Resident/Student Issues: Board Certification

The Florida Travesty

Below is a summary of recent Common Sense articles that hopes to answer any questions residents or students may have about this issue.

The Florida Travesty threatens Emergency Medicine's recognition as a separate specialty with its own body of knowledge, accredited training and certification process.

What's BCEM (Board Certification in Emergency Medicine)?

The American Association of Physician Specialists, Inc. (AAPS) is an organization that provides medical specialty certification. It consists of 14 different specialty academies, including the Academy of Emergency Medicine. While most of its academies require formal residency training in their specialty before allowing candidates to undergo a certification examination, the Academy of Emergency Medicine does not. "Special considerations" allow candidates without residency training in emergency medicine to obtain "Board Certification in Emergency Medicine" (BCEM).

Any physician who has completed 1) an anesthesia or primary care residency program and 2) five years (7,000 hours) of clinical practice or a one-year emergency training program at the University of Tennessee followed by one year of clinical practice (or two years of this program) is welcome to take the examination offered by the AAPS. It is important to also note this training program is not accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA). Prior to 2003, BCEM did not even require the completion of any residency training from physicians holding its emergency medicine certificates.

How is ABEM/AOBEM certification different?

Since 1988, the American Board of Emergency Medicine (ABEM) and the American Osteopathic Board of Emergency Medicine (AOBEM) have required a minimum three years of residency training in emergency medicine and passing written and oral board examinations to become ABEM- or AOBEM-certified. ABEM is a member of the American Board of Medical Specialties (ABMS), which is formally recognized across the country as the authority in the specialty certification of physicians. ABMS was created by several of the official main-stream organizations in American medicine, such as the American Medical Association, The Federation of State Medical Boards and The American Association of Medical Colleges. The AOA is the authority for the specialty certification of Osteopaths.

By contrast, the AAPS web site (http://www.aapsga.org) does not list any sponsoring organizations, and does it give any history of how or why it was developed. AAPS board certification requirements allow physicians to totally bypass the process that turns medical students into properly trained and certified specialists in emergency medicine.

What happened in Florida?

In 2002, the Florida Board of Medicine (FBM) and Florida Osteopathic Board of Medicine (FOBM) granted AAPS the same certifying power as ABMS and AOA. This gave the holders of its BCEM certificates equal status to ABEM and AOBEM-certified Emergency Physicians.

AAEM strongly believes that residency training is essential for new emergency medicine physicians. In a letter to the Executive Director of the FBM, AAEM/RSA President Joel Schofer, MD, and Vice President Mark Reiter, MD MBA, wrote:

"Allowing BCEM physicians to claim certification in emergency medicine after acquiring variable unsupervised exposure critically undermines the value of Emergency Medicine residency training in protecting unsuspecting emergency patients from the unnecessary harm of ill-prepared physicians, who practice EM unsupervised and learn through trial and error.....it critically undermines the whole process of specialty training and the entire graduate medical education system as it is currently structured within the house of medicine."

How did this happen?

No other state medical board has ever allowed physicians to use AAPS certification to declare themselves as formally board-certified in any specialty. FBM's decision was based on a flawed hearing in 2001, where no emergency medicine organization other than the Florida College of Emergency Physicians (FCEP) was informed or invited. FCEP is recognized by the Florida Medical Association as the state's medical specialty society for emergency medicine. FCEP has nearly 1100 members in Florida and represents the majority of practicing emergency physicians in the state.

AAPS/BCEM set up this maneuver very carefully, choosing Florida where two members of the Licensing Board of Medicine hold AAPS board certification. These two voting members did not conceal their agenda, as they also testified at the hearing. Nineteen testimonials were given with fourteen in support of AAPS. Most of the supporters were BCEM certificate holders, who claimed the legitimacy of AAPS training and deplored how licensing boards such as the one in Florida were discriminating unfairly against boards "comparable" to the ABMS and AOA-certifying bodies in structure and legitimacy. The one FCEP representative present was also sympathetic to the AAPS claim. The four witnesses who opposed the AAPS petition represented Dermatology, ENT and Plastics.

During the 2004 legislative session, AAPS sponsored a bill (SB 2584) to recognize AAPS in statute, rather than just in rule. Currently only the ABMS is recognized in statute. Such a status would have given BCEM and AAPS legal ground to sue in any context where they perceived discrimination against their certificate holders (eg. at the level of medical staff). The Florida Medical Association sought the input of specialty societies, but no one responded and the FMA dropped their initial opposition to the bill. SB 2584 passed the House (110-0!) and almost passed the Senate was it not for a technical glitch that delayed it in one committee. This bill is expected to return in the 2005 legislative session.

What is AAEM doing?

AAEM is determined to have this 2002 FBM ruling revoked and to bring justice to those who orchestrated the flawed hearing. AAEM and AAEM/RSA have sent letters to the FBM expressing our intent to challenge the vote and to petition the FBM and FOBM to conduct an internal review of the hearing. The Federation of State Medical Boards was also made aware of the issue. AAEM is independently investigating public records of the FBM and FOBM, as well as transcripts of the proceedings. Locally, two members are serving as state representatives to work with the local authorities to address this problem, a Patient Safety Committee has been established, and AAEM is working with the Florida chapters of the Plastic Surgery and Dermatology societies. The matter has also been brought to the attention of the ACEP President and other emergency societies (ACOEP, AAEM/RSA, CORD and EMRA), who have already expressed their concern to the FMA.

On July 10th at the annual FMA Council of Legislation, AAEM won its first victory in this fight. Written and verbal testimonials from AAEM, AAEM/RSA, AACEM, Florida AAEM (Fl-AAEM), ACEP/Florida ACEP (FCEP), ACOEP, CORD, EMRA and FOMA emphasized that there is no acceptable alternative to an accredited emergency medicine residency training for providing proficient emergency care. The FMA agreed to oppose any legislation that seeks to recognize AAPS in statute.

For additional documentation, see Florida Board Certification Documents (http://www.aaem.org/floridaboard/)

By Samantha Honner, MD
November, 2004