| Published correspondence (Annals of Emergency Medicine) Ann Emerg Med. 2007;50:622-623. |
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The IOM Report Recommends Multi-Disciplinary Approaches to
Workforce and Credentialing Issues
W. Anthony Gerard, MD
Lebanon Emergency Physicians, Good Samaritan Hospital, Lebanon, Pennsylvania
Assistant Clinical Professor, Penn State Department of Family Medicine
Kim A. Bullock, MD
Assistant Director Emergency Ambulatory Services
Providence Hospital Emergency Department
Arlen R. Stauffer, MD
Medical Director, Emergency Department
Bert Fish Medical Center, New Smyrna Beach, Florida
The recent release of the Institute of Medicine report, "The Future of Emergency
Care in the United States Health System," may prove to be a watershed document
(1). It served to expose the many problems in our emergency health care system
and the urgent need for change. The report delivered a poor prognosis and
predicted a grim future unless systemic problems are immediately addressed.
These problems include overcrowding, resolving current and future manpower
needs, inadequate coordination among emergency and primary care systems,
shortages of on-call specialists, and disaster preparedness.
We believe that important portions of the IOM’s message regarding workforce
issues are not being given adequate attention by the leaders of our specialty.
Annals of Emergency Medicine published the official IOM Summary Report in the
August issue along with a series of insightful and challenging editorials (2). The
publication’s IOM comprehensive project included three sections: emergency
medical care for children, hospital-based emergency care, and pre-hospital
emergency medical services. The IOM Report exhorted the leaders and educators
of Emergency Medicine to respond with vision and decisive action, but emphasized
that improving emergency care will require a new level of collaboration among a
number of specialties. Workforce issues remain a linchpin for the success of many
of the issues that the IOM addressed.
Cooperation among specialties and innovation in workforce modeling and
credentialing are common threads connecting all three IOM topics, and these were
not adequately described by the Annals’ editorials.
To date, there has been a remarkable silence about the workforce section of the
IOM Report, which recommends fundamental changes in the way that emergency
providers are credentialed and quality is determined. Many in the Emergency
Medicine community have chosen to exercise selective hearing regarding these
recommendations. For example, there have been no published or official
comments from Emergency Medicine's leadership concerning the IOM's request for
collaboration and inclusiveness on this issue. The Annals editorials merely
referenced this topic, even though the IOM's discussion of this issue is prescient
and prescriptive.
Comprehensive in scope and astute in analysis, the IOM Report stands as a
challenge to the current paradigms on workforce and credentialing. The importance
of residency training in Emergency Medicine is described, but the IOM challenges
the presupposition that has led to ABEM and AOBEM board certification as an
exclusionary criterion for the practice of Emergency Medicine. The essential role of
emergency physicians who trained in other specialties is described in detail, and
their competence, "acquired through a combination of post-residency education,
directed skills training, and on the job experience", is lauded. The need for
improved cooperation between these physicians and academic Emergency
Medicine is emphasized, and new credentialing standards that emphasize universal
core competencies rather than board certification are stressed. "These national
standards should ensure that core competencies for all disciplines working in the
ED are assessed ....regardless of board certification status."
The IOM Report contains a special insert on the "Specialty of Emergency
Medicine," with a summary of this topic. It reviews the history of the specialty, and
the organizations that are involved (ABEM, AOBEM, ACEP, AAEM, and the BCEM).
The BCEM is accurately portrayed as a certification process that requires residency
training plus five years of Emergency Medicine experience. (The IOM committee
describes BCEM diplomates as a small group, but may not have been aware that
there are actually more BCEM diplomates than AOBEM diplomates (3)).
Non ABEM and AOBEM certified emergency physicians are described as part of the
"essential component of the ED workforce at many hospitals, especially smaller
facilities in suburban and rural settings." The report identifies a reality that many
academic Emergency Medicine leaders have been reluctant to embrace: "workforce
issues in rural areas may never be solved by increasing the number of (residency
trained) specialists in rural areas." The report calls for alternative staffing models
for rural areas, and emphasizes the need for increased collaboration between
Emergency Medicine and primary care specialties (such as Family Practice).
Many of the solutions that the IOM Report challenges us to adopt are already within
the purview of the specialty of Emergency Medicine if we choose to listen to them.
