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I can't say I disagree with the premise... the more time in training the better but it is unfortunately more complicated than that (I am not telling you anything you don't already know but for benefit of the discussion will give my 2 cents).

Clinical competency is not only type of training but quality of training and skills established during this training.  We also need to accept that there exist an experience threshold where physicians can gain skills in practice.  It is convenient to say that training defines skill set for ever and throughout a persons practice but it is simply not true.  Skills not only decay but they can also be gained.   This is why we do ongoing certification to prevent decay and why boards and sub-boards in their outset will recognize a grandfathering pathway based on skills gained in practice.

There are also practical limitations.  Mandating that every community have every specialist does not work.  Try forcing the rural ED to hire based on patient sub-groups and they will go broke (let alone not having enough specialists to do this).  The pragmatic approach is to embrace our colleagues, disseminate training and education and support them from the tertiary centers.

We can argue faults in each training track...  The EM physician does not get enough pediatric experience.  The EM-PEM physician does not get the gen'l peds exposure that is so helpful in the majority of our PedED patients.  The Ped-PEM person does not get the procedure quantity and acuity that is routine on the adult side.  The double boarded EM-Ped person cannot certify in the sub-board... etc etc.  To be honest, I get tired of the banter.  There are attributes to each and plenty of kids who need to receive quality and timely care in the emergency setting so, let's all get together and get 'er done.

I can and will speak only to myself and my own decisions on training.  I am double boarded in EM and Peds.  I am not sub-boarded in PEM.  The lack of sub-board certification has zero impact on my practice.  I expect it would though if I wanted to live in a big city and work in a big Children's Hospital.  Here a true bias exists but is moot as I didn't want to work in such a setting.

When researching I saw limitations in both of the primary board's training and felt these were best accounted for by putting them together and double boarding.  I felt this the best way to compliment and account for either's deficiencies.   Others will likely disagree but, as a result of double boarding, I can work near anywhere: Adult ED, PedED, rural, urban, suburban.  I get paid at the adult pay grade.  Since I am double boarded, I can and do occasionally help out our pediatric hospitalist group when they are short staffed.  I work volunteer in the community offering sport physicals and doing undeserved care  (because I am also a pediatrician).  If I get a wild hair, I have access to all the sub-specialty training that the two boards have available.   -- Not bad for the best of both worlds.

In my EM practice, I very much prefer kids but occasionally miss the adult side.  I chose to do 20% adults primarily to maintain my procedural and critical care skills.  I will weekly (and often daily) resuscitate, run a code, do a central line, place an airway, do a chest tube, etc.  These are much rarer in the PedED and without my adult shifts fear that I would lose these skills.  I work in an academic center teaching students and residents.  Again, I am not sub-boarded in PEM.

Although double boarding was best for me it is not the right choice for all.  When advising medical students and residents, I try to be very thorough in pointing out the benefits and flaws of each training track.  Ultimately the REAL CHOICE is whether to work with kids in the emergency setting.  The 'how's and why's' can be figured out later and is very much an individual choice.

Again, my 2 cents.
Dale



________________________________
From: Robert Flood [[log in to unmask]]
Sent: Thursday, April 24, 2014 12:31 PM
To: Dale Woolridge
Cc: [log in to unmask]
Subject: Re: Adult patients in the PED

Dale,

Thanks for the correction regarding 3 vs. 4 months of training... I realized my mistake right after pressing "send".

We are in complete agreement regarding 16% not being enough time. Regardless of what pediatric volume a community ED will see, there is no doubt in my mind that pediatric patients cause much more than 16% of the "anxiety" of practicing adult ED physicians. Another scope of practice and comfort level issue.

For PEM physicians the math just doesn't make sense. Most of us trained at least 6 years of pediatrics, including fellowship. How can 6 years of training be the same as 4 months?

Put another way, 6 years equates to more than 10,000 hours of caring for children, which many will quote as the amount of time to become an "expert" in anything. How many years would it take for an adult trained physician to achieve 10,000 hours to become an expert in pediatric emergency care? I am sure some, but not many, achieve this.

The same can be said about PEM physicians seeing adult patients: most have no where near the requisite 10,000 hours to become an expert in adult care.

So, we should all practice within our scope and comfort levels, and refer the rest to the true experts.

