New TEE Requirement

[PoorInvestment]

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So my joint here in the upper midwest just had the regional head of CT anesthesia try to mandate that all hearts be done with TEE and that all of our practitioners that are doing cardiac (which is about 10 of us) must have ADVANCED periop TEE certification and in order to be eligible for hire, you must have the same certification. We do fewer than 100 cardiac cases a year and that number is dwindling year over year. In addition to managing our normal caseload, there simply aren't enough cases here to get certified in the first place, much less maintain proficiency. Has anyone else's place tried to pass a mandate like this and if so what was the ultimate outcome - we're fighting this.

 

[Man o War]

Yes. Here's what happened to me: several years ago one of my mentors that I respect a lot told me if I wanted to keep doing hearts I should quit my job and go back to fellowship. He said in the future hospitals will require Advanced cert to do hearts at all. Everyone said he was nuts, that will never happen. So almost 10 years out of residency I applied and went back....I interviewed at a ton of places afterwards and there were guys who had been doing hearts for 10-20 years being told they could either get the cert or their cardiac privileges would not be renewed, thus the reason they were hiring for cardiac. Seems insane to me, but it is happening. I should add- I really enjoyed that year. If you like cardiac and can swing it financially, it was worth the investment for me. Lots of good job offers afterward.

 

[Man o War]

The crap of it is, you really can't get initial advanced certification anymore without a fellowship. I looked into it and couldn't figure out a way to get it done.

 

[GaseousClay]

The crap of it is, you really can't get advanced certification anymore without a fellowship. I looked into it and couldn't figure out a way to get it done.

they won't accept testamur status?

 

[Man o War]

they won't accept testamur status?

I should've clarified, post 2009 graduates or guys like me who were doing hearts but never took the advanced boards in the first place who are looking for initial certification. Not sure about older guys/gals who were already advanced certified. I know many of these jobs I interviewed for would not accept the basic certification, had to be advanced. Maybe someone else knows the answer to that.

 

[Man o War]

So my joint here in the upper midwest just had the regional head of CT anesthesia try to mandate that all hearts be done with TEE and that all of our practitioners that are doing cardiac (which is about 10 of us) must have ADVANCED periop TEE certification and in order to be eligible for hire, you must have the same certification. We do fewer than 100 cardiac cases a year and that number is dwindling year over year. In addition to managing our normal caseload, there simply aren't enough cases here to get certified in the first place, much less maintain proficiency. Has anyone else's place tried to pass a mandate like this and if so what was the ultimate outcome - we're fighting this.

The other issue with this mandate at your hospital that I think you could use in your rebuttal is a doc who is advanced certified will have a difficult time maintaining advanced certification at that hospital if you're only doing 100 a year. The numbers aren't there unless they only hire 2 cardiac people which means q2 call. I don't know many people willing to do q2 call.

 

[PoorInvestment]

The call thing is a major issue that we've brought up! And frankly, just pulling up stakes and going back to fellowship is not feasible for 90% of our group. The mandate was for all of us to have certification by 2018. So, 8-9 full timers are just gonna run back to fellowship for a year? And how will our steadily increasing OR volume be managed? It's nice to know we're not the only place seeing this, but I can't accept this as a feasible request. I'm not opposed to learning the skill, don't get me wrong, I just don't see this as a practical request.

 

[Twiggidy]

i don't think you'll find much sympathy from the cardiac trained people on this board. this is one of the reasons why alot of us devoted that year to doing cardiac. In essence, i can provide pediatric anesthesia, but it's probably more appropriate (and maybe even medico-legally appropriate---can be argued) to let the peds fellowed anesthesiologist do it.

We manage critically ill patients just about everyday. Should non CC trained people be running the ICU?

This is all people wanting that cardiac pay but not having to take the sacrifice to do a year of cardiac, which like i said, earns zero sympathy from the people who passed on a year of salary for the extra training. My opinion, if you want to do hearts, go back and do a fellowship.

 

[GA8314]

i don't think you'll find much sympathy from the cardiac trained people on this board. this is one of the reasons why alot of us devoted that year to doing cardiac. In essence, i can provide pediatric anesthesia, but it's probably more appropriate (and maybe even medico-legally appropriate---can be argued) to let the peds fellowed anesthesiologist do it.

We manage critically ill patients just about everyday. Should non CC trained people be running the ICU?

This is all people wanting that cardiac pay but not having to take the sacrifice to do a year of cardiac, which like i said, earns zero sympathy from the people who passed on a year of salary for the extra training. My opinion, if you want to do hearts, go back and do a fellowship.

Fellowship in CT anesthesia are reasonably competitive. Based upon what criteria? Research? Good LORs? Good name institution? Connections?? Willingness to move across country for a slot?

That's the problem. If the "community" is requiring this, then they either need to ADD fellowship slots to give PP groups and smaller places the ABILITY to remedy their situation, OR change criteria for certification (i.e. reopen the damn thing) for the Practice Experience Pathway.

Just saying to groups, "you need Advanced Perioperative TEE Certification" isn't a viable solution.

 

[Man o War]

Fellowship in CT anesthesia are reasonably competitive. Based upon what criteria? Research? Good LORs? Good name institution? Connections?? Willingness to move across country for a slot?

