Many doctors are not aware that there are actually (at least) three board certifying organizations for physicians in this country. Today we're going to talk about each of them, as well as which employers prefer and how to keep your expensive certification in place. Before we get into that, let's discuss board certification in general.
What Does Board Certified Mean for Doctors?
What are the boards for doctors? “Board-certified” means some sort of external organization has looked at your knowledge, skills, and experience and deemed them adequate for the safe and effective practice of medicine. It demonstrates to patients, peers, and hospital credentialing committees that you are a “good doctor”. Whether it should or not is debatable, but that is certainly the way board certification is used these days. For that reason the answer to “Do I really need board certification?” is almost always going to be yes.
How to Be Board Certified
As you will learn below, there are a number of ways to get board certified. It usually requires some level of education, some level of training, and some degree of experience. There is usually a written and perhaps an oral test you must pass.
Can You Practice Medicine Without Being Board Certified?
In order to practice, a physician simply must be licensed to practice by their state. But in reality, most employers expect you to be board certified eventually. Nearly every hospital requires it.
There are actually at least three boards that certify physicians in the United States. You've probably only heard of one of them, ABMS.
American Board of Medical Specialties (ABMS) Board Certification
The first and most popular is the American Board of Medical Specialties (ABMS). If you are board-certified, it is likely your certification comes from this board. ABMS includes boards such as:
- American Board of Dermatology
- American Board of Obstetrics and Gynecology
- American Board of Orthopaedic Surgery
- American Board of Pediatrics
- American Board of Radiology
- American Board of Internal Medicine
- American Board of Surgery
- American Board of Anesthesiology
- American Board of Family Medicine
- American Board of Emergency Medicine
There are 24 total member boards under the ABMS umbrella, and they certify 40 specialties and 85 subspecialties. ABMS was founded in 1933. As of 2018, approximately 880,000 physicians in the US are board-certified by ABMS.
Other Board Certification Organizations for Physicians
American Osteopathic Association (AOA)
Some osteopathic physicians are board-certified by the American Osteopathic Association (AOA), which certifies in 29 specialties and 77 subspecialties. This board certification began in 1897. Approximately 30,000 physicians in the US are board-certified by AOA.
American Board of Physician Specialties (ABPS)
A lesser-known board certifying organization is the American Board of Physician Specialties (ABPS). It began in 1952 certifying DOs, and then started certifying MDs in 1984. Although I was not able to find the current numbers of doctors certified by ABPS, it was approximately 5,000 in 2010.
A Surgeon’s Perspective on the American Board of Physician Specialties
I had an academic surgeon reach out to me not long ago who was initially very complimentary toward my work asking me to promote ABPS board certification (“Monopolies are bad!”). I told him that was a controversial topic, but I would probably take a guest post on it that was formatted as a Pro/Con post. He seemed unaware of any cons to ABPS certification, so I informed him of the main one I was aware of (discussed later in the post) and even offered to take the Con side myself if he preferred. He subsequently became very upset with me and sent me this email:
“Given the questionable levels of competence of most EM doctors (most likely ABEM certified) that we as orthopedic surgeons continue to face on a routine basis, the ABPS has done you a huge favor by certifying family practice and other primary care fields to enter emergency medicine. Newsflash: It's no wonder why only medical students in the middle to bottom half of their class end up matching in EM! It makes total sense now. Thanks for clarifying things. Your idea of a ‘pro and con' article with nearly every slimy life & disability insurance company in the country advertising on your blog (not to mention you wanting to be the con-guy with having the final incorrect editorial say on your blog) ain't gonna happen bro.”
And actually continued to send me hate mail for months afterward saying things like:
“All of the surgeons (myself included) in our surgery lounge want to thank you for providing us with great laughter and amusement of the articles you keep writing as our online ‘financial guru'. Clearly, you are a disgruntled ER doc who must be certified by the ABEM.”
and
“Everyone thinks you're crazy and delusional as hell. Don't forget, you're just an ER doc. Trying to come across as someone that's condescending in your articles just makes you look like more of a fool than you already are. And before I forget, do yourself a favor and modify your psych meds that you're taking (if you're not seeing a psychiatrist, please do so). But most importantly, do us ALL a favor and stop writing. That is, unless you want us to continue laughing at you!”
Needless to say, I decided to write the post anyway. And in case anyone is wondering, EM is considered a moderately competitive specialty, more competitive than primary care, anesthesia and radiology, and less competitive than OB/GYN, Ortho, Derm, Plastics, and Neurosurgery, thus making it pretty unlikely that “only medical students in the middle to bottom half of their class end up matching in EM.”
The EM Perspective on The American Board of Physician Specialties
The ABPS website advertises that it offers a “higher standard” for board certification.
It was unclear whether they were comparing to someone without board certification or to someone with ABMS certification, but, if the latter, I found it somewhat ironic. You see, Emergency Medicine (EM) has a bit of a unique relationship with ABPS. EM is a relatively young field. Obviously, when a new medical specialty appears on the scene, none of its practitioners are trained in its residencies. They trained in something else and then specialized through their clinical experience. However, after a few years, the expectation in any medical specialty is that if you want to practice the specialty, you should actually get some training in that specialty. In medicine, we call that training residency (+/- a fellowship), and it lasts for 3-7 years. It's a big deal, and there is little way to replicate its intensive experience in any other way. So it is reasonable that, after some period of time of existence of a specialty, anybody who wants to call themselves a specialist in that specialty should plan to complete a residency in that specialty.