Improved relationships and collaborative credentialing standards could be quickly
developed between ACEP and the AAFP as an extension of the joint training
programs that the ABEM and the ABFM recently adopted (4). Evidenced based
credentialing and core competencies in Emergency Medicine should be developed
by cooperative efforts between our national specialty societies instead of by
internal debates. The IOM's approach to the controversy over recognizing
certifying bodies needs to be adopted by all specialty societies. These "national,
evidence based, multidisciplinary processes" for ensuring quality and competence
would clarify that the foundational importance of residency training in emergency
medicine (and the validity of the ABMS and AOBEM certification process) is not
threatened by the acceptance of the BCEM as an alternative board. Many of the
unique workforce challenges that exist for emergency care in rural areas would be
expedited by the collaborative approaches that the IOM report recommends.
These cooperative approaches to physician staffing have been proposed in the
past (5, 6), but were not seriously considered because the specialty of Emergency
Medicine has not wanted to acknowledge the role of other primary care specialties
in providing emergency care.
The IOM report's discussion of workforce issues challenges many of the current
policies in Emergency Medicine that promote the "specialty" of emergency medicine
ahead of the "practice" of Emergency Medicine. We have been exhorted before to
be "more specialty led, and less specialty driven" but we have been unable to
change this attitude (7). We have been driven by the importance of ACGME
training and ABMS certification in Emergency Medicine and have spent resources
promoting and protecting this qualification, instead of using this as a foundation for
leading the kind of collaborative efforts that the IOM report proposes. These are
not new ideas, and the history of Emergency Medicine has been tainted by debates
over board certification and credentialing (8, 9). Emergency Medicine has now
"come of age", and these debates need to be relegated to our history and seen as
part of our insecurity and adolescent development within academia. The IOM
report recommends that we adopt the cooperative approaches to scope of practice
issues that characterize a mature medical specialty.
Although these workforce recommendations are only a small part of the IOM's
comprehensive report, they are integral to the whole. The leadership of
Emergency Medicine must embrace the premises and recommendations of the IOM
on this issue. If they do not, the "mosaic necessary to pull off the (IOM) grand
scheme" (10) will be missing several pieces. These unbiased and consortium-
based recommendations from the Institute of Medicine exhort the specialty of
Emergency Medicine to be less introverted in its workforce policies: we must
"partner with professional organizations....and the Department of Health and Human
Services... (to) develop national standards for core competencies... (in emergency
and trauma care)… using an evidence-based, multi-disciplinary process."
We can not applaud the recommendations from this landmark report that we like,
but at the same time ignore the recommendations that make us uncomfortable.
Leaders within the specialty will need to accept these new paradigms concerning
the Emergency Medicine workforce in order to align the profession to meet the
public’s needs and to serve the public good.
References:
(1) Institute of Medicine Committee on the Future of Emergency Care in the U. S.
Health System. Hospital-Based Emergency Care: At the Breaking Point.
Washington, DC: National Academies Press; 2006. http://www.iom.edu/
(2) Ann Emerg Med. 2006;48:115- 148.
(3) Moorhead JC. A study of the workforce in emergency medicine. Ann Emerg
Med. 1999;40(1):3-15.
(4) American Board of Family Medicine. Guidelines for Combined Residency
Training in Emergency Medicine and Family Medicine. Lexington, Kentucky,
February 2006.
(5) Bullock K , Rodney WM, Gerard T, Hahn R. 1999. Advanced Family Practice
physicians as the foundation for rural emergency medicine services, ( Part 1 and
2), Texas Journal of Rural Health. XVII (1):19-30 and XVIII(2):34-44
(6) Williams J, Ehrlich, P, Prescott J. Emergency Medical Care in Rural America.
Ann Emerg Med. 2001;38:3:323-327.
(7) Beveridge B, Canadian Medicine. Ann Emerg Med. 1995;26:504-507.
(8) Sciammarella J, Gerard WA.. The credentialing debate: on the outside of the
house of emergency medicine looking in. Ann of Emerg Med.1994;24:293-295.
(9) Wicher JA., Cummings I, Gerard WA.. On credentials and manpower in
emergency medicine. Ann Emerg Med. 1993;22:1492-1496.
(10) Spaite D. IOM Subcommittee on Prehospital Emergency Medical Services.