That's the problem. If the "community" is requiring this, then they either need to ADD fellowship slots to give PP groups and smaller places the ABILITY to remedy their situation, OR change criteria for certification (i.e. reopen the damn thing) for the Practice Experience Pathway.

Just saying to groups, "you need Advanced Perioperative TEE Certification" isn't a viable solution.

They can't open more fellowship spots or the fellows won't get adequate case counts and experience in one year that will properly prepare them for practice....then you might be looking at a 2 year fellowship. The trend I'm seeing is the creation of cardiac anesthesia groups who are essentially a traveling team to only cover cardiac services at hospitals. This is a bit problematic when you have an isolated hospital though that doesn't do that many cases per year but needs coverage.

 

[Twiggidy]

They can't open more fellowship spots or the fellows won't get adequate case counts and experience in one year that will properly prepare them for practice....then you might be looking at a 2 year fellowship. The trend I'm seeing is the creation of cardiac anesthesia groups who are essentially a traveling team to only cover cardiac services at hospitals. This is a bit problematic when you have an isolated hospital though that doesn't do that many cases per year but needs coverage.

i was just about to reply that. There's no way these programs would be able to increase fellows. I remember a couple places I interview that had fellows doing spine cases when there weren't hearts to do. Not the biggest deal, but image 5,6, or even 8 fellows fighting to get TEE numbers, or instead of holding back 1 year of salary, now you're withholding 2 or 3 years of salary. You'll have alot of people saying, "screw it. i just wont do hearts."

To contrary your second statement, I'm pretty sure some cardiac dudes/dudettes on here would be a travelling circus as long as they didn't have to take in-house OB call or cover general OR call. Again, most of us did hearts TO DO HEARTS. Many of us don't mind getting called for the emergency CABG vs the emergency bowel obstruction or the 3 am epidural. I think even the BFE hospital that wants cardiac coverage can probably find a guy/gal because not everyone wants to live in the city.

 

[Man o War]

i was just about to reply that. There's no way these programs would be able to increase fellows. I remember a couple places I interview that had fellows doing spine cases when there weren't hearts to do. Not the biggest deal, but image 5,6, or even 8 fellows fighting to get TEE numbers, or instead of holding back 1 year of salary, now you're withholding 2 or 3 years of salary. You'll have alot of people saying, "screw it. i just wont do hearts."

To contrary your second statement, I'm pretty sure some cardiac dudes/dudettes on here would be a travelling circus as long as they didn't have to take in-house OB call or cover general OR call. Again, most of us did hearts TO DO HEARTS. Many of us don't mind getting called for the emergency CABG vs the emergency bowel obstruction or the 3 am epidural. I think even the BFE hospital that wants cardiac coverage can probably find a guy/gal because not everyone wants to live in the city.

True. I'd do a lot to never have to see the OB ward again. I feel like we are in this strange transition with cardiac anesthesia care at hospitals. One of my good friends from residency is now jobless because his group couldn't meet the TEE requirements the hospital put on their group. The group across town who already had the fellowship trained cardiac guys poached the contract.

 

[GA8314]

i was just about to reply that. There's no way these programs would be able to increase fellows. I remember a couple places I interview that had fellows doing spine cases when there weren't hearts to do. Not the biggest deal, but image 5,6, or even 8 fellows fighting to get TEE numbers, or instead of holding back 1 year of salary, now you're withholding 2 or 3 years of salary. You'll have alot of people saying, "screw it. i just wont do hearts."

To contrary your second statement, I'm pretty sure some cardiac dudes/dudettes on here would be a travelling circus as long as they didn't have to take in-house OB call or cover general OR call. Again, most of us did hearts TO DO HEARTS. Many of us don't mind getting called for the emergency CABG vs the emergency bowel obstruction or the 3 am epidural. I think even the BFE hospital that wants cardiac coverage can probably find a guy/gal because not everyone wants to live in the city.

The problem is that there are more hearts done in the community setting than many people in academia are aware of or know about. IF these hospitals trend towards requiring Advanced TEE Certification, then a viable solution needs to be in place. This is where the SCA/ASA needs to step up and meet a demand.

The solution can't just be "do a fellowship". UNLESS you increase fellowship number (which by your argument isn't feasible which is probably valid) OR bring back a pathway similar to what used to be available for TEE Certification, then we don't have a viable solution.

There are at TON of places doing hearts in the community which are having a hard time recruiting TEE Certified folks. Yet, existing anesthesiologists in that community (already doing those cardiac cases) should be offered a VIABLE solution to attain that requirement. It's clearly not sufficient to say "just do a fellowship". That isn't working.

The other non-viable solution is "just shut those places down for cardiac".......... The fact is that cardiac cases are being done in significant numbers in the community (and yeah, sometimes WAY OUT in the "community"...)

 

[Man o War]

The problem is that there are more hearts done in the community setting than many people in academia are aware of or know about. IF these hospitals trend towards requiring Advanced TEE Certification, then a viable solution needs to be in place. This is where the SCA/ASA needs to step up and meet a demand.

