The ACGME has proposed adding a year to emergency medicine residency training. Health systems will make millions from extra government payments and increased cheap resident labor.
Thank you for this. I authored the study you included to demonstrate the profitability of EM residencies. Your analysis is spot-on, and I share many of your concerns about the proposal. When I was doing this research as a resident a decade ago, there was a steady drumbeat from ACEP and national EM leaders warning of a dire shortage of EM doctors. In my naïveté, I assumed that the goal of these calls was to expand the number of EM-trained physicians. I thought that proving that residents were profitable would help. I didn’t suspect until I came to publish that the real goal was to pressure the government to expand GME funding. The howls of outrage when the number of EM programs expanded without GME funding seemed to confirm the matter. Whatever the truth concerning the quality of EM education (into which I claim no special insight), some of the proposal’s support surely stems from its potential to achieve the long-sought federal money - with the added bonus of coming at the relative expense of the newly-arrived competition. While many of the concerns about resident education are, no doubt, genuine, couching self-interest in those terms would be a maneuver with long historic precedent. We ought to be clear-eyed about our motivations. And the benefit to resident education, if it is there, ought to be demonstrated, not assumed.
Great comments all, but the discussion begs a major question that lies at the root of this conundrum. MISSION CREEP. What happened to the “Emergency” in emergency medicine ? As an old school dual trained/certified IM/EM graduate myself , I feel compelled to ask obvious but overlooked dimension in this discussion to wit , Why is our speciality involved in addiction medicine /consulting/ follow up at all ?telemedicine ? Even observation medicine? Smoking cessation programs ? Even critical care ? Would any of my colleagues argue we don’t have too much to do already taking care of core emergencies ? We should be resuscitating and stabilizing patients, not delivering extended critical care. We should be ruling out life and limb threatening situations, not providing data for long term precise diagnoses or facilitating longitudinal care for chronic illness. These should be handled in appropriate cost effective venues under the purview of OTHER specialities. Critical care beyond the first hour should in the controlled , staff defined, more longitudinal environment of an ICU or in the OR. Hospitals are not only exploiting the GME game detailed here,but they are shifting work that logically should be handled as in patients by in patient services OR outpatients in clinic. Our original sin is we allowed ourselves to be all things to all patient and administrators. This stems from our 24 hour availability, the broad interests of most emergency physicians (I am a poster child in this regard) ,and even professional insecurity ….but our leadership failed to envision the longer strategic game (again another trait of emergency physicians) of controlling Our own specialty rather than let it be defined by hospital administrators and other specialities selecting offloading work they should be doing by training and expertise, but eschew for convenience and financial reasons. This is a unique vulnerability of our speciality and deserves much more attention and action. Concomitant to any discussion about expanding training periods is a equally intentional discussion of LIMITING our scope of practice, and thus need for extended training. It’s already out of control. We can’t expect other specialities and administrators to NOT exploit our 24 hour a day presence, intellectual curiosity , and selflessness . Any speciality calling itself a speciality has to control their scope of practice, and thus training requirements. We need to stop going around looking for more things to do, more relevance to hospital administrators. Decades into our development, we still project ourselves as the 7-11 of medicine. We have only to look to ourselves in this regard. We have been complacent and passive, and in many cases naive or even causative. Don’t look just to the stars, dear Brutus.
Thanks for the reminder, but I have to cavil a bit with Drs Carley and Weingart . Dr carley thinks we are doing swimmingly well just as we are, and Dr Weingart overlooks that there just aren’t enough patients for us to hang around all day (and night) waiting for the next code as a resuscitologist. I admire Dr Carleys commitment and enthusiasm , but it’s simply not possible to sustain that for a standard career length given our current challenges. Dr Carley undoubtedly has seen the same workload, decreased in patient beds and speciality backup that Dr WEingart has, but he works in a no fault country, doesn’t have press gainey scores to meet, and probably is unionized, indeed possibly an NHI (ie government) employee. Sounds like heaven to me. I do agree with Dr Weingart that we were managing to maintain our equilibrium in the past , but no longer when hospitals, our colleagues in other specialities and even our patients are exploiting our sense of mission and availability. Who wouldn’t ?
