AAEM Position Statement: Raising Emergency Medicine Residency Standards

[Amazingmuzmo]

Raising Emergency Medicine Residency Standards | AAEM - American Academy of Emergency Medicine

AAEM was established in 1993 to promote fair and equitable practice environments necessary to allow emergency physicians to deliver the highest quality of patient care.

www.aaem.org

"AAEM recommends the ACGME Emergency Medicine Residency Review Committee take action to raise emergency medicine training and quality standards by setting a minimum number of patients at the primary site emergency department per resident and setting a maximum percentage of emergency department patients seen by non-physician practitioners (NPPs). Specifically, AAEM advocates for the implementation of a standard of one resident per 3,600 patient volume at the primary residency training site and a maximum of 25% of patients seen by NPPs. This proposal would decrease the number of emergency medicine residency slots per year by ~40%. Residency programs will be able to devote more resources to each resident and faculty/resident ratios would improve."

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[GeneralVeers]

LMAO

 

[gamerEMdoc]

Not sure how they came up with the 3600 per resident, but that seems kind of off. And 25% seen by NPPs seems too high. Appreciate the effort, just disagree with the numbers.

 

[TrashCanMan]

Not sure how they came up with the 3600 per resident, but that seems kind of off. And 25% seen by NPPs seems too high. Appreciate the effort, just disagree with the numbers.

It's to get close to the required 40% reduction in emergency medicine graduates that is needed as per the report by ACEP to reach a stable equilibrium. Most faculty such as yourself will disagree, because a lot of programs don't meet the requirement. But it is what is necessary. It's not to close programs, but reduce the residents per class.

 

[GonnaBeADoc2222]

Like an old man shouting at the clouds.....

 

[sylvanthus]

Yaaaa not gonna happen, buy hey at least they are trying. Which reminds me, my ACEP membership just expired. Renew?

 

[bravotwozero]

Yaaaa not gonna happen, buy hey at least they are trying. Which reminds me, my ACEP membership just expired. Renew?

Trade it in for an AAEM membership.

 

[CoolDoc1729]

Trade it in for an AAEM membership.

My CMG pays for acep membership. I still don’t belong to acep. +1 for AAEM. At least they try ..

 

[RustedFox]

One day, we won't hear "my CMG pays for ACEP".

It will be "my group is good".

 

[Rekt]

Like an old man shouting at the clouds.....

Our other option is old woman collects checks from corporations to do their bidding.

 

[Groove]

I wonder if everyone cancelled their ACEP memberships and joined AAEM, if it would send a clearer message. I'm glad AAEM continues to have the balls to put out things like this fighting for our best interests. They have zero clout IMO and are akin to the small "yappie" dogs that are all bark with no bite, but at least they are making some noise.

 

[gamerEMdoc]

It's to get close to the required 40% reduction in emergency medicine graduates that is needed as per the report by ACEP to reach a stable equilibrium. Most faculty such as yourself will disagree, because a lot of programs don't meet the requirement. But it is what is necessary. It's not to close programs, but reduce the residents per class.

I mean I'm not opposed to trying anything, it just seems like a foreign concept to me as it would basically lead to the end of the concept of "resident run" departments. Which is fine. I think its odd to have a program where residents might only see half the patients in the ED, but if that's what we have to do, that's what we have to do. I've worked in that environment, where residents saw mayb 30-40% of the patients, attendings saw all the others; teaching and supervision definitely suffered, but it is what it is. It does seem odd to me to have a residency and ask PA/NPs to see 1/4 of the patients because you are training fewer and fewer residents then at the same time say PA/NPs shouldn't be getting a bigger foothold in the ED.

The other thing I wonder about, which doesn't pertain to my program, is the "primary site" thing. There are some big name residencies that spread their residents out over multiple hospitals. I just can't see the ACGME basically cutting a big Univ based program down to a 1/3 of their class size bc their "primary site" volume only supports that, despite the residents working at 3 different EDs whose total volume is quite high.

