Emergency Medicine Advocacy Handbook

Ch. 13. Board Certification: Why It Matters

Krishna J. Patel, DO; Sandra Gad, MSc; Kathleen Cowling, MS, DO, MBA, FACEP

Chapter 13. Board Certification: Why It Matters

Recorded by Rajkumar Pammal, MD | Mount Sinai Morningside West

In our humble beginnings, emergency medicine was the melting pot of various specialties, making us now one of the most flexible and adaptive areas of medicine. However, this has also contributed to dissonance with regards to board certifying organizations- American Board of Emergency Medicine (ABEM), American Osteopathic Board of Emergency Medicine (AOBEM) and Board of Certification in Emergency Medicine (BCEM). ABEM and AOBEM certify emergency medicine residency-trained physicians only, while BCEM will certify non-emergency medicine specialty-trained physicians. And in many areas, emergency departments are still staffed by physicians with no EM certification at all.

To the layperson and general public, stating that one is a board-certified physician in a certain field implies that a physician is an expert in that field. True expertise in medical specialties can only be reached by completing specialized residency training.

Why It Matters to EM and ME

The practice of emergency medicine requires physicians to have a broad fund of knowledge and thorough specialized training. Our patients come to us in their most vulnerable states, and they deserve quality care from well-trained physicians. This can only be effectively achieved with formalized emergency medicine graduate medical education. The persistent push for non-emergency medicine-trained physicians to obtain board certification through BCEM questions the legitimacy and value of an emergency medicine residency.¹ Training in a primary care residency program focused on family medicine, internal medicine, pediatrics, or general surgery is not equivalent to the number of hours of training in acute care required during an emergency medicine residency. The same would be true for emergency physicians wanting to practice a specialty in which they are not residency-trained.

Emergency medicine residents are required to meet rigorous detailed milestones during training and must demonstrate competency in a multitude of procedures set forth by the American Council of Graduate Medical Education (ACGME).² These benchmarks ensure that every resident graduating from an accredited emergency medicine residency program is a highly proficient and qualified physician. The ACGME requirements differ from specialty to specialty,³ therefore it is unreasonable to assume that non-EM trained physicians would have achieved competency in emergency medicine. The specialty of emergency medicine “has grown such that residency training is widely available and should be the pathway for new physicians entering the practice.”¹

How We Got to This Point

Once known as the “weakest link of the hospital,” emergency departments have evolved into the strongest frontline defense of any hospital system.⁴ Our specialty was created to fill the vast gap in health care that once existed in an acute setting. A growing number of physicians in the early 1960s began training in emergency medicine. This paved the path for ACEP to be established in 1968.^5,6 The college initially was composed of physicians from various other specialties who took a keen interest in developing emergency and trauma medicine. As the specialty gained national momentum, a physician trained as a hematologist in Cincinnati sought to improve emergency care through formalized education. The first emergency medicine residency program was born in 1970 at the University of Cincinnati.6 Through continuous national expansion and advocacy, emergency medicine became recognized by the American Board of Medical Specialties in 1979. Thereafter, specialized boards for emergency medicine were created and the American Board of Emergency Medicine (ABEM) certified its first physicians in 1980, later gaining conversion to primary board status in 1989.⁶ During this conversion period, the Accreditation Council for Graduate Medical Education (ACGME) approved specific requirements for emergency medicine residency training programs.

Prior to establishing primary board status, physicians from other specialties not undergoing emergency medicine residency training could still be certified under ABEM with proof of work experience in emergency departments. After a lengthy grace period, ABEM eliminated the “practice track” option of being board eligible into the specialty in 1988.⁷ Yet some physicians still wanted to practice emergency medicine without formalized training, and in 1987, they created the Board of Certification in Emergency Medicine. Later that year, BCEM certified its first physicians who were not ABEM or AOBEM eligible. In the years to follow, there was rising strife among residency-trained emergency medicine physicians versus non-EM trained physicians. This contributed to the formation of another body of emergency physicians: the American Academy of Emergency Medicine (AAEM). However, currently both bodies of physicians, ACEP and AAEM, only recognize ABEM or AOBEM certified emergency physicians as qualified trained specialists in the field.^4,7