Bob


On Thu, Apr 24, 2014 at 1:54 PM, Dale Woolridge <[log in to unmask]<mailto:[log in to unmask]>> wrote:
Very good points Dr. Flood.  I did although want to make one correction...

The EM RRC requires a minimum of 16% 'pediatric experience'.  They equate a dedicated pediatric month (PedED, PICU, Peds Wards etc) to 4%.  This means that the bare minimum of pediatric exposure for board eligibility through ABEM is an equivalent of 4 months.  (sorry for splitting hairs but wanted to make sure the correct info went out).  Few EM programs are at the minimum and most are comfortably in excess.

Personal opinion is that I don't think allowing a minimum of 16% is enough since national studies have shown that an ~27% of ED volume is minors (<17 yo) most of which are seen in general ED's.  (emphasizing the need to get solid ped training to our primarily adult care colleagues).

Great discussion string.  Thx to the group.
Dale


 ________________________________________
From: Pediatric Emergency Medicine Discussion List [[log in to unmask]<mailto:[log in to unmask]>] on behalf of Robert Flood [[log in to unmask]<mailto:[log in to unmask]>]
Sent: Tuesday, April 22, 2014 3:30 PM
To: [log in to unmask]<mailto:[log in to unmask]>
Subject: Re: Adult patients in the PED

Dear Dr. Chavda:

With respect to PEM trained physicians, it is a scope of practice issue, as
defined by your medical staff credentials committee and your own personal
comfort level in managing adults.

Still, since all PEM fellowships require at least 2-3 months of adult
experience, one could argue that all PEM Fellowship Trained physicians have
had adult experience and expertise. After all, our Adult EM trained
colleagues are required to do only 3 months of pediatrics in a 3 year
residency, and then are privileged to care for children who present to EDs
throughout the country.

Most malpractice coverage is all encompassing for all ED Emergencies so
that you are indeed covered to manage all patients under the EMTALA
standard. Still, you might want to check with your specific carrier if you
have any concerns.

Whether PEM physicians CAN care for adults is not so much in question as
much as SHOULD PEM physicians care for these older patients, and I am not
sure you will get a clear answer from the PEM community.

Bob Flood






On Tue, Apr 22, 2014 at 2:49 PM, Chavda, Kamal <[log in to unmask]<mailto:[log in to unmask]>
> wrote:

