Re: FL Senate Bill 1478, FL House Bill 805

The Association of Emergency Physicians (AEP) is a national Emergency Medicine (EM) organization established in 1993 that represents all emergency physicians regardless of board certification status. Legislative bills SB 1478 and HB 805 have come to the attention of our board of directors. This correspondence is sent in opposition to the above bills regarding the criteria for board certification in a medical specialty.

The issue of board certification status should not be the focus of the ability to practice Emergency Medicine in the state of Florida or the country. If enacted, 38% of all practicing emergency physicians would not be board certified by this definition and it would limit their eligibility for employment and create an overnight artificial worsening of the ER doctor shortage. More importantly, there are not now, nor will there soon be, enough Emergency Medicine Residency Trained (EM-RT) physicians to solely meet the needs of all emergency departments in the country.

Background:
Emergency medicine is a relatively young medical specialty with the first residency program established in 1970 and the first board certifying exam in 1980. Prior to residency programs, the emergency department coverage was staffed entirely by physicians in other specialties including internal medicine, family practice and surgery. For almost twenty years these physicians in other specialties were able to take the certification exam given by the American Board of Emergency Medicine (ABEM) and grandfather into the system without completing an Emergency Medicine residency training program. In 1988 an arbitrary date was set for closure of this tract. This was not well thought out, and didn’t fully address the ongoing absolute need for other physicians not trained in Emergency Medicine residency programs to continue to meet the ongoing staffing needs in many of the countries ERs. No where is this felt more severely than in the smaller and rural emergency departments. This arbitrary date also did not anticipate the huge physician shortage that is predicted in the next 15 years and is already occurring in many areas. The Association of American Medical Colleges (AAMC) expects a needed physician increase across the board of nearly 40% in the next fifteen years, and likely higher numbers in states like Florida and Texas. In fact, the AAMC has already called for a 30% increase in medical school enrollment from the nations medical schools and this is likely a continuing issue for your current legislators. In spite of these realities, leaders in the Emergency Medicine community continue to choose to ignore these ongoing workforce needs and provide no real solutions to these staffing shortages.

The only currently available option for these experienced, non EM-RT, "Legacy Physicians" to earn certification and testing of their competency was, and is, from the AAPS Board Certification in Emergency Medicine (BCEM). The criteria for these boards are very similar to the old "grandfather" practice track for ABEM available until 1988. In order to be eligible for the exam, one must have at least 7000 hours and a minimum of 5 years of clinical emergency medicine experience, and a residency accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA) or board certification in another specialty. One must also maintain certification in Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), and Advanced Trauma Life Support (ATLS), which is more than is required by the Emergency Medicine Residency Trained physicians. In addition, one must maintain continuing education (a minimum of 50 credits per year with at least 25 credits in emergency medicine) and recertify every 8 years whereas ABEM is presently only recertified every 10 years. The BCEM board exam has been validated and meets stringent eligibility criteria.

As noted above, BCEM is the only means for non Emergency Medicine Residency Trained physicians to test and demonstrate their competence. If BCEM is not recognized it could backfire and devalue this program. This could actually lead to less stringent criteria for working in Florida emergency rooms that this extra testing step offers. After much review by the Florida Medical Board, the State of Florida presently recognizes this as a valid board certification exam meeting the State’s stringent criteria. This battle is now being brought to the legislature after lobbying efforts were unsuccessful in the medical board where this has already been addressed, reviewed, discussed, debated and decided.

In 2006 the Institute of Medicine (IOM) released not one, but three reports on the state of emergency healthcare. This provides a relatively unbiased look into the crisis in emergency care in the US. They note:

• "Approximately 62 percent are board certified in emergency medicine. Approximately 20 percent of emergency physicians are board certified as emergency physicians but not residency trained in Emergency Medicine." pg164
• "Approximately 38 percent of practicing emergency department physicians are neither board certified nor residency-trained in emergency medicine." pg 166
• "The supply of board certified emergency physicians is not sufficient to staff all emergency departments physician positions, and in the absence of a large scale expansion of training positions, will not be sufficient for several decades. Although they [Legacy Physicians] lack board certification, these physicians represent an essential component of the ED workforce." pg 166
• "Although, ideally, all EDs would be staffed by residency trained board certified emergency physicians, this is highly unlikely to occur in the near to middle term, if ever." pg 193
• "These concerns are especially important now that the physician workforce is projected to be inadequate for the future needs of this country." pg 185

In addition, the American College of Emergency Physicians (ACEP), the national parent organization for the Florida chapter spearheading this misguided effort, has acknowledged the important role of the Legacy Physician as of June 2006. The most important determinant for the Legacy Physician, as well as the residency trained physician, should be meeting standards of care rather than an issue of board certification. The college also recognizes that these legacy physicians play an important role in emergency healthcare. This organization had instituted a task force to explore separating board certification status from recognition for contributions to the field of emergency medicine for all of its members. The issue again is focusing on meeting standards and showing commitment to the field of emergency medicine rather than strictly training or board certification status.

In conclusion, please oppose these bills which are not based on the reality of today’s or tomorrow’s emergency healthcare environment, and would restrain employment opportunities for nearly 40% of practicing emergency physicians and lead to a worsening of the current workforce shortage. This issue has already been discussed and dismissed by the Florida Medical Board on several occasions since BCEM was recognized as a validated board certification exam in your state. Please recognize that the non Emergency Medicine Residency Trained physician is essential and will remain essential in our emergency departments for years to come. While an Emergency Medicine Residency Training is important for the future, it currently and may never provide adequate numbers to staff all of our emergency departments. In facing this crisis, the issue of board certification and training should not be the focus but instead ensuring that all practicing emergency physicians are competent and meet accepted standards of care. The BCEM is the only means that allows this and no other solution has been offered by the leaders of the emergency medicine community. The focus should be shifted to maintain higher standards through obtainable and measurable means including recertification in PALS, ATLS and ACLS. Please consider these points and feel free to contact the AEP Office and Board of Directors at 866-772-1818, if you have any further questions or need clarification.

AEP Board of Directors:

Resources

Hospital -Based Emergency Care: At the Breaking Point (2006): IOM report, Chapter 6 pages 163-200
http://books.nap.edu/openbook.php?record_id=11621&page=163

The Role of the Legacy Physician in the 21st Century
http://www.acep.org/webportal/PracticeResources/PolicyStatements/certcred/legacyep.htm

ACEP Resolution 24(05) Task Force Final Report
http://www.acep.org/NR/rdonlyres/ED494E43-0CBF-48F4-AD93-ED66F9607C96/0/Res2405TFFinalReport.pdf

Eligibility for BCEM exam
http://www.abpsga.org/certification/emergency/eligibility.html

Association of American Medical Colleges (AAMC)
http://www.AAMC.org

Previous president letters:

President:	Date:
Jeff Bates	March 2007
Mike Misko	April 2006
Mike Misko	February 2006
Mike Misko	October 2005
Geoffrey Ruben	September 2004
Geoffrey Ruben	Summer 2004
Mike Misko	October 2003
Mike Misko	Autumn 2003
Mike Misko	July 2003
Mike Misko	Autumn 2002