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By Francis L. Counselman, M.D., CPE, FACEP
In the August 2013 issue of ACEP News, the various pathways available to current and future emergency medicine residency graduates to achieve Critical Care Medicine (CCM) certification through fellowship training were reviewed. In this issue, the options available to ABEM diplomates who completed a Critical Care Medicine fellowship prior to the establishment of the current pathways will be discussed.
First, there is no “practice only” pathway for Critical Care Medicine. All CCM certification requires successful completion of ACGME-accredited CCM fellowship training, and practice of Critical Care Medicine. Secondly, there is no “grandfather” pathway available through the American Board of Surgery (ABS) for Surgical Critical Care. This decision by ABS was made for internal policy consistency, and there are no exceptions. Finally, like all “grandfather” pathways, there is a time-limited window during which one can apply for certification. Please make yourself aware of these dates.
American Board of Internal
Medicine (ABIM) Critical Care Medicine
For Internal Medicine-Critical Care Medicine (IM-CCM), the “grandfather” pathway requires both the completion of a 24-month CCM fellowship and the practice of Critical Care Medicine. This pathway is scheduled to close on June 30, 2016. For the 24-month CCM fellowship to count, it must meet one of the following criteria: a) an ACGME-accredited IM-CCM fellowship completed prior to September 21, 2011; b) an unaccredited IM-CCM fellowship that subsequently became ACGME-accredited on or before December 31, 1992; or c) an ACGME-accredited fellowship in another critical care specialty (i.e., Surgical CCM, Anesthesiology CCM).
The second component, the practice portion, is a little more complicated. The EM applicant must have met the practice criteria as of the date on which the application is submitted to ABEM. For at least three years, not necessarily contiguous, of the five years prior to submitting the application (including the 12 months immediately prior to submission), the applicant must have met one of the following criteria: a) 40% of post-training clinical practice time in the practice of CCM; or b) 25% of total post-training professional time in the practice of CCM.
Finally, for those ABEM diplomates who completed an ACGME-accredited IM-CCM fellowship in the recent past (i.e., between September 21, 2008, and September 20, 2011) criteria can be met if, during 60% of the time between completing fellowship training and applying for certification, the applicant completed one of the following: a) 40% of post-training clinical practice in the practice of CCM or; b) 25% of total post-training professional time in the practice of CCM. For example, if an applicant completed fellowship training on June 30, 2011, and applied for certification on July 1, 2013, 60% of the time (i.e., 24 months) would be 14.4 months. So, during that 14.4-month period between completion of fellowship training and application submission, the applicant must meet either the 40% or 25% criterion, as described above.
Physicians whose total practice exceeds 40 hours per week may use 40 hours as the denominator for the “40%” or “25%” calculations for either of the above scenarios.
American Board of Anesthesiology (ABA)
Critical Care Medicine (ACCM)
ABEM diplomates seeking certification through the “grandfather” pathway must have completed both an ACGME-accredited ACCM fellowship program (one or two years in length) and the CCM practice component by the time of application submission, and no later than June 30, 2018; this is the final date of the last application period within the grandfather pathway. The ACCM fellowship training must have been started prior to July 1, 2013. In order for the fellowship program to count, it must have been ACGME-accredited at the time of the applicant’s training; it does not count if the fellowship subsequently became accredited.
For the practice component, during the two years immediately preceding the application submission, the applicant must have completed one of the following: a) 40% of post-training clinical practice time in the practice of CCM, or; b) 25% of total post-training professional time in the practice of CCM. For either calculation, if total practice time exceeds 40 hours per week, 40 hours may be used as the denominator for the “40%” or “25%” calculation.