And lets be candid-how we can we thrive in current conditions when we see ourselves as a ‘paradigm’ , part of a ‘system’, (thats not a specialty mentality). striving in Sisyphean manner against the full panoply fo social ills , corporate exploitation, and deprofessionalization rather than discrete medical biological conditions like all other specialities ? What other speciality thinks of itself as a paradigm part of a system, as concerned about the “team” and their speciality colleagues , or allows EmCare to staff their academic department or surgery or radiology, or NO limit on how many patients we have to see regardless of a acuity ? I don’t have all the answers, but we have to ask the right questions and that comes from observing root causes. The delicate balance that gave rise to our speciality has eroded drastically and we are at best treading water. I would submit what ails our specialty most these days is we are the only ones who don’t have an emergency department to send all our problems too.
As always, thank you for your excellent analysis of the data. I believe in evidence based decisions, however I also believe for many reasons, that we do not have to be as pessimistic. First of all, Medicare GME subsidy to residency program slots are capped so that established programs will not receive more money to add residents. It is more likely they will keep the same number of residents they have but spread over four years instead of three…9 for 4 years instead of 12 for 3 years. We will not need to attract as many of the top candidates as we do now. Will for profit systems still try to make money from EM programs? Sure, but not from the feds.
I also think about how much more there is to learn now than in the past. From FAST to POC US… from treating every patient the same to realizing individual patients have different needs…from treating men or women to care for many possible genders and identities…from treating and streeting addicts to MAT, counseling and referral… from admit or discharge to possible observe or board or care at home…, to many more ways to address the airway and more options for sick patients. We use to work our residents mercilessly, but with duty hour limits and enlightened work life concerns, why not modify diminish the stress of training.
The ACGME proposes to address the diluted critical care experience and procedural experience. There is a chance for everyone to work in under resourced places, to get better at taking care of anybody, anywhere. And it will give opportunity to give fourth year residents more independence and autonomy, so they learn to better handle uncertainty.
It’s not just about adding a year, it what we do with it. EM has gotten big, matured and changed. We did this once before https://www.emdocs.net/history-of-em-three-years-or-four/. We can’t just stop. We have to look forward. I’m kind of optimistic.
Quick question: why would Medicare not fund a fourth year of EM residents' GME if that fourth year is mandated by the ACGME?
From what I can find, Medicare pays GME for a resident's Initial Residency Period (IRP), which is defined as the minimum number of years required for a resident to become board eligible in the specialty in which the resident first begins training, as determined by the ACGME. (source: https://www.aamc.org/media/71701/download) In other words, when ACGME mandates that EM residents receive four years of training, the IRP for all incoming EM residents would be four years.
Also, Medicare GME caps are calculated based on the number of residents who start their IRP each year, not total resident-years.
There are two different concepts: 1. eligibility and 2.cap for actual payment. You are correct that once the IRP is increased to 4 years, the additional year will now be eligible for full DME and IME payment. But I believe Ted is correct that the cap is not specific for a specialty but based on the number of residents reported on the 1996 hospital cost report and is hospital specific. So even if 4th year residents would be eligible, there is no provision I have read that would automatically increase the cap for a specific hospital. (https://www.gao.gov/products/gao-21-391).
Quick question: why would CMS not fund a fourth year of DME if that fourth year is mandated by the ACGME?
From what I can find, Medicare pays GME for a resident's Initial Residency Period (IRP), which is defined as the minimum number of years required for a resident to become board eligible in the specialty in which the resident first begins training, as determined by the ACGME. (source: https://www.aamc.org/media/71701/download) In other words, when ACGME mandates that EM residents receive four years of training, the IRP for all incoming EM residents would be four years.
