Each year, ACEP Now catches up with the President of the American Board of Emergency Medicine to discuss the state of the specialty, training priorities and education trends. Recently, ACEP Now Medical Editor in Chief Cedric Dark, MD, MPH, FACEP, and ABEM President Diane L. Gorgas, MD, sat down for a quick update.

Dr. Dark: First, I want to start by learning a little bit more about you. Can you tell us about your journey through emergency medicine, how you wound up joining ABEM, and how you took on the role of leading the organization?

Dr. Gorgas: I finished my emergency medicine and residency training in 1994. I got involved with ABEM early in my career. Right after being board certified, I waited for the obligatory five years and then became an oral examiner. I found ABEM to really be a dynamic organization and one whose mission I really believe in. I’ve had the privilege – or misfortune depending on your perspective – of being a patient and having family members who are emergency medicine patients. I realize how important it is on both sides of the curtain and what that patient-physician interface and interaction looks like. It has really spurred me on in my continued volunteer activity with ABEM.

I am also a clinically active emergency physician. I’m Vice Chair of Academic Affairs and the Executive Director for Global Health at The Ohio State University.

Dr. Dark: I’ve heard a lot from some newer graduates and people that are in training now about the changes to the certifying oral examination. It’s transitioning from virtual back to in person. Can you talk a little bit about the impetus for ABEM to switch it back to an in-person exam from what it’s been for the past few years?

Dr. Gorgas: Conceptually, I think it’s important to understand that this is not the old oral examination. It will look nothing like what you took, or what I took, as part of an exam. The new certifying exam was the outcome of a two-year-long fact-finding mission to ask, “what is the critical skill set of an emergency physician? What part of that critical skill set are we at ABEM obligated to assess? And what are we assessing now? What were we assessing in 2022 when we started this process? And how much of a slice of the pie is that?” Is it fair to say that somebody is competent without ever looking at their procedure skills, without ever looking at their Ultrasound skills, without ever looking at their patient communication skills, without ever realizing how they manage a changing clinical course?

Medical knowledge is clearly the tenant of what’s important in emergency medicine. But how smart you are only takes you so far in your success as an emergency physician. It’s important to know how you communicate with your patients, how you communicate with coworkers, how you prioritize patient acuity, and how you think in a fluid environment. Although our previous testing was valid, it needs to be broadened to align with the specialty now and in the future; the practice of EM has drastically expanded in breadth and depth compared to when the oral exam first started. This initiative started in 2021 and really went into 2024 where we sought opinions from 4,300 different individual stakeholders, including employers and hospital administrators, ABEM diplomates, the public, residents, and our ABEM volunteers.

All those stakeholders leaned into this opportunity and spoke to the truth of where they thought some of the strengths of our certification process were – and the opportunities. The big opportunities were procedural, Ultrasound, and communication.

Dr. Dark: It sounds a little bit like transitioning from a tabletop exercise, which I think is the way I experienced the oral examination, to more of a simulation.

Dr. Gorgas: Yes. I think that that’s entirely accurate.

Dr. Dark: Let’s get back to the written examination. A report recently came out that says the pass rate for first-time test takers on the written “qualifying” exam was 82 percent, down from 88 percent.¹ This is following a trend we’ve seen for a few years. What do you think the explanations are for changes in written exam performance over time?

Dr. Gorgas: Let me put it this way, focusing on the very early realm of discovery and association without postulating on causation. The number of EM residency training programs has increased. We know the number of medical students who then become residents taking qualifying exams is a larger number than it was before. The model of emergency medicine has expanded over time, and we’re going to have another model revision here in another couple months in 2025.² The number of patient encounters that an average resident sees during training has gone down; it’s gone down to historically low numbers. The number of patient encounters used to be between 3,000 and 5,000. Today, residents in EM are lucky if they can get 3,000 patient encounters during their training.

Dr. Dark: I remember reading somewhere that you need to do something 10,000 times to be an expert at it.³ So that’s very interesting that you bring up that the number of cases that someone sees over time has gone down. It kind of spills into my next couple of questions. JACEP Open recently published an article that explored the difference in exam passing rates among programs. The qualifying exam (i.e., the written exam)pass  rates were slightly higher for those in three-year programs. The percentages were very narrow, like 93 percent versus 91 percent, probably not clinically significant but statistically different.⁴ Does ABEM think there’s much difference between a three-year and a four-year program in terms of the quality of the graduates that are being put out there?

