Rules, Exceptions & Double Standards

First, let me say I don’t know Dr. Tony and absolutely have no reasons to doubt or question his sincerity or abilities — but!

Second, I’m in a very large multi-state Emergency Medicine group with many partners that are neither residency trained or board certified in Emergency Medicine. Several of my past and present partners (where I work) are in these categories — which is not the issue. Neither is the notion that a specific physician with specific training and specific certification is better than another the issue. These are always put forward, not necessarily intentionally, but nevertheless put forward to hide the true issue.

Third, Emergency Medicine¹ is the only one of the twenty-four recognized medical specialties² in the United States that is routinely challenged by those not certified in Emergency Medicine as being monopolistic and “not the only path.” No one ever complains about the monopolistic behavior of ABS³, ABP⁴ or ABFM⁵.

Fourth, all specialties took a similar path to residency training and board certification by their respective boards as the fundamental and absolute requirement for “Board Certification.” Many of these specialties also had for a limited time a practice track (to allow the grandfathering of current practitioners). Emergency Medicine’s practice track was widely advertised for ten years and closed in 1988. It is a sheer feign of ignorance that anyone would claim not to know that the practice track for Emergency Medicine has been closed for 17 years!

Fifth, there are not enough board certified emergency physicians (BCEPs) in the U.S. to meet demand. Many BCEPs do not and will not work in certain practice settings (e.g., rural or low volume ERs). Board certification in any speciality does not imply quality of work product or success or happiness in one’s chosen or adopted specialty! Many non-BCEPs working in ERs are just as good and productive as BCEPs. And, now for the resounding — so what! The “rule” always gives birth and defines the “exceptions,” but only with Emergency Medicine do some take the exceptions and challenge the validity of the rule. There are not enough neurosurgeons in many more communities in the U.S. than there are communities lacking BCEPs. Under the logic being examined here, gynecologists and pediatricians should be able to perform neurosurgery if they had one month rotation (perhaps two) in neurosurgery during medical school or residency.

Sixth, the true issue is of a double standard. Dr. Tony states, “I am board certified in Family Practice, Sports Medicine ….” What this tells me is that the very parent entity, ABMS, that gives validity to his board certification in Family Medicine by ABFM and his subspecialty certification in Sports Medicine is somehow less when it comes to ABEM and board certification in Emergency Medicine. In similar logic the lock that ABMS has on ABFM board certification in Family Medicine is not monopolistic, but for Emergency Medicine is monopolistic. AAPS⁶ is always trotted out to buttress the double standard — because it is used to question the validity of ABMS.

The irony of this double standard logic is that to stand taller in their adopted specialty (EM), the self-disenfranchised will call into question the very certifying body that gives validity to their chosen specialty and certification. Emergency Medicine is historically and by necessity a big tent, those that have adopted our tent as their home are welcome — but don’t detract from those that have built the tent and have always called it home.

The vast majority of physicians and healthcare institutions in the U.S. understand that we have specializations in medicine. Less understand the many reasons why this occurred. Still fewer understand that non-medical reasons are at play in these specializations as well. Emergency Medicine is one of twenty-four recognized specializations in the U.S., recognized by the vastly prevailing certifying organization ABMS. All have post-graduate training requirements. All have board certifying examinations. All derive prestige, respect, and position within healthcare’s echelons because of their exclusive certifications. Emergency Medicine is not greater than the other twenty-three, and it is not any less …

Perhaps George Harrison said it best in It Don’t Come Easy:

1. American Board of Emergency Medicine: along with the sister board of ABOEM are the nationally recognized certifying bodies for Emergency Medicine in the United States.
2. American Board of Medical Specialties: a not-for-profit organization comprising 24 medical specialty boards, is the pre-eminent entity overseeing physician certification in the United States. For more than 70 years, ABMS’ mission has been to maintain and improve the quality of medical care by assisting its Member Boards in developing and implementing educational and professional standards to evaluate and certify physician specialists. Through its coordination of Member Board activities, ABMS also serves as a unique healthcare industry influencer, bringing focus to issues involving specialization and certification in medicine. ABMS is recognized by the key healthcare accreditation organizations as a primary equivalent source of board certification data on medical specialists for credentialing purposes.
3. American Board of Surgery: certifying organization for surgery, a member of ABMS.
4. American Board of Pediatrics: certifying organization for pediatrics, a member of ABMS.
5. American Board of Family Medicine: certifying organization for family meidicine, a member of ABMS.
6. Association of American Physicians and Surgeons