Clinical Innovators | Paul Teirstein, MD, is the chief of cardiology for Scripps Clinic and director of the Scripps Prebys Cardiovascular Institute for Scripps Health in San Diego, CA. He received training at the Mount Sinai School of Medicine, the Brigham and Women's Hospital, Stanford University, the Mid-America Heart Institute, and the National Institutes of Health. Dr. Teirstein joined Scripps in 1987 and is the founder and director of the interventional cardiology program at Scripps Clinic. With a primary focus on complex coronary interventions and new technology development, Dr. Teirstein pioneered the first effective treatment for restenosis (low dose radiation therapy) and was one of the early investigators of medicated stents. Dr. Teirstein has been a vocal opponent of the American Board of Internal Medicine's maintenance of certification requirements, which he discusses in a recent New England Journal of Medicine Perspective article "Boarded to Death—Why Maintenance of Certification Is Bad for Doctors and Patients." He and his colleagues founded a new recertification organization called the "National Board of Physicians and Surgeons."

You have been a practicing physician for over 30 years. What changes have you seen in maintenance of certification requirements over the course of your career, and what lead you to say "enough is enough?"

When I started practice, certification was life-long. In the mid-1990's, the 10-year recertification requirement was initiated. Then, this past January 2014, the new maintenance of certification (MOC) requirements were started that required annual payments and completing modules every 2 years at a minimum.

You started a web-based petition against MOC requirements. What kind of response have you seen?

In my experience, every physician I come in contact with is against MOC. The only MOC supporters I know work within the structure of the American Board of Medical Specialties (ABMS). We have over 22,000 signatures on our petition to recall MOC. The petition website is filled with a large number of comments very critical of ABIM. Physicians seem to be most offended by the costs involved with MOC and the large ABIM budgets and administrator salaries.

The ABIM argues that there is evidence supporting the value of MOC—what is the relationship between test results and clinical outcomes?

The evidence supporting MOC is ambiguous at the very best. Most of the published studies show no correlation between MOC and patient outcomes. Every time a claim is made that MOC is supported by data, I encourage readers to go to the written papers. Read the papers and you will be amazed at A) how weak the data is (it is all registry data, nothing randomized, and the results are usually ambiguous) and B) how so much of the data is written by ABMS and ABIM employees. Highly-paid ($300,000 to $450,000 annual salary) vice presidents of these nonprofit organizations write the papers that are used to justify MOC. In some cases, the papers are "self-published" in supplemental journal issues that are paid for by the ABMS. I also encourage readers to visit NBPAS.org and click on the first line to view my comments during a recent debate on MOC with the CEO of ABMS and ABIM. In this debate, I discuss the evidence base, study by study, and show how the data are weak and the authors conflicted.

You and your colleagues recently formed a new recertification organization called the "National Board of Physicians and Surgeons." How does this organization differ from ABIM?

NBPAS.org is a 501(c)(3) nonprofit certification board that provides an alternative for continuous certification. It offers board certification in all the ABMS specialties. For life-long learning, we substitute ACCME-accredited continuing medical education instead of test modules and secure exams. All candidates must have initially received board certification by an ABMS board (we are not objecting to the initial board certification process). The application is simple and takes about 10 minutes to complete. The cost is $85 per year, and we hope to reduce this in the future.

You have issued a call to action for practicing physicians to take back the leadership of medicine in an age where "our profession is increasingly controlled by people not directly involved in patient care." How have you been able to lead the charge while maintaining a demanding clinical and research practice?

Finding the time for this project has, indeed, been a challenge. I love taking care of patients, teaching our clinical fellows, and contributing to innovation. This political work is hard and at times downright annoying. Fortunately, I have a lot of help from my colleagues and my co-workers at NBPAS. I am highly motivated because I think this is an important project. I find that if one really wants to do something, one makes the time—even if it means speaking on two phones at once while typing e-mails on your computer.

You have spoken about the opportunity cost of increased recertification requirements—loss of time for activities that actually improve patient care. What other projects are keeping you busy these days?

I have a very busy interventional cardiology practice, doing a number of stents and/or TAVRs every day. I also run an interventional cardiology fellowship program, head the Scripps Clinic cardiology division, and direct the Scripps Health Cardiovascular Institute. I also try to fly small planes a few late afternoons each week, and I am taking lessons and trying very hard to be a better salsa dancer. I am very, very busy. I am almost 60 years old. I think the main reason I am so offended by MOC is that I recently have had to acknowledge to myself that I am no longer 30 and I am not going to live forever. There is a lot in life I want to accomplish. I can't stand wasting time. Perhaps my concluding comment to the ABMS and the ABIM is, "Please, do not waste my time!"

Katlyn Nemani, MD, is a physician at New York University.

ACC Note: The complex situation presented by the American Board of Internal Medicine’s changes in Maintenance of Certification (MOC) requirements continues to be top-of-mind for ACC leadership, staff and most importantly for the ACC members affected by the changes. The ACC’s approach to addressing the changes over the past year has been careful and deliberate – looking for the best ways to help members and their patients in proceeding forward. In these matters headway has been made, and continues to be made, both in terms of working with ABIM to re-evaluate and change their requirements, and also in exploring alternative options to ABIM. Read more on the ACC’s approach to MOC on the ACC in Touch Blog and in the May issue of Cardiology coming soon.

Keywords: ACC Publications, CardioSource WorldNews

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