About EPs in small EDs instead of internists

[samdaman]

Hi guys,

I was wondering if anyone has any information on Internists being phased out of EDs around the country and EPs being hired instead? I know that its going to happen sooner or later, but is anything being done on that at the official level? Because technically, its cheaper for small hospitals to hire an internist to run the ED instead of an EP. So basically, is there going to be a time when it'll be a MUST for EDs to hire EPs if available over internists, or even FPs for that matter? Because that also raises the liability question. Its more expensive for the hosp as far as insurance premiums are concerned to hire an EP...

-samdaman

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[Sheerstress]

At present, most of the large medical centers only let EM residency-trained practitioners to work their EDs, particularly those in urban and suburban areas.

However, I think it's going to be a LONG time before primary care docs (FP, IM) are completely "squeezed" out of emergency departments.

Right now there are about 15,000-20,000 EM practitioners out there, with about 35,000 spots in nationwide emergency departments. Most of the positions that are difficult to fill are those in the small, rural hospitals, and right now there simply aren't enough EM residency-trained grads to take up all the slack.

 

[Apollyon]

Its more expensive for the hosp as far as insurance premiums are concerned to hire an EP...

This is not logical - IM and FP pay less in THEIR specialties for malpractice insurance, but, if I was an insurer, I would charge MORE for someone working outside their field, since they would not have the training to meet the standard of care; this is not to say they don't meet the standard, but their training is not specific, so the chances would be higher of an error, and, thus, higher premiums. Coincidentally, I would expect to pay higher rates if I was an EM-trained physician, who decided to do primary care (if I could get insurance at all).

 

[docB]

At present, most of the large medical centers only let EM residency-trained practitioners to work their EDs, particularly those in urban and suburban areas.

I think what we're really talking about here is being EM boarded not residency trained. Eventually the residency trained crowd will take over but there are still a lot of grandfathered docs that trained in IM, FP, Surg and so forth. Many of the senior faculty where I did residency and med school were grandfathered.
My group is opening an ER in a rural hospital right now and the director and most of the docs are EM boarded but the staffing is difficult enough that we will be using some IM, FP docs if they meet certain requirements.

 

[Sheerstress]

I think what we're really talking about here is being EM boarded not residency trained.

I agree - for right now a lot of primary care docs who were "grandfathered" in by the practice track back up til the late 1980s make up physicians who are presently board certified in EM. But the focus of ACEP (and I assume AAEM) is to eventually have only those specifically trained in emergency medicine working in any and all EDs. That's at least decades away.

 

[Apollyon]

Since wholesale grandfathering ended in 1992, and the ABEM (or was it SAEM, or ACEP) estimated 2015 or 2020 when all spots could be filled by EM-trained folks, I think non-EM trained, EM-boarded practitioners would be near (or at) the end of their careers.

 

[southerndoc]

This is not logical - IM and FP pay less in THEIR specialties for malpractice insurance, but, if I was an insurer, I would charge MORE for someone working outside their field, since they would not have the training to meet the standard of care; this is not to say they don't meet the standard, but their training is not specific, so the chances would be higher of an error, and, thus, higher premiums. Coincidentally, I would expect to pay higher rates if I was an EM-trained physician, who decided to do primary care (if I could get insurance at all).

Apollyon, you are right... non-EM-trained physicians staffing the ED should be charged higher malpractice insurance premiums. A study demonstrated that non-EM trained physicians working in the ED had higher malpractice rates when compared to EM-trained physicians.

J Emerg Med. 2000 Aug;19(2):99-105.

Malpractice occurrence in emergency medicine: does residency training make a difference?

Branney SW, Pons PT, Markovchick VJ, Thomasson GO.

Denver Health Residency in Emergency Medicine, Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA.

We evaluated the effects of Emergency Medicine (EM) residency training, EM board certification, and physician experience on the occurrence of malpractice claims and indemnity payments. This was a retrospective review of closed malpractice claims from a single insurer. Outcome measures included the occurrence of claims resulting in indemnity, indemnity amounts, and defense costs. Differences in the outcome measures were compared based on: EM residency training, EM board certification, EM residency training versus other residency training, and physician experience using both univariate and multivariate analyses. There were 428 closed EM claims with indemnity paid in 81 (18.9%). Indemnity was paid in 22.4% of closed claims against non-EM residency-trained physicians, and in only 13.3% against EM residency-trained physicians (p = 0.04). The total indemnity was $6,214,475. Non-EM trained physicians accounted for $4,440,951 (71.5%), EM residency-trained physicians accounted for $1,773,524 (28.5%). The average indemnity was $76,721 and the average defense cost was $17,775. There were no significant differences in the mean indemnity paid per closed claim or the mean cost to defend a closed claim when comparing EM-trained and non-EM residency-trained physicians. The total cost (indemnity + defense costs) per physician-year of malpractice coverage was $4,905 for non-EM residency-trained physicians and $2,212 for EM residency-trained physicians. EM residency-trained physicians account for significantly less malpractice indemnity than non-EM residency-trained physicians. This difference is not due to differences in the average indemnity but is due to significantly fewer closed claims against EM residency-trained physicians with indemnity paid. This results in a cost per physician-year of malpractice coverage for non-EM residency-trained physicians that is over twice that of EM residency-trained physicians.