 

[Birdstrike]

If we're ever going to successfully do anything to help our profession, we need a strategy other that this one:

1. Lose ground
2. Publish powerless statement
3. Leverage no power
4. Mutter something about "our public image" or "the patients" to justify always losing
5. Wait for our opponents to plan their next move
6. Return to step #1

 

[Brigade4Radiant]

Nice suggestion but it’s the ACGME who has power and they keep giving accreditation also even if they did this they would be faced with a lawsuit for antitrust.

EM is on its deathbed

 

[gamerEMdoc]

Nice suggestion but it’s the ACGME who has power and they keep giving accreditation also even if they did this they would be faced with a lawsuit for antitrust.

EM is on its deathbed

Correct. I don't think you'll talk to any reasonable ED doc, academics or not, that thinks rapid expansion is a good thing. Its just clearly not going to be legal to cap residencies from a trust standpoint. The ACGME could certainly make accreditation harder, or they could make it harder for places to view residencies as a business decision, or both. I'd imagine doing that would be legal. Examples would include requiring residencies to exist in hospitals with a given volume or specific resources. Increasing the number of core faculty a residency must have. Increasing the academic output requirements. Require core faculty to have paid protected non-clinical time. Etc. If you do make accreditation harder, eventually the places that are opening residencies for labor will just no longer find it profitable and will just pivot to using midlevels.

 

[bravotwozero]

.....and absolutely no one in the EM community has any significant role at the ACGME, so kiss that option bye bye

 

[GeneralVeers]

I've said before, easiest, simplest way is to make the primary training site be at least a Level 2 trauma center, and have a Peds EM rotation IN THE SAME COUNTY. It would get rid of a lot of the crappy residencies.

 

[Rekt]

Everybody screams antitrust. Does anyone think that would even happen? Who's the one going to court? You can easily say CMGs are purposely flooding the market to control physician salaries for their gain. Which is simply true.

 

[gamerEMdoc]

I've said before, easiest, simplest way is to make the primary training site be at least a Level 2 trauma center, and have a Peds EM rotation IN THE SAME COUNTY. It would get rid of a lot of the crappy residencies.

I dont know what distance from the nearest Peds EM rotation has to do with anything but agree on the trauma center. Peds EM is heavily localized in more urban areas, this would essentially eliminate a ton of community residencies that are actual good training programs for a very arbitrary reason. I honestly cant believe you can establish an EM residency at a primary site that isn't at least a 2. Thats nuts to me.

Don’t get me wrong, I’m all for raising the bar with training programs and making accredidation harder. I just don’t know what being in the same county as a peds hospital has to do with anything. If anything, when in the same county as a peds hospital, the primary site then doesn’t see any Peds.

I think things that would be good markers or would raise the bar to rid some of the questionable sites include things like:
- Limit on class size based on Volume and raise the bar. Right now its way off and too easy to get accreditted for a larger size.
- Increased core faculty / paid academic time for core faculty (which was removed several years ago)
- Increased scholarly requirements
- agree on the trauma center
- increasing procedure requirements
- core faculty can not be employed by CMG (good luck with this one)

 

[GeneralVeers]

I dont know what distance from the nearest Peds EM rotation has to do with anything but agree on the trauma center. Peds EM is heavily localized in more urban areas, this would essentially eliminate a ton of community residencies that are actual good training programs for a very arbitrary reason. I honestly cant believe you can establish an EM residency at a primary site that isn't at least a 2. Thats nuts to me.

Don’t get me wrong, I’m all for raising the bar with training programs and making accredidation harder. I just don’t know what being in the same county as a peds hospital has to do with anything. If anything, when in the same county as a peds hospital, the primary site then doesn’t see any Peds.

