American Academy of Emergency Medicine

Update on the AAEM-CORD-SAEM Consensus Proposal to the Federation of State Medical Boards (FSMB)

by Antoine Kazzi, MD FAAEM
AAEM Board of Directors and CAL/AAEM President

The Board of Directors of the Federation of State Medical Boards (FSMB) considered the "Consensus Proposal" of the Society for Academic Emergency Medicine, Council of Emergency Medicine Directors and American Academy of Emergency Medicine regarding postgraduate training and licensure standards. As you may recall, AAEM, CORD and SAEM submitted in January 2001 an official proposal to the FSMB endorsing its May 1998 Policy Statement on Physician Licensure which recommended the restriction of independent physician licensure to a minimum of three years after the completion of medical school. "Such practices potentially compromise patient safety. Additionally, resident physician moonlighters provide unsupervised care, many with inadequate training and experience." If full licensure were restricted to physicians who have completed three years of post-graduate training, moonlighting by residents would suffer a radical prohibitive blow.

AAEM, CORD, and SAEM had also strongly opposed the May 1998 FSMB recommendation to mandate yearly reporting by program directors of residents in trouble to the state medical boards. The full text of the "AAEM-CORD-SAEM Consensus Proposal to the FSMB" was jointly published in the April 2001 issues of the Journal of EM and in Academic EM as well as in the official newsletters of the three national EM organizations.

We are happy to report the following FSMB response
"The (FSMB) Board was appreciative of the stated support for the Federation's policy requiring three years of postgraduate training prior to licensure as the ultimate "gold" standard. The Board carefully considered the rationale behind the dependent practice of medicine license (DPML) proposal and recognized that in a particular state, circumstances could result in it being viewed as a 'vehicle' toward achieving the ultimate standard as Brian Zink, MD FAAEM stated in his e-mail letter of March 2, 2001.

All that being said, the Board reaffirmed Federation policy recommending medical boards pursue a requirement of three years of postgraduate training prior to licensure. This should not be construed as a lack of support for your organizations' efforts to pursue incremental or compromise steps in this arena.

As to your recommendations regarding required annual reporting of program directors, graduate medical education offices can be designated for annual reporting as long as a licensee of the state medical board is ultimately accountable for said reporting."

The SAEM-CORD-AAEM working group discussed the response, and viewed this as a positive and encouraging FSMB position. While the FSMB did not respond by endorsing the DPML as a resolution for the April, 2001 FSMB delegate meeting, their message carries two positive messages. The FSMB is leaving the option of a DPML open to us to use as a vehicle to incrementally implement - at the state level - the three-year requirement which the FSMB, SAEM, CORD and AAEM all support. The FSMB also stated that it would be satisfied with mandatory reporting by the institutional GME chair - another entity than the PDs. This would allow the preservation of the PD-resident confidentiality that is crucial to provide effective training.

The SAEM-CORD-AAEM working group through follow-up communications with the FSMB further confirmed this interpretation. We asked "if we were to work with the local state medical boards to implement such legislation (re DPML) at the state level (state by state), the FSMB would be supportive of our effort. Is that a reasonable interpretation?"

The FSMB leadership responded that it was "pleased the letter conveyed the 'positive messages' you reference. That was certainly the intent. As to your questions, the GME chair could be held responsible for the annual reporting. IF s/he is a licensee of the board of medicine in the state - it all comes down to accountability. GME offices or functions of institutions are not regulated by medical boards and thus can't be held accountable for reporting. And yes, your interpretation that the FSMB would be supportive of a state effort pursuing the dependent license concept as a step toward the 3-year PGT requirement for licensure is accurate."

In summary, it is now time to move forward at the "state" level and work with our state medical societies, medical board and EM leadership to write legislation that incrementally meets our stated objectives. Such legislation would establish the DPML AND implement simultaneously the FSMB-SAEM-CORD-AAEM-recommended restriction of full licensure to physicians who have completed 3 years of post-graduate training. The specifics of a DPML should be defined individually state-by-state, while taking into consideration their regional workforce needs. Gradually, we could modify this legislation at the state level based on the gradual changes in its regional workforce to the point where only board-certified EPs docs can practice in EDs.

What does such legislation mean in the short run?
The majority of EM residents would then be restricted to moonlighting in double coverage EDs. Non-EM residents would be restricted to their own areas of specialty training and away from EM. In states and rural areas with a shortage of EM board-certified EPs, exemptions can be introduced that allow only EM residents with the appropriate dependent license to moonlight in EDs - with appropriate off-site oversight.

As stated by Dr. Carey Chisholm, Dr. Jerris Hedges, and me in a recent communication on behalf of the SAEM-CORD-AAEM working group, "Our desire was to create a safety net, for both the patient and the resident, by linking resident moonlighting practice to direct supervision by a responsible board certified physician. Any moonlighting activity is thus an 'extension' of that physician's practice in much the same way that residents practice under the supervision of faculty members in their residency programs.

The goal is to provide the public with fully-trained EPs when solo coverage is needed. As a matter of fact, the 'dependent practice' license would mandate that physician groups that employ residents would provide for a reasonable degree of resources, orientation, oversight, and legal liability protection. Moonlighting residents currently lack such systematic predefined support from the party that chooses to employ them."

Efforts to consider or develop such legislation at the state level have begun in California, and have been well received by CAL/ACEP in its collaborative relationship with CAL/AAEM. EPs who wish to work on this within their own state should not hesitate to contact any member of the SAEM-CORD-AAEM working group or info@aaem.org to participate in this effort to protect the quality of medical care our patients deserve and should receive.