The American Association of Physician Specialists (AAPS) is pushing for wider acceptance of its board certification in emergency medicine through its affiliate, the American Board of Physician Specialties (ABPS). The quest has put leaders of emergency medicine's professional organizations on edge, and brings into question the value of an emergency medicine residency, an issue the specialty thought it had put to rest with the case of Daniel v. the American Board of Emergency Medicine (ABEM).
“We have a very aggressive and active governmental affairs program for 2010,” said Timothy Bell, the AAPS director of governmental affairs. “Our strategic plan for 2010 includes Alaska, Montana, Idaho, Utah, and North and South Dakota. It will put us on the path of achieving the goal of being recognized in every state.”
The plan puts ABPS on a collision course with the American Board of Medical Specialties as well as the Bureau of Osteopathic Specialists and Boards of Certification of the American Osteopathic Association, the most widely accepted agencies for medical specialty certification. Nowhere is the clash more evident than in the field of emergency medicine, perhaps because of the Daniel v. ABEM suit that spanned 15 years, casting a shadow over the field's attempt to move from grandfathering for the field's pioneers, who had no chance to enter an emergency medicine residency, to a residency-based approach. While ABEM bases board certification on completing an emergency medicine residency and testing, ABPS's certifying body, the Board of Certification in Emergency Medicine (BCEM), allows applicants to have completed a primary care or anesthesiology residency along with 7,000 hours of experience in an emergency department.
“ABEM's position has always been that it's not just the test, it's also the training,” said Mary Ann Reinhart, PhD, the group's executive director. “ABEM has always maintained that accredited, specialty-specific training is the foundation of specialty board certification, and that remains its position to the present.” She said the group would have no additional comment.
AAPS efforts to achieve recognition for its board certification are close to fruition in Texas, where the board's director and legal counsel ruled that existing regulations appear to allow physicians to advertise that they are board certified by ABPS. In Oklahoma, new rules specifically recognize board certification by the group. In 2006, ABPS lost its bid for recognition by the board in North Carolina, and it is now renewing that proposal as North Carolina reconsiders a variety of licensing rules. In September, a federal district court granted the state of New York summary judgment in a suit by AAPS that claimed the state agency had violated the Constitution's 14th amendment on equal protection by not recognizing the group's medical specialty certification. That ruling is now being appealed in higher courts.
Angela Gardner, MD, the president of the American College of Emergency Physicians (ACEP), said the issue will confuse the public. “When a member of the public sees board certified, he or she assumes a certain level of training and testing is involved and the credentials are important and consistent.”
In a statement, she said, “As outlined in ACEP's policy statement ‘ACEP Recognized Certifying Bodies in Emergency Medicine,’ ACEP recognizes ABEM and AOBEM as the only certifying bodies for emergency medicine. This has been ACEP's position for many years, and it has not changed. In recent years, ACEP and its chapters have actively defended this position in opposing similar ABPS initiatives in other states including Florida, Kentucky, New York, and North Carolina.” (The full statement is available at www.acep.org/pressroom.aspx?id=47259.)
She has taken considerable heat over the issue. “The fact is I don't intend to be disrespectful or disregard the considerable talents of people who have not trained in emergency medicine. My concern is for our specialty and our patients. Today … people should not enter the practice of emergency medicine without doing a residency in emergency medicine.”
Larry Weiss, MD, JD, the president of the American Academy of Emergency Medicine (AAEM), was blunt, noting that emergency medicine is not a legitimate specialty if anyone can call himself a board certified emergency physician with no training in the field. “The ABPS largely exists to grant board certification to untrained physicians working in emergency medicine. Most of the public knows that if someone is board certified, it means they have some advanced training in a specialty. It's a public health issue,” he said. “Should I be able to call myself a board certified surgeon if I never completed formal training in surgery? At the core of this controversy is whether emergency medicine is a legitimate specialty.”
Dr. Weiss maintained that certification through BCEM is the major activity for ABPS, accounting for 70 percent of ABPS board certifications. James Marzano, the director of public relations and marketing for the AAPS, said approximately 2,000 physicians are certified by BCEM, but the number of physicians certified in all the specialties or on a specialty-by-specialty basis is proprietary, and the group will not reveal those numbers.