I think things that would be good markers or would raise the bar to rid some of the questionable sites include things like:
- Limit on class size based on Volume and raise the bar. Right now its way off and too easy to get accreditted for a larger size.
- Increased core faculty / paid academic time for core faculty (which was removed several years ago)
- Increased scholarly requirements
- agree on the trauma center
- increasing procedure requirements
- core faculty can not be employed by CMG (good luck with this one)

Our CMG residency that we are forced to take part in has NO TRAUMA CENTERS in a 6-hospital system. All these programs are getting around the Trauma/Peds requirements by sending residents to other states.

 

[gamerEMdoc]

Our CMG residency that we are forced to take part in has NO TRAUMA CENTERS in a 6-hospital system. All these programs are getting around the Trauma/Peds requirements by sending residents to other states.

That is… nuts.

 

[Brigade4Radiant]

Everybody screams antitrust. Does anyone think that would even happen? Who's the one going to court? You can easily say CMGs are purposely flooding the market to control physician salaries for their gain. Which is simply true.

Yes but that isn’t illegal.

 

[Prehealth1011]

@gamerEMdoc do you share the same concerns about EM as the ACEP report suggested?

 

[namethatsmell]

It would be extremely challenging for anybody to successfully sue the ACGME for strengthening accreditation requirements for EM residencies.

But I would love to see HCA and the CMGs try...these companies detailing their financial "damages" for any suit they'd file would make public just how much these guys profit off the system and where their priorities truly lie. The optics would be delicious, and who knows where that may lead...

 

[bravotwozero]

I’m taking this with a massive grain of salt, but FWIW ACEP’s newsletter talked about tightening ACGME requirements.

 

[Birdstrike]

"Let's make it harder to train doctors, while lettings PAs be doctors without doctor-training at all." An endangered species couldn't plan it's own extinction any better.

Every single leader of these organizations need to be thrown out on their butts and replaced with people who'll be street fighters for doctors' rights.

 

[gamerEMdoc]

@gamerEMdoc do you share the same concerns about EM as the ACEP report suggested?

I believe the data in the ACEP report, yes. I think the job market at the moment has improved considerably, at least for everyone I know personally looking for jobs. Honestly, all my residents that just graduated found jobs last year too, but I know that nationally it was really tight, so that was an outlier. Some of my newly minted 3rd years are already finding jobs, half that class has jobs already. But I also realize that there are areas in the country where the market remains incredibly tight, I'm not discounting that. I definitely believe we are going to get tighter and tighter if the current rate of residency expansion continues on its current trajectory.

 

[gamerEMdoc]

"Let's make it harder for doctors-in-training to become doctors, while making it easier for PAs to be doctors, without doctor-training at all." An endangered species couldn't plan it's own extinction any better.

Every single leader of these organizations need to be thrown out on their butts today, and replaced with people who'll be street fighters for doctors' rights.

Agreed. This is the one thing about making residency accreditation harder that irks me. We are saying the standards many or all of us trained under isn't good enough (when we know it is), while at the same time saying its ok to allow people with no residency to practice in the ED. I don't think we can have it both ways.

The issue is that some hospitals have found a way around the ACGME guidelines by putting residencies in spots that in no way support a residency, then farming their residents out all over the place for rotations. If the ACGME would just tighten down small areas that would stop the rapid expansion of these popup HCA residencies in small hospitals that have no business supporting a residency, that would make way more sense than increasing the standard for every other residency in the country. Like... just don't have residencies in tiny community hospitals that aren't trauma centers?

But in the end, I suspect making residency accreditation harder will happen, in some way shape or form, for all of us. Which is fine. Is what it is. I just think its dumb to say we can have 25% of our patients seen by people with no EM training, but all of our training we currently have isn't good enough to work in the ED. Seems like an oxymoron to me.

 

[gamerEMdoc]

One idea I'd support iis lengthening the residency to 4 years at some point going forward. But cracking down on work hours. No more than 40 hrs/week in the ED. Set a standard of pay that is higher than the average. State that independent moonlighting must be allowed per state laws if the resident is in good standing (so pgy3s and 4s can make more money). And at the same time, making class sizes smaller by making the number of residents per class have to have so many ED patients per year. Maybe like no less than 8k per class spot. Ie a residency with 6 per class in must have about 45-50k volume.

