Texas (National, really) issue: qualifications of your ER doc | Houston & Texas News | Chron.com – Houston Chronicle

Texas is at the center of a heated national battle over the training emergency physicians need in order to advertise themselves as board certified.

At stake is the welfare of patients requiring immediate medical attention. Leaders of the traditional board say allowing physicians without proper training to advertise themselves as board-certified would mislead the public. Leaders of the alternative board say the proposed rule change will undermine the ability of Texas’ rural hospitals to staff their emergency departments with board-certified ER physicians.

A final verdict may only come, given one board’s already delivered threat, in a court of law.

via Texas issue: qualifications of your ER doc | Houston & Texas News | Chron.com – Houston Chronicle.

At stake also are the careers of a lot of practicing Emergency Physicians, many of whom I’m proud to call friends and colleagues.  (And it’s not just docs at rural hospitals, they’re in nearly every ED in Texas, and your lesser state).  They practice high quality Emergency Medicine, and I have no qualms about the practice of those who are alternately boarded.

I’m a residency trained, BCEM doc, so I’m in the group that’s considered Board Certified by definition.  I’m also still in the minority in US ED’s.  The majority are ‘alternately trained’ docs, the vast majority of whom always wanted to practice EM but either there was no such training when they finished med school, or the few EM programs were full.

Most are FP or IM trained, have worked hard and have been and continue to be ED and hospital leaders.  Again, I’m proud to have them as friends and colleagues, and have no questions as to their abilities.  They’re not interested in practicing EM for a few years then establishing a private practice somewhere, they’re EM docs, who didn’t do EM residencies.

In an ideal world would I like all docs in the ED to be residency trained as a requirement?  Yes.  Is that at all practical?  Not unless you want to close a whole lot of ER’s across the country, and the rural ones (where there is arguably more need for an EM doc who knows what they’re about) would be the first to go.

EM is either the newest or the second newest specialty in medicine, and for a primer on the brief history of EM, look here, (and there appreciate the spirit and the gamble that made my specialty):

Unlike the residents of today, those physicians who pursued Emergency Medicine residency training in the early 1970’s faced an uncertain future. They had no opportunity to be certified by a specialty board, and had no guarantee their chosen field would persist. They were pioneers and mavericks in spirit and action.

Now, about the Board Certified thing…

The reason this is an issue is the recognition that physician credentials are important (they are), that it’s desirable for physicians to be Board Certified in their chosen specialty field (it is), and the public is becoming more sophisticated about who’s trained in what (good).  The reason this is a problem is that as of now the only ‘officially approved’ path to Board Certification in EM is to complete a residency, as the ‘practice track’ to grandfather other-trained docs closed in 1988.  It had to close eventually, there would always be some people stuck no matter the chosen date, but it’s done.  (I now think it was closed too early, but that’s not under my control).  Every medical specialty has had the same issue, the conversion from docs who filled a need to specialty-trained specialists in their field.

In 1990 Texas had one EM residency, taking either 6 or 8 residents per year (3 year program) in El Paso.  Texas then had a population of nearly 17 million.  Most EM docs I know work hard, but that seems like a pretty steep workload for those 6-8 grads a year.  (There are now 8 residencies in Texas, with at least one more opening in 2011).

Therefore, Texas ED’s have been staffed (mostly) with other-trained docs who only wanted to practice Emergency Medicine.  A few did the then accepted thing of working ED shifts to supplement their income while they built a private practice then bowed out of the ED, but most didn’t.  Most worked, many ‘grandfathered’ into a specialty that literally developed as they practiced, and more and more residencies in EM started.

So, the practice track closed several years ago when there were nowhere near enough EM training programs for the demand.  These docs worked hard, but needed to demonstrate they were EM pros.  Enter the ABPS which provides Board Certification through an alternate pathway, thus they’re often referred to as ‘alternate boards’.  per their website:

must have practiced Emergency Medicine on a full-time basis for five (5) years AND accumulated a minimum of 7,000 hours in the practice of Emergency Medicine and maintained currency in ACLS, ATLS, and PALS.

In any career, if you’ve been able to do it for 5 years full time you’re good enough to be recognized as able to do it long-term.  Alternate boards are the only path open to anyone who practices EM but wasn’t grandfatherable in the late 80’s.

(My issue with alternate boards is those 5 years of independent practice as an EM doc without EM training, which I’m not a big fan of, but I cannot come up with a reasonable / workable alternative.)  (And stop it with the ‘they should go back and do an EM residency’: it’s economically unfeasible both for the residency and the doc, and that would cause a shortage of EM docs as they’d be a) in residency and b) taking slots from new med-school grads who also want to do EM).

I think Texas should accept ABPS Boarding of EP’s for the foreseeable future, with the recognition that in 10-20 years it’ll need to be re-addressed as the number of residency grads is able to take up the slack in US ED’s.  There should not be a permanent need for an alternate pathway to EM boarding.

