Editorial Views  |   April 2017
A Road Map to Assess Clinical Competency in Basic Transesophageal Echocardiography
Author Notes
  • From the Department of Anesthesiology, Weill Cornell Medicine, New York, New York.
  • Accepted for publication September 15, 2016.
    Accepted for publication September 15, 2016.×
  • Corresponding article on page 718.
    Corresponding article on page 718.×
  • Address correspondence to Dr. Skubas:
Article Information
Editorial / Cardiovascular Anesthesia / Radiological and Other Imaging
Editorial Views   |   April 2017
A Road Map to Assess Clinical Competency in Basic Transesophageal Echocardiography
Anesthesiology 4 2017, Vol.126, 582-584. doi:
Anesthesiology 4 2017, Vol.126, 582-584. doi:

“In the current era of outcome-driven performances, the comprehensiveness and diagnostic accuracy of such basic TEE studies should not be ignored.”

Image: J. Fox/S. Shernan, Brigham and Women's Hospital.
Image: J. Fox/S. Shernan, Brigham and Women's Hospital.
Image: J. Fox/S. Shernan, Brigham and Women's Hospital.
A BASIC transesophageal examination is focused on intraoperative monitoring rather than on specific diagnosis. Except in emergent situations, diagnoses requiring intraoperative cardiac surgical interventions or postoperative medical or surgical management must be confirmed by an individual with advanced skills in transesophageal echocardiography (TEE) or by an independent diagnostic technique.1  Certification in basic perioperative TEE requires passing a written test and demonstrating clinical competency. The trainee must provide a case log to show that she or he interpreted at least 100 TEE studies and personally performed at least 50 basic TEE studies under supervision. In this issue of Anesthesiology, Bick et al.2  report an investigation that tested whether a trainee performs comprehensive and clinically meaningfully basic TEE studies.
Teaching the essentials of basic echocardiography is possible via a variety of written and web-based didactic material, tutorials, and conferences, along with acquisition of necessary tactile/dexterity skills by practicing on physical or web-based TEE simulators.3–5  The next step in learning basic echocardiography is to integrate knowledge and manual skills and perform basic TEE studies on real patients. In the typical academic anesthesiology department, the trainee, usually a second- or third-year clinical anesthesiology resident, performs a basic TEE study under the supervision of an attending. This requires the presence of both resident and teacher, usually an attending anesthesiologist who is certified in basic or advanced perioperative TEE, at the same time and location, an activity that may be too costly in manpower needs, i.e., when clinical circumstances are demanding, or the attending anesthesiologist supervises multiple locations. In the current era of outcome-driven performances, the comprehensiveness and diagnostic accuracy of such basic TEE studies should not be ignored. Bick et al.2  addressed this in a creative way.
Electronic Basic TEE Report
The authors constructed an electronic training basic TEE report.6  It contained essential components of a basic TEE study, i.e., global and regional ventricular systolic function, anatomy and function of the cardiac valves, presence of pericardial effusion, aortic dissection, or interatrial communication.7  The resident had to assess all components for the study to be considered complete and uploaded.
Definition of the Competent Candidate
Passing scores for the basic TEE test were set twice. At baseline, a group of expert anesthesiologists, certified in advanced TEE, convened to set the minimum passing score for each component of the basic TEE study. The group adopted the Angoff method,8  whereby the borderline or minimally competent basic TEE practitioner was defined and an estimate of performance was determined. Afterward, the group reconvened to revise the minimum passing scores having considering the residents’ performance in basic TEE.
Performance Evaluation
The diagnostic accuracy of the basic TEE study was automatically compared with the findings of the attending anesthesiologist, who performed an advanced TEE study on the same patient and filed an electronic advanced TEE report on the patient’s electronic medical record. The authors compared how the diagnostic accuracy of the residents’ basic TEE evolved. Overall, the residents’ performance during basic TEE was acceptable, even when the experts’ performance expectations were raised during the second group meeting.
The study by Bick et al.2  is important for all anesthesiologists involved in the clinical practice and/or education of echocardiography at any level.
First, it is manpower efficient. The electronic basic TEE training report can be easily constructed de novo from free access web-based resources.9  It requires some groundwork to prepare the electronic data collection form and link it to the patient’s electronic medical record or a research database. Afterward, it is very easy to collect TEE reports, automatically grade them, and automatically display one’s individual performance against benchmark scores or experts’ findings. This real-time feedback to the student facilitates learning and helps to shift resources to the components graded below expectations.
Second, it is easy to verify whether the performed TEE study addresses all essential components. Every single study is scrutinized and the educational focus is on quality, comprehensiveness, and competence, and not solely on the number of accomplished tasks, similar to how competency in anesthesiology is assessed.10  Likewise, the ability to use acquired knowledge is tested in real-life circumstances. This paradigm can be applicable for echocardiography, i.e., residents training in basic TEE, fellows training in advanced TEE, or even attending anesthesiologists participating in quality assurance processes within a department or group. This may also be applicable for other training topics, such as electrogardiographic interpretation or hemodynamic waveform analysis, as was proven for advanced cardiac life support training11  or auscultation skills.12 
Third, creation of such real-life educational activities will shift learning, training, or quality assurance activities from time-based to result-based performance. For that to happen, a group of experts will always be required to define, and revise, as in the current study, the minimum expectations that warrant a competent clinical performance. Testing for performance should be adjusted based upon the trainee’s actual performance. Deciding a priori benchmark scores to assess diagnostic performance, particularly for life-threatening conditions such as hypotension and cardiovascular instability, will be as important as revising these scores upward if the trainee’s performance consistently exceeds expectations.
The study by Bick et al.2  should be considered a preliminary report only. While the expert group set the minimum passing scores according to the same, well-accepted method that is also used by the National Board of Echocardiography (Raleigh, North Carolina), the number of trainee third-year clinical anesthesiology residents was rather small (n = 12). All basic TEE studies were performed on cardiac surgical patients, with varying pathologies that were known to the trainees. Not all life-threatening basic TEE components, such as venous air or pulmonary embolism or hypovolemia, were evaluated because they could not be matched against the components of the advanced TEE performed by the experts.
The perioperative use and clinical application of echocardiography and ultrasound are essential, from insertion of catheters to monitoring and diagnosing a multitude of cardiac and extracardiac pathologies.13,14  Bick et al.2  offered us a prototype method to measure applied echocardiographic knowledge and link education to performance. Their paradigm is easy to put together and modify for nonechocardiographic topics. It should be adopted so that residents, fellows, and anesthesiologists continue to master the field of echocardiography in particular and anesthesiology and perioperative medicine in general.
Competing Interests
The author is not supported by, nor maintains any financial interest in, any commercial activity that may be associated with the topic of this article.
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Image: J. Fox/S. Shernan, Brigham and Women's Hospital.
Image: J. Fox/S. Shernan, Brigham and Women's Hospital.
Image: J. Fox/S. Shernan, Brigham and Women's Hospital.