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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

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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)

• 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 programI 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”)

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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?”

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?

So, about 5 months and 500 hours of unpaid work later…

Dr. Teirstein, what are you going to do about this?

www.NBPAS.org

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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

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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• 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

Initial Certification vs. MOC?

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

Study limitations: Non-randomized Propensity matching followed by a regression analysis

Beware of unmeasured confounders

Exercise caution interpreting small differences

Statistician's comment:

Highly adjusted analysis

Propensity matching followed by regression analysis

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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 grand-

fathered cohort that were not published?

•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

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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.

Hypothetical trial

The HOLIE CHUTE trial

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

Group A Group B

If you have 22,000 physician signatures on a petition saying MOC is not meaningful, maybe you don’t need a lot more data?

If you have 22,000 physician signatures on a petition saying MOC is not meaningful, maybe you don’t need a lot more data?

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• 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,

Continuing Medical Education and MOC

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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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• 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…

What about the cost?

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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

ABIM is now under fire from many organizations!

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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

• 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.

■ Candidates must have been previously certified by an American Board of Medical Specialties member board.

■ 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).

■ Candidates must have been previously certified by an American Board of Medical Specialties member board.

■ 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).

Complete criteria for NBPAS certification:Complete criteria for NBPAS certification:

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 

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

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

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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.

Vol.CLV18. .No. 34,682 NEW YORK. November 6th, 2010

Breaking News:

Physicians Finally Extract Heads From SandDocs 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

•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