May 25, 2023

State Advocacy Win: Closing the Road to Alternative Certification in Puerto Rico

The legislation was touted as a way to help alleviate the growing physician shortage in Puerto Rico. Instead, Senate Project 1134 would have created an alternative pathway to a certification in emergency medicine avoiding the training and certification standards supported by ACEP and the American Board of Emergency Medicine.

Puerto Rico ACEP (ACEP PR) responded with a comprehensive advocacy campaign that included grassroots, coalition outreach, direct lobbying, and earned media to push against the legislation.

Senate Project 1134 (“project” is the name used in Puerto Rico instead of “bill”) was introduced by Senate President José Luis Dalmau-Santiago. The intended goal of the legislation was to remove perceived barriers to entry to practice medicine and to address the shortage of specialist physicians. One such proposal in the legislation was to create an alternative pathway for general practitioners to become “certified” as emergency physicians based on the amount of time working in an emergency department, 10 years, and not based on completion of the training, residency, and board certification programs required for emergency physicians.

ACEP is a strong proponent of the pathway to board certification through training and residency with a certification issued by the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM).

Since the moment ACEP PR leadership was made aware of Senate Project 1134 and its potential effect on the specialty of emergency medicine and the standard of medical education in Puerto Rico, the chapter took immediate action, reaching out to national ACEP for assistance. Led by Cesar Andino-Colon, MD, FACEP,  ACEP PR contacted ACEP’s state government relations department for assistance on a strategy to oppose the legislation.

The first step was to establish a clear position on the proposed legislation. ACEP PR and national ACEP sent individual letters to the Senate President and the Presidents (chairs) of the Senate and Assembly Health Commissions (legislative committees) formally expressing opposition to the legislation.

Concurrently, Dr. Andino raised awareness of the problems in the legislation, participating in several public affairs television programs popular among policymakers and the public. These appearances were subsequently shared through the chapter and members’ social media channels. Being a small chapter with limited resources, ACEP PR’s initial outreach was through social media posts on Facebook and Instagram - creating posts and stories that helped attain public and media attention through tagging newspapers, TV, and radio news commentators along with state senators. Those efforts helped generate media attention, resulting in the chapter receiving calls from different news outlets for interview requests which in turn helped to amplify the concerns and the reasons for the opposition to the legislation.

Additionally, ACEP reached out for national organizational support including the American Board of Medical Specialties (ABMS), amongst others. The outreach generated additional advocacy and letters of opposition. The ABMS provided additional support and guidance to ACEP PR on hiring a contract lobbyist. ACEP PR was able to coordinate a written public statement by a newly formed coalition of 38 medical specialties and subspecialty organizations and the Puerto Rico Physician and Surgeons College, and abroad, with national organizations sending statements that the chapter was able to strategically make public in coordination with the organizations.

The initial response from the bill proponents (senators, Puerto Rico Medical Licensing and Disciplinary Board, and Puerto Rico Health Department) was mute. However, as support grew within Puerto Rico for the physicians’ arguments, the proponents could no longer stay silent. Despite attempts to clarify their position on the legislation, the amount of opposition to the bill was too much.

At this moment, the media started performing back-to-back interviews among proponents and the opposition, and the facts could not be denied. This bill would in essence destroy the high standard of ACGME-accredited medical education Puerto Rico has strived for and maintained for years and would destroy the specialty of emergency medicine among other specialties by creating an alternate pathway towards local certification.

The culmination of the advocacy and media efforts along with the groundswell of opposition to the legislation led to the bill being pulled from consideration before a hearing could be held in the Senate Health Commission.

A small medical specialty chapter was able to coordinate a grassroots effort that gained the support of thousands and was able to stand up against government institutions (Puerto Rico Medical Licensing and Disciplinary Board and the Health Department), and special interests, defeating Senate Project 1134 before public hearings could be conducted. This effort has shown what we can achieve if we work towards a common goal and in the best interest of our specialty and our patients.

