Letters to the Editor

TEE Board Certification

Rarely, if ever, does the SCA Newsletter publish "Letters to the Editor". However, we decided that the Letter printed below by Drs. Riedel, Shaw, and Thakar was important because it addresses concerns (voiced by others as well) regarding the recently-introduced TEE Board Certification process. In order to clarify this perhaps misunderstood process, Dr. Gravlee and I solicited "Response" Letters from Daniel M. Thys, MD (President-Elect, National Board of Echocardiography) and Jack Shanewise, MD (Chair, NBE PTE Certification Committee) that follow.

Mark A. Chaney, MD
Chair, SCA Newsletter Committee

To the Editor:

It is with interest that we read the 'President's Message' in the Society of Cardiovascular Anesthesiologists (SCA) monthly newsletter.1 Herein the President of the SCA addresses the recently introduced program of Board Certification in Transesophageal Echocardiography by the National Board of Echocardiography (NBE). Under this new program, candidates who passed the TEE examinations administered by the NBE are now no longer considered TEE-certified, but are instead described as NBE Perioperative Transesophageal Echocardiography (NBE-PTE) 'Testamurs' (passed the NBE exam but not board certified).2,3

As experienced TEE practitioners who have practiced cardiac anesthesia and actively trained numerous practitioners in TEE for more than 5 years each, and have now moved to non-cardiac anesthesia and intensive care medicine where we continue to offer valuable TEE services, we wish to offer our perspective on the next step in TEE certification in the USA.

Although a 'grandfather' pathway to Board Certification (through proof of having completed fellowship training in cardiovascular anesthesia) currently exists in the USA, we believe that physicians in positions similar to ours who are now involved predominantly in non-cardiac practice will find it hard to meet the required diversity and the required number of cases per year to maintain credentials after the first wave of recredentialling scheduled for 2008. Furthermore, TEE practitioners within non-cardiac anesthesia who have not completed fellowship training in cardiovascular anesthesia are unlikely to qualify for Board Certification in Transesophageal Echocardiography as it is implemented this year, based on the requirement of 150 patients per year in the two years immediately preceding their application.2,3 We perceive it merely a matter of time before those with testamur status will be denied clinical privileges, reimbursement and so on. Have we been disenfranchised?1 Contrary to the President of the SCA's opinion, we think so.

A similar controversy currently surrounds TEE certification and credentialing in the UK 4,5 and unless provision is made for those not actively engaged in cardiac practice, we believe that a valuable intra-operative monitoring and diagnostic tool, that is relatively non-invasive and highly effective in clinical decision making, will be forced out of the hands of non-cardiac anesthesia and ICU practitioners and reserved for a select group of individuals practicing cardiac anesthesia, to the detriment of non-cardiac surgical and ICU patients.

Bernhard Riedel, MB.ChB, FCA, M.Med, FAHA
Andrew Shaw, MB.BS, FRCA
Dilip Thakar, MD

Division of Anesthesiology and Critical Care
The University of Texas M.D. Anderson Cancer Center
1515 Holcombe Boulevard
Houston, Texas, USA
briedel@mdanderson.org

References

  1. Gravlee GP. President's Message. TEE Certification: The next step. Society of Cardiovascular Anesthesiologists Newsletter 2004;3:3-8.
  2. Quinones MA, Douglas PS, Foster E et al. American College of Cardiology/American Heart Association clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence. Circulation 2003; 107:1068-89.
  3. Thys DM. Clinical competence in echocardiography. Anesth Analg 2003; 97:313-22.
  4. Wright SJ, Barnard MJ, Smith A et al. Accreditation in transoesophageal echocardiography. Br J Anaesth 2004; 92:446-8.
  5. Swanevelder J, Chin D, Kneeshaw J et al. Accreditation in transoesophageal echocardiography: statement from the Association of Cardiothoracic Anaesthetists and the British Society of Echocardiography Joint TOE Accreditation Committee. Br J Anaesth 2003; 91:469-72.

Responses:

Thank you for the opportunity to respond to the letter from Riedel et al. Their concerns center on three issues: 1) the introduction of a board certification process for perioperative transesophageal echocardiography by the National Board of Echocardiography (NBE), 2) the recertification process, and 3) the ability of non-cardiac anesthesiologists to qualify for board certification. My response will address each of these concerns in the same sequence.