For both the IM-CCM and ACCM eligibility criteria, the “practice of CCM” is strictly defined. An acceptable practice must occur in a designated critical care unit. Caring for critically ill patients in the ED does not count toward the practice component. For more detail on what constitutes the practice of CCM, please visit the ABEM website at www.abem.org
For all CCM subspecialty pathways, the ABEM diplomate must: meet the requirements of the ABEM Maintenance of Certifications (MOC) program at the time of application and throughout the certification process; be in compliance with the ABEM Policy on Medical Licensure; and provide information about someone who can independently verify the physician’s clinical competence in CCM, successful completion of ACGME-accredited CCM fellowship training, and the physician’s practice of CCM. No opportunities for CCM certification existed just two years ago for emergency physicians, but we now have three pathways going forward, including two grandfather pathways. It is a very exciting time for emergency physicians interested in Critical Care Medicine. The opportunities that now exist are the direct result of the hard work, persistence, and energy of many of our colleagues. To all involved, “Thank you!”
Dr. Counselman is Chairman of the Department of Emergency Medicine at Eastern Virginia Medical School, and President-elect of ABEM.
Here’s a link to the first article in this two-part series
When something interesting happens in the ED, you tell friends about it.
When a clinical study or great article comes out, you discuss it with other emergency physicians. Why not tell this work-related stuff to 33,000 people who know you best? Say it right here on The Central Line blog. The Central Line is ACEP’s official blog, and to get your blog posted, send your thoughts to this email address.
Once you become a regular, we’ll offer up the keys to the store and let you post directly. Get started!
By Jon Mark Hirshon, MD, MPH, PhD, FACEP
Report Card Task Force Chair
With the release of the 2014 ACEP Report Card on Emergency Medicine, the nation learns how well each state supports emergency medicine and your emergency department.
The nation received an overall grade of D+.
ACEP has produced Report Cards in 2006 and 2009 to evaluate the overall emergency care environment both nationally and on a state by state basis. This is not a report on the emergency care delivered in any specific hospital or by any individual physician, but rather an evaluation of how well the country supports emergency care.
The 2014 Report Card is based on 136 objective measures in five areas:
- Access to Emergency Care (30%)
- Quality & Patient Safety (20%)
- Medical Liability (20%)
- Public Health & Injury Prevention (15%)
- Disaster Preparedness (15%)
It reflects the most recent data available from high-quality sources such as the Centers for Disease Control and Prevention, the National Highway Traffic Safety Administration, the Centers for Medicare & Medicaid Services, and the American Medical Association. Additionally, two surveys were sent to state health officials to gather data for which no reliable, comparable state-by-state sources were available. These data elements were then combined to create the components of the Report Card.
Since 2006, ACEP chapters have used the Report Cards to help with the establishment of new emergency medicine residency programs, support the funding of a statewide trauma system, to help with the enactment of liability protection for federally mandated EMTALA related care, and to increase awareness of emergency medicine issues among state and national lawmakers. We plan to use the 2014 Report Card to educate policymakers and the public about the pivotal role of emergency medicine, help change the conversation from preventing “expensive” emergency visits to protecting access to emergency care, and use communications tools to achieve the national and state recommendations of the Report Card in order to improve the emergency care environment.
To access the most current state by state information, including state and national grades, and to be able to compare the 2014 Report Card with the previous Report Card, please visit: http://www.emreportcard.org/
-Jon Mark Hirshon, MD, MPH, PhD, FACEP
Report Card Task Force Chair
Dr. Hirshon is Board Certified in both Emergency Medicine and Preventive Medicine and has authored approximately 75 articles and chapters on various topics, including the development of public health surveillance systems in emergency departments and placing emergency care on the global health agenda. He has a doctorate in epidemiology and is a federally funded researcher and teacher with specific interest in improving access to acute care and in developing emergency departments as sites for surveillance and hypothesis driven research in public health.
Dr. Jeremy Brown is the director of the newly created Office of Emergency Care Research (OECR) at the National Institutes of Health (NIH). He trained as an emergency physician in Boston, and prior to joining the NIH he worked in the Department of Emergency Medicine at the George Washington University (GW) in Washington, DC. While at GW, he founded the emergency department (ED) HIV screening program and was the recipient of 3 NIH grants that focused on a new therapy for renal colic. He continues to teach at GW on the practice of clinical research, as well as teaching a course on science and religion. He is the author of more than 30 peer-reviewed articles and 3 books, including 2 textbooks of emergency medicine, all published by Oxford University Press. Annals News & Perspective editor Truman J. “TJ” Milling Jr., MD, interviewed Dr. Brown in his Bethesda, MD, office, on the importance of the OECR and how he plans to use his new position to coordinate and grow emergency research within the NIH. His comments have been edited for clarity.
