386 COMMENTARIES Hedges, Chisholm • PHYSICIAN LICENSURE POSITION STATEMENT

Building a Profession

Many of us gray-haired folksremember the old days

when emergency medicine (EM)was a wide-open field that any-one could enter—if they had amedical license. We told our-selves, as we engaged in our res-idency training, that this wouldchange. We were developing abody of knowledge relevant toour practice, creating a board ex-amination process, and creatingthe infrastructure (three- to four-year residency programs) totrain future generations of emer-gency physicians (EPs) whowould be specialists in our field.Yes, the day would come whenthe public could walk into anyU.S. emergency department(ED) and receive care from a res-idency-trained, board-certifiedEP. We told ourselves thesethings. The infrastructure hasbeen built and much of this vi-sion has been realized. Unfortu-nately, EM remains a field thatanyone can enter—if they havea medical license.

Why are we in this deplorablepredicament, where most se-verely ill or injured patients maybe cared for in many states by aphysician who need only havedone one year of postgraduatetraining? Of note, these incom-pletely trained physicians maywell have spent their limitedtraining period in specialtiesother than EM. It is obvious thatpartially-trained residents lackthe experiential skill set and ex-posure to wide ranges of patientsencountered in an ED patientpopulation. In a country that hashad EM residency training pro-grams for 30 years now, this is anational disgrace. In part, thisnational shortcoming has beenperpetuated by antiquated statemedical licensing regulations.Indeed, the licensing regulationsfor physicians have changed lit-tle during the scientific and clin-

ical knowledge-base explosion ofthe last 30 years.

It is important that the un-supervised clinical practice ofphysicians-in-training from allspecialties, including EM, bereassessed. In May 2000, repre-sentatives of the Council ofEmergency Medicine ResidencyDirectors (CORD), the AmericanAcademy of Emergency Medicine(AAEM), and the Society for Ac-ademic Emergency Medicine(SAEM) began to discuss recentFederation of State MedicalBoards (FSMB) proposals aboutmedical licensure and reportingduring the postgraduate trainingperiod. A resulting conjoint pro-posal from these three EM or-ganizations to the FSMB ap-pears in this issue of AcademicEmergency Medicine.1 The pro-posal has been forwarded to theFSMB for action at their Febru-ary 2001 Board of Directorsmeeting. Although we are collab-orators on the proposal pub-lished in this issue of AcademicEmergency Medicine, this com-mentary provides further insightinto the potential impact of theproposal’s two important ele-ments.

One element opposes a priorFSMB recommendation for man-datory reporting of adverse ac-tions against residents (e.g.,probation or remediation) by pro-gram directors to the state li-censing board.2 This recommen-dation was made by the FSMB toenhance information sharing be-tween training programs andstate medical licensing boards.While the intent of the recom-mendation is appropriate, theapplication of the recommenda-tion is problematic from an edu-cational perspective.

Such a reporting activitywould interfere with the nurtur-ing environment needed in atraining program. Residents,

afraid that any error or remedi-ation activity could potentiallyadversely impact their ability tosecure a medical license andpractice their profession, wouldtend to hide their areas of dis-comfort from their faculty ratherthan seek needed assistance.Such an environment is the an-tithesis of the educational pro-cess for adult learners. CORD,AAEM, and SAEM forwarded analternative recommendation thatall reports come from the teach-ing institution’s graduate medi-cal education office, and thatonly serious actions (e.g., termi-nation) be reported. Thus thesanctity of the professionalteaching relationship betweenprogram director and residentcould be maintained.

The second element may alterthe future practice of EM and seta new standard for practice byphysicians-in-training. This ele-ment is a recommendation forthe creation of a ‘‘dependent-practice’’ license. Given the com-plexities of modern clinical prac-tice, it makes sense that full,unrestricted clinical practice inany specialty should occur onlyafter completion of an approvedresidency training program. Thisexpectation ensures that thepublic will receive care eitherprovided directly by a licensed,boarded specialist appropriatefor that individual patient’s med-ical condition, or provided by apartially-trained clinician di-rectly supervised by such an in-dividual.

Physicians-in-training whoseek to practice outside of theirresidency prior to completion oftheir postgraduate training couldobtain such a ‘‘dependent-prac-tice’’ license. This form of a lim-ited license would permit resi-dents to work in their ownspecialty in specific supervisedwork conditions independent oftheir postgraduate training pro-gram. If enacted, clinical super-vision must be provided byAmerican Board of Medical Spe-

ACADEMIC EMERGENCY MEDICINE • April 2001, Volume 8, Number 4 387

cialties (ABMS)- or American Os-teopathic Association (AOA)-cer-tified physicians in thatresident’s specialty. These phy-sicians must be on site andwould share medicolegal respon-sibility for patient care renderedby the resident.