PMID: 10903454 [PubMed - indexed for MEDLINE]

 

[juddson]

Explain to me how this works. University Hospitals of Cleveland has an ED (it's a major teaching hospital associated with Case med) but no ED residency. The ED is staffed by IM and FP residents. My question is WHAT kind of training does the attending have? An attending on the ED is required by statute, isn't it?

Judd

 

[edinOH]

Explain to me how this works. University Hospitals of Cleveland has an ED (it's a major teaching hospital associated with Case med) but no ED residency. The ED is staffed by IM and FP residents. My question is WHAT kind of training does the attending have? An attending on the ED is required by statute, isn't it?

Judd

I would imagine that the ED attendings are EM trained or boarded. It is just the FP/IM residents who are rotating through there as a part of their training.

 

[southerndoc]

I would imagine that the ED attendings are EM trained or boarded. It is just the FP/IM residents who are rotating through there as a part of their training.

I have a feeling the majority of patients are seen by ED attendings with no resident involvement.

The school I attended doesn't have an EM residency. The residents from FP and IM rotate through the ED, and when there, they see patients. These patients are also seen by an ED attending. The majority of patients are actually seen by the ED attending without resident or student involvement (since there are 2-4 ED attendings on duty at any one time).

 

[samdaman]

If a hospital wants to hire someone for the ED and is faced to choose between an internist (old and experienced in IM) and an ED boarded physician (grandfathered or otherwise), does the EP have a higher chance of getting selected against all odds, including the definite higher payscale?

The thing is, I have been hearing that you dont really need to do EM to work in an ED. You can train as an internist, work in the ED, and then when u get bored or burnt out, go into private practice. The argument is that internists will be working in the ED for quite a long time yet, and because of their experience, they wont be kicked out of the ED in the future either. I obviously dont agree with that, but i need a good argument for rebuttal.

 

[southerndoc]

The thing is, I have been hearing that you dont really need to do EM to work in an ED. You can train as an internist, work in the ED, and then when u get bored or burnt out, go into private practice. The argument is that internists will be working in the ED for quite a long time yet, and because of their experience, they wont be kicked out of the ED in the future either. I obviously dont agree with that, but i need a good argument for rebuttal.

Just tell them that you're training in emergency medicine, and when you get burnt out with the ED, that you're going to open up a private practice and see patients in the clinic just like an internist does. There's no law preventing you from doing so.

 

[Jeff698]

UTMB, a level I trauma center in Galveston has no EM residency program. Our ED is staffed largely by attendings with training in IM or FM. We have, at last count, three or four EM boarded folks.

Having said that, we recently hired a boarded EP as department chair with the goal of creating a residency program. This will obviously require replacing the IM/FM guys with EPs.

Take care,
Jeff

 

[dr.smurf]

i dont know what the hype is about EM boarded people..the trauma surgeons and GS residents run the show in most cases anyhow. EM is not that glorified when it comes to trauma! an experienced FP with ATLS is just as good as an EM trained guy!

 

[Seaglass]

i dont know what the hype is about EM boarded people..the trauma surgeons and GS residents run the show in most cases anyhow. EM is not that glorified when it comes to trauma! an experienced FP with ATLS is just as good as an EM trained guy!

Hmm. It seems the American Board of Medical Specialties disagrees with you. Maybe you should write them a letter. It's clear that you must know much more about the issue than they do.

C

 

[southerndoc]

i dont know what the hype is about EM boarded people..the trauma surgeons and GS residents run the show in most cases anyhow. EM is not that glorified when it comes to trauma! an experienced FP with ATLS is just as good as an EM trained guy!

Hmm, if this person had only one post to his or her name, I would say the person was a troll posting this...

but then I viewed his/her profile and found out the person is doing a residency in......................................... FP. Imagine that.

 

[samdaman]

Hmm, if this person had only one post to his or her name, I would say the person was a troll posting this...

but then I viewed his/her profile and found out the person is doing a residency in......................................... FP. Imagine that.

Quite self explanatory... Lets get all NP and PAs ATLS certified, and let the FPs run the EDs, and do away with the EPs altogether?