Ann Emerg Med. 2006;48: 2; pg 130
Workforce and Credentialing Issues
W. Anthony Gerard, MD
Lebanon Emergency Physicians, Good Samaritan Hospital, Lebanon, Pennsylvania
Assistant Clinical Professor, Penn State Department of Family Medicine
Kim A. Bullock, MD
Assistant Director Emergency Ambulatory Services
Providence Hospital Emergency Department
Arlen R. Stauffer, MD
Medical Director, Emergency Department
Bert Fish Medical Center, New Smyrna Beach, Florida
The recent release of the Institute of Medicine report, "The Future of Emergency
Care in the United States Health System," may prove to be a watershed document
(1). It served to expose the many problems in our emergency health care system
and the urgent need for change. The report delivered a poor prognosis and
predicted a grim future unless systemic problems are immediately addressed.
These problems include overcrowding, resolving current and future manpower
needs, inadequate coordination among emergency and primary care systems,
shortages of on-call specialists, and disaster preparedness.
We believe that important portions of the IOM’s message regarding workforce
issues are not being given adequate attention by the leaders of our specialty.
Annals of Emergency Medicine published the official IOM Summary Report in the
August issue along with a series of insightful and challenging editorials (2). The
publication’s IOM comprehensive project included three sections: emergency
medical care for children, hospital-based emergency care, and pre-hospital
emergency medical services. The IOM Report exhorted the leaders and educators
of Emergency Medicine to respond with vision and decisive action, but emphasized
that improving emergency care will require a new level of collaboration among a
number of specialties. Workforce issues remain a linchpin for the success of many
of the issues that the IOM addressed.
Cooperation among specialties and innovation in workforce modeling and
credentialing are common threads connecting all three IOM topics, and these were
not adequately described by the Annals’ editorials.
To date, there has been a remarkable silence about the workforce section of the
IOM Report, which recommends fundamental changes in the way that emergency
providers are credentialed and quality is determined. Many in the Emergency
Medicine community have chosen to exercise selective hearing regarding these
recommendations. For example, there have been no published or official
comments from Emergency Medicine's leadership concerning the IOM's request for
collaboration and inclusiveness on this issue. The Annals editorials merely
referenced this topic, even though the IOM's discussion of this issue is prescient
and prescriptive.
Comprehensive in scope and astute in analysis, the IOM Report stands as a
challenge to the current paradigms on workforce and credentialing. The importance
of residency training in Emergency Medicine is described, but the IOM challenges
the presupposition that has led to ABEM and AOBEM board certification as an
exclusionary criterion for the practice of Emergency Medicine. The essential role of
emergency physicians who trained in other specialties is described in detail, and
their competence, "acquired through a combination of post-residency education,
directed skills training, and on the job experience", is lauded. The need for
improved cooperation between these physicians and academic Emergency
Medicine is emphasized, and new credentialing standards that emphasize universal
core competencies rather than board certification are stressed. "These national
standards should ensure that core competencies for all disciplines working in the
ED are assessed ....regardless of board certification status."
The IOM Report contains a special insert on the "Specialty of Emergency
Medicine," with a summary of this topic. It reviews the history of the specialty, and
the organizations that are involved (ABEM, AOBEM, ACEP, AAEM, and the BCEM).
The BCEM is accurately portrayed as a certification process that requires residency
training plus five years of Emergency Medicine experience. (The IOM committee
describes BCEM diplomates as a small group, but may not have been aware that
there are actually more BCEM diplomates than AOBEM diplomates (3)).
Non ABEM and AOBEM certified emergency physicians are described as part of the
"essential component of the ED workforce at many hospitals, especially smaller
facilities in suburban and rural settings." The report identifies a reality that many
academic Emergency Medicine leaders have been reluctant to embrace: "workforce
issues in rural areas may never be solved by increasing the number of (residency
trained) specialists in rural areas." The report calls for alternative staffing models
for rural areas, and emphasizes the need for increased collaboration between
Emergency Medicine and primary care specialties (such as Family Practice).
Many of the solutions that the IOM Report challenges us to adopt are already within
the purview of the specialty of Emergency Medicine if we choose to listen to them.
