Revise position on short courses.

Recently the ACEP board of directors approved a policy statement denouncing the use of short courses in emergency medicine as criteria for privileges or employment. The specific policy states:

“ACEP believes that board certification by ABEM or AOBEM demonstrates comprehensive training, knowledge, and skill in the practice of emergency medicine. Certificates of short course completion in various core content areas of emergency medicine may serve as evidence of focused review; however ABEM or AOBEM certification in emergency medicine supersedes evidence of completion of such courses.”¹

“Accordingly ACEP strongly discourages the use of certificates of completion of courses such as ACLS, ATLS, PALS and BTLS, or a specified number of medical education hours in a sub-area of emergency medicine, as requirements for privileges or employment for physicians certified by ABEM or AOBEM.”¹

“Certificates of completion of focused courses should only be used as requirements for privileges or employment for ABEM or AOBEM-certified physicians in conjunction with new procedures that evolve into the practice of emergency medicine and in which physicians have not received formal training.”¹

The best way to look at this is by setting up two scenarios. The first scenario is a recent graduate of an approved EM residency that follows the EM model, and encompasses the six new core competencies: patient care, medical knowledge, practice-based learning and improvement, interpersonal skills, professionalism and systems based practice.²

Whether this graduate has passed the ABEM written and oral exams, or is still in the process (and therefore board-eligible), there should be no doubt that this individual does not need any “short courses” for privileges or employment…

Scenario Two: It is now 8 years later, and this same individual has decided to change jobs, and is therefore applying to a new hospital for credentialing and privileges. The physicians’ first job was at an academic medical center, with EM residents, that was not a trauma center. The new job is at community hospital, with no residents, that is a level II trauma center, with the level I center 50 miles away.

Based on the ACEP Policy: Physician Credentialing and Delineation of Clinical Privileges in Emergency Medicine: this process “must be defined by the medical staff and department bylaws, policy, rules or regulations”.

It goes on to state that “ACEP believes the ED medical director is responsible for periodic assessment of clinical privileges for emergency physicians; the ED medical director will, with the input of department members, determine the means by which each emergency physician will maintain competency and skills and the mechanism by which to monitor the proficiency of each physician.”¹

“At a minimum, those applying for privileges as emergency physicians should be eligible for ACEP membership. Board certification by ABEM or AOBEM is an excellent but not the sole benchmark for decisions regarding an individual’s ability to practice emergency medicine. Other qualifications may include objective measurement of care provided; sufficient experience; prior training; and evidence of continuing medical education.”¹

The ACEP Policy Resource and Education Paper has a sample of requested procedures, and states that specific procedures and qualifications to perform each of them can include graduate training, postgraduate training (may include human in-vivo, postmortem or animal laboratory experiences. The medical director may determine other acceptable training methods (i.e., computer aids, mannequin simulation, applicable CME or other educational technology).”³

These policies seem a bit at odds with the recent denouncement on short courses. In this second scenario, how should a medical director certify that this new hire can manage a trauma patient? How can they watch them assess a trauma patient, practice inserting a chest tube, perform a pericardiocentesis, or even a thoracotomy, before they are hired?

While ATLS provides one with a chance to perform these procedures, its strength is teaching the physician a step by step assessment of the trauma patient, and being able to tell a trauma surgeon at their institution or 50 miles away exactly what they have found, procedures they have performed, and why the patient needs an urgent operation or transfer to a higher level of care. It also covers areas such as care of the elderly, disaster management and emergency preparedness⁴, which are not listed in the EM model.

Granted ATLS does not make you competent in these procedures (that takes practice, which many EM physicians may not get even in years of working in an ED), but it is a step in the right direction. In addition, if a physician has been a supervising attending for EM residents, it is likely that they have supervised procedures, rather than performing those procedures themselves, so a “refresher” short course may be in order.

One may say, if I maintain my board certification in EM, through Maintenance of Certification (MOC), then that should suffice for my ongoing qualifications; however, there is no procedural competency associated with this.

The MOC covers professional standing, lifelong learning and self-assessment (LLSA), assessment of cognitive expertise, and assessment of practice performance.⁵ LLSA consists of readings and a test on these readings. Practice performance focuses on patient care practice improvement (PI) activities, and communication/ professionalism patient feedback programs.

Assessment of cognitive expertise is done by taking the ABEM ConCert exam, and professional standing means having a current, valid, full, unrestricted, and unqualified medical license.

In most states, physicians need a specific number of continuing medical education (CME) hours over a specified number of years. This later area is where continuing medical education comes into play.

The ACEP short courses are updated periodically, so it is a great way to stay up-to-date and learn about advances in the specific areas (resuscitation, trauma management).

The Short Course policy also states that there should not be “a specified number of continuing medical education hours in a sub-area of emergency medicine, as requirements for privileges or employment for physicians certified by ABEM or AOBEM.”¹

However, in several states, there are laws that do mandate a specific number of trauma CME hours for physicians working in trauma centers.

This then supersedes the ACEP policy. In Illinois there is also a specific number of pediatric-specific CME hours for physicians working in Emergency Departments Approved for Pediatrics, as well as Stand-by Emergency Departments Approved for Pediatrics. (While this facility recognition process is voluntary for the hospital, there are specific physician staffing requirements including that if you are ABEM, or AOBEM board certified that you do not require PALS.)

In Illinois the total number of CME hours is 50 hrs/year accrued over a 3 year period. These hours can be obtained in a number of ways: by taking a short course, doing on-line reading, attending annual meetings (such as the ACEP Scientific Assembly), or attending other CME courses.

The long and short of it is there are benefits for these “short courses.” It is a way to gain valuable up-to-date information, practice some skills, and obtain CME hours.