The solution can't just be "do a fellowship". UNLESS you increase fellowship number (which by your argument isn't feasible which is probably valid) OR bring back a pathway similar to what used to be available for TEE Certification, then we don't have a viable solution.

There are at TON of places doing hearts in the community which are having a hard time recruiting TEE Certified folks. Yet, existing anesthesiologists in that community (already doing those cardiac cases) should be offered a VIABLE solution to attain that requirement. It's clearly not sufficient to say "just do a fellowship". That isn't working.

The other non-viable solution is "just shut those places down for cardiac".......... The fact is that cardiac cases are being done in significant numbers in the community (and yeah, sometimes WAY OUT in the "community"...)

Keep in mind the TEE certification comes through the National Board of Echocardiography, not ASA or SCA. My understanding is the policy makers for this board come from both anesthesia and cardiology, so the chances of getting any requirements loosened are slim to none. The cardiologists want to maintain a similar standard for both cardiology and anesthesia. Before I went back to fellowship, we would get some basic views for our cardiac surgeons, but the cardiologist would have to come up to the OR and do a complete exam, which would at times change the course of the surgery, so it is important. This is super inefficient, and now the hospital has to pay a stipend to both cardiology and anesthesia for the same case. Much easier to pay one stipend to the person already in the room.
On another note, the same mentor who correctly advised me to go back has also told me that due to provisions in Obamacare and where medicine is heading, we are going to see a "centers of excellence" approach to some service lines. He thinks cardiac surgeries (and ortho, neuro, etc) are going to be more concentrated in less facilities to increase the likelihood of better outcomes. We will see.

 

[GA8314]

Keep in mind the TEE certification comes through the National Board of Echocardiography, not ASA or SCA. My understanding is the policy makers for this board come from both anesthesia and cardiology, so the chances of getting any requirements loosened are slim to none. The cardiologists want to maintain a similar standard for both cardiology and anesthesia. Before I went back to fellowship, we would get some basic views for our cardiac surgeons, but the cardiologist would have to come up to the OR and do a complete exam. This is super inefficient, and now the hospital has to pay a stipend to both cardiology and anesthesia for the same case. Much easier to pay one stipend to the person already in the room.
On another note, the same mentor who correctly advised me to go back has also told me that due to provisions in Obamacare and where medicine is heading, we are going to see a "centers of excellence" approach to some service lines. He thinks cardiac surgeries (and ortho, neuro, etc) are going to be more concentrated in less facilities to increase the likelihood of better outcomes. We will see.

I hear you on all points. Center of excellence is a good idea, but it will be very hard to make this happen for many reasons. Not impossible, but you are talking uprooting physicians and revenue streams, not to mention requiring patients to travel potentially long distances. I'm not sure this is an improvement in access to care.

I wonder if any models exist like this in other countries? Meantime, however, we have hearts and healthy peds being done in the community. We need a better solution, it seems, IF hospitals continue this trend which they can simply NOT continue once they realize how hard it is to recruit TEE trained folks to some of these locations in the community......

 

[Man o War]

I hear you on all points. Center of excellence is a good idea, but it will be very hard to make this happen for many reasons. Not impossible, but you are talking uprooting physicians and revenue streams, not to mention requiring patients to travel potentially long distances. I'm not sure this is an improvement in access to care.

I wonder if any models exist like this in other countries? Meantime, however, we have hearts and healthy peds being done in the community. We need a better solution, it seems, IF hospitals continue this trend which they can simply NOT continue once they realize how hard it is to recruit TEE trained folks to some of these locations in the community......

I know. It seems far fetched, interesting times we all chose to be doctors in, that's for sure.

 

[Psai]

Keep in mind the TEE certification comes through the National Board of Echocardiography, not ASA or SCA. My understanding is the policy makers for this board come from both anesthesia and cardiology, so the chances of getting any requirements loosened are slim to none. The cardiologists want to maintain a similar standard for both cardiology and anesthesia. Before I went back to fellowship, we would get some basic views for our cardiac surgeons, but the cardiologist would have to come up to the OR and do a complete exam, which would at times change the course of the surgery, so it is important. This is super inefficient, and now the hospital has to pay a stipend to both cardiology and anesthesia for the same case. Much easier to pay one stipend to the person already in the room.
On another note, the same mentor who correctly advised me to go back has also told me that due to provisions in Obamacare and where medicine is heading, we are going to see a "centers of excellence" approach to some service lines. He thinks cardiac surgeries (and ortho, neuro, etc) are going to be more concentrated in less facilities to increase the likelihood of better outcomes. We will see.

We already have that where I am, all of the major cardiac services are concentrated in two facilities from the two major systems and they each receive a ton of referrals from the other hospitals in their group.

 

[Man o War]

The call thing is a major issue that we've brought up! And frankly, just pulling up stakes and going back to fellowship is not feasible for 90% of our group. The mandate was for all of us to have certification by 2018. So, 8-9 full timers are just gonna run back to fellowship for a year? And how will our steadily increasing OR volume be managed? It's nice to know we're not the only place seeing this, but I can't accept this as a feasible request. I'm not opposed to learning the skill, don't get me wrong, I just don't see this as a practical request.

In my experience, they don't care if it's practical. Plus you don't need 8-9 docs doing 100 hearts a year. Are you the only show in town hospital wise doing hearts?