By spreading it out over 4 years while making work hours more humane, but at the same time reducing class sizes across the board, I think it would actually be good for everyone. The only real downside for future residents would be the extra year, but the trade-off would be a much better schedule across 4 years.

I don't expect anything like that to happen mind you, but I think it wouldn't be a bad idea.

 

[skougess]

One idea I'd support iis lengthening the residency to 4 years at some point going forward. But cracking down on work hours. No more than 40 hrs/week in the ED. Set a standard of pay that is higher than the average. State that independent moonlighting must be allowed per state laws if the resident is in good standing (so pgy3s and 4s can make more money). And at the same time, making class sizes smaller by making the number of residents per class have to have so many ED patients per year. Maybe like no less than 8k per class spot. Ie a residency with 6 per class in must have about 45-50k volume.

By spreading it out over 4 years while making work hours more humane, but at the same time reducing class sizes across the board, I think it would actually be good for everyone. The only real downside for future residents would be the extra year, but the trade-off would be a much better schedule across 4 years.

I don't expect anything like that to happen mind you, but I think it wouldn't be a bad idea.

I feel like HCA programs are frothing at the mouth to require all EM residencies be four years.

 

[GeneralVeers]

I feel like HCA programs are frothing at the mouth to require all EM residencies be four years.

Yes worst idea ever. HCA gets another year of slave labor. That will only promote more residencies.

 

[namethatsmell]

Another way to cut out the HCA and CMG chaff: ACGME mandates that interns are paid 100k/yr+full bene's with a 10%/yr salary increase during training. All the sudden making a pop-up EM residency doesn't look too hot on a balance sheet.

 

[bravotwozero]

So there’s your catch 22: making residency requirements harder, midlevels and non EM boarded people get a clear edge in the job market. Don’t do anything and the problem gets worse regardless…you can’t stop HCA from expanding and MLPs from encroaching on our turf at the same time, if it were even possible..

 

[gamerEMdoc]

Yes worst idea ever. HCA gets another year of slave labor. That will only promote more residencies.

Under what I proposed, HCA doesn't benefit at all and is hurt by making residency 4 years.

Making it 4 years doesn't increase the # of residents. It just spreads out the training. If an HCA program has 24/3, they would have 24/4. Class would shrink from 8 to 6. They aren't financially gaining. They are being hurt. Because they now have to pay the residents more and they can only work them 40 hrs a week while maintaining the same number of residents.

You can't just increase to 4 just to do it, of course hospitals trying to exploit resident labor for staffing would drool at that. You have to couple it with making it no longer financially viable to do so.

Increasing the length of residency only works if it is tied to reducing class size as well so the residency stays the same size. When that is tied to reducing work hours and increasing pay, it disincentivizes places who are exploiting resident labor for $.

 

[namethatsmell]

I'm confused by people saying that if EM residency spots shrink it'll somehow be bad for the specialty. I mean, we are in the middle of an explosive overproduction of EM docs (albeit of varying quality) and we generally do NOT control the staffing side of our specialty (which is completely pathetic and should have it's own thread).

Even if we cut 25% of training spots we're still gonna have a metric ton of EM docs for many years. Even with the record high # of EM physicians available...I still know plenty of EM docs being laid off and/or passed over during hiring so the CMG can bring on more midlevels.

An individual pit doc has basically no control over our specialty. If our collective voices can influence our specialty societies to lean on the ACGME to achieve a single rational act like eliminating residencies that should not exist, it'd be a g*ddam miracle. I'm not holding my breath, but it seems like word is picking up on this so eh maybe there's a chance something meaningful will happen. And if we can unite to achieve something like that, then maybe, just maybe, we'll have a chance at going after some of the more expansive issues plaguing our field.

