In the USA, the National Board of Echocardiography (NBE) recently introduced a programme of Board Certification in Transoesophageal Echocardiography and candidates who passed the TOE examinations administered by the NBE are now no longer considered to be TOE-certified, but are instead described as NBE-PTE Testamurs (passed the NBE exam but not board certified).3 4 Although a grandfather pathway to Board Certification currently exists (through proof of having completed fellowship training in cardiovascular anaesthesia), we believe that physicians in positions similar to ours who are now involved predominantly in non-cardiac practice would find it hard to meet the required diversity and required number of cases per year to maintain credentials after the first wave of recredentialling, scheduled for 2008. Other TOE practitioners within non-cardiac anaesthesia and intensive care medicine who have not completed fellowship training in cardiovascular anaesthesia are unlikely to qualify for Board Certification in Transoesophageal Echocardiography as it is implemented this year, based on the requirement of 150 patients per year in the 2 yr immediately preceding their application.3 4 Furthermore, it is probably only a matter of time before those with testamur status will be denied clinical privileges, reimbursement and so on. Have we been disenfranchised?5 We think so. Unless provision is made for those not actively engaged in cardiac practice, we believe that a valuable intraoperative 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 anaesthesia and intensive care medicine personnel. It will be reserved for a select group of individuals practising cardiac anaesthesia, to the detriment of non-cardiac surgical and critically ill patients.
Houston, TX, USA
As previously explained, this process is the result of long-term negotiations between ACTA and BSE.2 Although the aim of this process is definitely to be as inclusive as possible, it is important to set a minimum standard. ACTA does actively encourage non-cardiac anaesthetists to take part in perioperative TOE. This is demonstrated by regular TOE lectures and workshops given by ACTA members, on behalf of ACTA, at meetings of the Association of Anaesthetists, Intensive Care Society, and other non-cardiac anaesthetic scientific meetings.
From the onset, it was decided not to have a grandfather pathway to accreditation after previous experience in the BSE Adult Transthoracic Accreditation process. The participation of a large group of experienced echocardiographers (both anaesthetists, cardiologists and echotechnicians) in the first ACTA/BSE TOE Accreditation examination in October 2003 demonstrated the support for this process. The ACTA/BSE TOE Accreditation process does not involve cardiothoracic fellowship training because it is designed to include all disciplines of medical doctors and also non-medical echocardiographers. The logbook is therefore essential as proof of ongoing experience and practice. Together with CME/CPD obtained at echocardiography scientific meetings, this will most likely also be the cornerstone of a future reaccreditation process. Details will be announced in the foreseeable future.
The concerns of the authors who presently work in a non-cardiac hospital are certainly very applicable in the USA where clinical privileges and reimbursement depend on accreditation.3 5 That is a problem that the NBE would have to take in to consideration. In the UK this is not the case and presently nobody will be prevented from performing echocardiography if this person is not accredited.
At a recent meeting of the ACTA/BSE TOE committee, the feedback from concerned members1 of both bodies has been discussed in great detail. It has been decided that certain changes to the original process have to be made to make the process more inclusive and flexible. The number of cases for the logbook will decrease to 125, the time period to collect these will be increased to 24 months, and the case report mix will be more flexible. The delegate must be exposed to a wide range of pathology. During the period of accreditation, a candidate in a non-cardiac hospital must take some initiative to show wider experience. Although its value is beyond any doubt in intensive care and the non-cardiac theatre, the fact is that TOE is mainly a cardiac investigation. In most UK hospitals at present this expensive equipment is readily available only in the cardiac arena. There will inevitably be discussions with the Intensive Care Society and the accident and emergency fraternity to incorporate their needs into this evolutionary accreditation process.
Leicester, UK
References
1 Wright SJ, Barnard MJ, Smith A, et al. Accreditation in transoesophageal echocardiography. Br J Anaesth 2004; 92: 4468
2 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: 46972
3 Thys DM. Clinical competence in echocardiography. Anesth Analg 2003; 97: 31322
4 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 PhysiciansAmerican Society of Internal Medicine Task Force on Clinical Competence. Circulation 2003; 107: 106889
5 Gravlee GP. President's Message. TEE Certification: The next step. Society of Cardiovascular Anesthesiologists Newsletter 2004; 3: 38