66 COMMENTARIES Wagner • ABEM ANNIVERSARY

COMMENTARIESHappy Anniversary, ABEM!

Editor’s Note: The AmericanBoard of Emergency Medicine(ABEM) celebrated its 20th an-niversary in 1999. In honor ofthis event, we asked some of thefirst members of ABEM andfounders of our specialty for theirrecollections of the early days ofour specialty, and for their pre-dictions for the future of emer-gency medicine. Their responsesare published on the pages of thisand subsequent issues of Aca-demic Emergency Medicine.

This commentary was writtenby David Wagner, MD, Chair ofthe Department of EmergencyMedicine at the MCP–Hahne-mann University School of Med-icine. As his words suggest, Dr.Wagner was involved in the in-ception of ABEM, and served onthe Board from 1976 to 1988. Hismemories expressed here illus-trate the dedication and thehumanity involved in the devel-opment of the specialty of emer-gency medicine.

It was the best of times—thatwonderful, wacky earth mam-

ma, driven, fun-filled, creativewindow of time between the dis-covery of the pill and the adventof AIDS. It was the worst oftimes—that terrible and turbu-lent era encompassing the Viet-nam experience with its residueof disgust, depression, anddrugs. It was surprising times aspeople in every segment of thecountry came flocking to emer-gency ‘‘rooms.’’ They arrived byfoot, public conveyance, ambu-lances which were often ownedby funeral directors, and early-on volunteer fire rescue efforts.They came 24/7, and everyonewas overwhelmed. It was a timeof turmoil, a time of ferment, atime of radical change in thehealth care system as Medicare,‘‘the greatest issue ever to

threaten the practice of medi-cine,’’ was created. Physicianswere specializing in unheard-ofnumbers and no longer enteringgeneral practice. The black bagno longer carried adequate diag-nostic or therapeutic remedies,and home-based visits were nolonger a significant part of amedical practice. As a result ofall of the above, both communityand teaching hospital ERs wereflooded with business, and some-thing needed to happen. In Vir-ginia and in Michigan, groups ofpracticing physicians came to-gether to provide coverage andservice to community hospitalemergency centers. In Virginia,they gave up their private prac-tices and became the first full-fledged group devoted exclu-sively to providing medical carein the emergency department. InMichigan, some 20 physicians in-corporated to provide coverage ofemergency services while retain-ing their office practices. The for-mer became known as the Alex-andria plan, the latter, thePontiac plan. Around the coun-try, permutations of these plansdeveloped, and not too longthereafter, these individualscame together to have the firstnational meeting of emergencyphysicians at the Marriott TwinBridges Motel in Arlington, Vir-ginia. The year was 1968. Duringthe same time in medical schoolsand their hospitals, certain fac-ulty gravitated to ‘‘help the in-terns’’ who, by tradition, werecalled upon to service emergencyroom visits. For most of the aca-demics, this was viewed as astepping stone to a ‘‘true’’ aca-demic position; others caught thefever and became more and moreimmersed. Most commonly withsurgical backgrounds, this some-what disparate group of individ-uals came together to form the

University Association for Emer-gency Medical Services. The yearwas 1970. From these two orga-nizations whose paths continuedto intertwine, individuals rootedin one or the other, or sometimesboth, came together to form theAmerican Board of EmergencyMedicine. The year was 1976. Avoluntary assessment was con-tributed by over 4,500 ACEPmembers, amounting to morethan $800,000. These dollars,which were later to be repaid, in-itially bankrolled the foundingBoard’s activities. The charge tothe Board was to develop an ex-amination process to certifyemergency physicians, and to es-tablish the criteria by which in-dividuals could credential and sitthe examination.

