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Ch. 18 - Controversies in Board Certification

Kristin Kahale, MD; Yagnaram Ravichandran, MBBS, MD, FAAP; Nathan Deal, MD, FACEP

Within the landscape of medical specialties, emergency medicine is a relative newcomer. Although emergency care existed long before, it wasn’t until 1979 that the American Medical Association and the American Board of Medical Specialties recognized emergency medicine as the 23rd medical specialty. Since that time, the field has grown at a rapid pace. More than 220 emergency medicine residency programs now exist,1 with more than 40,000 board-certified/board eligible emergency physicians practicing in 2018.2

It is imperative that all emergency physicians continue to advocate for the importance of board-certified, residency-trained emergency physicians caring for patients in the ED.

A Brief History of ABMS and ABEM

At the turn of the 20th century, interest in specialty training and certification was growing within the medical community. The beginnings of residencies and fellowships were materializing, and the first specialty examining boards were coming into existence. Between 1917 and 1932, specialty boards of ophthalmology, otolaryngology, obstetrics and gynecology, and dermatology were established. A pivotal moment came in the summer of 1933, when representatives from these specialty boards — along with delegates from the AMA, Association of American Medical Colleges (AAMC), and the Federation of State Medical Boards (FSMB) — convened during an AMA meeting.3 The group acknowledged that additional specialty examining boards would form in the near future and that an advisory council should oversee the process of specialty certification. This council would be composed of members from each of the individual specialty boards and became known as the ABMS.4

The journey toward a specialty board in emergency medicine began in earnest in the 1970s. ACEP and the University Association of Emergency Medicine (UAEM), a predecessor to the Society of Academic Emergency Medicine (SAEM), recognized a need for the development of emergency medicine training programs, as well as a means of certification. In 1976, ABEM was created, and in 1979, the ABMS recognized the specialty.

Residency Training, Practice Tracks, and Board Eligibility

ABMS currently requires residency training for board certification, but this was not always the case. With the creation of any new specialty board, it was common practice to allow non-residency-trained physicians to take the certifying examination if they had worked in the specialty for a sufficient amount of time. This pathway to certification, often referred to as a “practice track,” allowed physicians who trained before the era of a specialty’s residencies to obtain board certification. From 1979 to 1988, ABEM allowed both residency-trained and practice track physicians to obtain board certification in emergency medicine. In 1988, ABEM discontinued the practice track as a means of eligibility, in effect requiring all future diplomats to complete an accredited emergency medicine residency.5

Before any ABMS specialty board candidate is allowed to sit for the examination, that physician must meet the necessary criteria to be “board-eligible.” In order to be board-eligible for the current ABEM exam, a physician must:

  1. Graduate from an approved/accredited medical school.
  2. Complete an ACGME or the Royal College of Physicians and Surgeons of Canada (RCPSC) accredited residency in emergency medicine OR an accredited combined training program approved by ABEM.
  3. In most cases, hold a valid medical license.

On Jan. 1, 2015, ABEM added further stipulations to the term “board-eligible,” the most significant of these being new time criteria. ABEM will allow a physician to remain board-eligible for a maximum of 5 years following residency graduation as long as the candidate continues to meet certain conditions, including the completion of continuing medical education (CME).

Maintenance of Certification Controversies6

Once ABEM certified, one must participate in the Maintenance of Certification(MOC) program, which promotes continuous professional development and learning. The program, initially implemented in 2004, underwent additional changes in 2011 in an effort to ensure a high standard of care and meaningful standards of assessment. There are currently 4 components:

  1. LLSA (Lifelong Learning and Self-Assessment)
  2. IMP (Improvement in Medical Practice)
  3. ConCert (Continuous Certification Exam)
  4. Maintenance of Professionalism and Professional Standing via state licensure

In addition, one must maintain an average of 25 AMA Physician’s Recognition Award (PRA) Category 1 credits (a metric for verifying participation in CME) per year or the equivalent in the first and second 5 years of initial ABEM certification. ABMS proposes that MOC is an important form of professional self-regulation and assures the public that board-certified physicians are meeting strict standards for professional development. However, there has been controversy regarding the cost of MOC requirements, the time required for completion, and whether participation demonstrably improves physician performance and/or patient outcomes. ABMS asserts that MOC activities are based on evidence-based guidelines and specialty best practices, with each ABEM member board reviewing the standards for MOC. Yet, those who disagree with current MOC requirements often point to the lack of studies that link completion of MOC requirements to improvements in patient care. Additionally, many MOC requirements are associated with significant out-of-pocket costs for the physician. These include LLSA readings and tests, as well as the ConCert exam testing.