In contrast, BCEM is a certifying board that provides eligibility for non-EM trained physicians to be certified in emergency medicine. BCEM is a member of the American Board of Physician Specialties (ABPS)⁸ – not to be confused with the American Board of Medical Specialties. To be certified in emergency medicine, BCEM offers three pathways. One of the aforementioned pathways requires completing an approved residency in a primary care specialty (family practice, internal medicine, pediatrics, or surgery). Candidates must also demonstrate at least 5 years of full-time emergency medicine experience with a minimum of 7,000 hours in the practice of emergency medicine, where a minimum of 1,400 hours per 12-month period is accumulated, although there is a slight difference in timeline depending on the residing state.⁹ Another alternative pathway requires candidates to complete either a 12- or 24-month emergency medicine fellowship approved by the BCEM. There are currently 13 approved BCEM fellowships available.10 All candidates regardless of BCEM eligibility track, must pass both an initial written exam with a subsequent oral examination to be fully recognized. Additionally, all candidates must provide 10 case reports in which they led emergency medicine care.^9,11

It is important to note that the ACGME is the overarching governing body for all graduate medical residency programs, while there is no umbrella organization that sets education standards for BCEM-recognized emergency medicine fellowships – although the ABPS-affiliated American Association of Physician Specialists, Inc. (AAPS), does offer an EM fellowship recognition program.¹² This is an important distinction, as the ACGME has rigorous and detailed requirements for emergency medicine residents to complete in order to demonstrate specialty competency.²

Current State of the Issue

After closing the pathway for non-emergency medicine specialty trained physician certification by ABEM, a growing number of physicians pushed to be grandfathered into the specialty. This led to the landmark case of Daniel vs. ABEM. In 1990, Gregory Daniel and numerous co-plaintiffs sued ABEM in an effort to reopen this certification tract. After 15 years of court arguments, the case was ultimately dismissed in 2005, reaffirming the current residency-based approach for physicians wanting to specialize in emergency medicine.¹³

However, this case did not put an end to all certification pathways for non-emergency medicine trained physicians. AAPS, alongside its affiliate, ABPS, continues to advocate for alternate certification pathways without requiring emergency medicine residency training. ABPS was created as the parent organization to BCEM, and BCEM accounts for approximately 70% of ABPS board certifications. The exact number of physicians certified through ABPS, and BCEM specifically is not available and is proprietary information, per ABPS leaders.¹

Recognition of a “board certified” physician is ultimately up to the licensing state medical board. However, this varies from state to state. ACEP, AAEM, and EMRA, among other widely known and respected emergency medicine associations, stand by the American Board of Medical Specialties (ABMS) and Boards of Certification of the American Osteopathic Association in defining a “board certified” emergency medicine physician as one who has passed qualifications through ABEM/AOBEM. BCEM certified physicians are recognized as emergency medicine “board certified” physicians in multiple states, including Texas and Florida.^1,14 In Oklahoma, BCEM and ABPS were briefly successful in gaining “board certified” recognition in 2010, before this decision was swiftly reversed after “pressure from emergency physicians and state legislature.”¹⁴ To date, ABPS/BCEM and ABMS/ABEM continue to be on colliding paths in numerous states. ACEP continues to recognize “only ABEM and AOBEM as the only certifying bodies for emergency medicine.”¹

So why does using the term “board certified” matter? To the layperson and general public, stating that one is a board-certified physician in said field implies that a physician is an expert in that field. True expertise in medical specialties can only be reached by completing specialized residency training.^1,14 The premise of BCEM certifying non-emergency medicine specialty trained physicians in emergency medicine questions the legitimacy of residency based medical education in general.^1,14 Additionally, a physician who practices outside of their scope of specialty and residency training may be a patient safety risk.¹⁴ If physicians fail to earn certification by the end of their eligibility period, they are no longer considered board eligible and must complete one year of residency retraining or a fellowship program in order to reestablish eligibility. But BCEM offers board certification options to these physicians “who are no longer board eligible.”¹⁵ This is alarming and threatens the safety of patients.