It was the best of Boards. Itwas wonderful and wacky. It cel-ebrated diversity, an eclectic col-lage, often driven by iconoclasty,yet melded by a common belief inthe mission to which it had beencharged. Who were the earlyBoard personalities? Several hadlittle formal graduate training aswe know it today, but were longon the pragmatic aspects of pol-itics and practice. One of these,whose Harvard backgroundbrought a certain amount ofcredibility, had already been in-strumental in getting formal ap-proval for the discipline of familymedicine, and was determined‘‘to take that ride again.’’ Politi-cally adroit, he always wore redsocks readily visible beneath apair of hiked-up trousers, a rec-ognizable hallmark in any gath-ering of important people. Sev-eral were keenly aware of thepragmatic implications thatcredibility, respectability, andcompetency could engender, orconversely, acutely concerned ofthe results should credibility, re-spectability, and competency belacking. These individuals inparticular were important in rec-ognizing the need for indepen-dence and internal control of allcritical emergency medicine ac-

ACADEMIC EMERGENCY MEDICINE • January 2000, Volume 7, Number 1 67

tivities. There were enoughchain smokers to give everyone agenerous dose of second-hand ex-posure, and at least one brittlediabetic who would periodicallyattract attention and shorten de-bate by becoming profoundly di-aphoretic and appearing to needa ‘‘911’’ resuscitation. The so-called academic contingency wasa somewhat rag-tag group, withsome testing a new career direc-tion and others dabbling in anexperience to be abandoned if ac-ademic points failed to accrue.Somehow this constellation ofcharacters came together to forma solid working group. Whetherit was a marriage of convenienceor a combination of passion andpragmatism, it operated as a fo-rum without subcommittees todiscuss and dissect at lengtheach issue of substance as wellas many of lesser consequence.

Overriding concern about thefirst examination, and overshad-owing interest in the credential-ing process, was a single omni-present problem. How should theBoard be structured, and howshould it interact with the tra-ditional boards of establishedmedicine? This was, in manyways, a replay of the issues ofhow emergency medicine as adiscipline was fitting into eachhospital setting. Was it a triagefunction, the ground rules to beestablished by traditional spe-cialists, or was it an educationalprogram significantly or totallydependent on resources fromother disciplines? Did it own theturf, or was it there to organizeand encourage cooperation be-tween the carved-up segments ofthe emergency room? How theBoard came down on these issueswould have a significant effect onthe direction the specialty wouldtake in the years ahead.

To most, the choice was obvi-ous, a no-brainer. There was anindependent body of knowledge.We have the capacity to repro-duce our own programs from in-ternally held resources. We own

the turf, and we will no longercall it the emergency ‘‘room.’’ Itwill become an ‘‘emergency de-partment’’ to be run by fullytrained, properly credentialed,and certified emergency physi-cians. To accomplish this and setthe ship on course, all thatneeded to happen was accep-tance of the Board’s applicationfor primary board status by theAmerican Board of Medical Spe-cialties. The year was 1977. Atthe Spring meeting of ABMS, theapplication was presented andreceived. At the September meet-ing, ABMS voted 100 to 5 againstthe founding Board’s application.The air was out of the balloon.The rose tint was off the glasses.I remember standing in the cor-ridors of the Chicago Marriott asthe ABMS members filed out. Itwas not a happy moment, andsubsequent Board discussionsbecame increasingly strident.The counteroffer from ABMSwas to accept conjoint boardstatus. With a conjoint board,sponsoring boards from tradi-tional specialties appointed themembers. Sponsoring boardscould veto credentialing require-ments. In short, sponsoringboards controlled the process.Seven boards wished to sponsora conjoint Board for EmergencyMedicine.

The Board’s alternative wasto establish our own independentor ‘‘jake-leg’’ board, as had some70 to 80 entities done previously.Jake-leg boards have not had en-during qualities. Does anyone re-member the American Board ofAbdominal Surgery or the Amer-ican Board of Temporomandibu-lar Joint Disease? The choice be-came ‘‘jake-leg’’ vs dependency,death by attrition or death by ac-quisition. It was a time whenneither red socks nor hypoglyce-mia seemed to be effective. Then,somehow, the Board came upwith an idea. Why not submit anapplication for a conjoint board,but structure the board to func-tion exactly as a primary board.