 

[criticalelement]

FIGHT THE BEAST foks.. STOP THE INSANITY.. Dont continue getting certified. IT will never end. Stop bending over. If we continue bending over it will continue. Certification for OB.. certification for robot cases.. certification for u/s... We dont want that. So stop ****ing getting certified. Its all BS and a money making scheme..

 

[seinfeld]

a program doing 100 hearts per year better have top of the line outcomes to keep going. Even for the surgeons that is not enough.

I am in a very large community program 1200+ hearts per year. Not a single fellowship trained person on staff. We get NO, none, zilch, nada cardiology support. We have all studied hard, read, taken courses and rely on each other. All of us have passed the advanced exam, never needed a fellowship.

 

[pjl]

I hear you on all points. Center of excellence is a good idea, but it will be very hard to make this happen for many reasons. Not impossible, but you are talking uprooting physicians and revenue streams, not to mention requiring patients to travel potentially long distances. I'm not sure this is an improvement in access to care.

I wonder if any models exist like this in other countries? Meantime, however, we have hearts and healthy peds being done in the community. We need a better solution, it seems, IF hospitals continue this trend which they can simply NOT continue once they realize how hard it is to recruit TEE trained folks to some of these locations in the community......

Not hard, expensive. I would not mind seeing a FAT subsidy for a "cardiac anesthesiologist" so that they dont have to close their cardiac surgery and interventional cards service lines 😉 Unfortunately it is more likely they would just make their cards guys come over for TEE.

Also, why are we trying to convince each other that you need X fellowship to do X case? Isn't training in all specialties what we did residency for? Healthy peds does not require peds fellowship. Peds hearts, sure, I will give you that.
But tonsils or an appy on a 3 year old? Really?

 

[PoorInvestment]

We do have good outcomes mostly because of patient selection. Our surgeons are bright enough to know when to refer. And frankly, the argument that "if you wanted to do hearts you should have done a fellowship" is bogus. It's an expectation at a lot of community programs that you'll be doing cardiac, fellowship or not. If we rely on subspecialty anesthesia to cover all these kinds of cases the answer will mainly be that we need to offload them to other centers since it's very difficult to get fellowship trained folks to come to places with volume as low as we have. And it's easy to say, Mr. Sienfeld, that you get no cardiology support and you all passed the advanced exam because you're doing 1200+ hearts a year. We're nowhere near that. It's ludicrous to compare the two scenarios. It's not a question of working hard, reading, putting in the time - we just don't have the numbers. The next ? I have is this even a cash grab? Is TEE reimbursed that well that the captured billing would offset the cost of training us? Insights?

 

[Man o War]

Not hard, expensive. I would not mind seeing a FAT subsidy for a "cardiac anesthesiologist" so that they dont have to close their cardiac surgery and interventional cards service lines 😉 Unfortunately it is more likely they would just make their cards guys come over for TEE.

Also, why are we trying to convince each other that you need X fellowship to do X case? Isn't training in all specialties what we did residency for? Healthy peds does not require peds fellowship. Peds hearts, sure, I will give you that.
But tonsils or an appy on a 3 year old? Really?

That sounds good in theory, but the administrators make the rules, crazy and nonsensical as they may be. I do believe this TEE certification requirement will become common place as the years go on, so I took a gamble on that and lost a year's salary. If they hadn't closed the practice pathway to get TEE certified, I probably wouldn't have done it.

 

[jope]

Playing Devil's Advocate, in a way forcing these new requirements could make things better for new grads who are often having trouble finding jobs due to the old guys hanging on.

 

[deleted126335]

I am a regular old anesthesiologist who finished training just as TEE was coming into the ORs in academic programs. My first job I was a cardiac anesthesiologist who did it all. Over 1,000 pump cases. In my current job I was only good enough to do hearts at night, including thoracic aneurysms with circulatory arrest. Did this for a decade till enough fellowship trained cardiac anesthesiologists could be recruited to staff a cardiac call team who leveraged their credentials and skills to the max within the group and with administration. I am not at all surprised by the OPs post.

The first TEE certification exam came along around 1998. Nobody gave a damn whether you passed the exam or not as long as you had the skills. That started to change about a decade later.

As far as predictions go---Nobody knows nothing. Me included. In the mid 90s I attended a panel discussion at an ASA meeting. The biggest names in academic cardiac anesthesia at the time were on the panel. The overwhelming consensus of opinion among the panel "experts" was that the number of cardiac surgery programs in the US would drastically shrink over the coming decade because CMS would insist on the outcome benefits of high volume centers. What happened is of course the opposite. The number of CV surgery programs exploded. They were initiated as a backstop to the lucrative invasive cardiology cath labs who needed CV back up.

To extrapolate the current trends to peds anesthesia, I suspect that ABA peds certification will be needed to do anything other than bread and butter peds in a decade. Skills won't matter.

 

[IlDestriero]

The problem is that there are more hearts done in the community setting than many people in academia are aware of or know about. IF these hospitals trend towards requiring Advanced TEE Certification, then a viable solution needs to be in place. This is where the SCA/ASA needs to step up and meet a demand.