Pragmatism and practicality aren’t dirty words, they’re how life is lived, and in the ED they’re how lives are saved.  Let’s keep our experienced Emergency Medicine physicians.

Update: reminded by the comments, the standard should be residency training in EM for anyone getting new Board Certification today.  The above argument applies, IMHO, only to those who are already alternately boarded (and yes, there’s another group that’s excluded…)


  1. I find one of your arguments troubling. You say:

    “the vast majority of whom always wanted to practice EM but either there was no such training when they finished med school, or the few EM programs were full.”

    A lot of my friends wanted to do Dermatology. Should they be able to do an Internal Medicine residency, then take an alternate Dermatology board exam and start practicing as board certified?

    There were 1556 EM residency positions last year, a number which grows every year. Almost 500 more positions were offered in 2010 than General Surgery. How long can we continue to use the argument that there are too few residency positions?

    I understand “amnesty” for those who are in practice now, but why continue to certify, new, non-EM-trained physicians as “board certified?” If that remains the case, what is the point of my EM residency?

  2. Really wish there was a preview for the comments, I managed to mung that one up quite a bit. I love your blog by the way. As a current EM resident still green behind the ears, it’s great to read the insights a veteran has about the specialty.

  3. The problem is not those people who want to grandfather from the late 80s and early 90s who just missed the cutoff. It’s everyone else. ABEM had to set an arbitrary cutoff which is now 22 years in the past. There are kids entering med school who weren’t even alive when this started

  4. I have several ABPS colleagues (I’m ABEM boarded myself)… and they’re every bit as sharp, and every bit as competent as any residency-trained colleague I have.

    They’ve also been doing it for 10-15 years.

    Residency training should be the standard going forward. However, it would a VERY foolish move indeed to cast out all those alternative-boarded people, some of whom have a wealth of clinical experience. EM is one of those situations where you learn an incalculable amount via OJT (sometimes from your colleagues, and sometimes from your nurses and patients).

    If you’ve worked in the pit for 20 years, I don’t care if you’re residency-trained or not… I’ll listen to what you have to say.

  5. The argument should clearly focus on what it means to be “Board Certified”. Board Certification implies to the medical/lay communities that you are ACGME residency trained in that specialty. Can you imagine this happening in Surgery or OB/GYN? I can’t. Those boards would step in the middle of anyone calling themselves board certified if they did not go through an ACGME residency program in that specialty. Why should Emergency Medicine be any different?
    The fact that there are not enough EM trained doctors to fill the spots that the ABPS certified doctors are filling may be true, but it has nothing to do with who should be labeled “Board Certified in Emergency Medicine”. That is not what the argument is about.
    I also find it revealing that the other board certifications offered by ABPS( OB/GYN, Surgery, etc.) requires residency training in that specialty…

  6. EMDOC,

    The argument you are making isn’t what it means to be board certified, you are making the argument; what it takes to get to the test to be come board certified.

    IF BC was residency, then why aren’t you given your certification when you graduate from your residency?

    BC is a testing process to show you have mastered the skills it takes to be a specialist in a field of medicine, not how you gop to that point.

    Unfortubnatley, both ACEP and ABMS have people convinced that it’s all about the training and pre-requisites, not that actualt testing process that makes up BC.

    Who may call themselves BC is at the core of most of the arguments since many of the hospitals out there are now requiring that their physicians all be BC’ed and in Em that means over 50% of the physicians practicing would be pushed out of their positions simply because they chose a specialty where they could not be certified by the dominant organization. How does this serve the public safety?

    ABPS requires other specialties to have a residency in area because there isn’t the massive shortages in those other areas and the residency programs are creating enough graduates to fill the slots.

    This is not the case in EM, where according to Carlos Camargo in a study sanctioned by ACEP stated that there may NEVER be enough residency trained and certified EP’s to meet the need. Because of this ABPS still offers alternative pathway in which the physician MUST have a primary care residency (which are the core of what the current EM residency is abiult around) and 5 years/7000 hours of direct ED experience….which, by the way is more than what ABEM requires.

    The vast majority of the ABPS guys are vets of the ER who have decades of experience and who don’t think they need to quit their jobs, uproot their families and compete against fresh new docs for residency slots in ER…which are in short supply and very competitive. That Doc needs a way to show his/her mastery of the field and let the new guys take those residency slots since they are the ones who will eventually replce the old guys.

  7. Thank you for your piece highlighting the challenges of the physician workforce in the state of Texas. This is especially acute in the field of Emergency Medicine, which is still a young specialty, which grew out of a market need from a variety of medical disciplines. As such, a large number of Emergency Physicians in the state of Texas have been filling the need for qualified Emergency Physicians. Most of these doctors are board certified and residency trained in related specialties, and have supplemented their expertise with years of experience in our EDs.

