Response to Dr. Petrack's Follow Up Posting
Dr. Petrack noted that only PEM boarded or board eligible physicians should
provide primary ED coverage in children's hospitals and implied that in
difficult times another type of physician may be substituted.
Although this is a popular opinion there is no objective evidence to
support this point of view. Multiple studies have been conducted in which
the care of children managed by one "type" of physician has been
retrospectively evaluated for major or minor errors. Variations of this
approach include a number of studies in which a given group of physicians
was provided with a set of x-rays or clinical scenarios and then evaluated
for missed findings. Underlying all of these are anecdotal reports of "I
know a case where the referring doc really screwed up". Unfortunately none
of these provide clear data that any one type of physician is any better
trained to treat pediatric emergencies than any other.
Probably the most important determinant of which physician should treat
children in any Emergency Department is the outcomes of the patients that
physician treats in the department in which they practice. Should a
general Emergency Physician with excellent outcomes be removed from the
schedule because they don't have speciality boards. Is there a reason why
the same pediatric intensivist who presents immediately to the ED to help
with the stabelization of a critically ill child can't also be part of the
Emergency Department staff and work shifts in the ED.
Physicians committed to excellent pediatric emergency care will always be
an asset to an Emergency Department, regardless of their board status. To
restrict the practices of excellent clinicians ultimately undermines the
total care of all children.
Like all certification processes, board certification in PEM can only be
applied on a macro level and used to describe a population of physicians.
Individual physicians, working independtly in a given ED must be judged on
their own performances, not on their credentials.
This entire topic has been the source of considerable discussion in a
number of professional organizations over the past decade and it is very
likely that this dialogue will continue for the remainder of this century.
Al Sacchetti, M.D.
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