  1. Riedel et al. state that with the introduction of board certification by the NBE, ".candidates who passed the TEE examinations administered by the NBE are no longer considered TEE-certified...". Since NBE's inception, its certificates have clearly stated that the Board of Directors of NBE certified that a particular physician had successfully completed the Perioperative Transesophageal Echocardiography Examination. This remains unchanged today. Never did NBE imply that a physician was board certified or TEE-certified. While it always was NBE's intent to introduce a board certification process, the absence of training guidelines for perioperative TEE made this impossible. Board certification in all fields of medicine is issued on the basis of documented training and the successful completion of an examination process. Once training guidelines for perioperative TEE were introduced in 2002, they were adopted verbatim by the NBE and used as the training requirements for board certification in perioperative TEE.1
  2. A recertification process for perioperative TEE has not yet been developed, but such a process is well underway for general adult echocardiography. If parallels can be drawn, it is most likely that recertification will require success in a modified examination and documentation of continued practice involvement in perioperative TEE. It should be noted that the ACC/AHA clinical competence statement on echocardiography indicates that for maintenance of competence in perioperative TEE, the performance and interpretation of at least 50 examinations per year is required.2 Since NBE develops all of its policies on the basis of published guidelines, the verbatim adoption of this requirement is also very likely.
  3. The intent of NBE concerning which physicians qualify for diplomate status is explicit and absolutely clear. The NBE brochure states that: ".the board certification process will publicly recognize as Diplomates of the NBE those physicians who have completed training programs or significant practice experience in the perioperative care of surgical patients with cardiovascular disease and in perioperative TEE and have additionally passed the PTEeXAM". The NBE could not have been more inclusive!

Daniel M. Thys, MD
President-Elect
National Board of Echocardiography

References

  1. Cahalan MK, Abel M, Goldman M, et al. American Society of Echocardiography and Society of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography. Anesth Analg 2002; 94: 1384-8.
  2. Qui¤ones MA, Douglas PS, Foster E, Gorcsan J, Lewis JF, Pearlman AS, Rychik J, Salcedo EE, Seward J, Stevenson JG, Thys DM, Weitz HH, and Zoghbi WA. ACC/AHA clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians -American Society of Internal Medicine Task Force on Clinical Competence (Committee on Echocardiography). Circulation 2003;107(7): 1068-1089.

I would like to respond to some of the concerns expressed by Drs. Riedel, Shaw and Thakar about the NBE's Board Certification in Perioperative Transesophageal Echocardio-graphy (PTE). This process in no way changes or devalues what has gone on before. Those who passed the PTEeXAM were and still are certified as having successfully completed the exam. The NBE changed the original name of the test from the "PTE Certification Exam" to "Examination of Special Competence in Perioperative Transesophageal Echocardiography" when it assumed from the SCA responsibility for writing and administering the exam.

Board certification in any specialty requires demonstrating competency by not only passing a board examination but also completing a specific training program. Typically, newly created specialties for a period of time also allow current practitioners to substitute practice experience for training. The NBE created PTE Board Certification to allow practitioners to demonstrate this level of competence for PTE in a credible way. The echocardiography training requirements for PTE Board Certification were adopted from the ASE/SCA Training Guidelines in Perioperative Echocardiography.1,2 The level of knowledge and experience necessary to achieve PTE Board Certification is high, and is not intended for all anesthesiologists who might use TEE in their practice. The requirements are set at the level of a practitioner who is able to independently perform and interpret a comprehensive, diagnostic TEE examination and make surgical treatment decisions based on the findings. It is not the intent of the NBE to limit the use of TEE for other purposes.

PTE Board Certification does not require specific training in or the practice of cardiac anesthesia. There are five requirements: 1) passing the PTEeXAM, 2) a current license to practice medicine, 3) current board certification in any recognized medical specialty, 4) specific training/experience in the perioperative care of surgical patients with cardiovascular disease, and 5) specific training in echocardiography. Taking care of surgical patients not having cardiac surgery can fulfill requirement 4; in fact, the NBE accepts fellowship training in Critical Care for requirement 4. Performing TEEs on surgical patients not having cardiac surgery can fulfill requirement 5.

Please know that the primary motivation of all the physicians with whom I have worked with over the years in this arena has been quality of care. I realize this is a clich‚, but it's true. We have watched the level of knowledge in echocardiography among anesthesiologists increase dramatically over the years in part as a direct result of the PTEeXAM. I am sure we will continue to see significant improvements in the extent and quality of echocardiography training provided to anesthesiology residents and fellows because of the ASE/SCA Training Guidelines in Perioperative Echocardiography. PTE Board Certification by the NBE is the next logical step to allow physicians to credibly demonstrate attaining this high level of competence. I am sure it will help to keep us focused on the goal we set out on long ago, improving our ability to take care of the most critically ill and complicated patients.

Jack Shanewise, MD
Chair, NBE PTE Certification Committee
Director, Division of Cardiothoracic Anesthesiology
Columbia University College of Physicians and Surgeons
New York, NY

References

  1. Cahalan MK. Abel M. Goldman M. Pearlman A. Sears-Rogan P. Russell I. Shanewise J. Stewart W. Troianos C. American Society of Echocardiography. Society of Cardiovascular Anesthesiologists. American Society of Echocardiography and Society of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography. [Guideline. Journal Article] Anesthesia & Analgesia 2002; 94(6):1384-8.
  2. Cahalan MK. Stewart W. Pearlman A. Goldman M. Sears-Rogan P. Abel M. Russell I. Shanewise J. Troianos C. Society of Cardiovascular Anesthesiologists. American Society of Echocardiography Task Force. American Society of Echocardiography and Society of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography. [Guideline. Journal Article] Journal of the American Society of Echocardiography 2002; 15(6):647-52.
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