Viewpoint: Merit Badge Madness

Abstract

Dr. Welch: is a fellow with Intermountain Institute for Health Care Delivery Research, an emergency physician with Utah Emergency Physicians, and a member of the board of the Emergency Department Benchmarking Alliance. Dr. Taylor is a physician executive for Microsoft Corporation's Health Solutions Group and the principle promoter of the national Emergency Department of the Future project. Dr. Cheung is a Malcolm Baldrige National Quality Award Examiner, former faculty of the Johns Hopkins Center for Innovation in Quality Patient Care and the Quality and Safety Research Group, and a member of ACEP's Quality and Performance Committee.Should board certified emergency physicians be required to earn certain “merit badge” credentials for hospital privileges? Should such certifications be required for activities like EMS base station medical control or specialty center designation? Hospitals, state EMS authorities, and specialty center designation bodies are increasingly turning to “merit badges” (see table) as proxies for competency in various specialty areas within emergency medicine. Does this make any sense? And where will this end? Will emergency physicians ultimately be required to hold certificates or earn CME hours in geriatric medicine, psychiatry, ethics, and ingrown toenail removal? An Internet search for “merit badge medicine” results in web sites for the Boy Scouts. Has it come to this? Should we wear merit badge sashes during our shifts? It's time to insert a bit of common sense into this madness. In the early days of the specialty, there were few training programs, and the first certifying examination in emergency medicine did not occur until 1980. As a result, most early emergency physicians gained on-the-job experience, and those who became board certified did so through the practice pathway. Since that time, training programs have expanded dramatically, and the only recognized path to board certification is now through emergency medicine residency training and the American Board of Medical Specialties' certifying bodies. Ironically, despite 30 years of formal emergency medicine board certification, “merit badge” requirements have re-emerged as a phenomenon. Are these efforts unwarranted, unnecessary, or even counterproductive? And what is driving this trend? The American College of Emergency Medicine and the American Academy of Emergency Medicine are clear on the use of “merit badges,” and these positions can be used as support exemption from merit badge requirements: The AAEM membership card notes that a fellow is board certified in emergency medicine and therefore has advanced resuscitation expertise in pediatric, trauma and cardiac care. The 1999 ACEP policy, “Use of Short Courses in Emergency Medicine as Criteria for Privileging or Employment,” strongly discourages the use of certificates in subareas of emergency medicine as requirements for privileges or employment. (http://bit.ly/ShortCourse.) Nevertheless, the growing list of merit badges required for hospital credentialing and privileging has become cumbersome. Resources for continuing medical education for physicians can be a zero-sum game. The time and cost for merit badge achievement will inevitably result in other, perhaps more important, educational areas being ignored. Most states and specialty societies require CME for maintenance of licensure and membership. On average, this requirement is 20 to 50 credit hours a year, and can often require up to two weeks away from work (worth $10,000 to $20,000) and $5000 to $8,000 for tuition and travel expenses. While making a financial argument against merit badges can be risky (i.e., “doctors make lots of money”), it can be done successfully. Arizona ACEP avoided state-mandated merit badges by pointing out the total annual cost for particular requirements. An effort to require PALS by all ED staff (including nurses) was defeated when it was suggested it should be funded as a state-mandated program at an annual cost of more than $8 million. This idea quietly went away. As a relatively young specialty, emergency medicine may suffer from a lack of understanding by the community, hospital administrators, and regulators on the breadth of expertise and training of board certified emergency physicians. Even among emergency physicians, considerable confusion exists over the Emergency Medicine Continuous Certification program requirements. These requirements, built on residency training and certification, are perhaps the best argument against merit badges. With the significant investment in initial training and the ongoing and increasing Maintenance of Certification requirements, merit badges are simply unnecessary. There is no evidence that any of these individual credentials correlate with improved clinical care. In contrast, one study demonstrated a quality correlation between board certification and quality measures. (Arch Intern Med 2010;170[16]:1442.) In addition, the “credentials equal quality” mental model is founded on a false premise, that putting more knowledge in the head of the practitioner will improve care. In the Agency for Healthcare Research and Quality whitepaper, “Mistake Proofing the Design of Health Care Processes” (www.ahrq.gov), the authors note that one of the biggest failed mental models in health care has been to assume that if we could put more into the practitioner's memory, we could avoid mistakes and provide better care. The premise is faulty because the human memory is fallible. The passage of time erases these efforts from memory if not used regularly. An example is pediatric resuscitation credentialing where pediatric critical care occurs only once every 30,000 to 40,000 ED visits. So the average PALS certified practitioner in a community hospital will go years or even decades before using the information, which is unlikely to be retrievable when actually needed. No other specialty requires physicians to jump through as many hoops to put on a white coat and practice medicine. Five arguments can be used against merit badge requirements for board certified emergency physicians: ACEP and AAEM have strong policy statements against merit badge requirements. Maintaining these credentials is growing more burdensome, expensive, and crowding out more important CME activities. The new ABMS Maintenance of Certification requirements supersede the need for merit badges. There is no proven quality correlation with merit badge requirements. The mental model of “knowledge in the head” is a false premise. Comments about this article? Write to EMN at[email protected]. Click and Connect!Access the links in this article by reading it onwww.EM-News.com. Typical Merit Badges Basic Life Support (BLS) Advanced Cardiac Life Support (ACLS) Advanced Trauma Life Support (ATLS) Advanced Pediatric Life Support (APLS) Pediatric Advanced Life Support (PALS) Advanced Airway Courses Procedural Sedation Courses Ultrasound Training and Credentialing Hazardous Materials Training (HAZMAT) The Joint Commission's Ongoing Practice Performance Evaluation (OPPE) 16 hours a year of trauma CME (for physicians practicing in American College of Surgeon Certified Trauma Centers) Various state-specific requirements (pain management, geriatric medicine, end-of-life care, infectious disease, risk management, sexual assault, domestic violence, cultural competence, appropriate prescribing, medical jurisprudence, ethics in medicine) CME Requirements Read a state-by-state listing of CME requirements at http://bit.ly/CMErequirements.