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Ethics of residents working unsupervised in the ED
Unprofessional and risky, some physicians say
Are residents in training who moonlight in emergency departments (EDs) more likely to experience clinical errors and oversights? The answer is a definite yes, say experts, and to allow them to practice unsupervised is unethical, they add.
"There is absolutely no doubt [that the practice increases the risk of errors]," says Tom Scaletta, MD, FAAEM, chair of the ED at Edward Hospital in Naperville, IL, and president of the American Academy of Emergency Medicine (AAEM).
A position statement issued in 2000 by the Society for Academic Emergency Medicine, the Council of Emergency Medicine Residency Directors, and the AAEM concludes that ED moonlighting is a form of dependent medical care.1 The statement concludes such residents must be actively enrolled in an emergency medicine program approved by the Accreditation Council for Graduate Medical Education or American Osteopathic Association, with supervision that is continuous, on-site, and provided by fully licensed physicians who are board-certified and prepared in emergency medicine by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine.
"There are several articles that make it clear that board certification or residency training in emergency medicine enhances the quality of care," says Scaletta.2,3
Moonlighting residents may take the "ignorance is bliss" approach, but this is legally risky and dangerous for patients, says Carey D. Chisholm, MD, director of the emergency medicine residency program and clinical professor of emergency medicine at Indiana University School of Medicine. "I'm not as worried when they realize they are in over their heads in that environment, but more so with the items they don't realize they are missing," he says.
Chisholm recommends that faculty members ask themselves the question, "How often do you have no input whatsoever when a resident, particularly a second year one, is managing a case in the ED?"
Unsupervised residents practicing in EDs continues to be a "significant problem" for the specialty of emergency medicine, says Chisholm. "It continues to propagate the impression within the global medical community that anyone can practice emergency medicine," he says.
It is unethical for a resident in training to practice emergency medicine unsupervised, says Scaletta. "It has been two decades since the practice-track, which amounted to learning-on-the-job, has been closed," he says.
Chisholm feels strongly that the practice is unprofessional, both for the practitioners involved and the specialty of emergency medicine. "Residents who moonlight in solo practice settings have made a decision to place their financial well-being ahead of the patient's. And you denigrate the specialty by saying it's OK to go out and practice it before you're fully trained," he says. "We don't see that happen with obstetricians or surgeons or dermatologists. They don't go out and practice before they complete their training."
However, Bruce David Janiak, MD, FACEP, FAAP, vice chair of the department of emergency medicine at Medical College of Georgia in Augusta, argues there is no ethical problem as long as the institutions in which they moonlight credential them appropriately.
"Requirements regarding board certification and residency completion are institution-specific," he says. "As it turns out, large urban hospitals can attract more ED docs; thus they usually require board certification. Small, rural hospitals do not have this luxury."
A bigger dilemma is that you can be sued for restraint of trade if you do not allow your residents to moonlight, says Chisholm. "Because if the state says they can work there and they have a fully accredited license, why can't they?" he says.
Allowing moonlighting in urgent care settings and double coverage EDs with a more experienced physician reduces the risks involved, says Scaletta. "Urgent care settings are not EDs. There is much less at risk," he says. "I think a senior ED resident would be fine in this type of setting."
Residents are more inclined to accept inappropriate recommendations from consultants, and this is one of the major liability risks involved, says Chisholm.
A physician who is a member of the medical staff working alongside the resident will be able to give input when the resident gets advice he or she doesn't feel comfortable with, says Chisholm. The physician also would be able to assist with patient dispositions such as transfers that may be rarely encountered in the academic center.
Though there are no concrete data to support this, most residents moonlight in low-volume institutions; therefore, their exposure to risky situations is likely to be lower, says Janiak.
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