An Interview With Maintenance of Certification Dissenter: Paul Teirstein

Robert A Harrington, MD; Paul S Teirstein, MD


January 07, 2015

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Board Certification vs Maintenance of Certification

Robert A Harrington, MD: Hi, this is Bob Harrington from Stanford University on and Medscape Cardiology. I like to have guests on this podcast who are engaged in the "hot issues" in cardiology. Over the past year or two, I can't think of a topic that's generated more emotional responses than the issue of maintenance of certification (MOC). In particular, we're talking about MOC through the program of the American Board of Internal Medicine [ABIM].

Now, if I think back to how many of us became board-certified; we did our residency in internal medicine, we became board-certified in internal medicine. We then did our fellowship in cardiology. Sometimes we did subspecialty training in interventional cardiology, for example. After we finished that training, we took a certifying examination and the ABIM deemed us certified in that subspecialty, cardiovascular medicine, interventional cardiology, etc. For most of us, the requirement was a recertification exam every 10 years. For some of us, if we had trained before about 1990, we took that exam once and never took it again. We were in a so-called grandfathered state of certification.

That's all changed,[1] and the ABIM is responding to demands about quality of care and patient safety, that certification be more of an ongoing process. This brings us to maintenance of certification, where a variety of educational activities are required every couple of years. You have to accumulate a certain amount of points in the MOC educational activities every 5 years, and there is a recertifying examination every 10 years. The response from the community has been to raise a lot of questions about how this is being done—it is one more thing being put upon cardiologists, it is being put forward as a policy without necessarily having evidence behind it. I think most of us support the notion of lifelong learning, quality of care, and patient safety; how one does that is a worthy topic of discussion and debate.

My guest today is a long-standing colleague who has been very involved in this issue and has written about it and is proposing alternative solutions. I'm lucky to be joined today by Paul Teirstein. Paul is the chief of cardiology and the director of interventional cardiology at Scripps Clinic in San Diego. Paul, thanks for joining is here today on Medscape Cardiology.

Paul Teirstein, MD: Thanks for the opportunity. Great to talk to you.

Dr Harrington: Paul, you've been in the middle of the debate and discussion of MOC. Let's start at the beginning: How did you become interested in the topic?

Dr Teirstein: I was grandfathered into cardiology and internal medicine but not interventional cardiology. I took the recertifying interventional cardiology exam about 5 years ago and did the required modules. I was struck by what a colossal waste of time that process was, but I did it and I paid my fee and I went to the testing center and I was happy to have it behind me. I figured I'd do it again in 10 years or maybe not. At that point, I'll be about 65, but I thought I'll probably do it again, but I can put it aside for 10 years.

Then in January, we all learned that we had to do this maintenance process, which required a lot more activity, as you described. We're all very busy doing a million things. I try to multitask all day long, and I had about 40 minutes free. I had to wait for a procedure, it was late in the day, and I thought "Paul, you ought to do that MOC thing."

I went on the website and within 5 minutes I was very frustrated. It wasn't clear what they wanted me to do. At one point I started saying out loud, "Just tell me where to click and I'll click." There were so many steps. To this day (I have been involved in this for 8 months) I couldn't outline the requirements off the top of my head because they're so complicated.

Now we have to waste our time every 2 years on this. I don't like wasting time. I sat down to do this project, and I credit Mort Kern (University of California, Irvine) for getting me started. Mort runs an email group stemming from his— "Conversations in Cardiology" series, published in Cath Lab Digest and Catheterization and Cardiovascular Interventions.

It's almost like a chat room, nothing fancy, it's not even on Facebook. There are about 120 doctors; most of them are interventional cardiologists, and most of them are program directors. If you have a clinical question in a gray area where there's not a lot of evidence, you can ask Mort to send it to the group and then you get about 20 or 30 opinions on what you should do with in a particular patient, for example. It's very valuable.

Dr Harrington: Great concept, yeah.

Dr Teirstein: It really is great. It's like getting 20 consults almost instantly from around the country. I asked Mort to pose a question about MOC. I titled the e-mail "Enough is enough. Has anybody else tried to do the MOC?" I asked how do you feel about it? Instead of getting 20 responses, we got almost 120 responses. Everybody was against it with the exception of two of our colleagues (they're friends of mine) who were supportive of MOC. The two who were supportive had worked for the ABIM on MOC, and they acknowledged their conflict but they tried to present the other side to it. After a lot of e-mail back and forth, the question that came back to me from the group, was, "Well, Paul, what are you going to do about it?"