    Dr. Carlos Camargo from Harvard has studied this, and shows that the need for EM residency trained docs will not be filled in the foreseeable future, so as such, Texas (more so than most states based on even your piece) has a responsibility to evaluate the competence and skill of Emergency Physicians practicing n our EDs. But ABMS and ACEP are doing what they can to prevent just this by their efforts to overturn Texas Medical Board Rule 164.4b, which has been in place over a decade with no adverse consequences for citizens of our state.

    The ABPS certification process offers a valid alternative for non EM Residency trained docs to demonstrate their commitment to mastering the practice of Emergency Medicine. These doctors have been proven to deliver safe quality Emergency Care for the citizens of the state of Texas, and as such this avenue needs to be supported by the TMB.

    A previous piece by you seemed to argue the opposite, which would only serve the special interests of groups with economic interests such as ABMS or ACEP. I urge you to write a balanced piece presenting the real facts of TMB Rule 164.4b in the context of the workforce challenges you describe, because to ignore this reality and overturn or change Rule 164.4b will only add to the peril the citizens of the state of Texas might experience.

    Thank you,


  8. In 2010, Fifty percent of current practicing Emergency Physician in the United States did not do a residency in Emergency Medicine. The President of the American College of Emergency Physicians (ACEP), Sandra M. Schneider MD, did not do a residency in Emergency Medicine. Half of the Board of Directors of American College of Emergency Physicians (ACEP) 7 out 14 did not do a residency in Emergency Medicine. The Chairman of the board of ACEP , David P. Sklar MD did not do a residency in Emergency Medicine. The current President of the Texas Collage of Emergency Physicians, James William DO did not do a residency in Emergency Medicine and many on the Board of Directors of the Texas College of Emergency Physicians did not do a residency in Emergency Medicine.

    In Texas 40 % of current Emergency Physician are not board certified in Emergency Medicine by ABMS and won’t be for the foreseeable future. Maybe in 30 years or never as published by Camargo et al from Harvard.
    (see http://www.emnet-usa.org/nedi/workforce.html )

    Emergency residency programs can NOT produce enough doctors to fill all the slots. We all support increasing Emergency Medicine residencies, especially in the state of Texas where the shortage is even more acute,and Emergency Medicine residency training has lagged far behind the rest of the country. In rural areas you can not get an Emergency Medicine residency trained doctor to work. Most of these rural physicians have done a residency in Family Medicine and work full time in the ED and do a great job. Maybe even a better job.

    In Emergency Medicine, the American Board of Physician Specialties (ABPS), a 60 year old organization established in 1950, requires a residency in EM but because of the shortage of residency trained Emergency Physician it allows the primary care option. The primary care option requires completion of a primary care residency plus 5 years of full time ED experience. A very rigorous written exam and a very rigorous oral exam. And re-certification every 8 years.

    The American Board of Physician Specialists created the Board of Certification in Emergency Medicine (BCEM) to fill a market need. This benefits the public by allowing a mechanism for physicians who are delivering quality care in America and Texas Emergency Departments to demonstrate their dedication and commitment to the practice of Emergency Medicine. There is no other avenue for them to demonstrate this, and as such OPPOSITION TO THIS AVENUE WILL LEAVE TEXAS CITIZENS SEEKING CARE IN EMERGENCY DEPARTMENTS WITH NO MECHANISM TO EVALUATE THE COMPETENCE OR COMMITMENT TO THE PRACTICE OF EMERGENCY MEDICINE.

    The American Board of Physician Specialties (ABPS) should be commended for the service it provides to the patients of Texas and the United States.

    If the TMB changes the rule it will hurt the quality of Emergency Medicine in Texas and the Citizens of Texas lose.

    Sincerely yours,


  9. One is left scratching one’s head what all the fuss and food fight between ACEP and ABPS (BCEM) is all about especially given the situation in Texas which has become ground zero for this battle.

    Perhaps we need to reorient ourselves and cooperate on what is good for the patient and not for our egos and pockets.

  10. Three thoughtful comments inside 30 minutes on an older post. All, BTW, in favor.

    So, who’s steering thoughtful comments here?

  11. Think this one may be coincidental GD.

    Lot of Docs are scanning the blogs with the big show down in Austin coming this week with the TMB rule change hanging over our heads.

  12. Thanks for the reasonable post, there has been so much vitriol regarding this topic, specially from AAEM, it’s a relief to read someone who’s actually considering the bigger picture.
    I can understand why ABEM/ABMS/ AAEM are rabidly against ABPS/BCEM since they are essentially trade associations for the EM residency trained/ABEM certified docs but ACEP is supposed to represent everyone.
    For updates on this topic, see: