Unfortunately, the majority of physicians practicing in the ED have not had residency training in either EM or pediatric emergency medicine (Moorhead et al., 2002). An assessment conducted in the late 1990s found that the supply of EM physicians was simply not sufficient to staff all ED physician positions, and not all EDs had access to a pediatric emergency medicine physician on staff (Holliman et al., 1997). This appears to be the case today as well (Moorhead et al., 2002). Therefore, physicians in some of the other disciplines (e.g., internal medicine, family practice) are needed to fill positions in EDs. It is difficult to determine the level of pediatric and EM training these physicians have received. Certainly those ED physicians who are pediatricians are familiar with children, but their formal training in EM may be limited. Likewise, ED physicians in such disciplines as internal medicine and family practice may have little formal training in either EM or pediatrics. Nevertheless, these ED physicians presently represent an essential component of ED staffing in many hospitals. Many may possess a high level of competency in pediatric emergency care, but it was gained through on-the-job experience rather than through formal training in a supervised setting.

As stated above, 3 percent of ED physicians are board certified in pediatrics. The committee is concerned not only about ED physicians lacking substantial training in pediatrics, but also about some pediatricians working in the ED lacking sufficient training in EM. According to the Residency Review Committee’s requirements for pediatric residency programs, pediatric residents must spend a minimum of 4 months receiving training in emergency and acute illness, but only 2 of those 4 months must be in EM (National Capital Consortium Pediatrics Residency, 2004). This means that some pediatricians practicing in the ED may have spent only 5.5 percent of their 3-year residency on EM, although again, many of these physicians may possess a high level of competency in EM based on their experience in the ED. Another concern is that sick children access care through their pediatricians, who may find it difficult to detect certain emergency conditions, such as meningococcemia, among their patients. A pediatrician who received little training in EM and who spends the majority of his or her time on well-child visits may have difficulty recognizing and addressing an emergency condition.

Beyond initial specialty training, physicians have a number of opportunities to obtain training in pediatric emergency care. Different hospitals have their own requirements in terms of continuing education for ED physicians. However, the most popular pediatric continuing education courses are PALS and advanced pediatric life support (APLS). These courses are often required during initial training as well; for example, the PALS course is required in 78 percent of EM residency programs and APLS in 17 percent of programs (Tamariz et al., 2000). Additionally, professional societies help



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