Dr. Gorgas: You’ve clearly done some work for this interview, and you’re right. Can you amass the medical knowledge needed to do well on the qualifying exam in a three-year span versus a four-year time span. Yes, the numbers show that. Can you develop some of the other skills that are unique to the oral examination or the virtual oral examination better in a four-year time span than you can in a three-year time span? Well, the statistics are starting to pull apart a little bit there, saying there might be a slight advantage to four-year programs. The next and very interesting question is, as we continue to extend that assessment scope, are we going to see a bigger difference in four-year programs than three-year programs?

What does ABEM believe? ABEM believes the numbers. Are you going to be a better emergency physician if you’re seven years into your experience instead of three or four? Likely you will be. What we’re looking at is, “What is the definition of competency?” What is that critical skill set to say you are able to independently practice emergency medicine?” That’s the fine line of ABEM.

Dr. Dark: Still talking about this three- versus four-year situation. The ACGME recently announced plans to have every emergency medicine program transition into a four-year pathway.⁵ Does ABEM have an official comment on that?

Dr. Gorgas: Much like ABEM took a couple of years to make a determination about the certifying exams, the ACGME Emergency Medicine Review Committee (RC-EM) has taken at least a couple of years to come up with their new program requirements. One thing that we will say is, we really respect the RC-EM and their ability and expertise in defining the learning environment that is critical for creating a successful emergency physician. ABEM looks at the individual and certifying the individual. The ACGME looks at the environment and accrediting the environment.

Consider that there are only now three specialties that have only three years of training besides emergency medicine. All three of those are primary care specialties—family medicine, pediatrics, and internal medicine. I think emergency medicine has really tried to label itself as a unique specialty whose primary focus is not primary care.

From a sense of pride, and from a sense of logic, do we belong in a three-year or a four-year bucket? ABEM has not leaned into the public comment period yet. We are hoping to hear from diplomates and candidates for certification as it relates to board eligibility. How do they feel? Board eligibility is going to be impacted by the change, and we will be speaking with the ACGME with that lens in mind.

Dr. Dark: We noticed over the past couple of years changes in the proportions of residency slots filled, and it looks like emergency medicine is back on track. But one of the observations we have noticed is that a larger number of those slots are being filled by international grads. I’m curious if ABEM has been tracking that and noticed any change in the in-training exam based on those kinds of criteria.

Dr. Gorgas: I think it’s very perceptive, and you’re absolutely correct that emergency medicine residents are now coming from multiple medical school backgrounds. Osteopathic residents traditionally were 10 percent or less of emergency physicians. Now, that number is increasing to the 30 percent range. We don’t know that there is an association, and we have not determined if there is a causation of the expansive number of residents and diversity of residents and the in-training exam and the qualifying exam scores. Again, you can use statistics in many different ways, and I would say that we don’t know if there is a link.

Dr. Dark: One thing that ACEP believes is that the gold standard is to have a board-certified emergency physician in every emergency department. Why do you think that the public should demand that?

Dr. Gorgas: We’re beginning to see publications that show outcomes are different when there isn’t a board-certified physician present. We’re beginning to understand that, and ABEM has published a few articles on it. I’m looking at State Medical Boards, disciplinary actions against physicians, and the fact that if you are board-certified in emergency medicine, practicing in an emergency department, your risk of a State disciplinary action is lower than if you are practicing in emergency medicine and not board-certified. We know that there are some early studies looking at resource utilization and board-certified emergency physicians versus non-physician providers in the emergency department.

There is no doubt that the rigor of the training, the rigor of the testing, and the rigor of continuing certification within emergency medicine is unmatched from a provider point of view in emergency medicine. And we think that ABEM is really the gold standard of that. Every patient should have access to an ABEM-certified physician when they come to the emergency department.

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References

1. ABEM. 2024 ABEM Qualifying Examination Scores.
2. ABEM. EM Model.
3. Gladwell M. Outliers: The Story of Success. San Francisco, CA: Little, Brown and Company; 2008.
4. JACEP Open. Differences in Exam Passing Rates Among Programs.
5. ACEP. ACGME Releases Proposed Changes to EM Program Requirements.