Boarded to Death: Why Maintenance of
Certification is Bad for Doctors and Patients
Paul S. Teirstein, M.D.
Medical Director, Scripps Cardiovascular Institute
Chief of Cardiology
Director, Interventional Cardiology
Scripps Clinic
SCRIPPS CLINIC
Paul Teirstein, MD
Disclosures:
Dr. Teirstein participates in and directs CME activities
in cardiology
Dr. Teirstein is President of the National Board of
Physicians and Surgeons (NBPAS.org)
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• On Feb 19th, 2014 at 3PM I had about 40 minutes of free time. So…like a
good citizen…I logged on to ABIM to start the new MOC requirements
I direct CV division, a system-wide CV service line and a fellowship program
I am not a political person. Not doing MOC never even occurred to me
I was confused. “What do they want me to do?”
“Just tell me where to click and I will click, I cant figure out where to click”
Conversations in Cardiology
Morton Kern, MD (>100 program directors and
cardiology “thought leaders”)
Mort Kern’s
“Conversations in Cardiology”
• “Enough is enough. Is anyone else profoundly
annoyed with the new MOC requirements..?”
•The response was overwhelming. Instead of usual 20
responses there were over 50.
•Pages and pages of very emotionally negative
responses. And these were our “thought leaders”
many were senior academicians!
After about a week of indignant complaining, a
unanimous question emerged:
“Paul…what are you going to do about this?”
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After about 6 months of collecting signatures, I
started getting emails and comments on the
petition site asking: What is the update? Has the
ABIM done anything?
Dr. Teirstein, what are you going to do about this?
So, about 5 months and 500 hours of unpaid work later…
www.NBPAS.org
Are there data supporting MOC?
ABIM/ABMS argue there are data supporting the
value of MOC. However, close examination of the
reports cited by ABIM/ABMS reveals they support
the opposite conclusion.
This is not just a tongue in cheek debating
tactic…I mean it, the ABMS’s own data support
the opposite conclusion
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Initial Certification vs. MOC?
• Almost all the studies in the literature evaluate board
certification, not recertification or MOC!
• Initial ABMS certification is earned, for the most part, by
spending several years in an ACGME credentialed training
program.
• The initial certification exam provided by the ABMS is simply
the “final exam” which is obviously a much smaller part of the
educational process.
• Should it be surprising that successfully completing 3 years of
training in an ACGME credentialed cardiology fellowship
makes a doctor better at treating MIs?
• It is absurd to equate the busywork of MOC…clicking on
computer modules for 10-20 hours each year…to the many
years of training required for initial certification
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One of the few studies examining lapsed certification found no
impact on patient outcomes following coronary intervention
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Study limitations: Non-randomized
Propensity matching followed by a regression analysis
Beware of unmeasured confounders
Exercise caution interpreting small differences
Should we worry about COI in a
non-randomized trial?
• Were the endpoints pre-specified?
• Was the small difference in cost discovered after
looking at multiple potential endpoints?
• Were there any differences favoring the grandfathered cohort that were not published?
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•Not a meta-analysis. It’s an “equivocal” literature review
•24/29 studies listed attempt to correlate clinical outcome
with certification not re-certification or MOC
•5/29 studies listed do attempt to correlate outcome with
MOC grades but no studies attempt to correlate outcomes
with the dichotomous endpoint of MOC participation
•Written by ABIM affiliate
Do we really need more data?
• In the debate I keep hearing calls for more “data.”
• “More data” - sounds good from the podium, looks
good in print.
• But, think about it. What kind of data quality will
ever be achievable?
• Level A? Are we really going to randomize
physicians to MOC vs no MOC? Can we blind the
doctors?
• Unfortunately, the data will always be registry data
with massive bias.
• In my opinion, asking for more data, is a cop out…it
just kicks the can down the road.
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Hypothetical trial
The HOLIE CHUTE trial
If you have 22,000 physician
signatures on a petition saying MOC
is not meaningful, maybe you don’t
need a lot more
Group B
Group Adata?
Primary endpoint = Mortality
Inexpensive trial
Expected 99% relative risk; 40 pts provides power 0.90, alpha < 0.05
DSMB halts trial early because of excess deaths in treatment
group B
Continuing Medical Education and
MOC
• ABIM makes the argument ‘CME is too passive”
Personally, its hard to imagine anything more passive than
sitting at a computer, clicking away on MOC modules, bored
to death,
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Continuing Medical Education and
MOC
• CME is a better approach to lifelong learning.