Lastly, there is an argument that written exams may not be the best way to test physicians’ knowledge. Some propose that many study programs meant for passing certification exams are “teaching to the test.” In addition, there are arguments that in today’s digital age with a plethora of medical resources available via digital applications, written testing in a closed-book environment does not represent how physicians practice.

The current ConCert exam assesses the medical knowledge of EM physicians seeking to maintain their board certification through a closed book examination. ABEM aims to maintain the value of its certification along with its rigorous standard without burdening physicians with unnecessary work.7 A nationwide survey of EM physicians demonstrated that a majority (~70%) of 13,000 respondents supported having knowledge-based testing as part of the MOC process, although ~90% voted for shorter, open-book assessment systems.8 Research also shows that the ConCert exam is a valid assessment of a physician’s cognitive skills. As a result, ABEM has proposed to pilot MyEMCert in 2019. This new assessment process puts a high priority on flexibility, enhanced relevancy, and greater opportunities to maintain certification by allowing shorter, more frequent tests on specified and relevant clinical topics, allowing more than one attempt to pass the tests, and facilitating remote or online testing that is also open-resource.9 Another issue most physicians cited about the ABEM certification in addition to time and effort is the cost. At approximately $3,000 (~$2,000 for the initial concert and ~$1,000 for LLSA modules over 10 years), the cost is comparable to the certification cost for other ABMS boards.10

In response to many physicians’ discontent with MOC, the Texas Legislature has taken action towards decreasing MOC requirements on most Texas physicians through Texas Senate Bill 1148.11 This new law passed in 2017 will prevent the Texas Medical Board from using MOC as a requirement for doctors to obtaining or renewing a medical license. SB 1148 also bars hospitals and health plans from requiring physicians to obtain MOC for credentialing or contracts, although hospitals may require MOC if their medical staff votes to support this requirement. SB 1148 has potential consequences for all physician specific privileges and some physicians are concerned that it weakens the claim to self-regulation by establishing a precedent for additional governmental intervention into the practice of medicine.12 Soon after this anti-MOC law was passed, Oklahoma and Michigan followed suit, although these bills were not passed. As a response to the recent atmosphere critical of MOC in the wake of Texas SB 1148, ABEM’s President has noted that board certification and recertification are linked with better quality of patient care, improved adherence to clinical practice guidelines, fewer state board disciplinary actions, and decreased health care costs.13

The social contract that medical boards and the AMA (which recommends recertification) have with the general public is based on self-regulation, altruism, and betterment of society. A total abandonment of recertification would likely not be well-received by a public that has already begun to wonder whether medicine is more interested in defending its privileges than in maintaining its standards.13 Therefore, efforts to limit or eradicate recertification programs through legislative action or other means may be seen by the public as nothing more than veiled attempts to lower professional standards.13

While MOC has been defended by ABEM and is being updated to fit modern physicians and the publics’ needs, ABEM and most major EM organizations have joined together against less clinically meaningful certificates. The Coalition to Oppose Medical Merit Badges (COMMB) advocates that board-certified emergency physicians who actively maintain their board certification should not be required to complete short-course certification in core competency skills like ACLS, ATLS, PALS, NRP. These “merit badges” add no additional value for boardcertified emergency physicians. Instead, they devalue the board certification process, failing to recognize the rigor of the ABEM Maintenance of Certification (MOC) Program, adding to the burden of time and finances. In essence, they set a lower bar than a diplomate’s education, training, and ongoing learning, as measured by initial board certification and maintenance of certification. 14

The Daniel Case

After the closure of the practice track toward ABEM certification, there remained a number of physicians practicing in EDs who had not received board certification and had not completed an EM residency. In 1990, Gregory Daniel, MD, and a collection of other plaintiffs sued ABEM to reopen the practice track to board certification. Many of these plaintiffs eventually established the Association of Disenfranchised Emergency Physicians, later renamed the Association of Emergency Physicians (AEP). The legal battle that ensued would last 15 years; in 2005, the 2nd Circuit Court of Appeals upheld a decision and dismissed all claims against ABEM.15

This legal decision legitimizes the long-held belief of many physicians that residency training is a necessary component in the education of a proficient physician. At present, ABEM and all other specialty boards of ABMS continue to require residency training for certification eligibility. The controversy of board certification continues, however, with a number of physicians interested in seeking alternative means of board certification.

