Emergency Medicine should stop existing as an independent specialty.
With the announcement from the ACGME pushing our specialty to a 4 year residency, we all should take a moment to reflect on our state of affairs and admit that the experiment of making EM independent in the house of medicine has failed. We have had about 55 years of this experiment since the University of Cincinnati opened the first residency to show the definitive need for our speciality, and despite being ABEM certified, I still struggle with to truly justify our existence.
In 2011, when I applied for EM residency I was told two things in particular by my mentors that gave me faith in the future and necessity of the specialty. 1.) Burn out is in physicians that were NOT trained in EM, but were IM or FM trained physicians that practiced Emergency Medicine. If you trained in EM, you were trained in such a way that made us resistant to this phenomenon and it wasn't really to be worried about. 2.) To practice EM, in the near future (in 2011) only Board Certified Emergency Physicians would be able to be credentialed to work with perhaps some leniency for physicians trained in other specialties with many years of EM experience. If you weren't BC EM, well, there would not be room at the table.
Both of these statements have proved to be false in my experience. The Burnout Problem stands for itself with a multitude of studies and surveys. I won't belabor this point. As for being BCEM? Yes, there are departments that only hire and credential BCEM, especially in large cities. However, for most community shops, board certified/eligible in EM, IM, FP or other are accepted. New graduate FM trained physicians practice side by side with me at a Level 2 trauma center. They are paid the same as I am with my BCEM and 10 years experience. And really, they do a pretty good job. Maybe I am a bit more savvy at some airway techniques and some fine points of EM, but overall, FM/IM does a good job and I dare say great job especially after a 1 year fellowship. The difference is when Burnout burns bright, they have the option of going to Primary Care outpatient work, while as a BCEM physician, I am mostly stuck in the pit. (Palliative care , CC and Pain fellowships being the few fellowships I am aware of that would get a BCEM physician out of the ED.)
The emergence of NPs and PA with independent practice authority further complicates the issue. I could write a novel on the issue. If a physician at minimum needs to have a 4 year medical school degree with 2 years of clinicals and then a three to four year grueling residency to be considered qualified to staff an emergency department, how is it even possible that an NP with only 500 hours of required clinical shadowing done without any clinical work experience as an RN, can independently staff an Emergency Department? But it happens all the time in the United States. Understandably there is some nuance to the NP/PA issues, but in the end, either training matters, or it doesn't. EIther the model is safe, or it isn't. How have ACEP, AAEM, AMA, the state legislatures, CMS, etc let this happen? Or perhaps it is the hard truth that we really are not as crucial as we thought we were. This is a thought that deeply stings after dedicating decades of my life to medicine. I don't personally believe that we aren't needed, but how are we being pushed aside?
Despite more than 50 years of struggle to define ourselves as a specialty unique and necessary in the house of medicine, we have not truly gotten a seat at the table. While the truth of the difference between training programs can be debated, at the end of the day, we are still viewed as an interchangeable spot-holder in a schedule. Board Certified in something? Good enough to fill a spot on the schedule. It is a tough pill to swallow after the sacrifices we have all made to try to gain respect in the house of medicine, in the eyes of staffing groups, and even administrators. Unfortunately, often our fellow doctors as fail to see our value. We have always risen to the occasion when asked to do more with less. Expand the original purpose of the ED? Less support, more output? Pandemic? We did it with a smile. But despite our efforts to put patients first and the mission of medicine in its purest form first, we as BCEM physicians have never gained our place. We are interchangeable cogs.
It is difficult in good faith to force our young physicians, burdened with the current the median cost of $286,454 at a public school and $390,848 at a private school with 8-9% interest rates, with an additional year of training without the built in outlet of outpatient clinic opportunities or fellowships to move away from Emergency Department medicine with all its associated circadian rhythm swings and modern problems. Either training matters, or it doesn't. The unfortunate truth looking at us is that no one really sees the value of BCEM except for ourselves.
I can already hear those in Ivory Towers stating that those who love EM and are truly good physicians would want the best specialized training, no matter the cost and time in training. I like this ideal. I really do. But at some point, we have to admit that money is real. Time is real. We only get so much. Extra training is lost time with family, lost years of fertility and youth, lost income, lost time compounding retirement investments, lost money to compounding interest on student loans. If we are not proving that the specialized training makes us better clinicians and proving it in a way that reaches legislatures, CMS, administrations and the general public, we need to stop the madness.
In the end, either training matters, or it doesn't. Period. To be able to bill and advertise as an Emergency Department, it should be mandatory to be at least 75% BCEM staffed and a physician in the ED 24/7/365 (exact percentage open to debate, of course). After 50+years of BCEM docs, this isn't a big ask. Or, if board certification doesn't matter, close all EM residencies and replace them with primary care residency spots. Give future EM doctors the same flexibility allotted to those with traditional primary care backgrounds and train primarily in primary care fields with an optional pathway within the residency or as a short fellowship for EM.