The solution can't just be "do a fellowship". UNLESS you increase fellowship number (which by your argument isn't feasible which is probably valid) OR bring back a pathway similar to what used to be available for TEE Certification, then we don't have a viable solution.

There are at TON of places doing hearts in the community which are having a hard time recruiting TEE Certified folks. Yet, existing anesthesiologists in that community (already doing those cardiac cases) should be offered a VIABLE solution to attain that requirement. It's clearly not sufficient to say "just do a fellowship". That isn't working.

The other non-viable solution is "just shut those places down for cardiac".......... The fact is that cardiac cases are being done in significant numbers in the community (and yeah, sometimes WAY OUT in the "community"...)

Certainly some places should close to cardiac. I'm sure a detailed study of their outcomes would show that they are significantly below the mark and grandpa probably should head off to "the big city" for his surgery and then do his recovery PT locally.
The other viable solution would have been for those anesthesiologists already doing cardiac to get the training or take the test when they were eligible to sit for it. They said they didn't need it and spent the $2000 on some new skis and a trip to Beaver Creek and now they wonder what the hell happened and think "academia" owes them something. Ha!

 

[Man o War]

We do have good outcomes mostly because of patient selection. Our surgeons are bright enough to know when to refer. And frankly, the argument that "if you wanted to do hearts you should have done a fellowship" is bogus. It's an expectation at a lot of community programs that you'll be doing cardiac, fellowship or not. If we rely on subspecialty anesthesia to cover all these kinds of cases the answer will mainly be that we need to offload them to other centers since it's very difficult to get fellowship trained folks to come to places with volume as low as we have. And it's easy to say, Mr. Sienfeld, that you get no cardiology support and you all passed the advanced exam because you're doing 1200+ hearts a year. We're nowhere near that. It's ludicrous to compare the two scenarios. It's not a question of working hard, reading, putting in the time - we just don't have the numbers. The next ? I have is this even a cash grab? Is TEE reimbursed that well that the captured billing would offset the cost of training us? Insights?

Considering the patient population and the insurance (or lack thereof) they carry in general for cardiac, no, reimbursement is not the driving factor (although the hospital gets a bigger cut than you do billing independently, so that is a factor). And let's be honest, it's probably got a lot to do with exactly what @dr doze eluded to- the cardiac guys use TEE to leverage job security and more cash because they're taking the call. It's also about outcomes and not having to pay the cardiologists to come do an exam. My insight is this- go back and do the fellowship. I didn't think it was feasible for me, but my wife and I just made it work. I've done a job search with the cert and without. HUGE difference with it. If you want to go back to your old group, go back and enjoy the call $ that will come with taking the cardiac call the others can't take. m I taking more call on paper? Yes, but it's from home and I don't get called in that much. 100 hearts a year, you're hardly getting called in at all. Obviously all this advice is assuming you like hearts.

 

[pgg]

The number of CV surgery programs exploded. They were initiated as a backstop to the lucrative invasive cardiology cath labs who needed CV back up.

Certainly some places should close to cardiac. I'm sure a detailed study of their outcomes would show that they are significantly below the mark and grandpa probably should head off to "the big city" for his surgery and then do his recovery PT locally.

Don't the cath lab cash cows need CT surgeons and CT-capable ORs around? If so, are those actual rules/regulations, or just limits that sensible people voluntarily embrace?

I haven't ever paid close attention to what the cardiologists can do with vs without a surgical plan B a couple floors away. But I sort of vaguely remember one medium sized community hospital where I used to moonlight talking about starting up a heart program specifically because it would allow the cath lab in the hospital to do a lot more. I don't think they ever did it.

 

[ryanjmy]

I'm not so sure centers of excellence is a good idea. When a pt is having an MI, time=heart muscle. The faster the pt is taken to the cath lab the better and I would never have an elective cath at a hospital that didn't have a ct surgery back up.

For the guys having certification pushed on them, are your surgeons happy? If your surgeons are happy with your tee skill level I can't see why administration would care if you have certification or not.

 

[OB1🤙]

I would negotiate to grandfather current people, maybe have them take the basic exam and do something in house to demonstrate proficiency.

Going forward, new hires can be mandated to be advanced certified.

Seems like a reasonable middle ground.

 

[Man o War]

Here is what I have on billing for TEE. Interpretation vs monitoring is the key:

Billing for Intraoperative TEE

Reimbursement for intraoperative TEE is dependent on third party payer contracts, whether the echocardiographer is a cardiologist or anesthesiologist, and the geographical region. Many third party payers have adopted the Center of Medicare Services (CMS) policy that defines reimbursable indications for intraoperative TEE:

“The interpretation of TEE during surgery is covered only when the surgeon or other physician has requested echocardiography for a specific diagnostic reason (e.g., determination of proper valve placement, assessment of the adequacy of valvuloplasty or revascularization, placement of shunts or other devices, assessment of vascular integrity, or detection of intravascular air). To be a covered service, TEE must include a complete interpretation/report by the performing physician. Coverage for evaluation, however, is not allowed for monitoring, technical trouble shooting, or any other purpose that does not meet the medical necessity criteria for the diagnostic test.”

