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Board Certification Standards: Should They Be Lowered?

This post at The Central Line caught my eye:

Texas Recognizes ABPS Certification

The Texas Medical Board ruled on Oct. 20 that physicians certified by the American Board of Physician Specialties (ABPS) could advertise themselves as board certified to the public.

The ABPS is the certifying body of the American Association of Physician Specialties (AAPS). The ABPS sponsors 17 boards of certification, including the Board of Certification in Emergency Medicine (BCEM).

For a number of years, ABPS, in conjunction with AAPS, has been seeking recognition from various state medical boards, requesting that they allow physicians certified through an ABPS board to advertise themselves as board certified. The organizations were successful in Florida in 2002 but were recently rebuffed by the State of New York due to the lack of residency training as a qualification for ABPS board certification.

ACEP does not recognize BCEM as a certifying body in emergency medicine.

This is bad. I’ve mostly stayed out of the internecine squabbles in the house of medicine, for a variety of reasons. Mostly because 99% of the issues are incredibly petty and provincial; for that reason I have a hard time getting/staying interested in these issues. This is a little different.

For background, the certifying body for Emergency Physicians for the last 30 years has been the American Board of Emergency Medicine (ABEM), which itself is under the umbrella of the American Board of Medical Specialties (ABMS), which has been the standard board certification organization of all allopathic physicians for the last 75 years. There is a companion organization for osteopathic physicians. The ABPS is relatively new in the last three years, though it is an offshoot of an organization which has been around for about 25 years, and it also purports to provide Board Certification in various specialties.

As it relates to Emergency Medicine, the ABPS is problematic. Specifically, it allows physicians to seek certification in Emergency Medicine without completing a training program in Emergency Medicine. It accepts training in a Primary Care specialty or, oddly, Anesthesiology, as equivalent to an Emergency Medicine residency. As best as I can tell, Emergency Medicine is the only such specialty certification for which the ABPS does not require completion of an ACGME-certified specialty training program. Residency training is required for ABPS certification in Radiology, Ophthalmology, Family Practice, Anesthesiology, and Orthopedic Surgery, at least. Why is Emergency Medicine held to a different, lower, standard under ABPS?

Unlike the other specialties, there are thousands of doctors practicing Emergency Medicine who are not residency-trained. This is in part an anachronism due to the relative youth of Emergency Medicine as a specialty; there are many ER docs who have been working in the ER since well before the ABMS recognized Emergency Medicine as a distinct specialty. It is also true that there are more ER positions than there are residency-trained graduates of EM residencies, and this is likely to remain the case for the foreseeable future. Even as new training programs open, the rate of graduation of new residents barely makes up for the retirement of practicing ER docs, let alone makes up the gap in the number of untrained ER docs.

Even today, many young primary care docs tire of the drudgery of office practice and give it up for the easier lifestyle and higher compensation of the local Emergency Department. Many small ERs, especially those in rural areas, have trouble attracting good physicians and as a result are willing to credential almost any physician willing to staff their department. This is not an ideal circumstance, of course, but when your ED cannot find doctors any other way, it does become something of a buyer’s market.

So it is necessary to recognize the existence of the thousands of moonlighters and other variously-competent doctors working in the nation’s ERs; it’s a reality that is not going to go away any time soon. It’s actually a good thing that there is a certifying body that can guarantee some minimum level of competency for these practicing physicians. As long as we have the necessary but undesirable situation of untrained physicians working in the ED, I am not opposed to the existence of the AAPS program.

What I am opposed to is the dishonesty of these physicians and their organizations in presenting themselves to the public as “Board Certified.” This is misleading in the extreme. Board Certification has always been held to mean a high standard of training and accomplishment. It is a standard across 24 specialties. For an alternate organization to set itself up and promote a lower standard is disturbing. More disturbing is the manner in which the ABPS/AAPS slipped this in through the Texas Medical Board apparently in the dead of night with no public discussion. If there is to be equivalency between ABPS/AAPS and the ABEM, it should be agreed upon after a full and open debate. For myself, I do not think that this equivalency is merited. The ABPS is like ACLS and ATLS — a nice merit badge to show that you’re not likely to hurt anybody while working in the ER, but not the same as a specialty training certificate. But if Texas (or any other state) medical board decides otherwise, then that decision should be the product of a public debate and consensus among the physician leaders in that state.

If the implication of the linked article is accurate, this decision was the result of a shameful bit of political sleight of hand. I hope that ACEP is successful in reversing this ruling.

Ultimately, this is a manpower situation that Emergency Medicine needs to come to grips with. While new residencies continue to open in dribs and drabs, and existing residency programs expand a bit, the rate of increase is far too slow. Unfortunately, the funding from Medicare which underwrites the cost of graduate medical education is very hard to come by in this difficult budgetary environment. In an ideal world, the residencies would grow to the point that all Emergency Physician positions would be filled by, you know, trained Emergency Physicians. I don’t know whether that will happen in my professional lifetime. The consequence is that many of the nation’s Emergency Departments will continue to be staffed by untrained doctors of uncertain quality. That is a pity for the patients who come through the doors, who are after all a captive audience, unable to make a choice of their treating provider. They deserve better.

*This blog post was originally published at Movin' Meat*

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2 Responses to “Board Certification Standards: Should They Be Lowered?”

  1. jamie says:

    your argument above is very weak and has no data to back up any assumptions.

    #1) This is “dishonest.” Many boarded ER physicians practicing today ER medicine are not residency trained. Many were grandfathered in. Are they a “lower standard? than the ER trained physician. ABPS could be viewed as really no different as the same standards which applied to those physicians prior to the arbitrary cut off date

    2) You assume that board certification in Emergency Medicine assumes competency in Emergency Medicine. This is an assumption and not reality. Some ER trained physicians are competent and many boarded ones are not. It is a good thing that hospitals credentail physicians at the local level to be able to address the gross inequities and abilities of physicians in general despite their credential. Many rural ERs are ecstatic to hire a “board certified” ER physician only to find that they are not adept in that environment at all as most weree trained in tertiary care facilities with extensive back up.

    You make the erroneous assumption that ER residency training will provide a competent ER doctor. This is a fallacy and cannot be backed up by any scientific data whatsoever. Residency training increases the odds by virtue of the exposure it gives young doctors but it does not supplant the reality that medicine is really learned “1 patient at a time.”

    You leave out the critical nature of experience and time as a factor in producing a comptetent ED workforce and choose to focus on 3 years of life of a doctor. Many of the most formative years of producing physicians comes AFTER residency.

    This type of training is not the same as surgical training at all.

    Should we begin to discern quality of physicians who trained before the 80 hour workweek rule versus after. I am certain that would definitely create an interesting debate.

    Your cry out for the wellbeing of patients who are taken care of non boarded physicians cannot be overcome by your clear bias and poor argument construction.

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