Organizations providing recognized CME programs are
regulated by a rigorous accreditation body (ACCME) requiring
each CME offering provide an educational gap analysis, “needs
assessment," speaker conflict of interest, course evaluations
and many other performance standards.
• Accredited CME must be independent of commercial interests
• MOC focuses on established knowledge while CME can
include future innovations that keep the physician on the
"cutting edge."
• CME offerings are highly competitive and provide choice. If
physicians do not perceive value in a particular CME offering,
they will go elsewhere. This contrasts with the monopoly ABIM
has on MOC.
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The 10 Year Recertification Exam
• Very controversial. Some think a test is important
• Arguments against:
 The exam questions are often not relevant to physician’s
practice. Questions often relate to parts of their specialty they
do not practice.
 The questions are often outdated. Most of the studying is done
to learn the best answer for the test, which is very often not
the current best practice.
 Testing often uses “Guidelines” as gold standard but there is
a long history of Guidelines changing and often reversing
 Closed book tests are no longer relevant. We care for patients
with our colleague’s input (ie conferences, the Heart Team,
curbside consults etc) and we are connected to the internet all
day long
 There are no re-certification or MOC programs outside the U.S.
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Don’t Pilots have to maintain
currency?
• Our flight reviews are required every two years. They involve at
least one hour of ground flight training and one hour flying with
a certified instructor (selected by the “applicant”)
• It is very practical
• There are no written exams or computer modules, you cant fail
• Cost is about $100-200 every two years.
• Commercial requirement is a more intense one week
experience, but still based in practice, not written exams
• Its NOT a waste of time.
• If every two years a doctor (whom WE selected and respected)
worked side by side with us for a day…we would LOVE it
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What about the cost?
• Costs (for one specialty) begin at $190 – 256/year
plus module fees.
• Costs increase significantly if you have boards in
multiple specialties
• On top of this are costs for review courses, travel to
review courses
• Time away from practice
• Which brings us to money…
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Value is Virtuous
• ABIM IRS Form 990 tells the story
• ABIM annual revenue is $55M (that’s per year)
• Directors are very well paid
• We have all had to tighten our belts in medicine
• Patients are NOT demanding MOC…but they ARE
demanding better “value”…better care, lower costs
• Recently, most physicians, have spent an enormous
amount of time cutting costs in their practices and
hospitals
• Physicians are now asking for a better value from
the ABIM.
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Beware of economic of other COIs
• Many organizations, like ACP and ACC make
money from selling MOC study and testing
materials
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ABIM is now
under fire
from many
organizations!
ABIM Apologizes - A Good First Step
• Part IV is suspended. Very good decision
• Other changes, however, are not meaningful:
Changing public reporting language of diplomat
status, freezing fees, and promises to consider
further changes
• We are still left with parts 2 and 3 that are onerous,
time wasting and expensive (self assessment
modules and repeat secure testing)
• The self-admitted poor roll-out of MOC by ABIM
illustrates the need for alternative certifying
organizations.
• Applications for NBPAS tripled after this apology
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• NBPAS does not replace ABMS boards
• NBPAS supports the initial ABMS certification
criteria, i.e. completion of ACGME accredited
training program and a secure test
• NBPAS strongly objects to the current MOC
requirements
• NBPAS supports choice. Physicians who believe
they benefit from MOC, should participate.
• Life-long learning is not one size fits all. No single
program will meet everyone’s needs.
• NBPAS provides physicians with an important
alternative.
Complete criteria for NBPAS certification:
■ Candidates must have been previously certified by an American Board of Medical Specialties member board.
Currently, NBPAS certifies physicians in non-surgical ABMS specialties.
■ Candidates must have a valid, unrestricted license to practice medicine in at least one US state. Candidates who
only hold a license outside of the U.S. must provide evidence of an unrestricted license from a valid non-U.S. licensing
body.
■ Candidates must have completed a minimum of 50 hours of continuing medical education (CME) within the past 24
months, provided by a recognized provider of the Accreditation Council for Continuing Medical Education (ACCME).
CME must be related to one or more of the specialties in which the candidate is applying. Re-entry for physicians with
lapsed certification requires 100 hours of CME with the past 24 months. Fellows-in-training are exempt.
