ABEM is over-reaching their role

The American Board of Emergency Medicine (ABEM) describes itself as:

Welcome to the American Board of Emergency Medicine (ABEM) public website.  ABEM certifies qualifying physicians who specialize in Emergency Medicine and is a member board of the American Board of Medical Specialties (ABMS).  ABMS certification is sought and earned by physicians on a voluntary basis. ABEM and other ABMS member boards certify only those physicians who meet high educational, professional standing, and examination standards.  ABEM and other ABMS member boards are not membership associations.

The thing I’d like to bring your attention to is that it’s a Voluntary organization.  For a voluntary organization they’re adding lots of requirements without asking members…

Since most of you don’t know about Board Certification, it’s a way for doctors to demonstrate (mostly to their peers and employers/hospitals but also to patients) that they not only finished their residency, but paid attention and learned enough to pass the Board Certifying exam.  Yes, it’s possible to be a doctor, finish a residency, but not pass the board exam and have a nice lifelong practice anyway.

I’m Board Certified by ABEM, which required completing an accredited residency, passing first a written then an oral examination.  Okay, I’m done, right?
Emmm, no. I’m BC for 10 years.  In order to re-test to be BC for another 10 years, I have to take (and pass) yearly tests over medical literature, tests payable to the ABEM.  Which ABEM didn’t bother to figure out how to give us CME credit for.  Genius.

Imagine my surprise at ABEMs’ latest addition to hoops to jump through to maintain my Board Certification: the Assessment of Practice Performance.  In a nutshell: show ABEM that 10 patients didn’t hate my medical performance, prove that on 10 hand-picked charts I’m keeping up with published treatment benchmarks (like aspirin for ACS, antibiotics in 6 hours for pneumonia, etc), and self-certify the same to ABEM.

While that’s easily doable for me at Giant Community Hospital where I work (we already keep track of this, and a lot more), it’ll no doubt be harder for very small ED’s.  I agree this sort of performance thing needs to be tracked, and practice outliers nudged back toward the middle, but what on earth does this have to do with being Board Certified?  Where in ABEMs’ mission statement does it say they’re going to certify we’re practicing on par?  Nowhere.

This would be an entirely different argument if Board Certification were required for employment in EM (it’s not), at my hospital (it’s not), in my group (not), exempted me from any state CME requirements (doesn’t), increased my pay (doesn’t), you get the idea.  That’s a lot of work to keep a voluntary certification that gives me back… nothing tangible.  Oh, I’m a Diplomate of the American Board of Emergency Medicine, and with that and $6 I can get coffee almost anywhere.

I find it interesting there’s not much push-back on this new requirement.  ACEP’s President-Elect ‘interviewed’ ABEM President Debra Perina about this latest addition, uncritically and without any challenge: EM Leaders Discuss ABEM’s Maintenance of Certification Program.

To paraphrase the question, why? The answer:

SS: Is it correct to say that the public is asking for more accountability regarding continuing medical education, even between board examinations?

DP: That’s correct. I know that ACEP and the emergency medicine community have been following testimony in House and Senate hearings from consumer advocates requesting assurances that physicians remain competent throughout the course of their practice. The public is questioning boards that test sporadically or in some cases offer lifetime certification.

Hmm.  I genuinely understand the desire of the public to make sure docs are keeping up, and practicing inside norms (and this is not asking for a flaming: I’m aware there are docs who give amoxicillin for everything imaginable, who don’t keep up, etc) but this is a) window dressing on that front and b) if meant to serve as some reassurance to the public, it’s inadequate, at best.

But that’s really beside my point, which is that it’s not ABEM’s role to make certain my practice is up to par, that’s the role of, ultimately, my State (which licenses me) and my peers, who have a lot more impact on my practice than the ABEM.  ABEM should document that the provable (I’m keeping up with my certification, meaning the every 10 year tests, grudgingly the yearly tests*), and that’s it.

In an upcoming rant: competition is good, is it way past time ABEM had some legitimate competition from another Board Certifying organization?

*In either the first or second year of these yearly tests, the article being tested was about Neseritide, which in the article was the best thing for CHF since phlebotomy.  Of course, by the time we were being taught/tested on it, Neseritide was out of vogue as it hadn’t worked out in practice as it had in studies.  But, you had to give the currently wrong answer to the test.  Pitfalls of keeping up through testing.