The first EM residency began in Cincinnati in 1970. EM became recognized as a specialty by ABMS in 1979 and got its own board. Board certification at the time had a relatively liberal grandfathering clause, that is, if you were practicing EM (8,000 hours before 1988) you could be grandfathered in to EM board certification simply by passing the test even if you never completed a residency. As the years went by, the percentage of board-certified emergency physicians who never completed an EM residency became smaller and smaller and is now a minuscule portion of practicing emergency doctors, all of whom are in their 60s and 70s. ABPS and its associates have been suing ABMS in an attempt to keep that back door into Emergency Medicine open for the last three decades, arguing that board eligibility should not require residency training.
Indeed, ABPS is still (50 years after the establishment of the first residency program) offering board certification in EM to people who have not completed a residency in EM. Their requirements? Well, you have to do one of the following:
- Complete an EM residency OR
- Complete a FP, IM, Peds, or Surgery residency AND a 12 month EM fellowship OR
- Complete a FP, IM, Peds, or Surgery residency AND work for 7,000 hours over 5 years in an ED.
Imagine you're an orthopedist and your board certification organization allowed someone who completed an FP residency and a one-year fellowship in ortho to call themselves board-certified. Or an OB/GYN who hung out a shingle and practiced obstetrics for 5 years. It's nonsensical. If you want to be board certified, go to residency. Every other specialty is allowed to restrict its specialists to those who did specialized training, why would it be any different for EM? How is that “a higher standard”?
So emergency physicians, at least those who bothered going to residency, haven't been super fond of ABPS for years. It's not just because they charge more, although they do that. It's because they cheapen the value of our residency training on the open market.
How to Maintain Your Expensive Board Certification: MOC Requirements
Over the last decade, a lot of physicians have become very frustrated at the board certification process and especially the newer Maintenance of Certification (MOC) requirements. The expenses in both time and money are not insignificant. In some specialties (perhaps most notably Internal Medicine) the doctors have gathered torches and pitchforks and attempted to storm the castle. Most ABMS boards have taken the criticism to heart at least somewhat and attempted to make the requirements less onerous.
It used to be that you would just become certified once. You would finish your residency and then pass a test and you were board certified for life. After a while, they implemented recertification exams, so you had to take the test again after a decade. That might require a few months of studying in the evenings to make sure you passed. Then, when annual MOC requirements were added on, the time and expenses started to seem ridiculous to a lot of doctors. Some even made movements in their groups and medical staffs to eliminate the requirement for board certification at all. In addition, other doctors started looking at other, less expensive and/or less onerous ways to be able to claim board certification, and thus interest in ABPS board certification grew.
The expenses of maintaining certification are not insignificant. Consider the current costs of acquiring and maintaining board certification with the American Board of Emergency Medicine.
- Application Fee: $420
- Qualifying Exam (written): $960
- Oral Certification Exam: $1,255
- Recertification Exam (every 10 years): $1,400
- Lifelong Learning and Self Assessment Exams (annual): $0 (used to be $105)
So all in, it's $2,635 to get certified initially and then averages $140 a year. Not terrible, but it really adds up when you consider licensing, DEA, and medical staff fees. You can see why doctors might start getting interested in cheaper alternatives. Along comes the ABPS. Fees for a ABPS board certification in Emergency Medicine are:
- Application fee: $500
- Written Exam: $1,100
- Oral Exam: $1,540
- Annual Fee: $895
So all in, it's $3,140 to get certified and then you pay $895 per year. That's right, 19% more to get certified and 539% more to stay certified. To make matters worse, you have to recertify every 8 years instead of every 10 years with ABPS. And this doctor didn't think there were any Cons to ABPS certification and that anyone who thought so just loved monopolies?
Options for Non-Board Certified Physicians
Is Board Certification Necessary for Employers? Board certification is not required for licensure, but employers and hospital medical staffs often want their doctors to already be board certified or at least expecting to become so soon. Thus it becomes a de facto employment requirement. Why take a doctor that isn't board eligible/board certified (BE/BC) when you have so many applying that are?
I know my group would not take a doctor in this day and age who did not train in Emergency Medicine. We probably would not be very impressed with someone who only had an ABPS certification, either. In EM, that tells us that they're either stupid ignorant (because they're paying 19-539% more for their board certification), and we don't want to work with someone stupid ignorant, or they are trying to get around the residency requirement (and we don't want to hire someone in this day and age who didn't bother going to an EM residency). However, I don't know that my group's experience or even my specialty's experience is universal. So I asked you guys what you thought, and this is how you responded:
On Twitter:
And in the WCI Facebook Group:
As you can see, a minority of people don't care which certification you get, but when people do care, they are far more likely to demand or at least prefer ABMS certification.
