Chapter 27. The TEE Board Exam

The American Society of Echocardiography (ASE) developed the initial formal exam in echocardiography over the years of 1993 to 1995. Following the pilot exam in 1995, the first exam was administered in 1996 and has been administered yearly since by ASEeXAM, Inc, an independent corporation designed to reduce any potential conflicts of interest between the professional society and the certifying entity. The ASEeXAM exam was designed to test all aspects of echocardiography and was intended primarily for cardiologists with additional training in echocardiography. Many in anesthesiology felt that this exam might result in their exclusion from using transesophageal echocardiography (TEE) perioperatively. Thus, in 1996 the Society of Cardiovascular Anesthesiologists (SCA) convened a task force for certification in perioperative transesophageal echocardiography.1 This committee was responsible for defining the appropriate fund of knowledge, for outlining the exam content based on this fund of knowledge, and for the development of fair multiple-choice questions.

The initial step in exam development was to define the content outline. The task force, with input from cardiology colleagues, set forth 23 initial knowledge categories that emphasized basic echocardiography and ultrasound principles, assessment and interpretation of echocardiographic images, Doppler calculations, and intraoperative applications. The next step for the committee was to write the questions with each member being given a category from the content outline on which to base their questions. All questions were then reviewed by both the committee and a medical editor for the National Board of Medical Examiners (NBME) for content, accuracy, clinical significance, and relevance.2 The pilot examination was given to 95 representative participants in 1997; this exam contained two parts. Part 1 was allotted 60 minutes and consisted of 15 videotaped echocardiography cases with two to four questions per case for a total of 43 questions. Part 2 consisted of both A-type (single best answer) and K-type (complex multiple choice) multiple-choice questions from one of two exam booklets.2 The initial responses to a survey about the initial exam were positive. Following question analysis and recommendations of the NBME, the K-type questions were removed for future exams. The first formal perioperative transesophageal exam (PTEeXAM) was administered by the SCA the following year. In 1998 the SCA and ASCeXAM, Inc, formed the National Board of Echocardiography (NBE). Within its charter, three of the 10 NBE members are anesthesiologists, and eight members are required to change any bylaws. Thus, anesthesiologists are appropriately represented within the NBE. Yearly since 1998, the NBE has developed and administered both the ASCeXAM and the PTEeXAM.

The PTEeXAM is now administered as a computer-based exam. The exam is currently administered once per calendar year at Prometric Testing Centers within the United States, U.S. territories, and Canada, but may increase in administration frequency in the future. The test is given in a standardized fashion; all personal belongings are to be left in a locker outside the testing room. A laminated note board, dry erase markers, and an eraser are provided by the testing center. Calculators are not allowed in the exam, but a simple calculator will be available on the computer. The application fee for the 2009 PTEeXAM was 995 USD.3 Though the certification requirements are significant and at times confusing (see Chapter 26), the application process is fairly straightforward. The application for the exam can be found at the NBE website (www.echoboards.org), and includes instructions and a checklist required for completion. After the applicant has applied for the exam, the NBE will confirm receipt of the application. The NBE will then provide a scheduling permit for the exam no later than 2 months prior to the test date. The applicant may also seek advanced perioperative transesophageal (PTE) board certification at the same time as applying to take the PTEeXAM. The requirements for board certification are also discussed in Chapter 26. It should be noted that the practice experience pathway is not available to those finishing their core residency after June 30th, 2009, and the fellowship pathway will be the sole pathway to advanced PTE board certification. The application for certification is located at the same NBE website and also contains an extensive checklist of required documentation. After the PTEeXAM is passed, the Committee for Certification reviews the certification application and, if appropriate, grants Board certification. The effective date of Board certification is actually retroactive and is the date the PTEeXAM was passed. The Board certification is valid for 10 years, after which a recertification process must be undertaken. This includes taking the RePTE exam and documenting continued competence and experience in echocardiography (50 TEEs per year in 2 of the 3 prior years and 15 hours of continuing medical education [CME] in the 3 prior years). The RePTE exam consists of a subset of questions from the PTEeXAM. Further details can be found at www.echoboards.org.