For reasons which, perhaps, dif-fered with each, the seven would-be sponsoring ABMS boardsbought onto the idea. One hurdleremained. It really was a pri-mary board in conjoint disguise,and the ABMS staff recognizedthis. On the night before theABMS meeting, it appeared asthough things would again comeunglued. It was late and every-one was tired when somebody (Ithink it was the executive direc-tor of ABMS) thought of an as-terisk. Why not asterisk the con-joint board and call it ‘‘modified’’?The next day the first and onlyever conjoint (modified) boardwas approved by ABMS. Emer-gency medicine became the 23rdofficial, legitimately recognizedspecialty, a primary board con-cealed in modified conjoint cloth-ing. The year was 1979.

The new Board voted to ac-cept representatives from seventraditional boards to sit onABEM. These individuals, who,in some instances, took a chanceat rejection by their traditionalspecialty colleagues, brought asense of maturity, dignity, andwisdom, which proved to be ofgreat benefit to the fledglingBoard. I remember late one eve-ning, along with three or fourothers, having a sandwich withone of these senior traditionalspecialists. He was an interna-tionally known cardiologist, aformer chair of the departmentof medicine in a major medicalschool. He believed in ‘‘re-invent-ing himself every seven years,’’and currently was again activelyinvolved in the clinical practiceof cardiology. Yes, he could stillbe a clinician after having beenin the throes of academia formany years. In any event, heasked us what we thought washis most important tool thathelped him diagnose and man-age his patients. After identify-ing all the various forms of EKGmachines and stethoscopes wecould think of and without re-ceiving affirmation from him, we

68 COMMENTARIES Wagner • ABEM ANNIVERSARY

all gave up. Whereupon, hereached into his pocket andpulled out a large toenail clipper.‘‘You see,’’ he went on to say, ‘‘mypatients are mostly elderly, andthey need to talk about theirlives, what they can do and whatthey cannot do. While they arelying in bed and talking with me,I trim their toenails. It’s some-thing that’s difficult for them todo, and it’s amazing what I learnabout how together we can worktowards maximizing their car-diac function.’’ I thought to my-self then, and many times since,there’s a real doctor. He listens,he learns, he provides a humbleservice. As you might imagine,he was also a real contributor tothe culture of that early Board.

In many ways, it was the bestof boards, and yet it was also theworst of boards. In its zeal to ‘‘de-velop respectability,’’ it pur-chased a series of basic sciencequestions, which it utilized in itsfirst examination. These ques-tions had as much relevance tothe discipline of emergency med-icine as questions about Ein-stein’s relativity or astrophysics.Smoking was allowed during

written examinations, and devi-ations from oral scenarios wereoften so blatant and so vocal asto disturb examinees a room ortwo away. It is indeed fortunatethat infancy and adolescence oc-cur only once in the course of aboard’s life cycle.

And so it was in the begin-ning. There was an insistence onindependence and acceptance ofthe responsibility that accompa-nies this choice. The ongoing is-sues to define and refine thebody of knowledge, develop acredible means to query thatknowledge, and define the crite-rion to access the testing processremained. Launched in the direc-tion of independence, responsi-bility, and respectability, subse-quent board directors wouldbring these issues to fruition.And what a marvelous job theyhave done! The credibility andrespectability that ABEM hascreated provide an unprece-dented opportunity for board-certified emergency physicians tofunction in a more comprehen-sive and competent fashion thanwas ever dreamed of in thoseearly days. Now is truly the bestof times, and we have the best of

boards. The outlook for emer-gency medicine to function as thecritical keystone between an in-patient hospital and an outpa-tient community was never bet-ter. The opportunity to takeresponsibility for acute interven-tions whenever and whereverthey occur is now available, andthe potential for such encountersto grow with the aging popula-tion is assured. The opportunityto expand the window of timeand scope of practice is upon us.ABEM, through its credentialingand certifying activities, willplay the seminal role in deter-mining the scope of practice ofemergency medicine and thestatus of the emergency physi-cian in the years to come. Creden-tialing, competency, responsibil-ity, and respectability. ABEM,you’ve got it. Continue runningwith that ball.—DAVID WAG-NER, MD (david.wagner@drexel.edu), Department of EmergencyMedicine, MCP HahnemannSchool of Medicine, Philadelphia,PA

Key words. American Board ofEmergency Medicine; history;ABEM.