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American Academy of Emergency Medicine

Landmark AAEM, SAEM and CORD Consensus Position Reached

by Antoine Kazzi, MD FAAEM
AAEM Board of Directors and CAL/AAEM President

As a result of months of meetings and deliberations coordinated with the Medical Board of California and chaperoned by the California Chapter of the American Academy of Emergency Medicine, the Society for Academic Medicine (SAEM), the Council of Emergency Medicine Residency Directors (CORD) and the American Academy of Emergency Medicine (AAEM) recently reached a landmark agreement on recommendations to the Federation of State Medical Boards (FSMB) pertaining to a controversial May 1998 FSMB policy statement. The recommendations of this consensus by leading EM organizations have been forwarded to the FSMB and await its official response. It will also be forwarded to remaining EM organizations and to the medical community for comment and to enlist their support. The recommendations and the comments that they will receive will be published soon in JEM and AEM.

Responding to FSMB's recommendation to restrict full licensure to physicians that have completed 3 years of post-graduate training, the consensus document reads:

We agree with this recommendation, which will raise the medical standards for new licensees. The current practice of moonlighting by physicians-in-training subjects patients to care by physicians with less than optimal training.

We also acknowledge that a shortage of board-certified emergency physicians persists at this point, particularly in rural and underserved areas.

We therefore propose the following addition to the FSMB recommendation: "the FSMB should support the establishment of a dependent practice of medicine license by state boards that a physician-in-training can secure after successfully completing one year of residency training in a US - accredited allopathic or osteopathic program (ACGME or AOA)."

The dependent practice license is to be time-limited. A "physician-in-training" is defined as a resident physician who maintains current, satisfactory enrollment in an ACGME or AOA approved residency-training program.

Such a dependent practice is to be restricted in scope to clinical activities consistent with those that the resident is performing in the course of their residency-training program and the scope of practice for that clinical specialty.

On-site supervision of the resident physician that is working under the dependent practice of medicine license is required.

Such supervision should be (1) continuous, (2) on-site, and (3) provided by fully licensed physicians who are board-certified/prepared in the resident's own field of training.

Board certification or preparation of the supervising physician must be provided by a certifying body recognized by the American Board of Medical Specialties or the American Osteopathic Board of Specialties.

Such a dependent practice of medicine is equivalent to extending eligibility for "Physician Extender" status to residents who are in good standing in their training program.

Such dependent practice licensure will require annual renewal.

Physician groups and institutions that contract or employ physicians who are practicing under a dependent practice license must share the legal liability for the quality of care provided by the residents working for them. They must assume the responsibility of clearly documenting the supervision mechanism for the dependent practitioner. This mechanism must not vary substantially from that provided in the resident's training program.

Responding to the FSMB's recommendation that all physicians enrolled in postgraduate training programs shall be subject to medical board regulation and oversight through a mechanism that requires the physician to obtain a training permit or limited license expressly designed for such purpose and that such mechanism shall also require that program directors report annually to the medical board on all individuals enrolled in their respective programs - the consensus document reads:

We believe this recommendation requiring program directors to annually report details of each resident's education process - is counterproductive. All represented Emergency Medicine organizations are strongly opposed to this requirement. We propose modifying this 1998 FSMB position by shifting the responsibility and timing of the reporting of residents and the permit renewals from the program director to the Graduate Medical Education Office (GME) of their medical institution.

The proposed revision is: "All physicians enrolled in postgraduate training programs shall be subject to medical board regulation and oversight through a mechanism that requires the physician to obtain a training permit or limited license expressly designed for such purpose. This mechanism shall also require that the graduate medical offices of training institutions report annually to the medical board any serious disciplinary action taken against a resident such as termination.

However, remediation programs and probationary actions are best handled internally within the training institution. Such a process permits deficiencies in performance to be openly addressed by the program director with the trainee rather than overlooked or inadequately addressed for fear of harming the resident's future career. Mandated reporting of such activities by the program director would create an environment in which residents attempt to hide or cover up educational mistakes or deficiencies, rather than proactively seeking assistance through the residency.

The consensus document was submitted to the FSMB on behalf of the following organizations by:

Ron Joseph, Executive Director, the Medical Board of California
Carey Chisholm, MD, Board of Directors, the Society for Academic Emergency Medicine
Jerris Hedges, MD, the Society for Academic Emergency Medicine
Sam Keim, MD, President, the Council of Emergency Medicine Residency Director
Marcus Martin, MD, President-elect, the Society for Academic Emergency Medicine
Robert McNamara, MD, President, the American Academy of Emergency Medicine
Joseph Wood, MD, Vice-President, the American Academy of Emergency Medicine
Antoine Kazzi, MD, President of the California Chapter, and Board of Directors, of the American Academy of Emergency Medicine