The exam consists of four blocks with 50 multiple-choice questions in each block. The first part consists of three blocks of 150 single answer-type questions with 60 minutes allotted for completion. The fourth block of 50 single answer-type questions is allotted 90 minutes and is video and case-based. Typically, there is a clinical vignette accompanied by a series of related videos and/or images followed by 2-4 questions based on the presented case. All questions are presented in digital format, including images and video loops that are imbedded within the questions. Thus, there is no longer a need to project the clips on a screen for all examinees to view at the same time, allowing examinees to advance at their own pace. Image quality may be variable as a consequence of the varying sources of the video loops and the need to use older loops, which are associated with questions that have previously met the rigorous validation and verification processes. While the questions are both challenging and fair, they are also designed to judge whether examinees have the requisite knowledge. There are appropriate distracters among the possible response options, which are of similar length and grammar and are unlikely to contain opposites. There is only one correct option given and there is no ambiguity. Further, in general, negative or exclusion-type (“except”) questions are discouraged.

The NBE does not recommend any particular course of study for any of its examinations. However, the NBE does publish the content outline each year for the PTEeXAM; see Table 27–1 for the complete 2009 content outline.4 The outline is extensive and all components of the outline are tested. However, not all of the components are equally weighted throughout the exam. As determined by the PTEeXAM writing committee, more important components are more extensively tested, and questions may require the knowledge of multiple topics to reach the correct answer. Many questions are designed to ensure that the practitioner is performing a complete echocardiographic exam and is focusing on all structures seen in the ultrasound images, not just the primary one. Examinees must be able to identify well-known structures in lesser-known views and lesser-known structures in well-known views. Of note, it is important to study all topics including those not directly related to a specific pathological condition, such as the physics of ultrasound and diastolic heart function.

The results of the PTEeXAM are posted 10 weeks after the exam. Certificates are then mailed 8 weeks after this date to those who pass. Even though the test is administered on computer, the delay between the test date and the posting of the results is a consequence of the need to review each question for validity and performance by the testing committee. If statistical evaluation of a question reveals that a large number of examinees consistently answer with the same incorrect response, then the question is closely evaluated for accuracy. If there are any inaccuracies noted, the question may be discarded or re-scored to ensure valid scores and a fair test. The passing score is determined by the NBE with regard to a minimum amount of knowledge required to pass. Candidates are not measured against each other and the test is not scored on a curve. The passing rate for the 2008 PTEeXAM was 76%,5 but varies from year to year. Test performance data are available from the pilot exam and the first four PTEeXAMs administered over 1998 to 2001. The variables evaluated in the pilot exam were length and type of dedicated echocardiography training, primary setting, primary clinical area, time spent in echocardiography practice, and number of echocardiograms interpreted weekly. The examinees who performed or interpreted more than six exams per week, had formal echocardiography training, were postgraduate year (PGY) 5 or greater, or had taken time off from practice for training attained higher scores.2 The results of the comparison of examinee subgroups from 1998 to 2001 are shown in Table 27–2. Again, the examinees at the PGY 5 or greater level of training and those performing more than three to five exams per week had higher passing rates.2

Though much of this chapter is dedicated to the actual PTEeXAM, the primary goals of the examination and board certification are, as stated by the NBE, to establish practice domains, to assess the level of knowledge of the practitioner, to enhance the quality of perioperative transesophageal echocardiography, to provide formal recognition to those having met the requirements, and to serve the public by outlining quality patient care.3 In accordance with these principles, the goals of teaching perioperative echocardiography should be quality patient care first and passing the exam second. There are basic skills required to obtain competence in echocardiography. As listed in Table 27–3, training physicians must have a basic knowledge of ultrasound physics, be proficient with technical aspects of the examination, know the cardiovascular anatomy and physiology, and be able to recognize both simple and complex pathology.6 This education process usually begins with basic two-dimensional (2D) image acquisition and ultrasound physics. The ASE has published guidelines for performing a multiplane TEE exam; these are available at www.asecho.com and are adapted from the original intraoperative guidelines put forth by Shanewise et al7 for the ASE and SCA in 1999. The natural progression in learning usually follows with 2D image assessment, Doppler assessment, and three-dimensional (3D) image acquisition and assessment. Mastery of these skills requires practice and repetition. The ASE, SCA, and NBE all recognize the importance of repetition in the learning process and have placed minimum requirements for echocardiograms performed and/or interpreted for board certification.

