American Journal of Emergency Medicine (2011) 29, 283-285

Original Contribution

Academic practice of emergency medicine in the nation’s Veteran’s Affairs Hospitals^?

Chad Kessler MD ^a,b,?, Vaishal M. Tolia MD, MPH ^c,

Xui Xie^d, Ravi Kasi^e, Bradley Kutka ^e

^aSection of Emergency Medicine, Jesse Brown VA Medical Center, Chicago, IL 60612, USA ^bDepartment of Emergency Medicine, University of Illinois-Chicago, Chicago, IL 60612, USA ^cDepartment of Emergency Medicine, University of California-San Diego, San Diego, CA 92101, USA

^dDivision of Epidemiology and Biostatistics, School of Publich Health, University of Illinois-Chicago, Chicago, IL 60612, USA ^eUniversity of Illinois-Chicago College of Medicine, Chicago, IL 60612, USA

Received 28 September 2009; revised 1 October 2009; accepted 2 October 2009

Introduction

During its first decade in existence from 1979 to 1988, the American Board of Emergency Medicine (ABEM) instituted a clause that granted board certification to non-emergency medicine (EM)-trained physicians who had completed a minimum number of hours working within an emergency department (ED) [1,2]. This practice was discontinued by 1988 as ABEM began to place a stronger emphasis on hiring EM residency-trained, board-certified (BC) physicians to staff EDs [2,3]. Although improvements were seen in EDs nationally, the same positive changes were not seen in Veteran’s Affairs (VA) EDs [4]. In addition, a study by Young et al [4] illustrated a severe lack of resident, especially EM resident, participation in the nation’s VA EDs.

In 1993, 26.1% of the surveyed VA EDs stated they were actively recruiting EM BC physicians [5]. Since Young’s publication in 1993, there has been no published interval data

^? This study received no external funding.

* Corresponding author. Departments of Internal Medicine and Emergency Medicine, Combined Internal Medicine/Emergency Medicine Residency, University of Illinois, Jesse Brown VA Hospital, IL 60612, USA. Tel.: +1 312 569 6508.

E-mail addresses: [email protected] (C. Kessler), [email protected] (V.M. Tolia), [email protected] (X. Xie), [email protected] (R. Kasi), [email protected] (B. Kutka).

0735-6757/$ - see front matter. doi:10.1016/j.ajem.2009.10.001

collected marking the progress of attending physician employment and residency program involvement in the VA. Thus, the goal of this study is to investigate the number of VA EDs employing EM BC faculty and identify the number and training program of residents rotating through VA EDs. We will then compare our findings to a similar study of VA EDs to assess the progress or lack thereof that has been made over the past 15 years. It is hypothesized that in light of continued recommendations from ABEM to increase the number of EM BC faculty, the data will demonstrate a modest increase in the number of EM BC faculty and

residency participation at the nation’s VA EDs.

Materials and methods

This is a prospective survey study conducted at 120 VA EDs nationally. The survey was developed and validated by the authors and conducted in February 2009 [6,7]. The study received exemption status from the institutional review board of the VA and University Hospital.

Surveys were emailed to ED section chiefs at the 120 VA facilities previously identified as having a fully functioning ED. Responses were collected over a 4-week period, and follow-up contact was made during those 4 weeks via telephone. Data analysis of the survey responses was blinded

284 C. Kessler et al.

and performed by an independent statistician without any knowledge of the study’s intentions.

Analysis involved standard descriptive statistics for mean values and standard deviations. Statistical analysis included the ?2 test for categorical variables (P <= .05). Data points were then compared to a previous study for statistically significant change. Analytical comparisons were made, where appropriate, using the Kruskall-Wallis nonparametric test computed via SAS 9.2 (SAS Institute, Cary, NC).

Results

All of the 120 VA EDs provided complete data regarding demographics of attending physicians and house staff. The data are subdivided into attending and resident coverage.

Attending coverage

Of the 120 VA EDs, all 120 (100%) had 24/7 coverage provided by an attending physician. Sixty-five of the 120 facilities (54.1%) employed EM BC-trained attending physicians in some capacity. These 65 facilities housed full-time EM BC physicians, part-time EM BC physicians, or both. There were a total of 185 full-time EM BC physicians and 25 part-time EM BC physicians distributed among the aforementioned 65 facilities. The other 55 facilities (45.8%) had coverage provided by attending physicians trained in Family Medicine, internal medicine, or both.

Resident coverage

Of the 120 VA EDs surveyed, 58 facilities (48.3%) had dedicated house Staff coverage while the remaining 62 facilities (51.7%) had coverage provided by attending staff only (Fig. 1). Nine facilities (7.5%) had coverage provided by residents training in EM. Moreover, in the 9 facilities staffing EM resi- dents, 8 (88.9%) also employed EM BC attending physicians. The level of training of the house staff working at the 58 facilities was found to be equally distributed between the 3

Table 1 Comparison of attending and resident data

Fig. 1 Resident coverage in Veteran’s Affairs ED.

postgraduate years: 29 facilities (50.0%) had PGY-1, 30

facilities (51.7%) had PGY-2, and 34 facilities (58.6%) had PGY-3 residents rotating through their doors.

Discussion

The survey results indicate a promising growth in the number of EM BC attending physicians working in VA EDs, but a substantial lack of growth in terms of resident coverage, spe- cifically EM residents, at these facilities. In 1993, a similar study of VA EDs identified only 21 facilities (18.9%) with EM BC attending physician coverage [4]. Current data collected 15 years later show a substantial increase to 65 total facilities (54.2%) employing EM BC physicians (P b .0001). With increasing numbers of BC faculty, EM is taking root in the VA; however, the impact of EM BC physicians in the VA is still unknown.

Resident participation in VA EDs has remained relatively stagnant in comparison to previous data (Table 1). In 1993, EM residents were rotating through 4 VA EDs (3.6%) [4]. Our current data show only a small increase to 9 VA EDs (7.5%) with EM residency participation (P = .15) (Table 1). Of the 58 VA EDs found to have resident coverage, an overwhelming 85% or 49 facilities staffed residents training in internal medicine or family medicine. The limited exposure to VA EM by categorical EM resident physicians is one reason the VA continues to have significant problems recruiting and retaining BC EM physicians [4,8].

In conclusion, this study suggests a significant increase in the number of EM BC physicians at VA EDs nationally when compared to past similar studies. In contrast, resident coverage, particularly EM resident coverage, has stayed relatively stagnant. Although certain progress has been made, there still exists a significant gap in EM attending and resident coverage in the nation’s VA EDs. Moreover, if the trend of staffing with more EM BC physicians continues, it is

2008 data		1993 data (from Young et al [4])	P
VHA facilities with	65 facilities	21 facilities	b.0001
BC EM faculty	(54%)	(19%)
VHA facilities with any	58 facilities	60 facilities	.43
resident participation	(48%)	(54%)
VHA facilities with EM	9 facilities	4 facilities	.15
resident participation	(7.5%)	(3.6%)
VHA facilities with	45 facilities	n/a	n/a
exclusive internal	(38%)
medicine resident
participation
VHA facilities with	4 facilities	n/a	n/a
exclusive family	(3%)
medicine resident
participation

VA academic emergency medicine 285

likely that more EM residency programs will be able to partner with VA EDs. This would expose the next generation of EM physicians to the VA system and become a positive recruiting tool for VA emergency departments.

References

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