The Creation of ABPS and the Controversy

The American Board of Physician Specialties (ABPS) exists as a competing organization to the ABMS. ABPS was created in 2005 as the parent organization to several specialty boards, including the Board of Certification in Emergency Medicine (BCEM), a direct competitor to ABEM.16 The creation of these alternative boards has attempted to open a separate gateway for emergency physicians who do not meet the requirements for ABEM board certification.

Controversy has surrounded the creation of BCEM, which allows non-emergency medicine residency-trained physicians to obtain “board certification” in the specialty from an alternative board. Currently, the BCEM offers 3 different requirement tracks that make a candidate eligible to sit for its exam. Two of these tracks offer eligibility after the candidate has completed a non-EM residency program and has worked in an emergency medicine setting for a specific amount of time.

Emergency medicine organizations, including EMRA, ACEP, and AAEM, have opposed the ABPS alternative board for a host of reasons. The central issue is the necessity of emergency medicine residency training for board eligibility. EMRA has taken a firm stance, adamantly asserting that residency training in the specialty is a critical component in the training of emergency physicians.

Board Certification and Advertising

Regardless of which certifying board a physician chooses, it ultimately is up to individual state medical boards to determine whether a physician can be publicly advertised as “board-certified.” Most states’ medical boards strictly regulate the use of this term, having decided that declaring board certification may impact the decisions patients make regarding their medical care. Until recently, the use of the term meant the physician was certified by the ABMS, or possibly the AOA. Over the past few years, ABPS and BCEM have asked for their processes to be considered equivalent to ABEM or AOBEM certification.

While state medical boards have been the stage for most certification battles, some of these issues have spilled over into the courts. The New York State Department of Health determined that BCEM certification was not equivalent to certification by ABMS or AOA; thus, BCEM physicians could not advertise themselves as board-certified. This resulted in a lawsuit between the ABPS and the state’s department of health, originally filed in 2006. In 2009, a district court ruled in New York’s favor, citing the lack of specialty-specific
training as an indication of the certifying bodies’ inequity. This decision was appealed; in 2010, the 2nd Circuit affirmed the Department of Health’s decision.17 Other states such as Texas have struggled with intermittent

approval of the use of the term “board-certified” for BCEM diplomates, but then reconsidered and removed that ability after objection and advocacy from the state ACEP Chapter, only to see it re-approved with minimal notice.18

Osteopathic Recognition and Training

The American Osteopathic Board of Emergency Physicians offers eligibility for board certification for doctors of osteopathy who have completed an AOA-approved residency in emergency medicine and who have either practiced for 1 year or have completed a year of subspecialty training. To meet this requirement, graduates of an AOA emergency medicine program must pass an oral and a clinical examination.

In 2012, the ACGME took the controversial step of limiting access to its fellowships by allowing eligibility only for graduates of ACGME residencies. This change prevented AOA residency graduates from participating in ACGME-accredited fellowships. This action ultimately set into motion the merger between the AOA and ACGME pathways. In July 2014, the AOA House of Delegates voted to approve a single accreditation.19 The merger toward a single-residency accreditation, called the Single Accreditation Process, is set to be complete in 2020, allowing both DOs and MDs to complete ACGME residencies and fellowships.

In January 2015, the AOA and the American Association of Colleges of Osteopathic Medicine (AACOM) became member organizations of the ACGME. Most osteopathic residency programs are actively working on getting precertified by the ACGME. At this time, board certification and recertification remains the same, with DOs certified through AOBEM and MDs through ABEM. However, it is expected that in the future, DOs will be able to take both certifications. MDs that complete osteopathic focused training will be eligible to take the osteopathic boards as well.20

Conclusion

Emergency medicine training and certification has developed rapidly since the recognition of the field in 1979. Today, EM is a widely accepted and influential specialty within the house of medicine. The term “board-certified” in emergency medicine has evolved over the past 30 years and now faces new challenges, as ABPS and BCEM attempt to provide alternative paths to certification. It is imperative that all emergency physicians continue to advocate for the importance of board-certified, residency-trained emergency physicians caring for patients in the emergency department.

WHAT’S THE ASK?

  • Monitor state level attempts to include new certifications that do not meet the standards of emergency medicine residency trained physicians.
  • Monitor MOC requirements and controversies, and advocate for appropriate modifications that reflect evidence-based medicine and are aligned with the current practice of emergency medicine.