What is ACEP Thinking?
Issue: January/February 2018
Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense
An emergency physician who grew up in the 21 st century may not know or appreciate the complex history of emergency medicine. Emergency medicine is still much younger than internal medicine, surgery, or pediatrics — but it is no longer an infant either. The days of the “ER” as a place for older or lost physicians who can't work anywhere else are gone. Emergency medicine is now a respected and competitive specialty. The early founders and supporters of our specialty were not residency trained in emergency medicine, of course, and did not have the mentors and role models available to budding emergency physicians now. Those pioneering physicians blazed a path which has blossomed into the specialty of emergency medicine.
All of us owe a debt of gratitude for their service and dedication to our specialty. It is now accepted that emergency medicine involves a unique and specific set of knowledge and skills, which are embodied by being certified by ABEM or AOBEM as a specialist in emergency medicine. A knowledge of our history is required to understand where we came from and where we are headed. The American College of Emergency Physicians was formed in 1968. The first resident in emergency medicine was Bruce Janiak, who entered residency in 1970 at the University of Cincinnati. Other residents and residencies soon developed, but the American Board of Emergency Medicine (ABEM) did not administer its first board examination until 1980. ABEM recognized that there were physicians who had been working in emergency rooms (this is long before they were departments) who did not have the opportunity to complete an emergency medicine residency, and were often the faculty of the original emergency medicine residencies. A “practice track” with a ten-year grace period was established, to allow these pioneers of our specialty the opportunity to become board certified by ABEM/AOBEM. This practice track to board certification closed — with ample, ten-year, advance notice — in 1988. Thereafter, any physician who desired to sit for the ABEM or AOBEM board exams would be required to complete an approved emergency medicine residency. In recognition of our development as a specialty, the American Board of Medical Specialists (ABMS) in 1989 designated emergency medicine as a primary board. I was a third year resident at the time, and remember proudly when my chosen spe - cialty finally made it.
Assaults on the value of residency training and board certification soon started. The Board of Certification in Emergency Medicine (BCEM) (which is now recognized by the American Board of Physician Specialties) initially allowed physicians who had never completed any residency to become “board certified” in emergency medicine, and even now will certify physicians who have never completed a residency in emergency medicine. The Daniels lawsuit began when a general surgeon who practiced emergency medicine (along with many others) sued ABEM (and others), claiming that ABEM’s closure of the practice track was an illegal conspiracy to enhance the economic status of ABEM-certified emergency physicians. Dr. Daniels and some of his co-plaintiffs formed the Association of Emergency Physicians. I had just graduated from a four-year emergency medicine residency, and was shocked and dismayed to read about this attempt to trivialize the sacrifices my family and I made to complete a residency and become board certified.
I still remember the day in 1992 when a colleague at an EmCare ED, where I was working part-time, handed me a copy of Jim Keaney’s The Rape of Emergency Medicine . I went home and read it cover to cover, and had a eureka moment. Suddenly, I realized there were doctors and corporations who had decided to profit off of my labor. I felt belittled and exploited. The idea that I was being used and abused was a shock. Dropping what I once thought of as my hard-earned and impeccable FACEP designation clearly seemed to be the right thing to do, and I joined AAEM and have been a proud member since its early days.
Fast forward to 2017: we are now a mature specialty, graduating thou - sands of expertly trained residents chosen from the top of their medical school classes. Our specialty is a highly sought-after Match spot for graduating medical students. You may not think so, but it really is a sign of respect for our specialty that patients are sent to virtually every emer - gency department in our nation by their physicians, so we can figure out what is wrong and decide on a course of treatment.
If you are under 40, you may be rolling your eyes as the old guy bemoans the bad old days of our specialty, and think we are past the infighting and divisive discourse between AAEM and ACEP. The issues dividing our two professional organizations are in the past, right? The thought that one of our specialty's professional societies could be led by an individual who is not a board-certified emergency physician is unthinkable, isn't it?