BCEM continues to claim the nation has an “ongoing shortage of rural physicians in emergency medicine” and this is why “certification options offered by ABPS are critically important.”¹⁶ But it is worth noting that the Emergency Medicine Physician Workforce Projections for 2030 predict a surplus of 7,845 emergency physicians in 2030, with the majority of these physicians being emergency medicine residency trained.¹⁷

Moving Forward

Patient care extends beyond a brief consultation with an individual patient. The scope of physicians’ duty to patients includes public health, political advocacy, cultural acceptance, and societal awareness. The future of emergency medicine depends on today’s advocacy efforts. We must continue to show representation to our respective state legislators and state medical boards.

“EMRA believes that the only pathway to the independent practice of emergency medicine in the 21st century is completion of an ACGME/AOA accredited emergency medicine residency training program and board certification by ABEM or AOBEM.”¹⁸ It is our responsibility to educate hospital systems the value an ABEM/AOBEM board certified emergency medicine physician brings to humanity.

• American Board of Emergency Medicine (ABEM)/American Osteopathic Board of Emergency Medicine (AOBEM) offer board certification to emergency medicine residency trained physicians only.
• Board of Certification in Emergency Medicine (BCEM) certifies non-emergency medicine specialty trained physicians.
• The leading nationally recognized and respected emergency medicine organizations - AAEM, ACEP, and EMRA, all recognize only ABEM and AOBEM as acceptable certifying bodies for emergency medicine.
• It is our responsibility to educate hospital systems and the public about the value an ABEM/AOBEM board certified emergency medicine physician brings to society.
• The future of emergency medicine depends on today’s advocacy efforts. We must continue to show representation at our respective state legislators and state medical boards.
• Physicians from non-emergency-medicine residencies continue to practice and train in emergency medicine, and have sometimes sought alternate board certification to do so (ABPS), so ongoing advocacy for the ACEP definition of an emergency physician is critical.

References

1. SoRelle R. AAPS ramping up campaign for recognition. Emergency Medicine News. 2010;32(3):1-20.
2. Accreditation Council for Graduate Medical Education. Emergency medicine program requirements and FAQs. Updated July 2022.
3. Accreditation Council for Graduate Medical Education. Specialties. ACGME.org. https://www.acgme.org/specialties/. Accessed May 31, 2022.
4. American College of Emergency Physicians. Making every moment count. Accessed May 31, 2022.
5. American Board of Emergency Medicine. ABEM History. Accessed May 31, 2022.
6. Suter RE. Emergency medicine in the United States: a systemic review. World J Emerg Med. 2012;3(1):5-10.
7. American Academy of Emergency Medicine. History. Accessed May 31, 2022.
8. American Board of Physician Specialties. What is the Board of Certification in Emergency Medicine (BCEM)?. Accessed May 31, 2022.
9. American Board of Physician Specialties. Emergency Medicine Eligibility. Accessed May 31, 2022.
10. American Board of Physician Specialties. Emergency Medicine Fellowships. Accessed May 31, 2022.
11. American Board of Physician Specialties. Emergency Board Certification from the ABPS. Accessed May 31, 2022.
12. American Association of Physician Specialists, Inc. Recognition for Emergency Medicine Fellowships. Updated July 2022.
13. Daniel v. Am. Bd. of Emergency Med. Docket Nos. 03-6153(L), 03-6163(XAP), 03-6165(XAP), 03-6157(XAP),03-6185(XAP), 03-6187(XAP), 03-6167(XAP), and 03-6177(XAP). Argued Oct. 25, 2004. Decided Oct. 7, 2005.
14. Walker A. AAEM Common Sense: Legitimate. Medscape. Sept. 14, 2010.
15. American Board of Physician Specialties. The American Board of Physician Specialties® Offers a Recognized Certification Option for Physicians Who Are No Longer Board Eligible. Accessed May 30, 2022.
16. American Board of Physician Specialties. Board Certification Options for Rural Physicians. Accessed May 30, 2022.
17. Marco CA, Courtney DM, Ling LJ, Salsberg E, Reisdorff EJ, Gallahue FE, Suter RE, Muelleman R, Chappell B, Evans DD, Vafaie N, Richwine C. The Emergency Medicine Physician Workforce: Projections for 2030. Ann Emerg Med. 2021;78(6):726-737.
18. Emergency Medicine Residents' Association. Policy Compendium. EMRA.org. https://www.emra.org/globalassets/emra/about-emra/governing-docs/november-2021-policy-compendium.pdf. Accessed May 31, 2022.