Alternative Training in Emergency Medicine Recently our specialty has been embroiled in a controversy over the merits of an alternative training proposal put forth by the American College of Emergency Physicians (ACEP). The proposal was initially developed by ACEP’s Manpower Task Force, which was charged with developing strategies to cope with the shortage of qualified emergency physicians in this country. This shortage is a very real problem, and most would agree that our specialty has a responsibility to address it. The college is to be commended for having the courage to step forward with this proposal, controversial though it may be. It should be pointed out right from the start, however, that enactment of the proposed program would have at best a negligible effect on the manpower shortage. This is because logistic difficulties inherent in the program severely limit its output. More important, all candidates for the program must be longstanding emergency medicine practitioners. This fundamental flaw in the proposal is immediately apparent, leading to the obvious conclusion that manpower was never the real issue. It could legitimately be claimed that enactment of this proposal, while not affecting the total manpower supply, would at least increase the qualifications of those already practicing emergency medicine. This is a laudable goal, given the fact that across this country thousands of physicians are practicing emergency medicine without the benefit of formal training in the discipline. Participation in this program would undoubtedly improve the qualifications of some physicians in much the same way that participation in ACLS or ATLS courses does. As the proposal was discussed however, it became apparent that important issues relating to physician qualifications would take a back seat to the politically charged notion that access to the American Board of Emergency Medicine (ABEM) examination should follow 12 weeks of clinical training and an at-home course of night and weekend study. It now appears that access to the certifying examination is and always has been the real issue. Reactions to the concept of weakening the standards for ABEM certification have been both varied and predictable. Undoubtedly many physicians who are unable to commit 3 or 4 years to residency training welcome the idea. Those who have completed residency programs are more likely to suggest that their untrained colleagues follow them down that same difficult path. It is probably fair to say that residency-trained physicians also respond to this concept with a mixture of anger, disbelief, and a sense of betrayal. Those who find amusement in life’s incongruities might ask the following: Is this the emergency medicine equivalent of those late night advertisements for the National Truck Driver’s Academy? Will the college have a toll-free number to help students caught in the quandary of when to intubate the chronic lunger? Will these students be able to take the ABEM examination, like their training, at home? While the answers to these tongue-in-cheek questions may

be obvious, it is clear the degree of opposition to this plan among those intimately involved with resident education was not anticipated. The Council of Emergency Medicine Residency Directors voted unanimously to oppose alternate methods of residency training that would ultimately lead to ABEM certification. This was not because the program directors are closed-minded, but because they believe training that is not equivalent undermines the legitimacy and the credibility of the residency training programs. For years the requirements for residency training have become progressively more exacting. High standards are now the norm. Residents become experts in diverse areas such as airway management, resuscitation of the critically ill, child abuse, and toxicology to name a few. All residents are exposed to research. Does 10 hours per week of “supervised” practice expose the candidate to the same patient pathology, variety of clinical problems, and procedural opportunities encountered in an American College of Graduate Medical Education-accredited residency? How does one make up for the lack of peer and faculty interactions that are essential elements of graduate medical education? Can equivalency to 36 or 48 rigorous months be accomplished through at-home study or by computer case simulations? Common sense dictates that it cannot. And if equivalency cannot be assured, it is unrealistic to expect access to the certifying examination. Emergency medicine residents might also be expected to find fault with this proposal. Participation in a residency indicates a willingness to invest considerable time and energy developing the skills of a specialist while simultaneously deferring the financial rewards associated with the practice of medicine. How does one explain to these individuals who represent the future of our specialty that the rules are changing, that access to the certifying examination can in effect be purchased by those willing and able to pay tuition? As might be expected Emergency Medicine Residents Association members have stated their opposition to any program that would circumvent the high standards associated with existing emergency medicine residency programs. It would be extremely short-sighted for the college to ignore the concerns of this crucial group of present and future members. Finally, it is appropriate to comment on the most serious problem with the alternative training proposal, namely that it undermines our specialty’s credibility. Emergency medicine has achieved remarkable success in the academic medical centers of this country during the past 20 years. We have done this by proving that we are committed to the traditional academic triad of patient care, education, and research, and that we stand for quality in everything we do. Credibility has been gained by following the traditional model of resident education, but in some cases we have been leaders, insisting that the standards be elevated (eg, resident supervision). We can afford to be innovative when it is clear that we are pro391




posing improvements in patient care or education. However, we are not so firmly entrenched that we can afford to put forth proposals that may compromise the quality of resident education or the legitimacy of the specialty certification process. The credibility for which we have worked so hard would be seriously jeopardized. As a specialty we will have to decide whether the concept of alternative training has merit which outweighs its divisiveness and potential for harm to the specialty. Thus far, the overwhelming evidence suggests that it does not. It is entirely appropriate to seek solutions to the problem of insufficient qualified emergency physicians. However, with over 90 extant residency training programs (and many more program applications pending approval), our specialty’s major manpower problem lies with our high rate of attrition, not



n Volume

10, Number

4 W July 1992

insufficient training. There are potential solutions to this problem that could strengthen emergency medicine and they are worthy of discussion. There are no quick fixes, however, and one organization cannot hope to solve this problem alone. We call on all emergency medicine organizations to find solutions to the problem that unite rather than divide our specialty. STEVEN C. DRONEN, MD

University of Cincinnati College of Medicine Cincinnati, OH CAREY CHISHOLM, MD

Methodist Hospital Indianapolis, IN

Alternative training in emergency medicine.

Editorial Alternative Training in Emergency Medicine Recently our specialty has been embroiled in a controversy over the merits of an alternative tra...
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