Thank you for this. I authored the study you included to demonstrate the profitability of EM residencies. Your analysis is spot-on, and I share many of your concerns about the proposal. When I was doing this research as a resident a decade ago, there was a steady drumbeat from ACEP and national EM leaders warning of a dire shortage of EM doctors. In my naïveté, I assumed that the goal of these calls was to expand the number of EM-trained physicians. I thought that proving that residents were profitable would help. I didn’t suspect until I came to publish that the real goal was to pressure the government to expand GME funding. The howls of outrage when the number of EM programs expanded without GME funding seemed to confirm the matter. Whatever the truth concerning the quality of EM education (into which I claim no special insight), some of the proposal’s support surely stems from its potential to achieve the long-sought federal money - with the added bonus of coming at the relative expense of the newly-arrived competition. While many of the concerns about resident education are, no doubt, genuine, couching self-interest in those terms would be a maneuver with long historic precedent. We ought to be clear-eyed about our motivations. And the benefit to resident education, if it is there, ought to be demonstrated, not assumed.
Great comments all, but the discussion begs a major question that lies at the root of this conundrum. MISSION CREEP. What happened to the “Emergency” in emergency medicine ? As an old school dual trained/certified IM/EM graduate myself , I feel compelled to ask obvious but overlooked dimension in this discussion to wit , Why is our speciality involved in addiction medicine /consulting/ follow up at all ?telemedicine ? Even observation medicine? Smoking cessation programs ? Even critical care ? Would any of my colleagues argue we don’t have too much to do already taking care of core emergencies ? We should be resuscitating and stabilizing patients, not delivering extended critical care. We should be ruling out life and limb threatening situations, not providing data for long term precise diagnoses or facilitating longitudinal care for chronic illness. These should be handled in appropriate cost effective venues under the purview of OTHER specialities. Critical care beyond the first hour should in the controlled , staff defined, more longitudinal environment of an ICU or in the OR. Hospitals are not only exploiting the GME game detailed here,but they are shifting work that logically should be handled as in patients by in patient services OR outpatients in clinic. Our original sin is we allowed ourselves to be all things to all patient and administrators. This stems from our 24 hour availability, the broad interests of most emergency physicians (I am a poster child in this regard) ,and even professional insecurity ….but our leadership failed to envision the longer strategic game (again another trait of emergency physicians) of controlling Our own specialty rather than let it be defined by hospital administrators and other specialities selecting offloading work they should be doing by training and expertise, but eschew for convenience and financial reasons. This is a unique vulnerability of our speciality and deserves much more attention and action. Concomitant to any discussion about expanding training periods is a equally intentional discussion of LIMITING our scope of practice, and thus need for extended training. It’s already out of control. We can’t expect other specialities and administrators to NOT exploit our 24 hour a day presence, intellectual curiosity , and selflessness . Any speciality calling itself a speciality has to control their scope of practice, and thus training requirements. We need to stop going around looking for more things to do, more relevance to hospital administrators. Decades into our development, we still project ourselves as the 7-11 of medicine. We have only to look to ourselves in this regard. We have been complacent and passive, and in many cases naive or even causative. Don’t look just to the stars, dear Brutus.
Great points!!! Scott Weingart made a similar argument about EM mission creep a few years ago:
https://emcrit.org/emcrit/emergency-medicine-failed-paradigm/
https://www.stemlynsblog.org/an-uncomfortable-truth-the-fragmentation-and-failure-of-the-em-paradigm-st-emlyns/
Thanks for the reminder, but I have to cavil a bit with Drs Carley and Weingart . Dr carley thinks we are doing swimmingly well just as we are, and Dr Weingart overlooks that there just aren’t enough patients for us to hang around all day (and night) waiting for the next code as a resuscitologist. I admire Dr Carleys commitment and enthusiasm , but it’s simply not possible to sustain that for a standard career length given our current challenges. Dr Carley undoubtedly has seen the same workload, decreased in patient beds and speciality backup that Dr WEingart has, but he works in a no fault country, doesn’t have press gainey scores to meet, and probably is unionized, indeed possibly an NHI (ie government) employee. Sounds like heaven to me. I do agree with Dr Weingart that we were managing to maintain our equilibrium in the past , but no longer when hospitals, our colleagues in other specialities and even our patients are exploiting our sense of mission and availability. Who wouldn’t ?