■ For some specialties (ie interventional cardiology, electrophysiology, critical care), candidates must have active
privileges to practice that specialty in at least one US hospital licensed by a nationally recognized credentialing
organization with deeming authority from CMS (ie Joint Commission, HFAP, DNV).
■ A candidate who has had their medical staff appointment/membership or clinical privileges in the specialty for which
they are seeking certification involuntarily revoked and not reinstated, must have subsequently maintained medical
staff appointment/membership or clinical privileges for at least 24 months in another US hospital licensed by a
nationally recognized credentialing organization with deeming authority from CMS (ie Joint Commission, HFAP, DNV).
NBPAS Board Members
• NBPAS board members are well respected,
high profile members of the academic
medical community
The NBPAS Board Members are physicians who value patient care, research, and life long learning. Board
members believe continuous physician education is required for excellence in patient care.
NBPAS Board Members:
Paul Teirstein, M.D., President NBPAS, Chief of Cardiology, Scripps Clinic
David John Driscoll, M.D., Professor of Pediatrics, Mayo Clinic College of Medicine
Daniel Einhorn, M.D., Immediate-Past President, American College of Endocrinology; Past President,
American Association of Clinical Endocrinologists
Bernard Gersh, M.D., Professor of Medicine, Mayo Clinic College of Medicine
C. Michael Gibson, M.D., Professor of Medicine, Harvard Medical School
J. Marc Pipas, M.D., Professor of Medicine, Dartmouth School
Jeffrey Popma, M.D., Professor of Medicine, Harvard Medical School
Harry E. Sarles Jr. M.D., FACG, Immediate Past President for the American College of Gastroenterology
Karen S. Sibert MD, Associate Professor of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA.
Secretary, California Society of Anesthesiologists
Gregg W. Stone, M.D., Professor of Medicine, Columbia University College of Physicians and Surgeons
Eric Topol, M.D., Chief Academic Officer, Scripps Health; Director, Scripps Translational Science Institute
Bonnie Weiner, M.D., Professor of Medicine, University of Massachusetts Medical School
Mathew Williams, M.D., Chief, Division of Adult Cardiac Surgery, New York University Medical Center
NBPAS website
• NBPAS.org
– Website is simple to navigate
– Contains links to NEJM opposing
“Perspectives” on MOC (Teirstein Vs
Irons/Nora) along with the apologetic press
release from ABIM and the NBPAS reaction
– Contains links to explanatory sample letters to
send to hospital administrators and colleagues
– Contains links to PowerPoint presentations
www.NBPAS.org
Simple
application takes
<15 minutes to
complete
NBPAS Fees and Application
• NBPAS is a not for profit 501(c)(3) organization
• The fee is $84.50 per year ($169 for two year
certification), irrespective of the number of specialty
applications. This one fee covers two years and all
specialties desired. Fees are used for staff, IT, offices,
equipment and marketing. The fee will be adjusted in
future years, determined by our expenses.
• Physician management is unpaid
• Go to NBPAS.org to view the website, apply for
certification, leave comments and help us educate
administrators and the public.
www.NBPAS.org
Conclusions:
The need for an alternative
• Irrespective of how the MOC issue is resolved, the
process of evaluating MOC has shed enormous light on
how medicine is regulated in the United States
• In the past, ABMS/ABIM has made contributions to
patient care by providing initial physician certification
exam.
• But it is also clear that ABIM is a private, self appointed
credentialing organization.
• ABIM has grown into a big >$55M business, unfettered
by competition, with zealous economic goals, selling
proprietary, copyrighted products
• It is time for other organizations to compete with ABIM
and offer alternative credentialing options.
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Vol.CLV18. .No. 34,682
NEW YORK. November 6th, 2010
Breaking News:
Physicians Finally Extract Heads From Sand
Docs came close to ceding
control of entire profession
•Sentinel event for many physicians
•Physicians are waking up to the fact that their profession is
controlled by individuals who are not involved with the day to day
care of patients
•When confronted with the inequities of MOC, many initially reacted
with jaded pessimism, saying "Its too late. MOC is here to stay. The
horse is out of the barn."
•But ABIM is making changes and alternatives have appeared
•We CAN put the horse back into the barn
•It is time for practicing physicians to take back the leadership of
medicine