Read the Q and A here
My name is Sara Paradise. I’m a fourth-year medical student at the George Washington School of Medicine in Washington, D.C., and a very soon-to-be emergency physician. Like 99 percent of you docs and future docs out there, I am 100 percent passionate about my chosen specialty and future patients, but have zero understanding of how government and health policy really works.
Which is why, after nearly four years of living only blocks from the White House and the epicenter of political drama, I was pumped to have the honor and privilege of doing an internship with the American College of Emergency Physicians. These are the premier group of people responsible for representing the policies, education, advocacy, and regulatory interests of emergency physicians.
Fast-forward five days, and I feel like I’ve gone from a toddler to a tween in my knowledge of health policy, being taken under the wings of the brilliant people working at ACEP in D.C. to amass a much deeper understanding of emergency medicine and our role in health policy.
So, let’s talk about how things work.
Much of my week has been devoted to meeting with members of Congress, who hold almost daily meetings to educate themselves on issues related to health care reform. The people in attendance tend to be lobbyists, or individuals hired to represent major medical specialty organizations such as ACEP. I was instantly struck by the important role that the medical lobbyists hold in these meetings compared to other public and private groups, often seated next to the Congressperson and directing the conversation. Lobbyists are not only experts in the nitty-gritty details of the Affordable Care Act and how it affects their specialty, but have an unparalleled adeptness in navigating Washington, D.C. politics to convey doctors concerns in a passionate, yet appropriate manner.
The Congresspeople who represent issues that your particular medical specialty cares about are the ones you meet with most frequently. In our case, that means anyone who champions funding poison centers, drunk driving prevention, and SGR reform (that is, ensuring that we as physicians are not fiscally-penalized for seeing Medicare patients). These legislators admit they are not experts, and fight for our doctors despite being stuck in a muddy Congress.
So other than rub elbows with political figures, what else do health policy people do? Apparently, they attend a lot of special panels and webinars that discuss details of healthcare-related legislation. They use their strong voices to bridge the gap between those creating health care-related laws, often non-clinicians, and America’s doctors. One such panel discussed the “Two Midnight Rule.” This rule, I learned, states that any Medicare patient who is marked as “Observation Status” – regardless of whether physically in the ER or an inpatient bed – does not automatically qualify to have their skilled nursing facility (SNF) stay covered, even if they are observed for the required three days and it is medically indicated; an unintended loophole, if you will [read more here]. The panelists were policy makers set on changing the laws for the better, with our local and national community’s input.
One of the highlights of my week was most definitely attending the release of the December issue of Health Affairs at the National Press Club on “The Future State of Emergency Care.”
My personal favorite was a talk by Dr. Maria Raven on the urban myth that Emergency Department “frequent fliers” guzzle our health care dollars faster than a non-hybrid SUV consumes gas. She and Dr. Billings’ research found that those patients utilizing the ED on a “frequent” basis (about 10 times per year) visited their Primary Care MORE frequently than the average ED patient. Perhaps they just have more complicated, and many comorbid conditions! Another talk, by Dr. Jeremiah Schuur, was on changing our emergency medicine infrastructure. Why not bring the right resources to the patient via tools such as Telemedicine, rather than dragging patient to the resource (which is often time-consuming, costly, and ineffective)? In the era of Facetime and Medicare reimbursement for Telemedicine consultation, makes sense to me.
One really informative meeting was with ACEP’s Quality & Health I.T. Manager. Even though I have an extensive background in Electronic Health Records, I felt as though she was speaking a foreign language. HL7? CCDA-1?? MU2? I nodded my head, thinking “What do these codes mean?!” Jumping on the Internet, I discovered the how we are standardizing the language of Electronic Health Records in hopes that Health Information Exchange can become a reality, outside of utilizing the same brand of system.