“What would you, as a board-certified emergency physician, think if you learned that ACEP has chosen a general surgeon as their president-elect?” Continued on next page From the Editor’s Desk What is ACEP Thinking? Andy Mayer, MD FAAEM Editor, Common Sense 5 JANUARY/FEBRUARY 2018 COMMON SENSE FROM THE EDITOR’S DESK What would you, as a board-certified emergency physician, think if you learned that ACEP has chosen a general surgeon as their president- elect? You might think that must be some sort of mistake or tasteless joke. What message does this send to tens of thousands of board- certified emergency physicians? I guess this resurrects the question of just who is an emergency physician. Does any physician who works in an emergency department automatically become one? I know what I think about that, but decided to see what ACEP thinks. Their website provides the answer:
“Definition of an Emergency PhysicianOriginally approved June 2011 An emergency physician is defined as a physician who is certified (or eligible to be certified) by the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM) or an equivalent international certifying body recognized by ABEM or AOBEM in Emergency Medicine or Pediatric Emergency Medicine, or who is eligible for active membership in the American College of Emergency Physicians.” 1
Reaffirmed April 2017
Please read that definition carefully, with emphasis on the end of the sentence. A quick reading sounds good and makes you think, “Well, okay.” However, it is the “...or who is eligible for active membership in the American College of Emergency Physicans” that is the important part to me. Again looking at ACEP’s website, the criteria for membership include “...or eligible for active or international membership in the College at any time prior to the close of business December 31, 1999.” Why was this last phrase added and who wrote it? I am not sure, but the candidate ma - terial Dr. John Rogers submitted for the recent election might shed some light. In his list of accomplishments, number six is:
“Helped to write ACEP’s current definition of an emergency physician.”2
Discovering that a physician who is not and never has been eligible for the ABEM or AOBEM exams helped ACEP define emergency physician gives me pause. I do not discount the years of service which Dr. John Rogers provided to ACEP. He may even be the finest clinician in the world, but does that matter? The president-elect of ACEP, who is listed as a fellow (FACEP) and who will be to many the face of emergency medicine in 2019, is not a board-certified specialist in emergency medicine. In my opinion, he is not an emergency physician. He is a surgeon who has worked in emergency departments for a long time. I do not think a doctor who does something for a long time transforms into something he is not. However, according to the ACEP definition of what an emergency physician is, Dr. John Rogers, FACEP is one. What do you think?
Does emergency medicine want to tell the house of medicine it is not a real specialty? Can just any surgeon or internist safely step into your shoes? The message ACEP sends to the emergency medicine community and medicine in general with this election is something I hope each and every one of you will carefully consider. The value of becoming a fellow of the College loses value when board certification is not required. This is not 1980. ACEP has many fine physicians who took the painful and arduous task of completing an emergency medicine residency and then passing the ABEM or AOBEM board exams. Why did ACEP decide to elect someone who did not? Did the fact that ACEP’s elections are not directly democratic come into play? Would this have happened with a direct, “one member-one vote” election like AAEM's? Did the councilors know that Dr. Rogers was not board-certified, and simply decide he had earned the presidency as a reward for long years of service?
In closing, I ask each of you to reflect on this issue. I had hoped, and still do, that AAEM and ACEP could grow closer and work together on common goals and interests. This act makes that idea less appealing. I am an emergency physician — a board-certified specialist in emergency medicine — and I want to be led by those with the same training, knowl - edge base, and values.
- https://www.acep.org/Clinical---Practice-Management/Definition-of-an- Emergency-Physician/#sm.0008xf81z1b56cu1q4x2ri7paz95n
This is a response which I received from Dr. Paul Kivela, the ACEP president, related to my article "What is ACEP Thinking?" The two of us had a lengthy conversation about the issue of ACEP electing a non- boarded physician and the importance of this decision. We certainly disagree as to the importance of this issue but do agree that AAEM and ACEP should try and work together whenever possible on issues on which we do agree. — The Editor
Response from Dr. Paul Kivela
Dear Dr. Mayer Thank you for reaching out to me. I understand your concerns that the current ACEP president-elect is not boarded in emergency medicine. There are several issues you raise which I think should be addressed. First of all, there is more that unites emergency physi - cians than divides us and I hope that ACEP and AAEM members and both organizations will stay united on the issues upon which all emergency physicians can agree. I doubt any emergency physician nor any patient will benefit from fighting each other. We need to work together where we can and concentrate on common goals and interests. Secondly, I have spent the past six years on the board with Dr. Rogers and I know him to be an honest, knowledgeable and thoughtful emergency physician and I believe he will be an excellent spokesperson for our specialty. Third, I cannot speak for Dr. Rogers and I encouraged you to reach out and speak to him directly. What I can say is that in the time I have known him, he has always been committed to ABEM/AOBEM as the gold standard in emergency medicine. It is my understanding that Dr. Rogers narrowly missed the ABEM window and serves in an area of the country where there are still very few emergency medicine residency trained individuals. Most importantly, Dr. Rogers has a long history of successfully advocating for emergency physicians and continues to fight for the best interests of emergency medicine and the patients we serve.
We may not agree on this issue. I hope that we can put this issue behind us and unite and work together on the important issues that face our specialty where we do agree including upholding the prudent layperson standard, ensuring fair payment for our services, defining scope of practice, reinforcing the importance of emergency physician led teams, resolving the opiate crisis, improving psychiatric care, decreasing boarding, and combating burnout by improving the emergency physician work environment. Let’s not get distracted and lose sight of what improves the lives of our patients and emergency physicians. Paul Kivela, MD MBA FAAEM FACEP President, ACEP