The key points for reimbursement of IOE services should include:

1. 1) Documentation that the surgeon or other physician is requesting echocardiography for a specific diagnostic reason. The medical record should indicate this request either by an order in the medical record, the operative consent form, progress notes, or at the very least within the dictated echocardiography report. It is a good practice for the patient report to indicate the medical necessity for performing the TEE and the physician who requested the IOE service. It should also be clear whether the IOE was performed for diagnostic, monitoring, or research purposes.
   
   
2. 2) A complete interpretation and report is generated by the echocardiographer. Best practices include submission of a copy of the completed, signed TEE report with the billing sheet.
   
   
3. 3) When TEE is used for monitoring by the physician who places the TEE probe and another physician provides a diagnostic exam and report, the monitoring physician only receives compensation for placement of the probe. There is no reimbursement for diagnosis when intraoperative TEE is used solely for monitoring.
   

 

[sevoflurane]

Interpretation with report: 6 units
CFD: 2 units
Spectral: 2units

10 units total.

I try and capture 20-30+ clips per exam. The studies get uploaded to our system and then I follow that with a dictated or typed report.

 

[sevoflurane]

I am of the belief that every heart case deserves an echo. I think it's better patient care. Those of us that do them routinely have picked up on pathology that has not been seen before... or prevented a sternotomy because the pathology was absent.

 

[sevoflurane]

BTW, it is very common for hospital systems to require advanced certification in order to do hearts. I personally know of 3 different systems where this rule was laid down. It upset a lot of people that had been doing them for a long time... they probably let go of some very competent clinicians yet brought in some well trained echocardiographers.

 

[urge]

1 There is no reason for a recent grad(post 2009) to be doing hearts without a fellowship. If you didn't see it coming, your bad. Be happy that you got to do hearts for a couple of years.

2 There is no reason for a dinosaur, who has been doing hearts before tee was invented, to not be tee certified. Again, if you didn't see it coming, your bad. Be happy that you got to do hearts for many years.

3 There is no reason for a 100 case/yr program to have 8 to 10 people doing hearts. That's a 1 or 2 people program.

4 I can't wait for the same logic to apply for OB jobs and fellowship. It speaks volumes about OB fellowships.

5 Centers of excellence sound great on paper, but how do you improve care when only a handful of places are getting the complex cases? You will end up with a lot of bad programs and very few good ones.

 

[IlDestriero]

The difference is that any dope can do OB, and many places have CRNAs running OB solo at night/weekends while they're home in bed. I cannot understand the appeal of an OB fellowship at all outside of someone wanting to an OB based academic career. Even then it's likely a waste of a year and a few hundred thousand dollars.

 

[GA8314]

We are talking about basic traini

1 There is no reason for a recent grad(post 2009) to be doing hearts without a fellowship. If you didn't see it coming, your bad. Be happy that you got to do hearts for a couple of years.

2 There is no reason for a dinosaur, who has been doing hearts before tee was invented, to not be tee certified. Again, if you didn't see it coming, your bad. Be happy that you got to do hearts for many years.

3 There is no reason for a 100 case/yr program to have 8 to 10 people doing hearts. That's a 1 or 2 people program.

4 I can't wait for the same logic to apply for OB jobs and fellowship. It speaks volumes about OB fellowships.

5 Centers of excellence sound great on paper, but how do you improve care when only a handful of places are getting the complex cases? You will end up with a lot of bad programs and very few good ones.

I don't know how you can say no recent grad needs to be doing hearts without a fellowship. Do you know how hard it is to recruit to our area? It's hard. In my state, I've seen running ads on GasWork for TEE certified folks going on 2.5 years now. It's crazy.

We need a better solution. I'm a new grad doing hearts at a small cardiac program. "Close it down then"?? It doesn't work that way. We do hearts. We do them pretty well. Most of us do hearts. We are a small group, so having 1 or 2 guys ONLY just doesn't offer the coverage we need. So, we do hearts.

This BS of "just do a fellowship" is just that. Again, expand the # of slots to meet the NEEDS of the community OR offer up another viable option for folks to get certified S/P 2009.

TEE is a TOOL of the trade. Yes, the Advanced PTe exam is tough by all measures. But, TEE is just a tool. New techniques and technologies are coming into surgery every year. Surgeons learn these important technologies and modalities on the job and with training courses and the like. I don't see how TEE (it's not ****.ng robotic surgery) should be any different.

Frankly, the certification requirement probably shouldn't be in place in the first place. This DOESN'T imply that just anyone should do cases they are not skilled at. It just means that we need realistic and viable solutions.

 

[urge]

We are talking about basic traini


I don't know how you can say no recent grad needs to be doing hearts without a fellowship. Do you know how hard it is to recruit to our area? It's hard. In my state, I've seen running ads on GasWork for TEE certified folks going on 2.5 years now. It's crazy.

We need a better solution. I'm a new grad doing hearts at a small cardiac program. "Close it down then"?? It doesn't work that way. We do hearts. We do them pretty well. Most of us do hearts. We are a small group, so having 1 or 2 guys ONLY just doesn't offer the coverage we need. So, we do hearts.

This BS of "just do a fellowship" is just that. Again, expand the # of slots to meet the NEEDS of the community OR offer up another viable option for folks to get certified S/P 2009.

