I. FSMB recommends "3. All applicants for licensure should have satisfactorily completed a minimum of three years of postgraduate training in an ACGME- or AOA-approved postgraduate training program, including completion of PGY3 level training prior to full and unrestricted licensure."
With regard to the FSMB recommendation to restrict full licensure to physicians that have completed 3 years of post-graduate training, we were in agreement that such a recommendation would raise the medical standards provided when care is delivered. We all agreed that the current practice of moonlighting subjected patients to care delivered by physicians who have less than optimal training.
We all acknowledged that a shortage for board-certified emergency physicians persists at this point, particularly in rural and underserved areas.
We therefore proposed the following addition to the FSMB recommendation: The FSMB should support the establishment of a "dependent practice of medicine" license by state boards" that "physicians in-training" could secure after successfully completing one year of residency training in a US -accredited allopathic or osteopathic program (ACGME or AOA).
- The dependent practice license would be time-limited. "Physicians in-training" is defined as maintaining current, satisfactory enrollment in an ACGME or AOA approved residency training program.
- Such a dependent practice would be restricted in scope to clinical activities consistent with those that the resident is performing in the course of their residency training program and the scope of practice for that clinical specialty.
- On-site supervision of the resident physician that is working under the dependent practice of medicine license is required.
- Such supervision should be 1) continuous, 2) onsite, and 3) provided by fully licensed physicians who are board-certified/prepared in the resident's own field of training.
- Board certification or preparation of the supervising physician must be provided by a certifying body recognized by the American Board of Medical Specialties or the American Osteopathic Board of Specialties.
- Such a dependent practice of medicine would be equivalent to extending eligibility for a "Physician Extender" status to residents who are in good standing in their training program.
- Such dependent practice licensure would require annual renewal.
- Physician groups and institutions that contract or employ physicians who are practicing under a dependent practice license would share the legal liability for the quality of care provided by the residents working for them. They would assume the responsibility of clearly defining the supervision mechanism for the dependent practitioner. This mechanism should not vary substantially from that provided in the resident's training program.
II. FSMB recommends "2. All physicians enrolled in postgraduate training programs shall be subject to medical board regulation and oversight through a mechanism that requires the physician to obtain a training permit or limited license expressly designed for such purpose. This mechanism shall also require that program directors report annually to the medical board on all individuals enrolled in their respective programs."
We believe this recommendation requiring program directors to annually report details of each residents' education process to be counterproductive. All represented EM organizations are strongly opposed to this requirement. We proposed modifying that 1998 FSMB position by shifting the responsibility and timing of the reporting of residents and the permit renewals from the program director to the Graduate Medical Education Office (GME) of their medical institution.
The proposed revision is: All physicians enrolled in postgraduate training programs shall be subject to medical board regulation and oversight through a mechanism that requires the physician to obtain a training permit or limited license expressly designed for such purpose. This mechanism shall also require that the graduate medical offices of training institutions report annually to the medical board any serious disciplinary action taken against a resident such as termination. However, remediation programs and probationary actions are best handled internally within the training institution so that deficiencies in performance are openly addressed rather than overlooked or inadequately addressed for fear of ruining the resident's future career. Mandated reporting of such activities would create an environment in which residents attempted to hide or cover up educational mistakes or deficiencies, rather than proactively seeking assistance through the residency.
III. FSMB recommends "1. All applicants for postgraduate training shall have satisfactorily completed Steps 1 and 2 of the United States Medical Licensing Examination (USMLE) or Parts 1 and 2 of the certifying examination administered by the National Board of Osteopathic Medical Examiners (NBOME) prior to acceptance into a postgraduate training program."
EM organizations found no strong objection to this recommendation. Concerns were expressed that a small minority of applicants who could potentially pass the USMLE before the beginning of their training would be discriminated against during the selection process of the match.
Conclusion
The AAEM, CORD and SAEM appreciate the efforts of the FSMB as it strives to provide patients with the most optimal level of protection and the highest standards that are available and achievable at this point in time.
We hope that the FSMB could formally adopt these modifications to their 1998 recommendations. We then could all begin working together to implement them via the legislative and regulatory processes they would each require.
Approved: 9/20/00