Glenn P. Gravlee, MD
President, 2003-2005

President's Message

TEE Certification: The Next Step

Recently the National Board of Echocardiography (NBE) introduced a program for Board Certification in Transesophageal Echocardiography (TEE). The intent of this message is to briefly explain the evolution of this process and its specific requirements, and to speculate about its potential implications to your clinical practice. I also hope to persuade you that SCA has been representing your best interests in supporting this endeavor. The SCA has been integrally involved in the development of this process, thanks to the strong efforts of Mike Cahalan, Jack Shanewise, Sol Aronson, Dan Thys, and many others.

Background. The National Board of Echocardiography was formed in 1998 with the express purpose of developing standards and administering examinations in the field of Perioperative Transesophageal Echocardiography (PTE). To date, NBE's principal activity has been the development and administration of an annual examination leading ostensibly to board certification in TEE. Approximately 1,500 physicians have passed this examination since its first administration in 1998, over 98% of whom are anesthesiologists.

In 2002 The American College of Cardiology and the American Heart Association were asked by a multidisciplinary task force to revise their 1990 joint document on Clinical Competence in Adult Echocardiography. This revised document was developed with SCA collaboration, endorsed by SCA, and published in 2003 (Quinones MA, Circulation 2003;41:687-708). As one might expect with any technically oriented clinical skill, the task force determined that simply passing a test would not be sufficient to withstand public scrutiny, so training and practice requirements were added. Those of us who have passed the TEE exam have thus recently been informed by NBE that we are no longer considered to be TEE-certified, but that instead we are now described as NBE PTE testamurs. As what? The creative term "testamur" (don't bother checking Webster's dictionary - it's not there) distinguishes those who have passed the PTE examination alone from those who have met the more detailed and rigorous standards required to reach the new NBE standards for Board Certification in Perioperative Transesophageal Echocardiography. Have we been disenfranchised? I think not. Read on.

NBE Requirements for PTE Board Certification. There are two pathways to certification. One pathway is designed for individuals who have completed fellowship training in cardiovascular anesthesiology, and the other is intended for those who have gained their TEE expertise while practicing cardiovascular anesthesiology. I will focus on the latter pathway, but either set of requirements can be reviewed at Most of the requirements are also described in last August's issue of Anesthesia and Analgesia (Thys DM, Anesth Analg 2003;97:313-22). Aside from passing the PTE exam, the practitioner needs to have a current medical license, current specialty board certification, specific experience in perioperative care of surgical patients with cardiovascular disease, and specific training in echocardiography.

Experience Requirement. To fulfill the experience requirement, one can either document a 12-month fellowship experience or a minimum of 24 months of clinical experience dedicated to the perioperative care of surgical patients with cardiovascular disease. The latter option must include personally delivered perioperative care to at least 150 patients per year in the two years immediately preceding the application. Bear in mind that this appears to include any surgical patient with cardiovascular disease without regard to the use of TEE, and also without regard to whether or not the patient is undergoing cardiac or vascular surgery. The standard requires documentation with a notarized letter from the appropriate departmental director, such as the Chief of Anesthesiology.

Training Requirement. For practitioners who are not pursuing the fellowship PTE training pathway (most SCA members will fall into this category even if fellowship-trained), specific training must include 300 complete PTE examinations within the four-year period immediately preceding the application. Assuming adequate supervision, 150 of these examinations could be your interpretations of TEE examinations performed by someone else. At least initially, it appears that NBE will require the supervisor to be a physician who is credentialed to perform and interpret transesophageal echocardiography at your hospital. Additionally, no fewer than 50 examinations can be performed in any of the four immediately preceding years, and at least 50 hours of AMA category I continuing medical education devoted to echocardiography must be obtained over that period. The training standard also requires a notarized letter from an appropriate department or division director to verify the number of studies performed, plus documentation of the CME credits devoted to echocardiography. The director of an echocardiography laboratory, a director of cardiac anesthesiology, or an anesthesiology department chair may be the appropriate letter-writer in any given institution. If you have personally performed and interpreted over 300 perioperative TEE studies in the preceding four years, then you will simply need to prove that to the individual writing the letter.

Must you obtain NBE PTE Certification in order to practice perioperative TEE? I am pretty confident that the current answer is "No" for most of us. NBE PTE certification is an option that some testamurs will choose, while others will not. It seems unlikely that hospital credentialing committees will require this standard in order to practice perioperative TEE anytime soon. To put this in perspective, the vast majority of practicing adult cardiologists who interpret (and charge for) transthoracic echocardiograms have not been certified by the National Board of Echocardiography in Adult Echocardiography. Nevertheless, one can argue that the burden of proof for echocardiographic competence is greater for an anesthesiologist than for a cardiologist. Some of us will undoubtedly be challenged by others to prove our TEE competence at some future time, particularly if local cardiologists should desire exclusive access to perioperative TEE. Since cardiologists typically can use their time much more efficiently outside the ORs, most of us will not experience such a challenge anytime soon.

If you, like me, passed the PTE exam and did not see this coming, you might feel that you have just become the victim of a classic "bait and switch". Although I empathize with that line of reasoning, I prefer instead to view this development as giving us an option that we can use to protect our practice in the future. Without much additional work or documentation (assuming that you document your TEE exams), we should be able to achieve PTE certification. Admittedly, the number of studies required seems high and may be prohibitive for those whose practice only occasionally involves cardiac surgical procedures. Please understand that the numbers evolved from a delicate interdisciplinary negotiation that was designed to provide this certification opportunity to anesthesiologists without devaluing other categories of NBE certification that are designed primarily for cardiologists. I anticipate that this certification option will protect our access to TEE in the event that someone should challenge our competency in that domain. I believe that most SCA members will be able to practice TEE indefinitely with just testamur status from NBE. Even testamur status is unlikely to soon be required by most hospitals, although I would support them doing so if reasonable notice were given (personal opinion, not that of the SCA).

Word to the wise: If you are not documenting your TEE examinations, wake up and start doing so, because sooner or later you may either desire NBE certification in PTE or be asked by your hospital's credentials committee to document your level of clinical activity in TEE. Like most new programs, the window of opportunity for the "grandfather" certification plan will eventually close. The clock is slowly ticking.

Glenn P. Gravlee, MD
President, 2003-2005

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