We believe that this ‘‘depen-dent-practice’’ license would en-hance the safety and welfare ofour patient populations. Patientspresenting for care at an emer-gency facility desire and deserveconsistently high-quality care.High-quality emergency care isbest rendered by an EM resi-dency-trained and board-certi-fied specialist. This new form oflicense would benefit the EMresident who practices in such a‘‘moonlighting’’ scenario. By func-tioning under the direct supervi-sion of an American Board ofEmergency Medicine/AmericanBoard of Osteopathic EmergencyMedicine (ABEM/ABOEM)-certi-fied physician, the residentwould have an on-site colleagueto provide backup during com-plex cases and when the resi-dent’s patient advocacy is chal-lenged by a consultant physician.The resident would be bufferedfrom sole responsibility for ad-verse outcomes during thislearning period. Given nationalmandatory reporting laws, tak-ing sole responsibility for ad-verse outcomes might adverselyaffect the resident’s future mal-practice fees and medical staffprivileges. Because the supervis-ing physician financially benefitsfrom the work of the resident, itis only appropriate that theyshare some of the risks associ-ated with that resident’s work.

Those who favor the fiscal re-ward of the status quo may op-pose the proposal forwarded tothe FSMB by the three EM or-ganizations. It may be arguedthat independent, solo practicerepresents an important part oflearning to be an EP and thatsolo-practice lessons cannot be ob-tained during a residency. Grad-

uated care responsibility is apart of every residency. Whilesolo practice incorporates somespecial practice skills, it is bestdone after the physician has de-veloped the full skill set requisitefor such practice and is trulyready to handle whatever rollsthrough the door.

Ironically, some private prac-tice groups have argued that aresident who is graduating froma training program is not yetready for solo practice. Paradox-ically, some of these groupsprovide opportunities for ‘‘moon-lighting’’ at nights and on week-ends before the resident hascompleted training. Other groupsstate that preference is given tograduates who have engaged insolo-practice moonlighting jobs.The exploitation of the residentin the former scenario is obvious,while the latter suggests that thegroup desires to have such ex-perience occur, but not with theirown patients. If a solo-practiceenvironment is too difficult forthe graduate without apprentic-ing with a private group, howcould an incompletely trainedresident possibly succeed doingpart-time solo coverage? The ar-gument that the resident mustengage in solo-practice work inorder to ensure success aftergraduation is intellectually in-defensible. No patient should betraining material for an unsu-pervised, partially-trained phy-sician.

With these changes comes amandate to those who work inthe academic teaching centersand EM residencies. Our resi-dents must be trained in a skillset that ensures success in anypractice environment. Residen-cies must ensure that their grad-uates are knowledgeable in thenuances of practice in the com-munity hospital ED. Whilethis proposal will continue to al-low access to such experiencesthrough extracurricular (moon-lighting) experiences, it is impor-tant that all EM residencies in-

corporate community practicepreparation into their curricula.

Another potential argumentagainst implementation of theseproposals is that there are notenough clinicians to meet cur-rent ED staffing needs, therebynecessitating coverge by ‘‘moon-lighting’’ residents. Many prac-tices that use moonlightingresidents already use the super-vised, dependent-practice modelthat is proposed. In other set-tings, the group members havechosen to assign moonlightingresidents to the unsupervisednight shifts (or major holidays)for the group members’ own ben-efit. This practice should be dis-couraged for both the public’sand the residents’ benefit. Insuch a situation there is no trueshortage of clinicians, only an in-appropriate assignment of shifts.Other practices may have self-in-flicted difficulties in attractingqualified, fully-trained individu-als due to their corporate struc-tures or simply due to greed. Insuch situations, moonlightingresidents (far less expensive tohire than other partners) sup-plant the need for fully-trainedpractitioners. Perpetuation ofgroup member inequities is nojustification for foisting unsuper-vised, partially-trained practi-tioners upon the public.