Dr. Fuchs is an emergency physician at the Ann & Robert H. Lurie Children’s Hospital of Chicago and a professor of Pediatrics at the Feinberg School of Medicine, Northwestern University, Chicago. She is an editor of APLS: The Pediatric Emergency Medicine Course, 5th ed, a joint venture between ACEP and the American Academy of Pediatrics. Dr. Fuchs is also chair of The Illinois Emergency Medical Services for Children Advisory Board.

References:

1. ACEP 2012 Policy Compendium. Accessed 6/25/12 at http://www.acep.org
2. 2009 EM Model Review Task Force: Perina DG, Beeson MS, Char DM, et al. The 2007 Model of Clinical Practice of Emergency Medicine: The 2009 Update. Acad Emerg Med 2011;18(3);e8-e28
3. ACEP Clinical and Practice Management: Guidelines for Credentialing and Delineation of Clinical Privileges in Emergency Medicine. Accessed 7/1/12 at http://www.acep.org/content.aspx?id=29628
4. Advanced Trauma Life Support for Doctors, 8th ed. American College of Surgeons, Committee on Trauma, Fildes, J, chair. Chicago, American College of Surgeons, 2008.
5. American Board of Emergency Medicine, MOC Overview. Accessed 7/5/12 at https://www.abem.org/RAINBOW/portal/alias__Rainbow/lang__en-US/tabID__3422/DesktopDefault.aspx.

ATLS, ACLS, APLS…will alphabet soup never end?

Short courses, such as ATLS, BLS, ACLS, APLS, ADLS, and PALS are still required by some institutions for hospital privileges.

Perhaps as a vestige of earlier days before emergency medicine was a recognized specialty, these courses were probably required in attempts to improve emergency care. However, little data exists regarding the merits of standalone courses in relation to patient outcomes. Several studies have demonstrated improved outcomes when using ATLS or ACLS interventions, but these studies were not conducted among board-certified emergency physicians.

One recent study demonstrated worse outcomes among trauma patients who were treated by ATLS certified physicians, compared to physicians not ATLS certified.

A study performed by EP Monthly in 2010 surveyed 769 emergency physicians and demonstrated that 85% of respondents did not feel that BLS improved care by an EP, and 69% felt that ACLS did not improve care by an EP.

The Model of the Clinical Practice of Emergency Medicine (EM Model), developed by emergency physicians, serves as the basis for ABEM content examinations, and the core content for training in Emergency Medicine. This document is updated every two years by experts from ABEM, ACEP, CORD, EMRA, RRC-EM, and SAEM.

As stated in the preamble, The EM Model is designed for use as the core document for the specialty. It will provide the foundation for developing future medical school and residency curricula, certification examination specifications, continuing education objectives, research agendas, residency program review requirements, and other documents necessary for the functional operation of the specialty.

The EM Model, a 45-page document, includes priority content in areas covered by short courses. For example, there are 10 sections of Cardiovascular Disorders, including Cardiopulmonary Arrest, Disturbances of Cardiac Rhythm, including critical, emergent, and lower acuity physician tasks. There are three sections of Traumatic Disorders, including detailed descriptions of anatomic trauma and management priorities.

Mastery of the content of the EM Model supersedes any short course, and makes any additional training or content superficial and redundant. ACEP has developed several policies relevant to this issue. (See boxed items).

Would we ask a college graduate to go back and take first grade math? Should the principal violinist in an orchestra take beginning violin lessons annually? Should a PhD psychologist take Psychology 101 every 2 years? Requiring a board certified emergency physician to take ATLS (or any other short course) is akin to this elementary level of remediation.

Emergency physicians should advocate for board certification by ABEM or AOBEM as the only meaningful evidence of qualification to practice Emergency Medicine.

Short courses may be useful to students or residents but are redundant and unnecessary for board-certified emergency physicians.

Dr. Marco is a professor of Emergency Medicine, Program Director of the Emergency Medicine Residency and Director of Medical Ethics Curriculum at the University of Toledo College of Medicine.

References

1. Hedges JR, Adams AL, Gunnels MD. ATLS practices and survival at rural level III trauma hospitals, 1995-1999. Prehosp Emerg Care. 2002 Jul-Sep;6(3):299-305.
2. van Olden GD, Meeuwis JD, Bolhuis HW, Boxma H, Goris RJ. Clinical impact of advanced trauma life support. Am J Emerg Med. 2004 Nov;22(7):522-5.
3. van Olden GD, Meeuwis JD, Bolhuis HW, Boxma H, Goris RJ. Advanced trauma life support study: quality of diagnostic and therapeutic procedures. J Trauma. 004 Aug;57(2):381-4.
4. Camp BN, Parish DC, Andrews RH. Effect of advanced cardiac life support training on resuscitation efforts and survival in a rural hospital. Ann Emerg Med. 1997 (4):529-33.
5. Drimousis PG, Theodorou D, Toutouzas K, Stergiopoulos S, Delicha EM, Giannopoulos P, Larentzakis A, Katsaragakis S.Advanced Trauma Life Support certified physicians in a non trauma system setting: is it enough? Resuscitation. 2011 Feb;82(2):180-4. Epub 2010 Nov 30.
6. http://www.epmonthly.com/features/current-features/merit-badge-courses-who-benefits/, accessed 4/27/2012
7. https://www.abem.org/PUBLIC/_Rainbow/Documents/2009%20EM%20Model%20-%20Website%20Document%20-%20clean.pdf, accessed 4/27/2012
8. http://www.acep.org/Content.aspx?id=29064, accessed 4/25/2012
9. http://www.acep.org/Content.aspx?id=29084, accessed 4/25/2012
10. http://www.acep.org/Content.aspx?id=29216, accessed 4/25/2012
11. http://www.acep.org/Content.aspx?id=29844&terms=atls, accessed 4/25/2012.