 

[GeneralVeers]

I'm confused by people saying that if EM residency spots shrink it'll somehow be bad for the specialty. I mean, we are in the middle of an explosive overproduction of EM docs (albeit of varying quality) and we generally do NOT control the staffing side of our specialty (which is completely pathetic and should have it's own thread).

Even if we cut 25% of training spots we're still gonna have a metric ton of EM docs for many years. Even with the record high # of EM physicians available...I still know plenty of EM docs being laid off and/or passed over during hiring so the CMG can bring on more midlevels.

An individual pit doc has basically no control over our specialty. If our collective voices can influence our specialty societies to lean on the ACGME to achieve a single rational act like eliminating residencies that should not exist, it'd be a g*ddam miracle. I'm not holding my breath, but it seems like word is picking up on this so eh maybe there's a chance something meaningful will happen. And if we can unite to achieve something like that, then maybe, just maybe, we'll have a chance at going after other issues plaguing our field. But we gotta start somewhere.

The key would be fore all the members to force a change at ACEP. ACEP could strong-arm the CMGs into essentially creating a "bill of rights" for ED physicians to improve our work environment, and due process for disciplinary actions as well as transparency with pay and billing. CMGs that don't want to participate will be banned from ACEP. This could only happen if EM physicians collectively grew spines, and withheld ACEP dues in protest. Only hitting their bottom line of $$$ and membership would force a change.

 

[namethatsmell]

The key would be fore all the members to force a change at ACEP. ACEP could strong-arm the CMGs into essentially creating a "bill of rights" for ED physicians to improve our work environment, and due process for disciplinary actions as well as transparency with pay and billing. CMGs that don't want to participate will be banned from ACEP. This could only happen if EM physicians collectively grew spines, and withheld ACEP dues in protest. Only hitting their bottom line of $$$ and membership would force a change.

Exactly.

I haven’t paid dues to ACEP in several years and I’ve told them precisely why and what it’ll take to get me back as a paying member.

But they don’t care about losing my dues. But they may notice the loss of several thousands of docs worth of dues.

And they may notice if AAEM suddenly starts getting a big influx of members and dollars.

 

[Rekt]

So there’s your catch 22: making residency requirements harder, midlevels and non EM boarded people get a clear edge in the job market. Don’t do anything and the problem gets worse regardless…you can’t stop HCA from expanding and MLPs from encroaching on our turf at the same time, if it were even possible..

The solution is this proposal. It's not really making EM "harder". It will curve the massive oversupply that's incoming without affecting current residents all that much. Cut future classes. It's not like a bunch of residents would just get fired. Then they can slowly fill positions for faculty as they cut residents.

I'm confused by people saying that if EM residency spots shrink it'll somehow be bad for the specialty. I mean, we are in the middle of an explosive overproduction of EM docs (albeit of varying quality) and we generally do NOT control the staffing side of our specialty (which is completely pathetic and should have it's own thread).

Even if we cut 25% of training spots we're still gonna have a metric ton of EM docs for many years. Even with the record high # of EM physicians available...I still know plenty of EM docs being laid off and/or passed over during hiring so the CMG can bring on more midlevels.

An individual pit doc has basically no control over our specialty. If our collective voices can influence our specialty societies to lean on the ACGME to achieve a single rational act like eliminating residencies that should not exist, it'd be a g*ddam miracle. I'm not holding my breath, but it seems like word is picking up on this so eh maybe there's a chance something meaningful will happen. And if we can unite to achieve something like that, then maybe, just maybe, we'll have a chance at going after some of the more expansive issues plaguing our field.

The only people crying about cutting spots are ACEP and residency faculty members. ACEP makes their daddy CMGs get mad and faculty has to get off their ass. They lose free labor and will have to hire to pick up the slack. Everyone else wants this to pass.

 

[gamerEMdoc]

The solution is this proposal. It's not really making EM "harder". It will curve the massive oversupply that's incoming without affecting current residents all that much. Cut future classes. It's not like a bunch of residents would just get fired. Then they can slowly fill positions for faculty as they cut residents.


