Primary Board Status: Only the End of the Beginning The announcement of primary board status for emergency medicine last year was greeted with understandable pride, enthusiasm, and relief within our specialty. The prior “conjoint” status was stigmatizing and patronizing, and most board-certified emergency physicians feel this step was long overdue. However, few appreciate the American Board of Emergency Medicine (ABEM)‘s protracted, complex, and sophisticated effort that achieved primary board status. Moreover, the practical limits of such are becoming apparent, and there will be a continued (perhaps indefinite) need for vigilance and vigorous advocacy to secure the substance of these gains. ABEM has made an important advance, but we must not fail to scrutinize the emperor’s new clothes or ignore a possible Trojan Horse. Among the cognoscenti, the mischievous nature of conjoint board status was manifest even before 1980. Although not readily apparent to all practicing emergency physicians, members of ABEM were acutely aware this was a vulnerable half-way house. Mandated representation on the board by other “interested” (ie, threatened) specialties was necessary to obtain any formal recognition under the house of organized medicine. To our great good fortune, non-emergency physician representatives on ABEM distinguished themselves by their responsibility, integrity, independence, and genuine good-will, and were instrumental in ABEM’s progress. ABEM’s decade-long pursuit of primary board status, while successful in a formal sense, deferred several crucial problems. ABEM’s decision in 1988 not to pursue certitication in critical care, along with the persistent discrimination against emergency medicine residency graduates by critical care fellowship programs, make it most unlikely emergency physicians will formally practice (and be compensated for) the increasingly large amount of extended critical care provided in emergency departments. We are left to pursue areas of subspecialization like toxicology or emergency medical service, of course, or (ostensibly), any other field with negligible compensation for professional services. It appears the American Board of Pediatrics will soon be certifying pediatricians in pediatric emergency medicine, and it will be vital to insist on formal input from ABEM and emergency medicine residencies. While ABEM will also be able to issue certificates of special competency in pediatric emergency care following emergency medical training, it is already apparent pediatricians will be able to, in effect, practice emergency medicine without any formal exposure to emergency medicine qua emergency medicine (ie, all training will be under the aegis of pediatric departments). Moreover, there is no effective reciprocity involved, and no one seriously believes emergency medicine graduates will be able to practice pediatrics after a fellowship in pediatric emergency medicine. This situation raises concerns beyond equity. It effectively allows pediatricians to “short-track” into formal credentialling in emergency medicine and encourages fragmented emergency-care training. Emergency medicine residents
may well find rotations at pediatric facilities filled by pediatricians doing fellowships, and pediatric organizations will doubtlessly issue protocols and develop “merit-badge” courses, unilaterally setting standards for all emergency physicians caring for children. (One needs only to reflect on the problems the Advanced Cardiac (ACLS) and Trauma (ATLS) Life Support programs created for emergency physicians to suspect such developments in pediatric emergency care.) Most troubling are the recent revelations with regard to internal medicine and ABEM. By in large, internal medicine remains reluctant to accept emergency medicine supervision of their residents while rotating through emergency departments (particularly in academic medical centers). It is not difficult to surmise that ABEM had to offer the politically powerful American Board of Internal Medicine (ABIM) inducements to support the change to primary board status. These considerations were not widely publicized when primary board status was announced with great (and otherwise appropriate) fanfare. Joint training, and the closely linked grandfathering of academic internists, were the doubtlessly the “price” of such consent. Unlike pediatric emergency medicine fellowships, joint training will assure reciprocity in terms of clinical practice options. However, while ABEM maintains joint residencies will still involve the same amount of training under the auspices of emergency medicine, only 12 months of actual emergency department rotations during the entire internship and residency will be required. (This is substantially less than the actual ED time in most categorical emergency medicine residency programs). Skeptics also quickly recall earlier years when “scrutiny” of credentials allowed a number of internists to short track, getting credit from both ABIM and ABEM for the same housestaff rotation. Moreover, its clear now that a number of academic internal medicine departments intend to use these openings as a means to establish/maintain control over emergency departments. ABEM maintains any internists so grandfathered will essentially be via the extant special category, yet the board felt compelled to develop a document entitled Special Credential Guidelines for ABIM Diplomats Practicing in Academic Centers. In theory, such candidates must demonstrate considerable and prolonged commitment and involvement in emergency medicine. In practice, one must ask why they didn’t become certified by the practice track many years ago (ie, 60 months of full-time practice by June 1988). ABEM’s intent appears to be to facilitate the development of joint training programs and acknowledgment by internists of the need for ABEM certification to practice and teach emergency medicine. However, a number of internists in academic medical centers, especially in the northeast, are interpreting this situation quite differently. They intend to aggressively exploit this opportunity to legitimize internal medicine’s control in their emergency departments. Their faculty will be able to grandfather into ABEM (again there will be no reciprocity for emergency medicine graduates to 89
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obtain ABIM certification), and faculty will then be required to be certified in internal as well as emergency medicine to practice in their emergency departments. This will effectively remove all pressure to have trained emergency physicians on their faculty-as one internist informed me, “Who needs training when you’ve got the certificate?” This situation will preclude our residency graduates from employment in these emergency departments, and eliminate any foreseeable potential for an autonomous academic existence for emergency medicine at these centers. (Indeed, this pathway will not be available to internists at institutions with extant residency programs in emergency medicine. While this will perhaps help protect established emergency medicine programs, it is also a powerful disincentive to initiate emergency medicine programs at university hospitals currently without a significant emergency medicine presence.) These considerations will have most debilitating impact on traditional, research-oriented medical centers in the northeast, precisely those institutions where our academic profile has been most disappointing. Indeed these scenarios are already being played out at a number of university hospitals. With the anouncement of primary board status, ABEM’s
OF EMERGENCY
MEDICINE
B Volume
9, Number
1 n January
1991
work has only begun. ABEM’s agenda must now focus on (1) expansion of certification into relevant, compensable areas of subspecialization, (2) securing our specialty’s ability to care for and expose our residents to acutely ill children, (3) ensuring joint residency training provides at least the same level of experience and competence in emergency medicine as our current programs, and (4) insisting any grandfathering of internists is selective, time limited, and involves only those inidviduals who are not able to take advantage of the previous practice track (expired in 1988) to ABEM certification. (This would effectively limit this option to internists who graduated from medical school after 1980.) Without such vigilance and scrutiny, we may well face the paradox of primary board certification limiting our academic profile, reducing the attraction of our (non-joint) residency positions, and severely restricting our training and involvement in the acute care of children. Primary board status is a tremendous opportunity for our specialty, but if it lulls us into complacency, it will not have been worth the price. J.
