no one wanna go to UW for EM because the program is not strong at all...but then agan, what do we know? we are just lowly MS4.

Again, from a perspective of applying this year, I know most of us would like to know everything about the program we are ranking...If the program have problems, we should know about it, and that's why we go to the interviews. And, why do you think this website exist? Simply withholding some crucial information from the applicants lest it will sabotage the program's matching and future entering class is, IMHO, not a good practice for the sake of applicants. Period.

BTW, who cares about UW? I was just saying things in general...so sorry to all those UW people out there. If you feel like you have to defend your program, do it in a productive way, like starting with UW medical students. Not with any anonymous person whose IQ might be below 100 on this internet, right?

Out.

This started off as a very informative thread since I was also interested to hear what was going on after getting that e-mail. Unfrotunately, it has now officially degenerated.

hello23 said:

Don't get too worked up, even if you have any connection with UW. If you think UW has strong reputation, and this and that, then good for you, and I hope there is more people who will agree with you, well at least in WA..but wait, my friend in UW told me that almost no one wanna go to UW for EM because the program is not strong at all...but then agan, what do we know? we are just lowly MS4.

Click to expand...

I have no connection to UW at all. Didn't go there, didn't apply there, and don't know anyone who did.

hello23 said:

Again, from a perspective of applying this year, I know most of us would like to know everything about the program we are ranking...If the program have problems, we should know about it, and that's why we go to the interviews. And, why do you think this website exist? Simply withholding some crucial information from the applicants lest it will sabotage the program's matching and future entering class is, IMHO, not a good practice for the sake of applicants. Period.

Click to expand...

And if the entire profession were made up of applicants, you would be right. Period. Remember, we are discussing the publication of two "open letters" to the EM profession (one by the ACEP and one by the AAEM) regarding the UW program and Harborview as a training site. Nobody is "withholding crucial information" from applicants, on this website or anyplace else. The ACEP and the AAEM have a duty to the profession as a whole, not just to this year's applicants. Intentionally timing a letter to effect the match would have been a bad precedent to set...

hello23 said:

BTW, who cares about UW? I was just saying things in general...so sorry to all those UW people out there. If you feel like you have to defend your program, do it in a productive way, like starting with UW medical students. Not with any anonymous person whose IQ might be below 100 on this internet, right?

Out.

Click to expand...

And I suppose this sums up the problem with your posts on this subject. UW is a long standing program with a great history. "Medic One", the ALS unit founded out of Harborview, has long been the success model for tiered response EMS. Like it or not, believe it or not, this profession has a history. And, given the (relatively) young age of this specialty, some of our history is going to include non-EM trained people. Dr. White from Mayo (father of AEDs) is an anesthesiologist, Dr. Boyd from Cook County (created the modern "trauma center" concept) is a surgeon, and heck, the "orange book", long a standard EMS text, is still published and written by the American Academy of Orthopaedic Surgeons.

I guess what I am saying is that we, as a group, should work to promote EM as a specialty. Harborview, if it is going to continue to train EPs, should be made to comply with ACGME standards. But to leap to shutting down a program over less than 10% (by time) of its instruction is simply counter productive.

And let's also be clear, you, as an applicant, have to do some level of "due diligence" yourself. UW, at the least, mentioned this "problem" to aplicants. Now, there is some debate here as to the extent of those discussions, but you have posted saying how upset and miserable you yourself know the UW medical students and residents to be. So, an applicant should have easily been able to figure out for themselves if this would preclude UW from their ROL. An open letter from ACEP and AAEM would have been unfair.

BTW - remember that other programs have been in much more serious trouble (e.g., King Drew) and the ACEP and the AAEM have not published open letters regarding those programs. So why do you think they "owed it to you" as an applicant to publish these letters about UW prior to the ROL due date?

- H