Recertifying Through the National Board of Physicians and Surgeons
In addition to these three organizations, there is another one that offers board recertification only. It is called the National Board of Physicians and Surgeons (NBPAS). The idea is that you have to be ABMS certified initially, but when it comes time to recertify, these guys will recertify you without making you take another test or do any MOC activities. Again, I'm skeptical that a lot of employers who require board certification will accept this (it turns out only around 60 hospitals do), but I guess it does allow you to say you're “board-certified” in many states, and maybe nobody is looking too closely. Maybe you can talk your hospital into it. It's certainly a lot cheaper, $169-189 initially and $145-165 to renew. If you are a fan of getting ABMS certified after completing residency but think any sort of recertification exam or MOC is dumb, this may be your organization to support.
Which Board Certification Organization Should You Pick? The Choice Is Yours
The doctor emailing me wanted residents to know they have a choice when it comes to board certifying organizations. That is true; you have a choice. Keep in mind that if you're in California, New York, or one of several other states, you can't call yourself “board-certified” if you are only ABPS certified (and that probably applies to NBPAS certification, too). So before you choose to go through the door that apparently fewer than 1% of physicians choose, you'd better check with your future employers, partners, hospitals, and state medical boards to make sure they don't care who certifies you. Might want to double-check the prices, too. Nobody likes to shell out thousands for board certification, but, in at least one field, ABMS is not only more widely recognized, but is significantly cheaper than ABPS certification.
What do you think? Are you ABMS or ABPS board certified? Would you get ABPS certified as a new residency graduate? Why or why not? Should we just throw out the whole board certification idea altogether? Comment below!
The fact that this Ortho “doc” was so hung up on this issue to start including demeaning you for being an ED doc is pathetic. Most people who do that are actually miserable in their own lives. This bro is hiding something and is himself probably the “butt” of all jokes.
-A GI doc
I thought so too. It was actually really bizarre. I have no doubt I’ll be getting more email from him soon.
Thank you for the article. I was embarrassed to read the ‘hate mail’ that you received. I can’t believe that came from a physician! Sounds to me that he or she is simply envious of your knowledge and success. That’s a shame. Hopefully you don’t spend one minute thinking about those negative comments other than to feel sorry for whoever wrote them. I can assure you nobody in my household or practice are laughing at you! Each blog post/article/podcase/conference lecture has taught me something that I am passing on to my family, employees and students. In fact, I am sure that by implementing what I have learned from you I will be reaching financial independence shortly and much earlier than I would have otherwise. What I have learned from you has been life changing and I thank you for that. Please keep it up!
Ha! You had me at academic surgeon. 😁
I would like to offer a unique perspective as an ABFM-only certified FM physician who has done a lot of work consulting with the ABPS in recent years. To be honest, I found it a little disheartening that this piece reads mostly as an anti-ABPS article with a bunch of random hate mail in the middle, and I wanted to offer some perspective on why the ABPS has done some of the things they have done. I am not employed or certified by them in any way so take this with a grain of salt.
First off, the ABPS was started as an organization because of DO surgeons that trained at Allopathic programs and were therefore not eligible for ABMS certification at the time. So they had completed residency and the current rules left them out to dry. The ABPS was literally the only organization to offer these residency trained surgeons board certification.
Over the years they have progressed to fill niches that have been left behind by ABMS. Specifically, there are many for FM. The reason for this is that ABPS operates on the philosophy that training is training regardless of the type of residency. Because of FM’s focus on primary care, it has historically been devoid of opportunities to specialize or pursue fellowship. Most fellowships are unaccredited, so after doing this additional training you have no “credential” to show for it.
Therefore, they have offered an avenue to show some credential for these family docs. With regards to EM, you listed 3 options:
1. Complete EM residency, which everyone can agree is sufficient.
2. Complete FM residency and EM fellowship. I suppose this is the one that I have never understood why the ABMS does not offer a certification pathway. If someone does 4-5 years of residency training in FM/EM, I find it hard to believe that their EM training would be insufficient to stand up against a 3 year EM program. Training is training. However, as mentioned above, all fellowships are unaccredited so upon completion of a fellowship you will still not be able to secure most EM jobs. Does this make sense? Residents who train in IM, EM, and anesthesia can all do ICU fellowships that lead to board certification, despite the differences in their initial training.
3. Experience. I understand why you as an EM doc don’t like this one, but no one is “hanging out a shingle” in the ED for 7000 hours and applying for certification. This is meant for docs who never went through the grandfathering process in the past. The perfect example is an FM doc I worked with in medical school who was the head of the department at a major NYC hospital despite being FM board certified only. It was his first job after residency and he has only worked in ED’s for decades since. In an instant, this person’s hospital bylaws could change and they could be out of a job because they now require board certification. It seems fair and safe to offer an avenue for a legitimate credential for a person like this.
So while I understand your points, I feel that your article displayed some bias that you may have towards the ABPS and wanted to offer some counterarguments. As with all internet discussions, I probably didn’t change any minds here.
Absolutely I have bias against ABPS. I think what they are doing with regard to EM board certification is wrong. I thought I made that very clear and the reasoning for it in the article. The FM doc you worked with in medical school had until 1988 to grandfather in to Emergency Medicine. Either he didn’t qualify to do that, or he opted not to. The consequences of that are that if he now wants to be board certified in EM, he has to go back to residency, just like any other doc and any other specialty.