The Straw That Broke the Cardiologist’s Back

Dr Harrington: That's a good opening. This notion of us wasting time is an important concept, because as you've rightly said, we're all busy. I was very disturbed when I was at AHA talking to a colleague who has an administrative and a research position and he said he is probably not going to continue attending at his institution because he can no longer keep up with the module of demands. This is an enormously talented person; pulling him out of the clinical service is a major loss for that hospital.

Paul, you're a researcher, you're an educator, you've run fellowship training for years. I've watched you do many live cases over the years. You're a superb teacher. How do you balance our obligation to keep up and the whole notion of lifelong learning against maintenance of certification? My sense is you're all in favor of keeping up, it's the process that you object to.

Dr Teirstein: Yes. It's make-work that I object to. I have never met a doctor who didn't want to be at the top of their game. Everyone wants to take good care of patients, and they want to keep up with the latest information and the latest practices. There are lots of ways we do that, you do it every day by taking care of patients, Googling questions, and asking your colleagues, that's probably the number-one way. Those of us who have hospital-based practices have weekly conferencing at a minimum. And we all go to conferences like the ACC, AHA, TCT, whatever it is in our specialty. This brings me to an important point, which is that I believe that continuing medical education (particularly at conferences that are accredited by the [Accreditation Council for Continuing Medical Education] ACCME) is extremely valuable. That's the main way that I achieve lifelong learning. There are a lot of really good things that happen in continuing medical education.

There's a lot of oversight now. The conferences are required to have a needs assessment, there are evaluations, feedback; conflict of interest is addressed. They're not perfect, but they're pretty good, and importantly, you have a choice. You can choose the conferences that are relevant to your practice, and that to me is the key. If the conference isn't any good, you don't go back. You have a marketplace that functions such that the good conferences are well attended and you get something from them. I direct a conference every year, and my goal is to make sure that the attendees go back home having learned something. That's how I do lifelong learning.

There's so much wrong with using a computer module. It's so boring, and you learn almost nothing. You might learn occasional tidbits, I'm not saying that it's completely worthless, but it's nearly worthless. You can't be tested on these modules. You can't really talk about things that might become guidelines. Frankly, if you're practicing medicine based on printed guidelines, then you're probably out of date because the guidelines aren't updated every month, and every month there's new research. I think the standardized-module way of learning has a lot of defects. I do much better going to conferences, interacting with my colleagues, learning from my patients.

Dr Harrington: That's been one of the big criticisms, if you think about the two essential types of maintenance of certification that the ABIM is requiring. The so-called Part II points and the Part IV points. People want to know why CME activities (Part II points) can't count for most of the requirements for the very reasons you have described (we like going to conferences, interacting with our colleagues, we understand that there's an evolving science that involves needs assessment and how you incorporate things in the practice, etc). And as a course director, you're paying attention so you can create some good educational opportunities, and that should count.

What's your view of the Part IV points, which are the practice-improvement points? These seem to be the ones that really drive people crazy.

Aren’t We Doing This Already?

Dr Teirstein: That's because it's a ridiculous process. The one I did entailed me basically doing a patient-satisfaction survey. Most of us did that one because they made it a little easy for you. If I remember rightly, there was a telephone number your patients could call to evaluate you (you had to give them a list of questions). I gave 20 patients some questions about how I did with them. Then you get some feedback and you have to formulate a plan for improvement. Of course, it's not real patient satisfaction. A real patient-satisfaction survey is given randomly, it's given anonymously. With this version, I would pick out the patients, it's fun at first, but after about five you get bored and you turn to your secretary and say, "Didn't I prescribe an antibiotic for you? You're my patient, fill this out." It's just not relevant. We don't get important information that way.

If you work at a big hospital, or if you're part of a big medical group, you're going to get patient-satisfaction surveys that are actually valuable if done correctly. You can hear from specific patients who had a bad outcome or a bad experience or a good experience. With the good experience, you can post it on the wall for the team and let them see it. If it's a bad experience, you can dig into it, and try to improve. I don't think it's worthless when done right. Most of us are already doing it, so to have to do it again is very frustrating.