The moment I felt my voice really matter was when I had informal discussion with my new colleagues about what I had experienced as a third-year medical student. Fresh off the wards of OB-Gyn, Medicine, and Psych, I had some solid opinions about how the Emergency Department interacts with each of these specialties and ways we could improve our health care system. I was shocked that they not only took my input seriously, but wanted to know more, leading to a number of meetings with different specialists on their calendars.
Reflecting on my first week, I now feel a much stronger responsibility to “represent” each and every G.W. medical student, future Emergency Physician, and maybe even late 20-something woman starting her career. I also want to emphasize: You, too, can set a meeting with these tremendous people and discuss your observations and ideas. You, too, can become an advocate and leader in your field. It takes a simple e-mail to your respective governing body, and a will to fight for something you believe in.
I’m already looking forward to what lies ahead…affter a quick detour to L.A. for a residency interview, I’ll be back for more next week!
Want to get in touch with ACEP regarding an issue you read about above? http://www.acep.org/contactus/
Have questions for the author? E-mail: firstname.lastname@example.org
Follow me on Twitter: @saraparamd
By Dr. Ferdinando Mirarchi
A 68-year-old male presents with a history of diabetes, hypertension, dyslipidemia, and CAD s/p CABG 10 years ago. Patient is experiencing chest pain. He is clammy. He is in mild distress. Vitals: T: 36C; P:60; RR:22; SaO2: 98%RA. The family gives you his list of medications and living will. Abruptly, the patient becomes unresponsive without palpable pulses. The monitor shows ventricular fibrillation. What next? Read the article, click here to look at the Will and take a two-question quiz.
Advance directives were created with the best of intentions, aiming to protect patient autonomy and honor end of life wishes. Until recently, the risks posed to patient safety by the various incarnations of advance directives were unknown and thus, undisclosed. Often, these well-meaning documents have produced unintended consequences. The TRIAD studies (The Realistic Interpretation of Advance Directives) have disclosed this patient safety risk as reality and on a nationwide scale. The risk is attributable to variable understanding and misinterpretation of advance directives which then translates into over or under resuscitation. At present, this is an unreported safety concern and only by clarifying the terms of advance directives and developing systems to educate providers will we be able to respect our patients’ wishes while still protecting their safety.
The living will was first legalized in California in 1977 and was known as the Natural Death Act.1 It was created by an attorney and utilized to decline life saving measures, essentially intended to provide patients with greater autonomy in end of life decisions. 2 Unfortunately, it also resulted in increasing risks to patient safety. Further fueling this patient safety risk was the development of The Patient Self Determination Act 1990. 3 This mandate, which was never evaluated for safety, requires patients to be provided information regarding their right to execute an advance directive at institutions receiving Medicare/Medicaid funding. With 90 million living wills in existence in the United States, 4 incorrect interpretation can lead to deleterious impacts on the care and safety of patients who summon 911 or experience a medical emergency in a healthcare setting. Clarification of terms, education of providers and implementation of safeguards are needed to protect the safety and autonomy of patients. In the TRIAD III nationwide study, high percentages of participants reported receiving training related to advance directives. However, those indicating receiving education produced no benefit. As health care providers, we need to work together on a national level to improve this education process. To further facilitate understanding, the following terms need to be defined and standardized:
Terminal Illness defined by law
Reversible & Treatable Condition
An “Effective” Living Will
An “Enacted” Living Will
For purposes of clarification, the mere presence of a living will does not mean it should be followed. It simply indicates that this document is “effective,” or that it is valid and legal.5 It should not be followed at this point to guide the care and treatment of the patient.