It will be argued that it is bet-ter to have EM residents thansomeone untrained in EM pro-vide ED coverage. We remindthose who raise this argumentthat the proposal does permitEM residents to moonlight. Itsimply provides patients thesame protection they receivewhen they present to a teachinghospital. Second, if urban or sub-urban EDs begin to staff withcurrently licensed clinicians whowere partially trained in a non-EM specialty, there will likely beeither a public or hospital medi-cal staff outcry. The public andour colleagues from other spe-cialties are becoming increas-ingly sophisticated about the

388 COMMENTARIES Hedges, Chisholm • PHYSICIAN LICENSURE POSITION STATEMENT

practice of EM and who can de-liver it best. Coverage in ruralEDs will likely remain problem-atic, but it is unlikely that resi-dents who are largely trained inurban centers have previouslymet or ever will meet the needsof smaller rural hospitals. Whatpercentage of total ED coverageis currently provided by EM res-idents in rural states such asNorth Dakota, Montana, Idaho,and Wyoming? Indeed, a changein licensing practices may fur-ther encourage rural hospitals torecruit fully-trained EPs and toexplore other service modelsthan the use of unsupervised,moonlighting residents.

We will not review the realityof resident debt and the impor-tance of moonlighting to someresidents and their families, be-cause this has been coveredelsewhere.3–6 However, as statedabove, the proposal does not sti-fle resident moonlighting. In-stead, it serves to protect boththe resident and the public. Onenational survey of 392 EM resi-dents noted that 85% of EM res-idents believed that unsuper-vised care by EM residents has ahigher risk of bad outcomes thanpractice after completion of aresidency.6 So why is somethingso obviously wrong so hard tochange? While we are talkingabout doing the right thing forour patients, we also are talkingabout changes that will fiscallyimpact residents, but more im-portantly will impact emergency

groups who have exploited theresident and the public for manyyears. Hence, aside from someresidents who may fear re-stricted moonlighting opportu-nity, practice groups who haveused unsupervised, partially-trained resident moonlighters orthose organizations representingthem nationally are most likelyto oppose such a change despitethe eventual advantages for boththe specialty and the public.

As we have recently stated,‘‘until we as a specialty insistthat fully-trained practitionerspractice EM, the impetus totrain adequate numbers of spe-cialists in EM will remain stifled.Our specialty, our training pro-grams, and ultimately, the publicsuffer as a consequence. No otherspecialty advocates that traineesshould be considered at the samelevel as their residency-trained,board certified colleagues. It istime for EM to step forward andadvocate for professionalism inour specialty. [A cornerstone ofprofessionalism is the idea thatthe needs of the patient super-sede those of its practitioners.] Apartially-trained physician whoworks in a solo-coverage EDplaces their own financial inter-ests above the health care needsof their patients. Revising thestandards for medical licensureis an important step in bringingour specialty’s practices in linewith other specialties.’’7 It is timefor EM, as a true medical spe-cialty, to step forward with a uni-fied voice and support these mea-

sures, which would protect ourpatients and our residents.—JERRIS R. HEDGES, MD(hedgesj@ohsu.edu), Departmentof Emergency Medicine, OregonHealth Sciences University,Portland, OR; and CAREY D.CHISHOLM, MD, Department ofEmergency Medicine, IndianaUniversity School of Medicine,Indianapolis, IN

Key words. professionalism; moon-lighting; licensure; resident train-ing.

References

1. Kazzi AA, and the SAEM–CORD–AAEM Writing Group. AAEM, CORD,and SAEM reach a landmark position:consensus recommendations to the Fed-eration of State Medical Boards (FSMB)for revisions to the FSMB May 2000 pol-icy statement on physician licensure.Acad Emerg Med. 2001; 8:393–4.2. Position of the Federation of StateMedical Boards in support of postgrad-uate training and licensure standards.http://www.fsmb.org/whpaper.htm (June27, 1999).3. Langdorf MI, Ritter MS, Bearie B,Ferkich A, Ryan J, for the SAEM Inser-vice Examination Task Force. Nationalsurvey of emergency medicine moon-lighting. Acad Emerg Med. 1995; 2:308–14.4. Li J, Tabor R, Martinez M. Survey ofmoonlighting practices and work re-quirements of emergency medicine resi-dents. Am J Emerg Med. 2000; 18:147–51.5. Chisholm CD. The moonlighting par-adox. Am J Emerg Med. 2000; 18:224–6.6. Kazzi AA, Langdorf MI, Brillman J,Handly N, Munden S. Emergency medi-cine residency applicant educationaldebt: relationship with attitude towardtraining and moonlighting. Acad EmergMed. 2000; 7:1399–407.7. Chisholm C, Hedges J. SAEM joinsCORD and AAEM in FSMB proposal.SAEM Newslett. 2001; 13(1):3.