Actions and Outreach by ACEP Puerto Rico


  • Radio Isla – Millie Mendez
    • Maria Ramos, MD (Emergency Medicine, UPR EM Residency Program Director)
    • Carlos Garcia Gubern, MD (Emergency Medicine, PHS EM Residency Program Director)
    • Jorge Falcon, MD (Emergency Medicine, and UPR SOM Dean of GME)
  • WAPA Radio – Normando Valentin
    • Wilfredo Gutierrez, MD (Emergency Medicine, PR ACEP Treasurer)
  • WAPA Radio: Quique Cruz
    • Deborah Silva, MD (Peds)
  • WKAQ – Mayra Lopez Mulero
    • Yazmin Pedrogo, MD (Peds)
  • Radio Isla 1320- Ines Quiles
    • Maria Ramos, MD (Emergency Medicine, UPR EM Residency Program Director)
    • Cesar Andino, MD (Emergency Medicine, ACEP PR President Elect)
  • Radio Isla - Marcia Rivera
    • Jorge Falcon, MD (Emergency Medicine, and UPR SOM Dean of GME)
    • Deborah Silva, MD (Peds)
    • Yazmin Pedrogo, MD (Peds)


  • El Poder del Pueblo – Canal 11
    • Cesar Andino, MD (Emergency Medicine, ACEP PR President Elect)
  • Los Datos son los Datos – WAPA TV
    • Cesar Andino, MD (Emergency Medicine, ACEP PR President Elect)
  • Jugando Pelota Dura – Canal 11
    • Deborah Silva, MD (Peds)

Facebook Live

  • Colegio de Medicos Cirujanos de PR (Puerto Rico Physician and Surgeons College) San Juan District forum:
    • Wilfredo Gutiérrez, MD (Emergency Medicine, PR ACEP Treasurer)
    • Maria Ramos, MD (Emergency Medicine, UPR EM Residency Program Director)

Newspaper Columns

  • El Nuevo Dia – newspaper with highest circulation in PR
    • Maria Ramos, MD (Emergency Medicine, UPR EM Residency Program Director)
  • Editorial de El Nuevo Dia
    • Newspaper editorial board opposition against the bill in a Sunday edition

Meetings in order of occurrence

  • Senator Marissa Jiménez
  • Senator Carmelo Rios – Senate Minority Leader – Bill Co-author
  • Arevalo - Senator Jose Luis Dalmau concillor
  • Senator Rubén Soto – Senate Health Comission Chair
    • Ramon Méndez Sexto MD – Puerto Rico Medical Licensing and Disciplinary Board President (bill proponent) met with Dr. Wilfredo Gutiérrez (Emergency Medicine, PR ACEP Treasurer) and Dr. Fernando Soto (PR ACEP Chapter President)
  • Representative Jesús Manuel Ortiz
  • Senator Thomas Rivera Schatz
  • Representative Héctor Ferrer Jr.
  • Senator Ana Irma Rivera Lacen
  • Senator José Luis Dalmau – Senate President - Bill Co-author
  • Senator Marially González Huertas – Senate Vice President
  • Senator Javier Aponte Dalmau - scheduled
  • Senator Keren Riquelme - scheduled

Public Support expression by:

  • Coalition of 38 Medical Specialties and Subspecialties
  • Colegio de Medicos Cirujanos de PR (Puerto Rico Physician and Surgeons College), the largest medical society in PR
  • All 4 Puerto Rico-based medical school deans:
    • Univ of Puerto Rico School of Medicine
    • San Juan Bautista School of Medicine
    • Universidad Central del Caribe School of Medicine
    • Ponce Health Sciences School of Medicine

Letters sent to key senators and bill authors by:

  • ACEP 
  • ABMS (American Board of Medical Specialties)
  • ABEM (American Board of Emergency Medicine)
  • NAEMSP (National Association of EMS Physicians)
  • AAEM (American Academy of Emergency Medicine)
  • University of Puerto Rico School of Medicine 2023, 2024, 2025, and 2026 classes
  • University of Puerto Rico School of Medicine residents


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