I believe that if your expectation was to be a lifetime cardiac anesthesiologists you should have done a fellowship if you graduated post 2009 (cardiac became an acgme fellowship in 2007) . If you were a general anesthesiologists who happily stepped up to cardiac because the institution couldn't fill a spot, then you should be just as happy stepping down when said position is filled with someone with the proper training (and motivation).

 

[IlDestriero]

Seriously, honest question, how did y'all not see this coming. You want to do cardiac, you get TEE certified. The writing was on the wall, and there was a grandfathering period for the white hairs (and not so white hairs).
How many people doing peds anesthesia at a children's hospital didn't get peds certified? None.
There are 30 year veterans that work 2 days a week retiring shortly that got certified.
If your hospital is remotely desirable in terms of location or income (fat stipend) I would expect them to ask for certified people. As for 10 people sharing 100 hearts a year, that sounds like you're asking for bad care with little ability to keep your skills up. That's one reason I'm not doing livers now. Too many on the team and too few a year. Why do I want the hassle and then potential struggle doing my 2-3 a year. If your program is so small you can't keep minimum skills up, that's a real problem. Not acknowledging that it is a problem is another problem.

 

[GA8314]

I believe that if your expectation was to be a lifetime cardiac anesthesiologists you should have done a fellowship if you graduated post 2009 (cardiac became an acgme fellowship in 2007) . If you were a general anesthesiologists who happily stepped up to cardiac because the institution couldn't fill a spot, then you should be just as happy stepping down when said position is filled with someone with the proper training (and motivation).

First of all, I have no problem doing cardiac or not. But, we are a small place. There are a limited # of grads coming out of fellowship. The whole point of my argument is that the SCA/ASA is dropping the ball a bit.

Recruiting for a program doing under 200/year is tough, but if you don't already know, there are plenty of community hospitals doing 200-300/year of cardiac. You're not going to have a lot of fellowship trained guys running to these places. You can sit there and say "it shouldn't be", but it is what it is.

BTW, my institution has no plans for mandating Advanced TEE certification for doing cardiac. We credential for cardiac anesthesia ourselves. And it's not about "motivation" or "proper" training. Where I trained, our cardiac guys were so specialized that the last time they did OB, Peds (even healthy peds), or regional was so long ago that most had simply lost those skills. I made a choice to join a practice where they NEEDED anesthesiologist doing all types of cases. That is the majority of anesthesia delivered in this country. Community hospitals. They serve an important need of the community. They are not always that easy to recruit to.

Frankly, we are NOT recruiting for a cardiac fellowship trained doc. We won't pay a premium for that given our volume (or lack thereof) and our needs far exceed a very narrowly focused subspecialty.

Again, the problem being described is much larger than "just close those places down". That's not a viable solution.

 

[GA8314]

Seriously, honest question, how did y'all not see this coming. You want to do cardiac, you get TEE certified. The writing was on the wall, and there was a grandfathering period for the white hairs (and not so white hairs).
How many people doing peds anesthesia at a children's hospital didn't get peds certified? None.
There are 30 year veterans that work 2 days a week retiring shortly that got certified.
If your hospital is remotely desirable in terms of location or income (fat stipend) I would expect them to ask for certified people. As for 10 people sharing 100 hearts a year, that sounds like you're asking for bad care with little ability to keep your skills up. That's one reason I'm not doing livers now. Too many on the team and too few a year. Why do I want the hassle and then potential struggle doing my 2-3 a year. If your program is so small you can't keep minimum skills up, that's a real problem. Not acknowledging that it is a problem is another problem.

We are not doing complicated valves. We are doing mostly CABG's, with the occasional AVR. Sometimes MVR's. We don't even do minimally invasive. It is what it is.

I was a graduate looking for a job. Advanced TEE was not a requirement. I did a lot of hearts during residency and have pretty good TEE skills. I'm comfortable in the heart room.

Not all anesthesia is now, nor will it ever, be done at large tertiary care centers. What our group needs is a GOOD, versatile, general anesthesiologist. I'm not devaluing specialty training. I would NOT want to do a healthy neonate or a sick kid. We don't do those cases. We do lots of bread and butter cases, healthy peds, some cardiac, and most other cases. The only cases we don't do are crani's.

The academic folks on this forum may not like it but it is what it is.

 

[deleted162650]

I cannot understand the appeal of an OB fellowship at all outside of someone wanting to an OB based academic career.

The only other reason is that there are a few very busy PP Women's Centers in some very desirable locations that are very lucrative. An OB fellowship may be you're only ticket in if you want to work at these locations

Sorry for the threadjack. Back to arguing about Big Black Snake certification.

 

[Man o War]

If these community hospitals are going to mandate advanced TEE, then they're going to have to come up with some cash to hire those people to come there. Simple as that. Big cities pay well for it at the moment, so that's what they're competing with.

 

[Ignatius J]

It's a scam. Some of the best cardiac guys I know never did a fellowship.

 

[GA8314]

If these community hospitals are going to mandate advanced TEE, then they're going to have to come up with some cash to hire those people to come there. Simple as that. Big cities pay well for it at the moment, so that's what they're competing with.