Dr Harrington: That's what I hear, given my positions within the American College of Cardiology or the American Heart Association: people want it integrated into their practice. These are things that we're doing anyway: sitting on quality committees, submitting data to get with the guidelines to [National Cardiology Data Registry] NCDR. Those of us who have hospital-based practices are part of performance-improvement committees; trying to get that to count is what I hear that docs want. I totally agree with you, Paul, I've never met a doctor who didn't believe in the concept of keeping up. We all want to keep up, we all want to take good care of our patients.

Dr Teirstein: I want to point out something to be aware of in this regard. For these things to count, the American Board of Medical Specialties [ABMS] or ABIM has to either vet them or establish that they can count, and that requires a fee. For example, if you went to TCT this year you could get MOC credits, but you had to go to the MOC sessions at TCT.

Dr Harrington: It was the same with the AHA and ACC meetings.

Dr Teirstein: The AHA and ACC have to pay ABIM for that session. It's very complicated, and if I want to make the practice-improvement plan that I use at Scripps count toward MOC, I'm going to have to have that vetted by the ABIM (and I'm sure there will be a fee associated with that).

Dr Harrington: We're trying to do that at Stanford; we're in the process of applying to have some of our quality projects vetted by ABIM so that our faculty can get credit. But you are absolutely right, there's a process involved, then somebody has to pay.

Big Money, Little Benefit

Dr Teirstein: When I started the petition, I didn't realize how much money is involved. I was a little naive. A lot of the comments I received related to the money. I was taken aback by the amount of money that's changing hands here. It's $55 million dollars a year for just ABIM, and MOC is about $20 million of that.[2] And if you talk to the practicing physicians, they believe strongly that this is motivated by money rather than a desire to make sure that physicians are keeping up. Each one of these modules costs money, and the administrators are pretty highly paid in these not-for-profit organizations. That's something to be aware of.

Dr Harrington: There's a lot of money changing hands. The ACC did a survey of its early career group, the fellows, and the amount of money it cost fellows to get certified is extraordinary at a time when they're making very little money.

Dr Teirstein: I know, because they come to me and ask for help, and I do help them because it's crazy. It's $10,000 a year, because they're doing their nuclear boards, their echo boards, and their interventional boards, and each one of these is a profit center, so to speak, within a not-for-profit organization.

Dr Harrington: It's even more expensive, Paul, because in addition to the money to take the test, they all feel pressured to pass it, so they're all going to preparatory courses. They're flying to places and paying for the course and a hotel. Our fellows are spending $15,000, $20,000, $25,000 to do this, and that's not good.

Dr Teirstein: If you ask practicing physicians, you'll find that they feel like they have to go to courses, and that takes time away from their practice. It's really expensive for them to take time from their practice to travel and even to take the test. Some of them don't live in a city that has a Pearson Test Center; they have to get on a plane. There's an economic component here that I didn't think about at first, but now that we've dug into it, I realize it bothers physicians much more than you would imagine.

I just want to respond to one thing you said earlier that I disagree with, and it was in regard to the ABIM and the ABMS responding to a public demand for more oversight. I don't have any evidence of that. I don't see any evidence of that. It sounds good, but I think it came from the ABMS, not from the public. I haven't seen any evidence of a public demand for this.

Dr Harrington: Maybe I used the word public in the broader sense in that we've now got pay for performance with [the Centers for Medicare & Medicaid Services] CMS, we've got an increasing emphasis on adherence to certain performance indicators; we got quality indicators being reported back at a state level. There seems to me to be a societal move away from accepting our word as practitioners that we're doing a good job to requiring us to provide data to demonstrate that we're doing a good job. What's our door-to-balloon time? What's our outcome after bypass surgery? How many times do people get readmitted after heart-failure admissions? That was the context of my comment.

Dr Teirstein: I agree with that, but that's not the public demanding, that's CMS, etc. Some of those outcome measures are valid. Of course, you have to watch out for the unintended consequences, which is that physicians may not want to take care of sick patients because they're going to end up with a higher rate of poor outcomes. There are a lot of caveats to be aware of.