If his hospital bylaws change and require EM board certification to practice EM at that hospital, then yes, he’s out of luck. Choices and actions have consequences. But most hospitals simply require board certification to be on the medical staff, not board certification in a given specialty. The credentialing committee has a lot of latitude as far as making exceptions.
The truth is that ACEP has done an excellent job of pushing family doctors out of EM and out the ER. However, these positions are largely being replaced by NPs and PAs. Ironically, NPs can do a 12 month fellowship to become a “EM specialist”, but you feel a FM doctor should not be able too? Many of my EM residency trained and boarded friends in the Chicago area are driving 3-4 hours for work. They are working in ERs that used to employee 3-4 physicians per shift and now only have one doc and 3 NPs per shift. The majority of the patients are never seen by a physician.
Also there are multiple FM/EM combined residencies. These take 5 years to complete. There is a great deal more similar to EM and FM, then FM and orthopedic surgery, so your comment above really isn’t fare. I actually agree that there should be more options for physician flexibility to go and do a different residency. However, a board certified FM doc who has completed a 3 year residency, really should not have to redo there internship year. Unfortunately, ACGME funding issues make is extremely difficult to complete a second residency. Meanwhile, I know several PAs who worked in our ER for 2-3 years and were EM providers, and then one day took a job in a specialty clinic with no additional training and were now urologist.
Lastly, we are all of the same team. The goal of the board certification process should be to ensure patients receive appropriate medical care. We should be lifting up all medical providers toward this goal. This article could have been easily written without any of the orthopedist comments, and avoided unnecessary negativity.
I have had four family docs in my group over the last decade. All were ABEM board certified and grandfathered in back in the 1980s. There is one left, he’s over sixty. That seems very reasonable to me. But if you want to practice emergency medicine now, you should go do an EM residency. EM/FM is a 5 year residency. The training is significantly different. Consider how much time a family doc spends in an ED during residency. Maybe a month. Versus perhaps 18 months for an emergency doc. How much time does an emergency doc spend in primary care clinic during residency? Probably not a single month. And the family doc probably spends 18 months there. That’s not similar training at all and they don’t take care of similar problems. They’re different specialties. Both important. Both more “specialties of breadth” than of depth, but not equivalent.
I disagree that becoming an NP and doing a one year residency/fellowship makes you the equivalent of an emergency physician. I’m also not a fan of what I’ll call the “anesthesia model” of EM. APCs, if used at all in the ED, should be very closely supervised. You can’t do that at a ratio of 1:3. You can barely do it at a ratio of 1:1.
I love that you see the person who anonymously quoted the hate mail sender as the “negative” one, rather than the sender of the hate mail.
I agree that an NP doing a fellowship does not make them a EM physician, or a physician of any other specialty for that mater. However, there are now ERs that will employ NPs, but not FM physicians. The justification for this can only be financial, and not patient centered.
I know multiple FM physicians who did 6 months or more of EM rotations in residency, followed by a 12 month of fellowship. Nearly all of their training was in level 1 and 2 trauma centers.
In fairness, if you have only worked with 4 FM docs, all of which graduated more than 40 years ago, and never worked with someone ABPS certified how can you speak to their quality?
Now, I actually agree that most of ABPS standards are not strong enough. They now have a FMOB board certification that only requires 50 CS, when ACGM requires 150 from a OBGYN resident who is part of a surgical residency requiring significant additional time in the OR. Is there a number of CS that a FM doctor could complete that would allow them to be privileged to perform CSs? I think so, but it should be at least the same number required of an OBGYN.
My point is, if a 5 year residency can board certify you in both FM and EM, there should be an option other than starting over. May be these fellowships should be 2 years rather than one.
Also the surgeon is clearly an dullard. Agree there. I have a huge amount of respect for your work, but just found this piece off brand. Nothing this orthopedist had to say was remotely intelligent or helpful for anyone, why even share it?
I agree I’d rather have an FP than an NP working in an ED.
I also agree that if an FP spends 18 months working in trauma center EDs under the supervision of academic emergency physicians that is worth a lot. Still not my preferred pathway to become an EP, but getting a lot closer to it.
ABPS devalues my residency training; why would I support it or those who devalue my residency training by getting certified there? If one wants to be an emergency doc, the best pathway is pretty clear in my view. Everything else is a less rigorous pathway. In places like SLC, we have 40 applications for every job opening. Eliminating those who didn’t complete an EM residency is a pretty easy initial screen. Now if you want to go work in a rural ED where they can’t get 1 application per job opening, all of a sudden some of those other pathways start looking “good enough.”
“ABPS devalues my residency training”
Does your residency training devalue 4-year EM residency training?
Yes. Just ask my partner who did a 4 year residency.
MidwesternDoc – I also found this piece off brand. I feel as though more respect was given to the pros/cons of whole life insurance than the possible legitimacy of this board certification. Adding in the completely bizarre emails from the surgeon (which were obviously inappropriate) did not serve any real purpose in the argument.