Additionally, the need for extensive reading in all aspects of echocardiography cannot be overemphasized. Though the practitioner may be familiar with most concepts and disease states, the interactions with ultrasound, the interpretation of images and Doppler, and the anticipation of probable therapeutic interventions with their likely resultant effects must be known in order to appropriately guide complex medical decisions. An example is the use of ultrasound to diagnose and categorize diastolic dysfunction with the goal of guiding therapeutic decisions.

Traditional supplements to the actual performance of transesophageal echocardiograms in the learning process have included seminars, books, and video/DVDs. More recently, interactive computer programs and simulation have initiated a transformation in the educational environment. In 2009, most of the simulators were in the early phases of use and had yet to be formally evaluated. The Heartworks simulator and the EchocomTEE simulator are both examples of this technology. The Heartworks simulator uses an accurate 3D virtual heart and the 3D data set then generates a simulated ultrasound image.8 This allows the user to develop the appropriate spatial anatomical knowledge required to accurately interpret the 2D ultrasound image. Similarly, the EchocomTEE simulator generates the 2D ultrasound images from a 3D data set.9 Both of these systems have available a mannequin and a dummy TEE probe to practice probe steering and image acquisition with the added 3D guidance. One simulator was evaluated with respect to both realism and usefulness for TEE training as judged by experienced echocardiographers.9 This group also evaluated novice echocardiographers as to the ease of use and the usefulness of the 3D image for 2D ultrasound image adjustment; 82% of the experts rated the mannequin as realistic and 68% rated the probe handling realistic. All of the experts thought that the simulator successfully established the relationship of the heart, probe, and multiplane ultrasound slice, and the resultant image. Thus, all of the experts would recommend the simulator as an additional aid in echocardiography training. For the novice group, 87% thought that the probe was easy to use and 90% found the virtual heart to be helpful in fine-tuning the image.

In 2006, the American Society for Anesthesiologists (ASA) formally requested a path for anesthesiologists who do not focus in cardiac anesthesia, to obtain experience and privileges in echocardiography as a basic perioperative monitor. Thus, the ASA and the SCA developed a plan for introductory CME courses to be made available four times a year. These are considered an introduction to perioperative echocardiography and teach practitioners the fundamental principles and applications necessary to perform a focused basic exam by transesophageal echocardiography (FBE-TEE). The course is designed for those who want to gain sufficient knowledge and experience to start to integrate basic TEE into clinical practice outside of cardiac surgery. Of note, the course includes a focus on determining which pathologies are appropriate to diagnose with just an introductory level of education and which require consultative assistance. For example, the diagnosis and treatment of hypovolemia would be appropriate with this basic level of training, but the interrogation of a prosthetic valve would require expert consultation. The ASA is also currently developing a Basic Perioperative TEE examination with the NBE that will be administered for the first time in the fall of 2010. Relevant practice and certification requirements are also being developed with the goal of creating a pathway to attain a Diplomate status in Basic Perioperative Echocardiography (www.echoboards.org).

The American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists administer the PTEeXAM as a means to promote education, certify basic competence, and promote quality patient care. The exam process is designed to achieve the education necessary to make important clinical decisions based on echocardiographic imaging. In contrast, a new (not yet named) exam is being formulated that will serve to certify individuals in basic echocardiography competence utilizing the FBE-TEE educational process.