Dr Harrington: The door-to-balloon time is an example. When we started measuring door-to-balloon time, how many false alarms did you get? I got a lot of late night calls where I'd be halfway to the hospital and then get paged to say, "Oh, never mind." That stuff just wears you out.

Dr Teirstein: There are so many problems with door-to-balloon time. There are very few patients who miss the door-to-balloon time now, and the reason is that when your hospital misses the door-to-balloon time, guess what happens, you get a board of administrators come down and figure out how to exclude the patient from the process because everybody is so fixated on these numbers.

If Not MOC, What?

Dr Harrington: I think you're right, there are some unintended consequences. Can you comment on two things for me? Your petition to the ABIM got a huge response from the community in terms of people signing it. Tell me about the response from the ABIM, and then the final question for you, where are you going from here?

Dr Teirstein: I started the online petition in response to Mort Kern's chat-room participants asking me, "What are you going to do about it?" The response was absolutely overwhelming. I gave it to my fellows the first night to see if it worked. The next day, I had 300 signatures and I said, how did that happen? And they had sent it to their Facebook friends. This internet is pretty powerful.

Dr Harrington: Social media at work.

Dr Teirstein: We now have over 19,000 signatures, and I'd encourage anyone who hasn't signed, go to and please sign. We've also started another petition, which is a pledge of noncompliance with MOC, and we have almost 6000 signatures.

One other point that we haven't discussed is whether there are data that indicate MOC or any type of certification is helpful. Those data are extremely weak. You'll hear people say, "If you have a heart attack, and you're treated by a doctor who's certified, the outcomes will be better." That's not quite the same. Being board-certified in cardiology is helpful for treating heart attacks. But that's a 3-year fellowship; it doesn't relate to MOC.

Dr Harrington: The quality of the evidence is not high.

Dr Teirstein: Now, what should we do about this? I think it's time for physicians to push back. We usually just accept changes. That's what I did—I sat down to do my MOC because I just wanted to get it over with. I wanted to get back to my real work. But MOC is a tipping point for me. We should say, no, we're not going to do this next task. It's going to have to be relevant.

I have launched a second certifying body. It's called the National Board of Physicians and Surgeons, we have some board members (maybe you'll be a board member, Bob), and some very high-quality institutions, and we are going to certify physicians as a substitute for MOC. The requirements are going to be fairly simple and relevant. There will be three or four requirements, and you have to be certified by an ABMS board initially. We're not taking that on. I think the fellowship process is great, it's like a final exam for residency and fellowship. I think most people agree that it's okay (not perfect, but okay). You'll also have to have a valid medical license and not to have been denied privileges recently in your specialty. Then the key requirement is 50 hours of continuing medical education, provided by an ACCME-accredited provider over 2 years. And the cost will be far lower. The cost will be as little as possible.

Dr Harrington: I applaud you, because you've not just complained about MOC, but you thought about it, and then you proposed an alternative solution. That's really what the community needs. We need alternative solutions to make sure that we have a mechanism by which we can stay current and maybe potentially offer an alternative to what's going on at ABIM. And my guess is ABIM has not formally responded to you, is that right?

Dr Teirstein: Dr [Richard] Baron sent me a nice email. We've had a couple of polite exchanges. I don't foresee major changes [on their part]. They're looking at it, which is great. If physicians want to do MOC, let them do it. But there should be some alternatives.

Dr Harrington: I fully agree with you; I'd love to see some actual evidence on how some of these educational activities are impacting quality. As a chair of medicine, I've bemoaned the fact that no one has formally studied residency work hours in a rigorous way. There have been a lot of extrapolations from other professions, but we're finally getting a randomized trial of resident work hours.

But you're absolutely right, we don't have that quality of evidence on lifelong learning maintenance of certification.

Dr Teirstein: If we do the randomized study, I want to be the control group.

Dr Harrington: We can have another conversation about what random means, but Paul, I want to thank you. This has been a wide-ranging discussion on a really important topic, maintenance of certification. I want to thank you for the leadership role you've taken in thinking about the issue and promoting some alternatives.

My guest here today on Medscape Cardiology has been Paul Teirstein, the chief of cardiology and the director of interventional cardiology at Scripps Clinic. I suspect, Paul, we'll get you back for some follow-up discussions, but thanks for joining me.

Dr Teirstein: Thanks for the opportunity.


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