We have disagreements, but this piece did not seem like Jim’s usual fair portrayal of both sides of a discussion.
I have immense respect for your work Jim and understand your arguments here, but disagree with your unilateral presentation.
It wasn’t meant to be an unbiased piece. I have strong feelings on the topic. Like many other posts on this blog, it contains my point of view and my opinions. The other doc was invited to write a Pro-ABPS piece. You read what he sent. If you’d like to send a Pro-ABPS piece, I can tack it on to the end of this post.
I totally agree that this insistence on formal residency training and board certification to work in the ED will serve only to hurt medicine and EM docs in general. They’re here fighting over the scraps saying FM docs can’t work night shifts in podunk hospitals (come on, that’s where most of these non-Em trained people are filling). Meanwhile their entire lunch is getting taken by NP/PAs. The residency forums are an absolute mass exodus from EM. There’s a sense that the bottom has totally fallen out for the field. Even academic hospitals are being filled with NPs, 3:1 or more versus physicians. Same thing happened to anesthesia but at least they didn’t bring it on themselves, there wasn’t an easy pool of physicians asking to take up the extra workload caused by the anesthesiologist shortage the way there was for EM. For the record, I have no skin in the game, I’m in a surgical subspecialty. I’ve just seen EM get decimated in all the hospitals near me. Replacing physicians with NPs cheapens my degree, and in my opinion EM board certification is partially culpable.
Nobody is saying they can’t work the shifts. The argument is that they can’t call themselves board certified emergency docs. If you want your OB care, your emergency care or your surgical care from an FP that’s an option. The only option in many places.
That was a delicious little side story in there!
I just did my second recert with ABEM. Basically, I used the pandemic free time to do 5 years of MOC. I am trying to decide if I am done…will I want/need to come back to a hospital, do I need it to volunteer, do I need it for any side gigs?
You will likely need it for main gigs or side gigs that involve practicing in the emergency department yes. But not usually to volunteer at a homeless clinic or internationally.
For sure at the big/desirable hospitals, but I’m not sure about the small shops that are staffed with locums. Around here it seems they take anybody not in prison as long as they don’t have a revoked license!
(Perhaps a tad off topic here, as it seems this post is more about ABPS vs. ABMS. For the record I don’t know why any new EM residency-trained physician would opt for ABPS, but I’m not an EM physician.)
I wonder much longer will AOA board-certification exist? AOA “merged” with ACGME last year, so all residencies are under one (“MD”) umbrella now. I don’t know how many (if any) programs applied for the “extra” AOA-qualified label.
AOA settled a class action suit in 2019 and no longer can charge yearly AOA dues as a condition to remain board-certified. AOA also reaffirmed that lifetime certificate holders will never be forced to do “OCC” (DO version of MOC.) I doubt any lifetime certificate holders are doing OCC but I don’t know that.
I now rather regret the DO residency, although if I’d been 3-5 years older I could have “lifetime” certification and that would be nice.
At NBPAS that (non-ageist) option, but it may require moving to a state that forbids insurance/hospitals from requiring MOC.
There’s a lot more on this topic out there of course, and it seems that each individual board has its own rules and controversies. In any event it just adds to the argument in favor of good financial habits toward FIRE.
Great question. I probably should have talked more about DO board certification in the post.
On a related question, I can’t figure out why they don’t just convert DO schools to MD schools. In fact, there are new DO schools popping up all the time.
If you’re not familiar with the reason that NBPMS exists, I encourage you to take at the information on this site: http://www.changeboardrecert.com/
I have a family member who is a Peds ED Doc who did his training in the 80s in Pediatrics. He has 30+ years experience now in ED. As he has switched jobs a couple times he mentioned to me that hospitals look for not just Board Certified in Peds ED, but looking for Fellowship trained Peds ED that are thus board eligible/board certified. So for him he said he doesn’t regret not doing the grandfathering process back then because he felt there wasn’t any meaningful distinction for him. I mean he has been able to take the jobs he was interested in, but I’m sure there are others he never could have interviewed for because he isn’t board certified in Peds ED.
It definitely varies, but many peds EDs will take docs that are Peds trained, that are EM trained, or that are Peds EM trained. But if they’re hiring someone new these days, they’ll prefer someone who has done a Peds EM fellowship.
I think I know the ortho doc you’re referring to in your side story. He was featured in this video: https://youtu.be/3rTsvb2ef5k
Oh, my goodness, that was fantastic!
“There is a fracture. I need to fix it.”
Thanks for sharing.
Lets not neglect to mention NBPAS – https://nbpas.org/about-nbpas/
There is a legitimate need for competition in medical licensure/certification and there is growing interest in alternatives to the current near monopolies which have no evidence to prove their stamp of approval conveys actually higher quality.
Discussed at the end of the post.
This has been a very interesting discussion. I appreciate the research you did in comparing the background of the different Board Certifying Bodies. I am glad you are discussing the American Board of Physician Specialities (ABPS). It is my estimation that few physicians, and fewer non-physicians know anything about Board Certifying Bodies or that there are choices for Board Certification. The ABMS and the ACGME do a tremendous job of restricting exposure and funneling residents in to ABMS Specialties and Board Certification. With one Certifying Body it would be difficult to fight back against MOC, cost and other healthcare decisions. But that is another discussion.