DOUGLAS WHITE,
Editor
MD. MPH
may well find rotations at pediatric facilities filled by pediatricians doing fellowships, and pediatric organizations will doubtlessly issue protocols and develop “merit-badge” courses, unilaterally setting standards for all emergency physicians caring for children. (One needs only to reflect on the problems the Advanced Cardiac (ACLS) and Trauma (ATLS) Life Support programs created for emergency physicians to suspect such developments in pediatric emergency care.) Most troubling are the recent revelations with regard to internal medicine and ABEM. By in large, internal medicine remains reluctant to accept emergency medicine supervision of their residents while rotating through emergency departments (particularly in academic medical centers). It is not difficult to surmise that ABEM had to offer the politically powerful American Board of Internal Medicine (ABIM) inducements to support the change to primary board status. These considerations were not widely publicized when primary board status was announced with great (and otherwise appropriate) fanfare. Joint training, and the closely linked grandfathering of academic internists, were the doubtlessly the “price” of such consent. Unlike pediatric emergency medicine fellowships, joint training will assure reciprocity in terms of clinical practice options. However, while ABEM maintains joint residencies will still involve the same amount of training under the auspices of emergency medicine, only 12 months of actual emergency department rotations during the entire internship and residency will be required. (This is substantially less than the actual ED time in most categorical emergency medicine residency programs). Skeptics also quickly recall earlier years when “scrutiny” of credentials allowed a number of internists to short track, getting credit from both ABIM and ABEM for the same housestaff rotation. Moreover, its clear now that a number of academic internal medicine departments intend to use these openings as a means to establish/maintain control over emergency departments. ABEM maintains any internists so grandfathered will essentially be via the extant special category, yet the board felt compelled to develop a document entitled Special Credential Guidelines for ABIM Diplomats Practicing in Academic Centers. In theory, such candidates must demonstrate considerable and prolonged commitment and involvement in emergency medicine. In practice, one must ask why they didn’t become certified by the practice track many years ago (ie, 60 months of full-time practice by June 1988). ABEM’s intent appears to be to facilitate the development of joint training programs and acknowledgment by internists of the need for ABEM certification to practice and teach emergency medicine. However, a number of internists in academic medical centers, especially in the northeast, are interpreting this situation quite differently. They intend to aggressively exploit this opportunity to legitimize internal medicine’s control in their emergency departments. Their faculty will be able to grandfather into ABEM (again there will be no reciprocity for emergency medicine graduates to 89
90
AMERICAN
JOURNAL
obtain ABIM certification), and faculty will then be required to be certified in internal as well as emergency medicine to practice in their emergency departments. This will effectively remove all pressure to have trained emergency physicians on their faculty-as one internist informed me, “Who needs training when you’ve got the certificate?” This situation will preclude our residency graduates from employment in these emergency departments, and eliminate any foreseeable potential for an autonomous academic existence for emergency medicine at these centers. (Indeed, this pathway will not be available to internists at institutions with extant residency programs in emergency medicine. While this will perhaps help protect established emergency medicine programs, it is also a powerful disincentive to initiate emergency medicine programs at university hospitals currently without a significant emergency medicine presence.) These considerations will have most debilitating impact on traditional, research-oriented medical centers in the northeast, precisely those institutions where our academic profile has been most disappointing. Indeed these scenarios are already being played out at a number of university hospitals. With the anouncement of primary board status, ABEM’s
OF EMERGENCY
MEDICINE
B Volume
9, Number
1 n January
1991
work has only begun. ABEM’s agenda must now focus on (1) expansion of certification into relevant, compensable areas of subspecialization, (2) securing our specialty’s ability to care for and expose our residents to acutely ill children, (3) ensuring joint residency training provides at least the same level of experience and competence in emergency medicine as our current programs, and (4) insisting any grandfathering of internists is selective, time limited, and involves only those inidviduals who are not able to take advantage of the previous practice track (expired in 1988) to ABEM certification. (This would effectively limit this option to internists who graduated from medical school after 1980.) Without such vigilance and scrutiny, we may well face the paradox of primary board certification limiting our academic profile, reducing the attraction of our (non-joint) residency positions, and severely restricting our training and involvement in the acute care of children. Primary board status is a tremendous opportunity for our specialty, but if it lulls us into complacency, it will not have been worth the price. J.
DOUGLAS WHITE,
Editor
MD. MPH
