By Nicole Lou, Senior Staff Writer, MedPage Today
August 21, 2026
In a significant challenge to the long-standing regulatory framework governing physician certification, the Society for Cardiovascular Angiography & Interventions (SCAI) has officially proposed the elimination of procedural volume requirements for interventional cardiologists. The proposal, released in a draft position statement this week, marks a pivotal moment in the ongoing national debate regarding how the American Board of Internal Medicine (ABIM) measures and maintains clinical competence among specialists.
The SCAI recommendation specifically targets the current mandate requiring interventionalists to perform 100 percutaneous coronary intervention (PCI) or equivalent procedures over a 2-year period. It also challenges the "low-volume alternative," which currently requires documentation of 25 consecutive primary operator procedures accompanied by explicit outcomes reporting. For many in the field, these metrics are no longer markers of quality, but rather bureaucratic hurdles that fail to reflect the nuance of modern medical practice.
The Case for Reform: Challenging Outdated Metrics
The core argument put forth by SCAI is that procedural volume is a flawed proxy for clinical excellence. In a virtual town hall meeting with society members, SCAI President J. Dawn Abbott, MD, of Brown University Health, underscored the practical and ethical consequences of these mandates.
"It is recognized that volume requirements are particularly hard to meet for the increasing population of low-volume operators," Abbott explained. She warned that in rural and underserved areas of the United States, these mandates risk creating "care deserts," where physicians might be forced to cease performing life-saving emergent PCI simply because their caseload does not hit an arbitrary numerical threshold. By prioritizing volume over accessibility and clinical judgment, the current ABIM requirements may inadvertently restrict patient access to essential cardiovascular care.
SCAI President-Elect Joaquin Cigarroa, MD, of Oregon Health & Science University, echoed this sentiment, suggesting that the professional community has largely lost faith in the current system. "Our community of interventional cardiology is overwhelmingly questioning the value of reporting volume and using this as a surrogate for quality in our ongoing maintenance of certification, and believe it is no longer relevant," Cigarroa stated.
A Question of Equity and Evidence
One of the most striking points in the SCAI draft statement is the assertion that interventional cardiology is being unfairly singled out. According to the society, no other medical specialty governed by the ABIM is subjected to similar procedural volume requirements for the maintenance of certification (MOC). This disparate treatment has sparked frustration among practitioners who argue that the link between "number of procedures" and "patient outcomes" is tenuous at best.
The SCAI draft statement, which is open for public comment until September 18, notes: "Evidence does not support the use of an operator volume threshold that reliably discriminates between operators with adequate and inadequate competence or risk-adjusted outcomes outside the normal distribution."
The society argues that modern medicine has moved toward competency-based frameworks that emphasize patient outcomes, the appropriateness of care, and performance within integrated systems. By clinging to volume as a primary metric, the ABIM is viewed by many as being misaligned with the realities of 21st-century cardiovascular medicine.
The American College of Cardiology Weighs In
The push for reform has gained significant momentum with the public support of the American College of Cardiology (ACC). As the largest professional organization for cardiovascular specialists, the ACC’s endorsement adds considerable weight to the SCAI proposal.
In a statement provided to MedPage Today, ACC President Roxana Mehran, MD, of Mount Sinai Medical Center, made the college’s position clear: "The American College of Cardiology agrees that procedure volume is not the most accurate measure of competency and supports it being removed as a condition of maintaining interventional cardiology certification."
Dr. Mehran emphasized that the transition to a more modern certification model is long overdue. "The College has long been a proponent of certification programs that emphasize continuous learning and competency-based assessment that are aligned with real-world practice," Mehran said. "Ultimately, the goal of certification should be ensuring that patients are receiving the highest quality care based on a clinician’s performance, not on their meeting a numerical procedure threshold."
The "Zero-Replacement" Policy
SCAI has been careful to frame its proposal not as a request for "easier" certification, but for "better" certification. A critical component of their position is the demand that once volume requirements are abolished, they must not be replaced by a new set of burdensome, potentially arbitrary metrics.
The society argues that the profession is already heavily regulated. Competency is currently assessed through a robust combination of patient outcomes, peer review, local credentialing, and institutional quality systems. Adding another layer of administrative reporting would simply shift the burden from one form of "paperwork" to another, without necessarily improving the quality of patient care.
A Chronology of Conflict: The MOC Standoff
The current dispute over volume requirements is merely the latest chapter in a long-running saga between practicing cardiologists and the ABIM.
- The MOC Backlash: For over a decade, physicians across multiple specialties have expressed growing resentment toward the MOC process, citing the high costs and time-intensive nature of recertification exams and requirements.
- The ABCVM Initiative: In a bold move last year, SCAI joined the ACC and other professional societies in a bid to create an independent "American Board of Cardiovascular Medicine" (ABCVM). This proposed board was designed to offer an alternative path to certification that would bypass the ABIM’s perceived rigid and unhelpful testing requirements.
- Regulatory Rejection: The momentum for the ABCVM suffered a significant blow when the American Board of Medical Specialties (ABMS) formally rejected the application, effectively maintaining the status quo.
- Legal Challenges: Beyond cardiology, the broader medical community has engaged in various lawsuits against the ABIM. These plaintiffs, often backed by physician advocacy groups, allege that the ABIM maintains a monopoly on board certification, profiting from a system that provides little to no evidence of actual clinical improvement for the practitioners involved.
Implications for the Future of Cardiology
If the ABIM chooses to ignore the call from SCAI and the ACC, the friction between the governing board and the specialty societies will likely escalate. Many leaders in the field are concerned that the current rigid requirements are contributing to physician burnout and an early exodus from the workforce—particularly among older, experienced cardiologists who may still be highly competent but find the administrative burden of MOC increasingly intolerable.
Furthermore, the shift toward a "competency-based" model could set a precedent for other surgical and interventional specialties. If cardiology successfully removes volume-based mandates, it may trigger a wave of similar requests from fields like vascular surgery, interventional radiology, and electrophysiology.
As the public comment period closes in September, the eyes of the cardiology community remain fixed on the ABIM. Will the board acknowledge the shift toward outcome-based medicine, or will it double down on the traditional, volume-centric metrics that have defined the last several decades of certification?
For now, the message from the bedside is clear: The clinicians responsible for patient care believe they have outgrown the numerical thresholds of the past. They are calling for a system that recognizes their commitment to quality through the lens of actual performance and patient safety, rather than through the counting of procedures performed. Whether the regulatory bodies are ready to embrace this transition remains the defining question of the year for the cardiovascular specialty.