> Hi  Dr. Flood,
>
>
> The question is not about patient showing up to a pediatric ED. That part
> is clear---If they show up all they need is screening exam and transfer
> them appropriately.
>
> The question was --- Hospitals where the pediatric and adult ED are
> adjacent to each other (separated by doors) the management at several
> institutions wants pediatric ED to take some of adult ED patients to ease
> the flow and waiting times etc ( Not to mention- improve customer service
> satisfaction- PG score)
>
>
> I had to do that sometimes out of courtesy for my adult ED colleagues when
> they got slammed ( did so very reluctantly and cherry picked patients)
>
> Other than not wanting to see adults as we chose to do pediatrics, my
> question would be.......
>
> If one is PEM trained  ---What does your malpractice insurance say in
> terms of age? Does it specify age?  In the event of a law suit could you be
> on your own?
>
>
> KKC,MD
>
> ________________________________________
> From: Pediatric Emergency Medicine Discussion List [
> [log in to unmask]<mailto:[log in to unmask]>] on behalf of Robert Flood [[log in to unmask]<mailto:[log in to unmask]>]
> Sent: Tuesday, April 22, 2014 3:02 PM
> To: [log in to unmask]<mailto:[log in to unmask]>
> Subject: Re: Adult patients in the PED
>
> Hi everyone:
>
> Regardless of the age range you care for in your ED, this entire
> conversation really focuses on two issues: Scope of Practice and EMTALA.
>
> EMTALA reigns supreme on all issues as it pertains to EM. As a physician in
> an ED, you must provide stabilization to the best of your hospital's and
> your personal capabilities. Since the training, expertise and experience of
> EM physicians vary greatly, everyone should keep these simple principles in
> mind.
>
> As such, I give the following advice to my staff:
>
> 1) All adult patients who present for care in our ED must have an EMTALA
> screening examination.
> 2) The extent of that screening examination is determined by your
> hospital's and your personal level of comfort of managing that patient to
> the point of Discharge or Transfer.
>
> For those who feel really uncomfortable managing adult patients, the extent
> of the medical screening will be much less than for say me, who trained in
> adult medicine.
>
> Lets not make this more complicated than it needs to be.
>
> Just my two cents.
>
> Bob Flood
> Division Director, PEM
> Cardinal Glennon, St. Louis
>
>
> On Tue, Apr 22, 2014 at 11:02 AM, Marjan Askar <[log in to unmask]<mailto:[log in to unmask]>
> >wrote:
>
> > I just wanted to point out that suturing a 30 year old May not be
> > different than the 15 year old, but the bottom line is that those of us
> who
> > chose to do a pediatric emergency fellowship following a pediatric
> > residency, are PEDIATRIC sub specialists.
> > We CHOOSE not to see adults .
> > Same argument goes for a heart surgeon performing general surgery .  Are
> > the able to and trsined? Yes
> > They CHOOSE not to.
> > This issue comes up where I work all the time.
> > In the era of see as many patients as quickly as you can and keep
> patients
> > satisfied , physician satisfaction with what they do is forgotten .
> > I simply CHOOSE to take care of kids.  This is what satisfies me.
> >
> > Marjan Askar
> > Lake Forest, IL
> >
> >
> > Sent from my iPhone
> >
> > > On Apr 21, 2014, at 7:46 PM, "Linzer, Jeffrey F" <[log in to unmask]<mailto:[log in to unmask]>>
> > wrote:
> > >
> > > Not to drag up too many old issues, but PEM's are emergency physicians
> > first. Yes, everyone who came up the peds track did only four months of
> > adult time and that won't make you an expert in figuring out whether to
> > start TPA on that 52 year-old who is having an evolving stroke or not.
> > However, I think doing a laceration repair on a relatively healthy 40
> > year-old isn't that much different than a 15 year-old.
> > >
> > >
> > >
> > > That said, the only "legal" issue is what services you are credentialed
> > by the hospital to perform (other than the occasional emergency surprise
> > that may so up at your door). If you work in a dual ED (adults and kids
> in
> > the same basic area), then the hospital is responsible for making sure
> you
> > are qualified to perform/provide services to certain patients. The
> > breakdown of peds care ending at 15, 17, 20 or 25 is purely artificial
> and
> > based on your specific hospital's policies. In fact the AAP recognizes
> > "young adults" (to age 26) under the purview of pediatrics (Guiding
> > principles for managed care arrangements for the health care of newborns,
> > infants, children, adolescents, and young adults. Pediatrics
> > 2013;132;e1452).
> > >
> > >
> > >
> > > So with that said, as long as the hospital has said your are qualified
> > to perform a service (and your malpractice carrier agrees) than you can
> go
> > ahead and provide the service.
> > >
> > >
> > >
> > > Just my 2₵
> > >
> > > Jeff
> > >
> > >
> > >
> > >
> > >
> > > Jeffrey Linzer Sr., MD, FAAP, FACEP
> > > Associate Professor of Pediatrics and Emergency Medicine
> > > Emory University School of Medicine
> > > Associate Medical Director for Compliance
> > > EPG/Division of Pediatric Emergency Medicine
> > > Children’s Healthcare of Atlanta
> > >
> > > [cid:[log in to unmask]]
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > > -----Original Message-----
> > > From: Pediatric Emergency Medicine Discussion List [mailto:
> > [log in to unmask]<mailto:[log in to unmask]>] On Behalf Of Lisa A Drago
> > > Sent: Monday, April 21, 2014 3:13 PM
> > > To: [log in to unmask]<mailto:[log in to unmask]>
> > > Subject: Adult patients in the PED
> > >
> > >
> > >
> > > Recently our adult colleagues have been requesting the PEM docs see
> > young adults ( under 30) when their volume becomes unbearable. Any PEM
> docs
> > seeing young adults in your practice and legally how are you handling
> this
> > (separate hospital privileges?)
> > >
> > >
> > >
> > > For more information, send mail to [log in to unmask]<mailto:[log in to unmask]><mailto:
> > [log in to unmask]<mailto:[log in to unmask]>> with the message: info PED-EM-L The URL for
> > the PED-EM-L Web Page is:
> > >
> > >                 http://listserv.brown.edu/ped-em-l.html
> > >
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The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html