  1. I generally agree with you on the continuous certification thing — both the way it’s been shoved down our throat and also the way that it’s been poorly executed. Having said that, it’s not just from ABEM being hypervigilant and restless. It came from above — from the ABMS itself. I’m not saying this to exonerate ABEM, because they sure seem complicit in the whole travesty, even enthusiastic. But ABEM isn’t a specialty society going rogue on this; it’s part of some painful groupthink that the entire ABMS felt like they needed to do to justify their continued existence to ensure quality of care.

  2. AMEN!

  3. 5mamacita5 says:

    Do we not trust our medical schools to educate and graduate doctors? Do we not trust our residencies and fellowships to adequately train our doctors? Do we not trust our state medical boards to oversee the practice of our doctors? Why do we need increasing hoops to jump through from voluntary certifying boards? (As Shadowfax noted, it isn’t just the ABEM.)

    Board certification itself is voluntary “window dressing,” and these additional requirements just increase the cost (money and time) of maintaining that feather in the cap. Doing well on a written test doesn’t always translate into doing well in practice and vice versa.

  4. Hey GruntDoc…this post kicked ass. Thank you for your effort in breaking it down…

  5. ABEM keeps adding hoops almost every year, but this one is really ridiculous. I completely agree with you. It will be interesting to see how many docs have complied with the LLSA at the 10 year point, at one time I heard it was very few. We need a real change in leadership there, not sure how to accomplish that.

  6. This is very similar to the standardized patient test required of all medical school graduates (USMLE Step 2 CS/COMLEX Step 2 PE). It is supposed to provide reassurance to the public that you are graduating competent doctors by have them perform exams on standardized patients (actors).

    In reality its nothing more than lining the pockets of the NBME/NBOME because medical schools already test students extensively with standardized patients through medical school and the vast majority of that test is whether or not you can read and write English. With a 93%+ first time pass rate- are we really weeding out bad doctors or just giving false reassurance? But at 1300 some odd dollars a pop for these tests I don’t see them going away anytime soon.

  7. Why not have people choose some form of yearly cme that is approved in place of some test every 10 yrs in addition to the annual pain in the …. test called LLSA? There are many opportunities for CME, including, but not limited to, EM-RAP, EM Practice, CME download etc. ABEM is the only organization that benefits from the current situation which no one is happy with. There are many excellent cme courses that do a superior job than the current situation.

    How did we allow an organization to dictate policy which makes the members unhappy? Apathy is killing us. :)

  8. The LLSA must be some kind of moneymaker. They get a C-note out of us every year on that deal.

    One more hassle I don’t need… and all so ABEM can wave around some papers. It reminds me of all the inane, useless training we used to be subjected to in the military, all so some admin weenie somewhere in the chain of command could check a box that said “trained.”

  9. By the way, thanks for the prayers and kind words for my cataract surgery this morning! Doing great. Who knew the big red signs said ‘stop’?

    As far as ABEM certification, years ago I wrote about the LLSA (Lifelong Learning and Self Assessment). Like you, I felt that it was a burdensome requirement, and a cash-generating tool. And, also like you, I felt that its lack of CME credit was insulting.

    Of course, the underlying assumption was that emergency physicians don’t keep up and can’t be trusted to stay current in their field. Which is untrue. We all just do it differently. I prefer to go to a conference each year, while some of my partners like doing monthly lessons at home. The state has published requirements for CME. And most of us learn from our partners and colleagues, as well as from (gasp!) the actual practice of medicine.

    One could read every bit of CME available, and take every course, and still be an abysmal doc from lack of practice; just as one could do the opposite (learn nothing new in any course) and practice inadequate medicine. Though option B is probably more functional.

    I’ve always been concerned that this entire endeavor is a way to secure jobs and secure income for board certification organizations. I’m sure there are well-meaning individuals in these organizations, but the whole process is so burdensome, expensive and patronizing that it leaves me wondering about underlying motives.

    I mean, a yearly test? And now, of course, the goal of having the ten year test reflect the yearly tests is out the window.

    Sure sounds like a cash-cow to little-old suspicious me.

    Have a great day!