An “enacted” or “activated” living will is one that has been activated by the triggers in the document, most commonly a terminal or end stage medical condition or a persistent vegetative state. 5 This “enacted” living will now necessitates adherence to its instructions regarding the care of the patient. A terminal or end stage medical condition has a legal definition which essentially states that a patient would be expected to die of their disease process despite sound medical treatment. Therefore, the mere presence of a living will “does not” dictate the care of a critically ill patient who presents with a reversible and treatable condition such as CHF or COPD; rather it applies when that same patient is permanently unconscious and has exhausted all treatment options. A do not resuscitate order (DNR) refers to an actual physicians order that directs health care providers not to intervene with CPR if the patient is found pulseless or apneic.6,7
Otherwise it should have no implication on the care and treatment that the patient is to receive.6,7
Despite the legal and societal definition of DNR, research reveals in the TRIAD studies that medical providers understand DNR to be synonymous with an order to provide comfort and end of life care.8,9,10 A relatively new document called the Physicians Orders for Life-Sustaining Treatment (POLST) is different as it is an order set to be followed that addresses the treatment options of a patient should they present in cardiac arrest as well as the patient’s preferences for care in a non-arrest situation.11
POLST is a national paradigm and its philosophy is being rapidly embraced on both a national and state level. Unfortunately, it is now being nicknamed the Pink DNR form. This nickname needs to be quickly clarified and resolved as patients can be designated as a Full Code or a DNR through the use of this form. This again is a situation where good intentions can have unexpected consequences. SafeGuards are created to promote patient safety. I would like to introduce the SafeGuard known as the Rescuscitation Pause (RP). The RP is a process similar to the surgical pause (time out is the correct term) which is already widely utilized to correctly identify patients and eliminate wrong site surgery. Resuscitation takes on many forms and is not limited to the cardiac arrest situation. Resuscitation takes place when a patient presents critically ill and requires active interventions for conditions such as respiratory distress, sepsis or GI bleeding, etc. Resuscitation takes place with conditions that require immediate evaluation and intervention such as trauma, cardiac and stroke system activations to define care and facilitate treatment. A Pause is a moment to quickly assess and reassess the situation to assure you are defining the appropriate care and treatment. Through the use of a secure, HIPPA protected and interactive educational platform, QuantiaMD, (www.quantiaMD.com) we have been able to educate over 24,000 medical providers and empower them with the RP as a patient safety tool. We have been able to confirm that the medical community nationwide supports the TRIAD concerns that there is a real and present risk to patient safety; they found the education and tool to be useful and have empowered it into their clinical practice.
Advance directives in their various forms have never been evaluated with regard to patient safety though they directly affect well over 90 million patients. This is a medical error and resolution of the issue will require increased awareness and education among medical providers of all disciplines. The Resuscitation Pause holds significant promise as a way to protect patient safety and autonomy. The importance of this issue cannot be overstated as understanding advance directives not only allows us to appropriately provide or withhold life-saving care, but also ensures that we safely honor our patient’s wishes in the process.
How to Interpret a Living Will <http://secure.quantiamd.com/player/yabhqcxpi?u=yxjzuqjvk>
What Do DNR Orders Really Mean? <http://secure.quantiamd.com/player/yafruujyt?u=yxjzuqjvk>
POLST: Physician Orders for Life-Sustaining Treatment <http://secure.quantiamd.com/player/ywebdxfnf?u=yxjzuqjvk>
Understanding Your Living Will; What you need to know before a medical emergency www.addicusbooks.com
Towers B. The Impact of the California Natural Death Act. J Med Ethics. 1978;4:96-8.
Kutner Luis. The Living Will: a proposal. Indiana Law Journal. 1969;44(1):539-554
Patient Self Determination Act http://nhdd.org/facts/
Source: U.S. Census Bureau, 2044 Population Estimates, Census 2000, 1990 Census (http://www.census.gov)
Mirarchi FL. Understanding Your Living Will. Addicus Books 2006
Do Not Resuscitate (DNR) Protocols within the Department of Veterans Affairs. Section 30.02
Code of Medical Ethics Opinion 2.22 Do-Not-Resuscitate Orders. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion222.shtml
Mirarchi FL, Hite LA, Cooney TE. TRIAD I – The Realistic Interpretation of Advanced Directives. J Patient Saf. 2008;4:235-40.
Mirarchi FL, Kalantzis S, Hunter D. TRIAD II: Do Living Wills Have an Impact on Pre-hospital Life Saving Care? J Emerg Med.2009;36:105-15
Mirarchi FL, Costello E, Puller J, Kottkamp N. TRIAD III: Nationwide Assessment of living Wills and DNR orders. J Emerg Med. 2012 May;42(5):511-20.