I'm suggesting that they, like we, NOT mandate such a thing. There are not enough fellowship openings to meet the demand for cardiac anesthesia in the community. The answer should not be massive subsidies/stipends for something which isn't necessary as evidenced by the very fact that these hearts are being done without such a mandate currently. Now, if there were a glut of cardiac fellowship trained docs around, then so be it. I wouldn't argue against that. But the reality is that at BEST you will get some locums guys come in for a buck or two for a few months or a year at at time as they shop for a better gig. That's what's happening at some of those more remote places that DO mandate TEE CERT. Is that good for patient care?

 

[Man o War]

I'm suggesting that they, like we, NOT mandate such a thing. There are not enough fellowship openings to meet the demand for cardiac anesthesia in the community. The answer should not be massive subsidies/stipends for something which isn't necessary as evidenced by the very fact that these hearts are being done without such a mandate currently. Now, if there were a glut of cardiac fellowship trained docs around, then so be it. I wouldn't argue against that. But the reality is that at BEST you will get some locums guys come in for a buck or two for a few months or a year at at time as they shop for a better gig. That's what's happening at some of those more remote places that DO mandate TEE CERT. Is that good for patient care?

I really don't know. Outcomes are king when it comes to cardiac surgery programs. Are these higher ups seeing something in the outcomes that are forcing this mandate? Hard to say. "Good for patient care" can mean a lot of different things. All I was trying to point out was if this is the route they want to go, they're going to pay for it handsomely. So they're going to have to do a cost vs benefit analysis. If they're getting Fellowship trained cardiac locums, I'm going to guess they're not slackers or bad docs, so I don't think they will provide substandard care.

 

[IlDestriero]

I think that if my group did cardiac and didn't have any cardiac/tee trained people and the CEO/BoD said they wanted them, my argument wouldn't be that we don't need one, it would be that we will hire/train one ASAP to be the Cardiac liaison and they will insure that we are all current on the latest techniques and handle cardiac chart reviews, QI, etc.
That might be a reasonable compromise for them, and make your group look proactive in dealing with the perceived problem.

 

[Impromptu]

We are a small community hospital in a medium sized midwest town. There are 5 docs and we share all of the hearts. I thought about asking to take all the hearts and get more certification. That would be good while I was there, but then the other guys would have to do it while I was on vacation, and they would get out of practice. No matter how much previous experience you have, if you are down to 1 or 2 cases a year those patients may do worse.

Though we have CRNAs we do all of the OB, cardiothoracic, and regional ourselves. We also have a neurosurgery residency here, so get to do craniotomies, which I really enjoy. We do pediatric ENT and pediatric dental. Level 2 trauma, lots of ortho, urology, and general. The Endo centers send all their ASA 3 and 4s to us. It is a killer lifestyle and we get no subsidy, but that makes us very valuable to the hospital. If you want to be proficient in all areas of anesthesia, this is the type of place to work.

This is the kind of community and hospital that would be hurt by those requirements. I don't think that the other mid-sized cities within a few hours of us have too many (if any) cardiac fellowship trained anesthesiologists. A 3 or 4 hours drive to a big academic center would be devastating for this population.

 

[seinfeld]

What is the standard of care for performing Cardiac Anesthesia? Honestly I don't know the answer but I am sure someone would argue that training in TEE is a modern day standard skill set for cardiac anesthesia.

In our group there are reasons why we have slowly evolved to a cardiac team.
1. When everyone was doing hearts I would get called into a room to perform a TEE while at the same time covering my 3-4 other rooms. Essentially doing multiple peoples jobs.
2. To any of us TEE people to keep our numbers up and say competent we needed to be in the rooms more often
3. It was very hard to be in room looking at an echo and not make recommendations to my partner and the surgeon what to do coming off pump- uncomfortable position
4. Cardiac surgeons wanted more reproducibly in the rooms.
5. Concern among some partners about being held to similar standards as the TEE guys especially with the middle of the night dissections. Some of that was a way for them to not work with the heart surgeons or have to deal with sitting in the long cases.

Don't get me wrong, I do NOT believe the ASA/ABA/NBE went in the right direction by requiring fellowship for doing TEE. It is a skill that can be learned on the job (the point i was trying to make with my last post). I feel it has done a disservice, especially to our Critical Care fellows who now feel they need to do extra years to be in the heart rooms. Should we all go back to fellowship before we place a continuous peripheral nerve catheter? I have yet to hear a general surgeon going back and doing a fellowship to learn robotic colectomies. Even a better example would be to ask the interventional cardiologists to redo a fellowship to place TAVRs.

Routine Cardiac Anesthesia is not difficult to preform. What i feel is the most important is having the skills that required no matter the case. IF you have been doing cardiac cases and have learned TEE and are comfortable that you perform an exam at the same level and standards as anyone who does TEE, then a fellowship should not be required.

Overall it sounds like the either the hospital, the surgeons or the lawyers ( malpractice ) are asking that a standard be obtained; Or its just that a couple of guys are trying to steal all the heart cases for themselves.

 

[nimbus]

It's a scam. Some of the best cardiac guys I know never did a fellowship.

Yes but they self-studied echo. If they didn't, they are not one of the best.