As Vice President of the American Association of Physician Specialists (AAPS) I would like to point out that the orthopedic physician you describe in this blog does not represent the AAPS or the American Board of Physicians Specialities. He is entitled to his opinion, however. I would like to point out that the AAPS has tremendous respect for the ABMS and all physicians. I am not familiar with the law suits you describe against the ABMS by the AAPS or ABPS. From an EM perspective, we believe in residency training in Emergency Medicine and in Board Certification for all who choose to practice in their chosen specialty. We also agree with the ABMS that Board Certification is a voluntary process. Where we disagree is that there is more than one path to practicing EM.
EM is composed of knowledge and skill synthesized from numerous specialities. As you pointed out, all ABPS EM Diplomates have completed a primary care academic residency (that is a minimum of three years of supervised training). Some do a one-year focused academic Fellowship in Emergency Medicine. Others have a minimum of five years and 7000 hours of experience in emergency medicine (residency training is about 6000 hours alone). They must then demonstrate their mastery through a validated and psychometrically evaluated written and practical examination. This is a rigorous process that measures entry level competency, the same as all Board Certifying exams. There still is personal responsibility for maintaining one’s ability to practice their profession.
You may also be aware that numerous ED’s across our country hire Nurse Practitioners and Physicians Assistants as the sole provider of EM because they are unable to hire a physician to work in their ED. Some ED’s hire Residents for the same reason. Many Residents moonlight in the ED during their Residency due to shortages. About 40% of ED’s are staffed by non-residency trained physicians. Many non-EM Residency trained physicians went in to EM because they saw a need. Or they realized their passion after residency. We are trying to fill these gaps in care. I think it is a travesty that the medical field does not have more paths for lateral opportunities. Or should we be stuck practicing for 40 years in a field we chose at 25? You suggest going back to residency, but it was pointed out that there are financial challenges to that path. Our goals is to make sure that the physicians that practice in their chosen field demonstrate their mastery, and that the patients we serve can be assured that they are receiving care by a professional that has demonstrated that mastery
You state that doctors should just do an emergency medicine residency if they want to practice EM. If that is the case, then you would hire an EM Residency trained physician that was certified by the ABPS, correct? But you said you would not hire an ABPS Board Certified physician. I know many physicians that have completed surgery, ortho, EM, primary care, and other residencies and are Board Certified by the ABPS in their speciality field. Some of our EM docs also hold the FACEP. Many of us are certified by both ABMS and ABPS organizations in a variety of fields. The ABPS also certifies specialties that ABMS does not have. Some of us work for Academic institutions. The reason many of us chose the ABPS is because we value the service we provide, we are proud of the profession we chose, and we want to demonstrate our mastery of that specialty. ABPS was founded on the basis of non-discrimination, and this is the path that is available to us. We should work together to help close these gaps and meet the needs of our patients.
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You use the comparison of OB as a reason we should not allow FM Docs to be EM Docs. Actually, there are numerous OB Fellowships, and even physicians that have a sufficient amount of OB experience even in residency to get credentialed by their hospital to provide OB care, including OB surgery. There is no mandatory Board Certification for OB for primary care physicians (though one is offered by the ABPS). But yes, it is recognized by some hospitals and not by others. Your orthopedic example is a little far-fetched however. There is much overlap between some specialties, not so much by others. But what is the problem if a physician wishes to take additional training after residency, acquire the necessary skills, demonstrate their competency, and change their field of practice? I know many EM Trained physicians that practice in fields other than EM for which they were not trained, or that they later gained additional knowledge and experience. I also know many EM trained physicians that are not comfortable in rural and remote ED’s because it is quite a different environment that that in which they were trained. Emergency Medicine environments are as diverse as the physicians practicing. Why are we trying to fit everyone into the same box?
So, is it the training (or perceived lack thereof) that is the reason you do not support this path. Or is it the Certificate issued from an organization other than the ABMS that you object to? Do we not have multiple mechanisms to ensure quality care (Peer Review, Board complaints, Malpractice, CME) in addition to just the Board Certification one holds? What is the real reason these Certifying Bodies cannot co-exist? It cheapens the value of EM Residency training? I would like to see more examples of this. I am disappointed that you posted a survey of only 90 respondents, though it should surprise you the number of respondents that did support ABPS (while not statistically significant).
Finally, you discussed the cost of certification. How much does an EM physician pay for ACEP and ABEM annually? I pay over $800/year for AAFP and at least $200/year for ABFM. I pay less than that for AAPS/ABPS. I choose to pay for both. Does that make me ignorant? You wouldn’t hire me for that reason?
I do thank you for discussing the three multi-speciality Board Certifying Bodies. Physicians should know they have a choice in Board Certification. Professional competition is a good thing. It promotes innovation and cost effective care. Perhaps if we focus on what we have in common and work together we can lessen the cost overall for all of us, and most importantly, make sure patients in ALL ED’s have access to the highest level of emergency care possible.
Thanks for weighing in in a civil way.
