certification in the mid-1990s reflects those individuals who did so before the grandfather provision for the subspecialty ran out. The figure since that time indicates a rather stable number of trainees in pediatric emergency medicine. Most of the slots in these fellowship programs are being awarded to graduates of pediatric residency programs. As a result, the vast majority of pediatric emergency medicine subspecialists (89 percent of the total between 1994 and 2003) hold their primary board certification in pediatrics rather than EM (see Figure 4-1) (ABMS, 2003).

The average hospital is likely to have a board-certified EM physician attending, but unlikely to have a pediatric emergency medicine physician attending. Approximately 23 percent of EDs have a pediatric emergency medicine physician attending. Children’s hospitals and hospitals with large volumes of pediatric patients (more than 7,500 pediatric ED visits per year) are more likely to have a pediatric emergency medicine physician attending than the average hospital (Middleton and Burt, 2006). Among those hospitals without a pediatric emergency medicine physician attending, just over half have a board-certified pediatrician attending, and 20 percent have a written protocol for calling a pediatrician; 17 percent of EDs have no EM, pediatric emergency medicine, or pediatric attending physician.

The physicians who work in the ED have varying degrees of training in pediatrics. Those with the most formal training are those who have completed a fellowship in pediatric emergency medicine. The goal of the fellowship program in this subspecialty is to produce physicians who are clinically proficient in the practice of pediatric emergency medicine, especially in the management of the acutely ill or injured child, in the ED (ACGME, 2004). The training period for pediatric emergency medicine subspecialty residents is 2 years for EM physicians and 3 for pediatricians. The Accreditation Council for Graduate Medical Education (ACGME) specifies that the curriculum must include at least 12 months of seeing children in an ED that treats children for the full spectrum of illnesses and injuries. The training

FIGURE 4-1 Number of subspecialty certificates in pediatric emergency medicine, United States, 1994–2003.

SOURCE: ABMS, 2003.