Letters to the Editor

Child Care in Hospital Emergency Departments
Physician care of children in hospital emergency departments has come under increasingly intense scrutiny in recent years, largely because of some well-publicized unfortunate outcomes. As an Emergency Physician practicing in a community hospital, I am faced daily with the possibility of my next patient being a critically ill or injured young child. To help meet this challenge, I regularly re-certify in both the Neonatal Resuscitation Program (NRP) and Advanced Pediatric Life Support (APLS), in addition to PALS. Maintaining Proficiency in NRP and APLS does not, by any stretch of the imagination, insure a favorable outcome in pediatric emergencies. However, these two courses do provide fundamental skills upon which to expand practice competencies.

Certification in the Neonatal Resuscitation Program for all Obstetric Delivery Room Nurses and Level I/II Neonatal Nursery Nurses is mandated by the JCAHO. Therefore, this one-day course is offered twice each year at all hospitals in the U.S. having an Obstetric Service. The Advanced Pediatric Life Support course is currently offered at twenty-two tertiary care medical centers across the country, semi-annually at each location. The fee for the NRP class is approximately $40 (cost of textbook); fees for the APLS class range from $350-$700, depending upon whether or not a live laboratory session is included with the program.

Any practicing physician who regularly treats pediatric patients, including the occasional newborn, infant, or toddler in distress, will definitely benefit by keeping current in both NRP and APLS standards, along with currency in PALS. Many of our Emergency Nurses and Paramedics routinely certify in these three programs; we should not accept less rigorous criteria for ourselves. In addition, continually enhancing one's clinical acumen directly promotes excellent quality of patient care.

Richard Cressey, M.D.
Diplomate, BCEM
Boston, MA

A Commentary on Graduate Training in Emergency Medicine
In the late 1980's, the American Board of Emergency Medicine (ABEM) closed the practice track for certifica- tion. This left thousands of career emergency physicians (EP's) who originally trained in other specialties and who often held leadership and academic positions, vulnerable to pressure from competitors holding board certification in emergency medicine. For most of the history of emergency medicine (EM), the majority of Emergency Physicians (EP's) have not been residency trained and, until recently, were not board certified. The infusion of graduates from EM residen- cies amounts to about 1,000 per year into a pool estimated to be 30,000 FTE's. The attrition rate is not well established but may be as high as 5-10 percent yearly. Many physicians also move in and out of EM practice, practice acute or minor care, "fast track," industrial/occupational, sports, correctional, and institutional medicine and clinics, as well as, function in administrative and academic situations.

Those physicians without EM credentials are frequently subject to "deselection" and downsizing; advertisements state "BC/BE in EM," even though the American Board of Medical Specialists states that board certification should never be the sole criteria for granting of privileges; that experience and training are appropriate criteria as well.

Into this climate the American Association of Physician Specialists, Inc. (AAPS) introduced methods by which career EP's without EM board certification could demonstrate capability in their field. Since the early 1990's AAPS has stepped forward with a mechanism for certifying EP's via the Board of Certification in Emergency Medicine(BCEM).

There are now three pathways to this designation: 1) completion of an EM residency training program; 2) completion of a residency in family practice, internal medicine, pediatrics, general surgery, or anesthesiology plus five years of full-time EM practice; 3) completion of a graduate training program of 12-24 months (plus sufficient practice time to comprise a full 24 months). Any of these pathways allows the candidate to sit for a written board examination to be followed by an oral examination. Thus far, over 1800 candidates have successfully qualified for board certification by the BCEM.

Graduate training programs (GTP's) in EM were not part of the original qualifications for the BCEM examination. Although EM training programs existed before BCEM and the GTP pathway in places such as North Carolina, New York, Iowa, West Virginia, and Indiana, it wasn't until recently that programs were credentialed by AAPS for the express purpose of allowing candidates to qualify for the examination. Programs currently operating include the University of Tennessee-Memphis and the University of Tennessee-Knoxville; two other programs at the University of Tennessee and one program each in Maine and Arkansas have applied for AAPS credentialing.

It is unlikely that graduates from non-EM residencies, who wish to practice full-time EM, will be able to go back and join an EM residency training program. This is due to the graduate medical education funding model, which does not allow Medicare funding to be used more than once for post-graduate training by a physician. In other words, if a physician goes through an internal medicine program (three years) that physician's eligibility is exhausted and no more training funds will be awarded for participation in any additional GME programs. Only a few EM residencies have sufficient endowments to forego the Medicare dollars that provide the funding for residents, faculty, and support for the majority of programs.

The GTP is based on the model established by the Residency Review Committee. A suitable site with appropriate institutional support is selected; a program director and staff are designated; and funding (non GME) is procured. The curriculum follows broad-based core competency guidelines as described by the American College of Emergency Physicians. The application itself can be used as a guideline for setting up a program, and it must be completed and sent to AAPS along with an application fee (download from aapsga.org). GTP's allow interested parties who already have suitable broad-based talents from their residency training to add the specific knowledge and skills necessary for EM without the burden and risk of on the job training via the practice pathway. Also the GTP can be completed in less time. Physician stress and liability are reduced by working under the tutelage of faculty proctoring, and quality assurance measures and standards of practice are more dependably adhered to.

Much of the emergency care available in rural and underserved areas is delivered by primary care physicians, especially family physicians who fill patient needs in the office, hospital, nursing home, and ED. Many of these physicians are essentially dual trained in family practice and emergency medicine, the two most broadly-based specialties. GTP applicants from family practice interested in GTP's have primarily been from states with rural and large, underserved populations without ready access to sub-specialists and tertiary care. Linkage between family practice and emergency medicine is extensive and practical due to the ability of both programs to train practitioners in patient care unrestricted by age, sex, or organ system.

Summary
In view of several great needs, GTP's in EM are considered important in planning management of the crisis in emergency medicine. ED visits ever increase while department closures have cut the number of facilities by over 20 percent during the past two decades. Managed care organizations and liability risk issues put pressure on the primary care practitioners to send patients with urgent and/or unexpected problems to the ED. ED's are overcrowded with patients, creating long waits secondary to hospital bed shortages. Ambulance diversions are rampant. Staffing in the ED is still primarily by non-residency trained EP's and the flow from EM programs is not likely to provide sufficient manpower for another 15-20 years. Practitioners are currently available and interested in demonstrating expertise in emergency medicine via BCEM credentialing. It is likely that non-residency trained practitioners will be needed until most of us "boomers" are retired. It is the belief of AAPS that ED staffing will be improved by the arrival of appropriately changed GTP graduates who will be able to supplement the EM work force and deliver quality care.

Loren A. Crown, M.D., FAAEP
Diplomate, BCEM
Covington, TN

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