I’m surprised that the lawsuits are news to you given your position. Here’s a link:
https://www.abms.org/news-events/statement-on-the-dismissal-of-aaps-v-abms/
The one I was most thinking about when I wrote this though was Daniel vs ABEM, which isn’t technically AAPS, but it’s basically the same group of docs making the same argument–that residency training shouldn’t matter.
I agree that physician education is substantially more than NP/PA education and they should not be considered equivalent.
I am sympathetic to the issue of doctors wanting to practice a different specialty than they originally trained in, but a residency in a specialty is an extremely intensive, structured, valuable experience that cannot be substituted in any other way. Offering board certification in a specialty without it confuses patients and others about what that doctor has actually done and can do.
While I can certainly understand why an ED might hire an FP (particularly one who has done an EM fellowship), that doc should still not be called a board certified emergency physician for the same reason an FP who has done a one year OB fellowship can likely safely deliver babies but should still not be called a board certified OB/GYN.
I’m more concerned about the training than the board certification, but one reason I don’t like AAPS is simply because they don’t value an EM residency in the same way I do.
I don’t know all the comparative costs of ABMS and AAPS for every specialty. Maybe AAPS is cheaper in some. But it isn’t in EM. ACEP or AAEM dues are irrelevant to this particular discussion as ACEP/AAEM membership is not required for board certification, licensure, credentialing etc.
Greetings,
Thank you for continuing the dialogue.
The AAPS you are referring to is the Association of American Physicians and Surgeons (AAPS). Our association is the American Association of Physician Specialists (AAPS), but not the American Association of Pharmaceutical Sciences (AAPS). Our certifying body is the American Board of Physician Specialists (ABPS), recognized throughout the U.S. as a leading multispecialty certifying body. I assume you are certified by the American Board of Emergency Medicine (ABEM), and not the American Board of Electrodiagnostic Medicine (ABEM). I don’t know who makes this stuff up, but maybe there ought to be rules about names and acronyms? So, no our AAPS did not sue the ABMS or the ABEM.
The reason this is important, however, is that there are over 12 recognized Independent Boards of Certification for physicians, separate from the three multi-specialty boards (only two if you count ABMS and AOA as one). Neither ABMS nor the ABPS are the only Boards that certify physicians-and we are good with that. I do believe we agree that residency training is the ideal path. However, while residency training should accelerate the learning process, I am not aware of evidence that residency training is superior to clinical experience. For example, does a physician with 3 years of residency training have better outcomes than a physician practicing in the same environment for 10 or 20 years? Is there evidence to support our medical school or residency models? IM is 3 years, and Peds is 3 years, IM/Peds is 4 years. But FM/EM is 5 years. What’s the evidence for any of this? Much of this is/was based on the amount of time to achieve a certain number of skills and patient contacts, and only as many years as might be tolerated. This is a much deeper conversation than I am qualified to discuss, and I certainly do not have all the answers. But my question is, if we as a profession or individuals intend to survive we need to evolve to the needs of the patient and those providing care. Protecting turf will only open the door to those factors over which we have little control and take away from patient safety and care – our primary duty. The ABMS is not the only path to Board certification for physicians.
Another point I would like to consider is what a residency offers. Residency training offers a structured, academic environment interacting with experts in a variety of fields. There is little or nothing to replace that apprenticeship, which, as stated, accelerates the learning process. Most residencies have a certain degree of overlap. They may have more in common than differences. What do residencies have in common? Structure. Supervision. Cognitive, psychomotor and affective learning. Research methods, etc. Residency prepares us to be “life-long” learners. Once we leave the program we should be programmed to keep learning. Thus, we need to tear down the silos and acknowledge that 1) a residency is better than no residency; 2) all one really needs is to fill in the gaps of what they did not learn in their original residency; and 3) what competencies one needs, and at what point one demonstrate those competencies. We should respect all academic residency training and allow physicians to train in other fields if that is their desire.
Another thought-does the public know the difference between a physician license and board certification? Do they know how long a training program is or ought to be? Do they care whether their physician passed the Board with, or without residency training? Many (most?) physicians don’t even know what ABMS is, or if they do that it is not the only certifying body. I did not know for years that ABFM or ABEM were affiliates of ABMS. Many do not know the difference between a “Certifying Body” and an “Association” (ABEM vs. ACEP, or ABFM vs AAFP). I think we make too many assumptions. If we do not even have the knowledge about our professional certifying bodies, how much can we expect the public to know. What most patients want is someone to listen to them, take their concerns seriously, help solve their problem or tell them why they cannot solve their problem? We should acknowledge that a Board Certification is only one piece of the puzzle that measures a physician’s competency to practice and that process includes: Peer Review, malpractice complaints, Board complaints, ongoing professional evaluation, CME, etc.
