Q&A: Paul Teirstein—The Doc Behind the Mutiny Against the MOC

Why he started a rival organization for recertification, what's wrong with the current approach, and what the MOC argument is really about.

Frustrated while filling in blue boxes on a monitor to satisfy new requirements for his board recertification, Paul Teirstein, MD, chief of cardiology for Scripps Clinic in San Diego, got a little perturbed with having to comply with maintenance of certification (MOC) requirements.

More than a little, actually.

So the renowned interventionalist, who has stented kings and Mother Teresa and does not shy from the limelight, is fighting back on a national scale.

He has organized the National Board of Physicians and Surgeons, which he says is a rational alternative to the MOC, the new two-year maintenance of certification (MOC) requirements that the American Board of Medical Specialties and 24 specialty boards, including the American Board of Internal Medicine, require doctors to complete to show their knowledge is up to date.

Teirstein says his effort is powered by 23,000 physicians who signed supporting petitions in the belief that the MOC's requirements are costly busywork that serve only to enrich certification board executives.

During an hour-long interview and e-mail follow-ups, Teirstein explains his rationale. This Q&A was edited for clarity and brevity.

HLM: What's wrong with requiring doctors to show they're up to date every two years instead of with an exam every decade? Medicine is rapidly changing today.

Teirstein: It's just a laborious waste of time. I'm not happy that the organization [ABIM] is making this a requirement so they can bring in more money and pay themselves more money; that's very clear to me. But my major objection is that it's wasting my time.

HLM: What's the issue with these two-year modules and tests? Can you give an example of why this is a waste?

Teirstein: I see a barrage of questions I don't need to learn. But I have to take a course to answer them because the [required] answer is a way I would never treat my patients. A lot of the questions are based on outdated material. One example, from a fellow who took the test in June, asked about anti-platelet 2B3 inhibitors, which we hardly use anymore; they don't have the benefit doctors thought they did 10 years ago.

Another example is what to do with a patient who has a [cardio] SYNTAX score above 22. I have to answer that I would refer that patient to bypass surgery, but in practice you don't do that because it depends on your individual patient. Most of the patients coming to me need to be kept away from bypass surgery because they have other problems. But that would not be the right answer for the test.

What I really do have to learn now, because I'm doing heart valve replacements, is how to read CT scans, which wasn't part of my training. If I had to take the MOC exam now, I'd have to drop everything—stop reading journals, stop learning how to read CT scans, and learn how to answer these questions correctly.

HLM: You also have an issue with the modules that you have to buy?

Teirstein: Maybe the first time it isn't, but the second, third, or fourth time it is. How many times can you do a module on washing your hands? Working for an organization with more than 200 employees, I have to do sexual harassment training every two years. I have to take a class.

HLM: So you intend the NBPAS to be an alternative to the ABIM?

Teirstein: We're supportive of the initial ABIM certification requirements [for new doctors]. But we don't like the ABMS and ABIM requirements for continued MOC certification. We're saying if you want to do MOC, go ahead. But we don't think most people will want to.

HLM: You've said current continuing medical education credit requirements are sufficient for board certification. I'd heard concerns that CME was getting too easy.

Teirstein: It's the opposite. CME is more difficult and is taken more seriously. You can't have industry-directing talks. You have to fill out evaluation forms or you don't get CME credit. You have to do a gap analysis to determine the need for what is taught, and you have to have all conflict of interests disclosed. The only thing that's a valid criticism—not substantial, though—is that we don't take attendance and we don't measure that you're actually paying attention during the CME conference. You could just tune out and do e-mail for an hour and get credit.

At some point you have to trust doctors are doing the things they say. We're not dealing with criminals here.

Also, you could take these [newly required ABIM] computer modules home and have your friend do them. You have to attest you're not doing that, but you could.

HLM: I've heard some doctors complain that if they don't do the MOC every two years, they'll be listed that way, and they worry it will affect their reputations, maybe affect hospital privileges.

Teirstein: They'll be listed as "not meeting MOC requirements." The concern is #1, the effect on their hospital privileges, and #2, their reputation.

HLM: What about the accusations, from cardiologist Westby Fisher, MD, and others, that the ABIM and other specialty boards are just doing this to get rich; that the ABIM made $55 million in profits (in 2012), and it pays hefty salaries.

Teirstein: I don't care how much money people make. I want all my friends to be rich. What's upsetting about the levels of these [boards] is that they're doing it on the backs of the physicians who feel it's meaningless work that doesn't add value. It works out to about $1,000 a year, and more if you include time away from practice. They'll tell you it only costs $300 for MOC registration. But if you add two or three certifications, then it's $400 or $600. And you have to buy the modules, which is usually $100 per module.

I'd write the check if they just make all this go away; the money doesn't bother me so much, but it really bothers the doctors. They don't like it when someone is taking advantage of them economically.

HLM: What convinced you that the ABIM was doing this just to generate revenue?

Teirstein: When I realized how much money they were making, and investing in things to make more money.

HLM: Like accusations regarding the ABIM's $2.3 million luxury Philadelphia condo and BMW 7-series "investments"?

Teirstein: Yes. They charge for everything. If you lose your certificate, you pay $75 for a new one. When I began this, I said "No, it's not about the money; these people [the ABIM] just need to be educated." But I was totally wrong. This is a fight about money.

HLM: How much will the NBPAS charge for certification?

Teirstein: It's $84.50 per year regardless of the number of certifications, with no plans for modules.

HLM: What's next? Do you need another agency's approval before you can board-certify?

Teirstein: We have 1,200 applications and we'll have thousands by year end. There are many hospitals that require board certification [as a condition of staff privilege], and we're waiting on their credentialing committees to change their bylaws to include the NBPAS. When a few of them change, the rest will follow.

HLM: That seems far away. Is the NBPAS really just a symbolic protest?

Teirstein: I would love to disband. I'm not getting paid for this, yet spending 3-5 hours a day. It's crazy. But I don't see that happening because I don't see them coming anywhere close to satisfying the issues physicians have. It's bigger than me now.

HLM: Where will this all end?

Teirstein: ABIM will make a lot of changes to make this simpler with less meaningless paperwork. Some doctors will choose to [continue] it. But some will choose the alternative.