The only people crying about cutting spots are ACEP and residency faculty members. ACEP makes their daddy CMGs get mad and faculty has to get off their ass. They lose free labor and will have to hire to pick up the slack. Everyone else wants this to pass.

Once again, as a "residency faculty member" I'm not opposed to spots going down. I am opposed to saying midlevels can see 25% of the patients. Because what will happen is residents will just get replaced by midlevels in resident run EDs. I just don't see how that is good for the specialty. It expands midlevel practice at training sites.

I just feel like that number that AAEM arrived at seems really high.

 

[FutureSurgical]

Once again, as a "residency faculty member" I'm not opposed to spots going down. I am opposed to saying midlevels can see 25% of the patients. Because what will happen is residents will just get replaced by midlevels in resident run EDs. I just don't see how that is good for the specialty. It expands midlevel practice at training sites.

I just feel like that number that AAEM arrived at seems really high.

Out of curiosity, how would you change the %ages? 60% residents, 15% mid levels? Somewhere along those lines? I'm not trying to be inflammatory; purely curious since you have a ton of experience with this issue.

 

[Lexdiamondz]

a dirty secret though is that in addition to the HCA and CMG programs, a fair number of academic EM residencies that have been coasting by on reputation will close as well

 

[GeneralVeers]

a dirty secret though is that in addition to the HCA and CMG programs, a fair number of academic EM residencies that have been coasting by on reputation will close as well

It's simple enough that mandating your primary site be at least a Level II trauma center. That alone would get rid of most of the bloat.

 

[Birdstrike]

Nothing’s going to change for physicians without a strike. Physicians have no leverage otherwise. Any other strategies are mere self-flagellation.

 

[Franzd'Epinay]

Once again, as a "residency faculty member" I'm not opposed to spots going down. I am opposed to saying midlevels can see 25% of the patients. Because what will happen is residents will just get replaced by midlevels in resident run EDs. I just don't see how that is good for the specialty. It expands midlevel practice at training sites.

I just feel like that number that AAEM arrived at seems really high.

It's a maximum, not a minimum. These guidelines are not forcing programs to replace residents with midlevels. In fact, they are doing the opposite--they realize the smaller class sizes will make hospitals want to replace residents with the next cheapest labor (midlevels) and are putting a limit on that.

 

[Rekt]

Out of curiosity, how would you change the %ages? 60% residents, 15% mid levels? Somewhere along those lines? I'm not trying to be inflammatory; purely curious since you have a ton of experience with this issue.

ESI 4s and 5s only. Percent doesn't matter at that point.

 

[RustedFox]

ESI 4s and 5s only. Percent doesn't matter at that point.

- and if that 4 becomes a 3, then they hand it over. My one shop was crazy about "re-triaging" people.

 

[sylvanthus]

Nothing’s going to change for physicians without a strike. Physicians have no leverage otherwise. Any other strategies are mere self-flagellation.

Ya, its nice that people are brainstorming ideas , but we all know deep down, not a damn thing is gonna be done.
Gonna put my effort into getting the F outta medicine as fast as I reasonable can before the ship completely sinks.

Were pretty much strategizing on how to bail out water on a ship with no hull integrity at this point.

 

[GeneralVeers]

Nothing’s going to change for physicians without a strike. Physicians have no leverage otherwise. Any other strategies are mere self-flagellation.

Physicians are too altruistic and bad at business to strike. Any time someone says "It's in the patient's best interest" we fall all over ourselves to get in line. As soon as we stop being guilt-tripped by manipulative CMG directors and admins, we can take things back.

 

[dchristismi]

I did cancel my ACEP membership. While I'm not practicing EM any longer, I made a point to say that I disagreed with all these new EM residencies at tiny hospitals that weren't trauma centers and had no business having residencies. They then said "you can apply to be a "retired member." I haven't replied. I'll keep my FAAEM thank you very much.