Improved relationships and collaborative credentialing standards could be quickly
developed between ACEP and the AAFP as an extension of the joint training
programs that the ABEM and the ABFM recently adopted (4). Evidenced based
credentialing and core competencies in Emergency Medicine should be developed
by cooperative efforts between our national specialty societies instead of by
internal debates. The IOM's approach to the controversy over recognizing
certifying bodies needs to be adopted by all specialty societies. These "national,
evidence based, multidisciplinary processes" for ensuring quality and competence
would clarify that the foundational importance of residency training in emergency
medicine (and the validity of the ABMS and AOBEM certification process) is not
threatened by the acceptance of the BCEM as an alternative board. Many of the
unique workforce challenges that exist for emergency care in rural areas would be
expedited by the collaborative approaches that the IOM report recommends.
These cooperative approaches to physician staffing have been proposed in the
past (5, 6), but were not seriously considered because the specialty of Emergency
Medicine has not wanted to acknowledge the role of other primary care specialties
in providing emergency care.
The IOM report's discussion of workforce issues challenges many of the current
policies in Emergency Medicine that promote the "specialty" of emergency medicine
ahead of the "practice" of Emergency Medicine. We have been exhorted before to
be "more specialty led, and less specialty driven" but we have been unable to
change this attitude (7). We have been driven by the importance of ACGME
training and ABMS certification in Emergency Medicine and have spent resources
promoting and protecting this qualification, instead of using this as a foundation for
leading the kind of collaborative efforts that the IOM report proposes. These are
not new ideas, and the history of Emergency Medicine has been tainted by debates
over board certification and credentialing (8, 9). Emergency Medicine has now
"come of age", and these debates need to be relegated to our history and seen as
part of our insecurity and adolescent development within academia. The IOM
report recommends that we adopt the cooperative approaches to scope of practice
issues that characterize a mature medical specialty.
Although these workforce recommendations are only a small part of the IOM's
comprehensive report, they are integral to the whole. The leadership of
Emergency Medicine must embrace the premises and recommendations of the IOM
on this issue. If they do not, the "mosaic necessary to pull off the (IOM) grand
scheme" (10) will be missing several pieces. These unbiased and consortium-
based recommendations from the Institute of Medicine exhort the specialty of
Emergency Medicine to be less introverted in its workforce policies: we must
"partner with professional organizations....and the Department of Health and Human
Services... (to) develop national standards for core competencies... (in emergency
and trauma care)… using an evidence-based, multi-disciplinary process."
We can not applaud the recommendations from this landmark report that we like,
but at the same time ignore the recommendations that make us uncomfortable.
Leaders within the specialty will need to accept these new paradigms concerning
the Emergency Medicine workforce in order to align the profession to meet the
public’s needs and to serve the public good.
References:
(1) Institute of Medicine Committee on the Future of Emergency Care in the U. S.
Health System. Hospital-Based Emergency Care: At the Breaking Point.
Washington, DC: National Academies Press; 2006. http://www.iom.edu/
(2) Ann Emerg Med. 2006;48:115- 148.
(3) Moorhead JC. A study of the workforce in emergency medicine. Ann Emerg
Med. 1999;40(1):3-15.
(4) American Board of Family Medicine. Guidelines for Combined Residency
Training in Emergency Medicine and Family Medicine. Lexington, Kentucky,
February 2006.
(5) Bullock K , Rodney WM, Gerard T, Hahn R. 1999. Advanced Family Practice
physicians as the foundation for rural emergency medicine services, ( Part 1 and
2), Texas Journal of Rural Health. XVII (1):19-30 and XVIII(2):34-44
(6) Williams J, Ehrlich, P, Prescott J. Emergency Medical Care in Rural America.
Ann Emerg Med. 2001;38:3:323-327.
(7) Beveridge B, Canadian Medicine. Ann Emerg Med. 1995;26:504-507.
(8) Sciammarella J, Gerard WA.. The credentialing debate: on the outside of the
house of emergency medicine looking in. Ann of Emerg Med.1994;24:293-295.
(9) Wicher JA., Cummings I, Gerard WA.. On credentials and manpower in
emergency medicine. Ann Emerg Med. 1993;22:1492-1496.
(10) Spaite D. IOM Subcommittee on Prehospital Emergency Medical Services.
Ann Emerg Med. 2006;48: 2; pg 130