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Interesting discussion.

The real issue is that clinical expertise can be attained by both formal
training and experience.  After my Med-Peds residency, I had over 11,000
hours of clinical ED experience, mostly at an academic center, before doing
my 3 year fellowship in PEM.

Still, the idea that PEM should do more adult time is really interesting,
but would not likely be well received by pediatricians.

On the other hand, it seems to me that the best clinical background for ED
would be as a sub-specialty of Internal Medicine, similar to the way PEMs
are trained. Unfortunately, ABEM has never and will never allow this
pathway for board certification. Politics more than any other reason.

The last of my 2 cents.

Bob


On Fri, Apr 25, 2014 at 11:26 AM, IOANNIS KOUTROULIS
<[log in to unmask]>wrote:

> True but not board eligible for PEM though..I think we have to realize that
> a PEM is primarily an ER doc (a pediatric subspecialist but like a peds
> neurologist that gets training in adult neurology as well) and although
> there are 2 routes to become a PEM, the result is the same..A PEM should be
> able to run an ED and if needed to see adults..If not, then PEMs through
> peds can be looked as second class citizens within the EM community..As an
> EM trained doc can see kids, a PEM should be able to see adults..I
> understand that we chose to do peds in order not to see adults but the ED
> is a unique place and why not having the qualifications and be the one to
> make the decision in the end? What I mean is that an EM residency is 3
> years long and a PEM fellowship is 3 years long as well. Instead of having
> so many research months, a PEM fellow should do more adult EM and be
> qualified in the end to see all patients. Then ultimately a PEM can decide
> to work in a children's hospital and see only kids or work in a general ED
> and see everything..If the training is the problems the 3 years of PEM
> fellowship are more than enough to get it!
>
> My 2 cents..
>
> Ioannis Koutroulis,MD
>
> St Christopher's Hospital for Children, Philadelphia
>
>
> On Thu, Apr 24, 2014 at 5:42 PM, Dr. Adam Friedlander <
> [log in to unmask]> wrote:
>
> > At least we're all in agreement that the most qualified docs for seeing
> > whatever comes in the door are those trained at combined EM/Peds
> programs.
> > :)
> >
> >
> > Adam D. Friedlander, MD, FAAEM
> > Nothside-Forsyth Emergency Department
> > Northside Emergency Associates
> >
> >
> > On Thu, Apr 24, 2014 at 4:42 PM, Don Zweig <[log in to unmask]> wrote:
> >
> > > Sounds like adult em trained should not see peds if peds should not see
> > > adult.
> > >
> > > From Don's fingers 2 u
> > >
> > > > On Apr 24, 2014, at 11:54 AM, Dale Woolridge <[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]] on behalf of Robert Flood [[log in to unmask]
> ]
> > > > Sent: Tuesday, April 22, 2014 3:30 PM
> > > > To: [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]
> > > >> 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]] on behalf of Robert Flood [
> > [log in to unmask]]
> > > >> Sent: Tuesday, April 22, 2014 3:02 PM
> > > >> To: [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]
> > > >>> 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]>
> > > >>>> 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]] On Behalf Of Lisa A Drago
> > > >>>> Sent: Monday, April 21, 2014 3:13 PM
> > > >>>> To: [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:
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> URL
> > > for
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> > > >>>>
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