Change my mind.
With the announcement from the ACGME pushing our specialty to a 4 year residency, we all should take a moment to reflect on our state of affairs and admit that the experiment of making EM independent in the house of medicine has failed. We have had about 55 years of this experiment since the University of Cincinnati opened the first residency to show the definitive need for our speciality, and despite being ABEM certified, I still struggle with to truly justify our existence.
In 2011, when I applied for EM residency I was told two things in particular by my mentors that gave me faith in the future and necessity of the specialty. 1.) Burn out is in physicians that were NOT trained in EM, but were IM or FM trained physicians that practiced Emergency Medicine. If you trained in EM, you were trained in such a way that made us resistant to this phenomenon and it wasn't really to be worried about. 2.) To practice EM, in the near future (in 2011) only Board Certified Emergency Physicians would be able to be credentialed to work with perhaps some leniency for physicians trained in other specialties with many years of EM experience. If you weren't BC EM, well, there would not be room at the table.
Both of these statements have proved to be false in my experience. The Burnout Problem stands for itself with a multitude of studies and surveys. I won't belabor this point. As for being BCEM? Yes, there are departments that only hire and credential BCEM, especially in large cities. However, for most community shops, board certified/eligible in EM, IM, FP or other are accepted. New graduate FM trained physicians practice side by side with me at a Level 2 trauma center. They are paid the same as I am with my BCEM and 10 years experience. And really, they do a pretty good job. Maybe I am a bit more savvy at some airway techniques and some fine points of EM, but overall, FM/IM does a good job and I dare say great job especially after a 1 year fellowship. The difference is when Burnout burns bright, they have the option of going to Primary Care outpatient work, while as a BCEM physician, I am mostly stuck in the pit. (Palliative care , CC and Pain fellowships being the few fellowships I am aware of that would get a BCEM physician out of the ED.)
The emergence of NPs and PA with independent practice authority further complicates the issue. I could write a novel on the issue. If a physician at minimum needs to have a 4 year medical school degree with 2 years of clinicals and then a three to four year grueling residency to be considered qualified to staff an emergency department, how is it even possible that an NP with only 500 hours of required clinical shadowing done without any clinical work experience as an RN, can independently staff an Emergency Department? But it happens all the time in the United States. Understandably there is some nuance to the NP/PA issues, but in the end, either training matters, or it doesn't. EIther the model is safe, or it isn't. How have ACEP, AAEM, AMA, the state legislatures, CMS, etc let this happen? Or perhaps it is the hard truth that we really are not as crucial as we thought we were. This is a thought that deeply stings after dedicating decades of my life to medicine. I don't personally believe that we aren't needed, but how are we being pushed aside?
Despite more than 50 years of struggle to define ourselves as a specialty unique and necessary in the house of medicine, we have not truly gotten a seat at the table. While the truth of the difference between training programs can be debated, at the end of the day, we are still viewed as an interchangeable spot-holder in a schedule. Board Certified in something? Good enough to fill a spot on the schedule. It is a tough pill to swallow after the sacrifices we have all made to try to gain respect in the house of medicine, in the eyes of staffing groups, and even administrators. Unfortunately, often our fellow doctors as fail to see our value. We have always risen to the occasion when asked to do more with less. Expand the original purpose of the ED? Less support, more output? Pandemic? We did it with a smile. But despite our efforts to put patients first and the mission of medicine in its purest form first, we as BCEM physicians have never gained our place. We are interchangeable cogs.
It is difficult in good faith to force our young physicians, burdened with the current the median cost of $286,454 at a public school and $390,848 at a private school with 8-9% interest rates, with an additional year of training without the built in outlet of outpatient clinic opportunities or fellowships to move away from Emergency Department medicine with all its associated circadian rhythm swings and modern problems. Either training matters, or it doesn't. The unfortunate truth looking at us is that no one really sees the value of BCEM except for ourselves.
I can already hear those in Ivory Towers stating that those who love EM and are truly good physicians would want the best specialized training, no matter the cost and time in training. I like this ideal. I really do. But at some point, we have to admit that money is real. Time is real. We only get so much. Extra training is lost time with family, lost years of fertility and youth, lost income, lost time compounding retirement investments, lost money to compounding interest on student loans. If we are not proving that the specialized training makes us better clinicians and proving it in a way that reaches legislatures, CMS, administrations and the general public, we need to stop the madness.
In the end, either training matters, or it doesn't. Period. To be able to bill and advertise as an Emergency Department, it should be mandatory to be at least 75% BCEM staffed and a physician in the ED 24/7/365 (exact percentage open to debate, of course). After 50+years of BCEM docs, this isn't a big ask. Or, if board certification doesn't matter, close all EM residencies and replace them with primary care residency spots. Give future EM doctors the same flexibility allotted to those with traditional primary care backgrounds and train primarily in primary care fields with an optional pathway within the residency or as a short fellowship for EM.
Change my mind.
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