And lets be candid-how we can we thrive in current conditions when we see ourselves as a ‘paradigm’ , part of a ‘system’, (thats not a specialty mentality). striving in Sisyphean manner against the full panoply fo social ills , corporate exploitation, and deprofessionalization rather than discrete medical biological conditions like all other specialities ? What other speciality thinks of itself as a paradigm part of a system, as concerned about the “team” and their speciality colleagues , or allows EmCare to staff their academic department or surgery or radiology, or NO limit on how many patients we have to see regardless of a acuity ? I don’t have all the answers, but we have to ask the right questions and that comes from observing root causes. The delicate balance that gave rise to our speciality has eroded drastically and we are at best treading water. I would submit what ails our specialty most these days is we are the only ones who don’t have an emergency department to send all our problems too.
As always, thank you for your excellent analysis of the data. I believe in evidence based decisions, however I also believe for many reasons, that we do not have to be as pessimistic. First of all, Medicare GME subsidy to residency program slots are capped so that established programs will not receive more money to add residents. It is more likely they will keep the same number of residents they have but spread over four years instead of three…9 for 4 years instead of 12 for 3 years. We will not need to attract as many of the top candidates as we do now. Will for profit systems still try to make money from EM programs? Sure, but not from the feds.
I also think about how much more there is to learn now than in the past. From FAST to POC US… from treating every patient the same to realizing individual patients have different needs…from treating men or women to care for many possible genders and identities…from treating and streeting addicts to MAT, counseling and referral… from admit or discharge to possible observe or board or care at home…, to many more ways to address the airway and more options for sick patients. We use to work our residents mercilessly, but with duty hour limits and enlightened work life concerns, why not modify diminish the stress of training.
The ACGME proposes to address the diluted critical care experience and procedural experience. There is a chance for everyone to work in under resourced places, to get better at taking care of anybody, anywhere. And it will give opportunity to give fourth year residents more independence and autonomy, so they learn to better handle uncertainty.
It’s not just about adding a year, it what we do with it. EM has gotten big, matured and changed. We did this once before https://www.emdocs.net/history-of-em-three-years-or-four/. We can’t just stop. We have to look forward. I’m kind of optimistic.
Hi Louis,
Thanks for the thoughtful response!
Quick question: why would Medicare not fund a fourth year of EM residents' GME if that fourth year is mandated by the ACGME?
From what I can find, Medicare pays GME for a resident's Initial Residency Period (IRP), which is defined as the minimum number of years required for a resident to become board eligible in the specialty in which the resident first begins training, as determined by the ACGME. (source: https://www.aamc.org/media/71701/download) In other words, when ACGME mandates that EM residents receive four years of training, the IRP for all incoming EM residents would be four years.
Also, Medicare GME caps are calculated based on the number of residents who start their IRP each year, not total resident-years.
-- Leon
There are two different concepts: 1. eligibility and 2.cap for actual payment. You are correct that once the IRP is increased to 4 years, the additional year will now be eligible for full DME and IME payment. But I believe Ted is correct that the cap is not specific for a specialty but based on the number of residents reported on the 1996 hospital cost report and is hospital specific. So even if 4th year residents would be eligible, there is no provision I have read that would automatically increase the cap for a specific hospital. (https://www.gao.gov/products/gao-21-391).
Hi Ted,
Thanks for the thoughtful response!
Quick question: why would CMS not fund a fourth year of DME if that fourth year is mandated by the ACGME?
From what I can find, Medicare pays GME for a resident's Initial Residency Period (IRP), which is defined as the minimum number of years required for a resident to become board eligible in the specialty in which the resident first begins training, as determined by the ACGME. (source: https://www.aamc.org/media/71701/download) In other words, when ACGME mandates that EM residents receive four years of training, the IRP for all incoming EM residents would be four years.
-- Leon
ACEP Council Resolution re 3 vs 4 yr residencies: https://drive.google.com/file/d/1v4z3VIWXAbojahv9y_kbq7FpQEt7sye2/view?usp=sharing
In Canada the Emergency training is 5 years long...
Most physicians practicing EM in Canada do the CCFP-EM track, which is three years. https://www.cfpc.ca/en/education-professional-development/examinations-and-certification/examination-of-added-competence-in-emergency-medic