Finally, what is the definition of Board Certification and who defines Board Certifications or sets the qualifications? The ABPS definition of Board Certification is: “measurement of a physician’s mastery of a core body of knowledge in the specialty in which they practice”-through valid written and/or oral, clinical or patient simulator exam. This is independent of the qualifications which are set by our organization for the various boards we offer – all of which have raised the standards in physician board certification. ABMS Boards set their requirements, and the other more than 12 independent specialty boards set theirs. We do not define Board Certification, and neither do ABEM or ABMS. We are a brand that sets the highest of standards, as are the ABMS Boards. Chevrolet is a brand and does not set the standard for automobiles. A credible certifying body must follow specific guidelines that ensures the integrity of their certification and patient safety and care. There are also several branches of the military, of different sizes and capabilities. They are all valuable, and size does not determine their value or effectiveness. Why are the non-ABMS Boards less familiar? The bodies that have long been determining one’s ability to advertise their board certification are controlled by ABMS/AOA physicians. In addition, one of the most important bodies in our field of study is the ABMS “partnership” or one could say “control” of the ACGME, ensuring residents do NOT have a choice in physician board certification – allowing for the largest monopoly in healthcare. Should others follow that pathway, I suppose we should let Chevrolet determine the standards for the auto industry and be the only ones allowed to sell cars?
In conclusion, the ABPS does support residency training. All our Boards require our Diplomates to be residency trained. But we also believe in allowing physicians a choice in board certification and allowing them to demonstrate their mastery in the specialty in which they practice. They must still pass a rigorous written and oral exam after meeting all the prescribed requirements. The American Board of Physician Specialists (ABPS) is a non-discriminatory body that has existed for over 60-years and believes in placing patient safety and care first while ensuring that physicians can provide the highest quality of care. We believe in diversity of thought, and we support competition because we believe that competition is key to innovation in medicine and the betterment of healthcare.
Jerry
Yes, you support residency training…just not in the same specialty one wants to get boarded in. Which is my whole point.
I believe the highest quality of care comes from doing a residency in the specialty before practicing it. You don’t. So we disagree and we’re probably going to keep on disagreeing no matter how many 1000 word comments you leave trying to justify your decision to do this.
You are correct, we do disagree, but not on providing the highest quality of care. I believe the highest quality of care is not measured solely by completing a residency. Anybody that has sat on a Peer Review Committee would recognize that. A true raising of the standards is meeting the needs of patients. To properly do so we must identify their needs and participate in lifelong learning. If residency training is the only answer, how is it that many specialties under the ABMS do not require a residency? How do we justify that? Is it your belief patients should have access to the highest level of physician care? If residency training is the solution, how is it that physician leaders are happy to delegate emergency department care to non-physicians? We should “walk the walk”, not just “talk the talk”. We should be ensuring the highest quality care to those that matter most – the patient. Or, should we just continue the status quo indoctrinated by the monopoly in physician board certification? I for one choose increased training and placing the patient first. (182)
Lots of talk there trying to justify your actions. Nobody is saying that residency training alone is sufficient. I’m arguing it is the minimum. You’re arguing it isn’t even necessary. I think you’re wrong.
Why do people hire non-emergency physicians to work in emergency departments? You’ll have to ask them, but it’s likely a combination of an availability and a cost issue, not because they think a non-residency trained doc is better than a residency-trained doc, all else being equal.
Where did I say residency is not necessary? I would not want your readers to leave with the impression that is my stance. Thank you again for sharing your platform.
So is a residency in Emergency Medicine necessary to become board certified in Emergency Medicine or not? I would argue it is. As I recall, you are arguing it is not. That’s what the whole disagreement is about, no?
Very Informative
The Joint Commission just accepted NBPAS as a certifying authority. As someone screwed over by an ABMS board right as my recertification deadline approached, I joined NBPAS and have never looked back. I think you are biased towards ABMS boards without good reason. Data points to initial ABMS board certification as correlating with better patient outcomes; MOC has *never* been shown to matter for patient care, only lining Board pockets. NBPAS leverages that, requiring ABMS certification up front to be eligible for recertification.
Bro, you sound insecure about your specialty. You are like that attending who always has to overcompensate for something. Trust me dude, you’re not anything special unfortunately.
As an FM resident with much more ED experience than a month, I had no real desire to call myself “board certified in EM” if I choose to complete an EM fellowship It would simply be more for experience. Especially after reading all of that. I’ve also had ED attendings, scoff, roll their eyes, or all of a sudden completely change their demeanor towards me when I expressed an interest in rural EM (used to be a rural Firefighter/EMT). I even considered going into an EM residency after finishing FM, but it seems a bit redundant and generally discouraged by both FM and EM physician’s I’ve bounced the idea off of. This all seems very petty. I wouldn’t want to be associated with that much pettiness. I’d be proud to just be a physician who is competent in a clinic, hospital floor, ED, or in non-surgical OB. I’ve taken admissions from the ED. I’m not totally convinced of the superiority in diagnosing or treating patients. I by no means think ED doctors are dumb like that gastly orthopod (which is rich for a specialty that seems to struggle with anti-coagulation). I have a lot of respect for the ED or at least used to before I really saw the culture. As far as most specialists are concerned we’re all just the dumb doctors. Hilariously even specialist mid levels will rip on us like a yappy lap dog sitting safely on their master’s lap. With the abysmal NRMP match for both our specialties last year I’ll bet some of this pettiness resolves if the oversupply of EM doctors resolves over the coming years. The ED is overworked especially recently. Probably by the time my career is over people will be defending that turf about as much as we feel like we need to fight other physicians away from primary care.