At the heart of the issue, of course, is residency training. While ABEM requires those seeking board certification to successfully complete an emergency medicine residency approved by the Accreditation Council for Graduate Medical Education or AOA, BCEM accepts those residencies but also offers other options for eligibility including:
* Practice emergency medicine full-time for five years, accumulate at least 7,000 hours of practice in the specialty, and complete an ACGME- or AOA-accredited primary care or anesthesiology residency; or be certified in a primary care specialty or anesthesiology by an ABPS-, ABMS-, or AOA-recognized board of certification.
* Complete a 12- or 24-month emergency medicine graduate training program approved by BCEM. Those completing the 12-month course must have practiced emergency medicine full-time for 12 months before or after completing the graduate training.
On Oct. 30, 2009, responding to a request from an attorney representing the AAPS, Mari Robinson, JD, the executive director of the Texas Medical Board, the state licensing agency, noted that the ABPS meets state requirements for advertising itself as members, fellows, diplomats, or board certified by ABPS. For physicians to advertise themselves as board certified, they must have successfully completed a written or oral examination that tests their knowledge of skills in the specialty or subspecialty of medicine.
She said the certifying organization also must have IRS 501(c) status, that it must have at least 100 members who must come from at least one-third of the states, and that all its applicants must have “demonstrable, substantial training in the specialty or subspecialty in the area in which the certification is sought, along with the use of acceptable peer review.”
In her letter, Ms. Robinson wrote: “The TMB has received information that clearly indicates that all the requirements of Board Rule 164.4(b) have been met in order to be able to advertise that the physician is board certified by the ABPS.” In that letter and a follow-up on Dec. 9, 2009, she emphasized that this was an interpretation of already existing rules. The matter was scheduled for discussion at a full board meeting Feb. 5, but that was postponed until April.
“ACEP's opposition is based on concerns that BCEM allows and encourages new physicians to enter unsupervised practice without residency training in the specialty,” said Dr. Gardner in her official statement. “ACEP has maintained a consistent position on the critical importance of residency training for physicians entering emergency medicine. The specialty has grown such that residency training is widely available, and should be the pathway for new physicians entering the practice of emergency medicine.”
Mr. Bell of AAPS noted that the organization does “require an ACGME- or AOA-approved residency,” but he acknowledged that it does not have to be in emergency medicine. “We do require that physicians complete five years of emergency department experience.” He pointed out that several leaders in both AAEM and ACEP did not complete residencies.
One reason BCEM accepts primary care residencies is that “emergency medicine is, in part, primary care,” said William J. Carbone, the chief executive officer of AAPS. The Texas ruling was not made specifically for his organization, he said. “We did not petition to change any rule whatsoever. They just applied the criteria equally and fairly.”
And former AAPS president Lewis Marshall, MD, noted that because the supply of emergency medicine-trained physicians doesn't meet the demand, BCEM helps ensure more physicians are qualified to work in EDs. “If we are going to have internists or family practice doctors practicing in the emergency department, we want them to have the same knowledge,” he said. “We need to test them, and the only way to do that is through BCEM.”
The Oklahoma rule was changed to include ABPS “based on several presentations by them in front of the [Oklahoma medical] board members and after several years of discussion with other medical and osteopathic boards that have recognized ABPS,” said Lyle Kelsey, the executive director of the Oklahoma State Board of Medical Licensure and Supervision, in an email. He wrote: “The Oklahoma Medical Board decided, at the November 18th public hearing on the subject of a rewrite of the Board's rule on Board Certification, to recognize the ABPS as another pathway to ‘Board Certification’ for the purpose of physicians advertising their credentials to the public. NOTE: The decision was made to include the ABPS in the proposed rule making for the Oklahoma Medical Board, but it has to have Legislative and Governor approval before the rule becomes effective which could take place by May 2010 at the earliest.”
Meanwhile, the situation in North Carolina remains in flux, said Todd Brosius, JD, the board's attorney. Advocates for both sides of the issue spoke at a Nov. 30, 2009, hearing. ABPS is not currently listed in the rule, he said, but has requested inclusion in it.
Leaders of AAPS oppose the ABEM exclusion of the practice track. Peter Lawrence, MD, JD, of Ossining, NY, who spoke as part of a conference call from AAPS leaders, said ABEM closed the practice track for board certification too soon.
He and other AAPS leaders pointed out that recent studies indicate that there is a severe shortage of emergency physicians and that current residency programs may not fill the vacancies. Dr. Lawrence and others said it would be better to have an ABPS-certified physician in the emergency department than NPs and PAs.
Find a FastLink to the American Association of Physician Specialists video, “Why Physicians Choose American Board of Physician Specialties for Board Certification” in this month's issue of EMNow on EM-News.com.
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