Physicians Orders for Life-Sustaining Treatment (POLST) http://www.polst.org/
The Annals podcasts are available here: http://www.annemergmed.com/content/podcast
The highlights for October are:
-What predicts ‘drug-seeking’ or prescription misuse among ED patients?
-hydromorphone 1+1 opiate dosing
-metoclopramide vs ketorolac for ED headaches
-Cost-effectiveness of helicopter EMS
-Attitudes toward sickle cell crisis management
And much much more…
I’ve noticed something.
At tertiary care hospitals, such as Level 1 trauma centers, there are all manner of specialists on call for the emergency department. In fact all specialties are represented. There’s no need to transfer patients to a higher level of care. It makes sense. After all, these hospitals are affiliated with medical schools, have residency programs, carry on teaching and research and act as referral centers for a certain geographical area.
At community hospitals, i.e. those that are not designated as tertiary care or Level 1 or Level 2 trauma centers, there is almost never a full complement of specialists. Often there is no neurosurgery, no cardiothoracic surgery , sometimes no plastics, maxillofacial or vascular services. In many of these hospitals, though a significant portion of the emergency population is children, there is no pediatric ICU.
In other words, in many hospitals in the USA, patients with serious medical and/or surgical problems have to be stabilized by the emergency physician and then transferred to a higher level of care.
Who manages these critical care emergency patients? Who manages the trauma patients, until they are transferred out? The emergency physician, of course. All this requires great skill and competence. Ask anyone who’s done it.
Who manages these types of patients at the Level 1 trauma center? The on-call specialists do.
It is believed, by some, that ACEP Legacy physicians are not competent enough to work in tertiary care hospitals and certainly not capable of teaching medical students and residents.
It is also believed, by some, that Emergency Medicine Residency-Trained (EMRT) doctors are more competent than their non-EMRT counterparts.
So, if the EMRT doctors are more competent, why aren’t they working in the community hospitals where a higher level of skill is required?
Why aren’t the non-EMRT docs working at the trauma centers, where all the back-up is available? If we’re less competent, don’t we need all the help we can get?
If the EMRT docs are more competent, shouldn’t they be working at the hospitals where there is less back-up, fewer resources?
Has someone got this whole thing bass-ackwards?
Why are only EMRT docs working at the tertiary care hospitals?
I’m just asking.
Marlene Buckler, MD, FACEP, CCFP(EM), DABUCM
Official Blogger for ACEP Emergency Medicine Workforce Section
Is it any easier now for ACEP Legacy Physicians to get jobs in American hospitals?
For the past 5 years I have been doing locum work abroad; in Canada, New Zealand and England and I’m currently looking at Australia. I haven’t applied for any jobs in US hospitals during that time. I live in Florida, have keep my medical license active and am considering exploring the possibility of working in Florida again in the near future.
Some of you might remember that previously I ran into problems applying for work in The Sunshine State, because I was not EM residency-trained nor ABEM-boarded. In spite of ACEP offering verbal support to the idea that Legacy physicians are an important part of the workforce and thus should be given consideration on merit and performance, in hiring situations, the reality was that most hospitals, especially those in desirable locations, were off-limits to doctors like me.
Numerous ads for ER jobs come into my email daily. A few years ago almost all of them “required” ABEM certification. Some even stipulated that applicants must be EM residency-trained, which, by the way, would exclude a number of ACEP past-presidents.
Lately there seem to be more than a few hospitals that will settle for certification in any primary care specialty, e.g. family medicine, internal medicine, etc. So, is the landscape changing? Are the realities of the workforce finally being realized by hospitals that find themselves in need of emergency doctors?
Do I have any hope of getting a job in a decent hospital in the Sarasota, FL area?
Is it any easier now for ACEP Legacy Physicians to get jobs in American hospitals?
I’m just asking.
Marlene Buckler, MD, FACEP, CCFP(EM), DABUCM
Official Blogger for ACEP Emergency Medicine Workforce Section