Certifiable or Certifiably Insane?
In searching the Merriam-Webster Dictionary for the definition of the word “certifiable,” one finds two common definitions: 1) “fit to be certified as crazy or insane” and 2) “capable of being certified.” If you are reading this newsletter, you probably would not describe those who choose an additional year of subspecialty cardiothoracic anesthesiology training, or those who dedicate a portion of their practice to caring for cardiothoracic surgical patients, as crazy. Though you might think they are capable of being certified.
Why would we want to have board certification in Adult Cardiothoracic Anesthesiology? Do we not wish to communicate to our patients that we have the training, advanced skill set, and experience to care for them? Don’t we wish for other medical professionals to respect the practice of cardiothoracic anesthesiology? They should understand that we maintain our skills by a focused dedication to caring for patients who manifest the extremes of cardiovascular and hematologic disease while they undergo complex cardiac-related procedures, nonpulsatile flow, and sustain end-organ dysfunction that must be managed in the acute and chronic setting. Do we not wish to be recognized as an invaluable member of the cardiothoracic management team, and to be called upon for having this exceptional expertise, to contribute to decision making, and to render a higher standard of care? Why would we NOT want to have certification in Adult Cardiothoracic Anesthesiology?
Perhaps it’s sufficient that we already have a metric recognizing us as having training and special competence in echocardiography. Many health systems, credentialing departments, and even payers equate transesophageal echocardiography (TEE) certification with the practice of cardiothoracic anesthesiology. Why have we allowed this to promulgate? Why would we want to define our subspecialty anesthesiology practice by a narrow centricity? There is clearly more to the practice of cardiothoracic anesthesiology than echocardiography alone.
Cardiothoracic anesthesiology has been recognized as a distinct area of study since the 1950s, when the advent of cardiopulmonary bypass enabled “open heart surgery” and anesthesiologists became expert in the pathophysiology of deep hypothermia, anticoagulation, and extracorporeal perfusion. Since that time, cardiac surgeons have recognized that to conduct successful and safe cardiac operations, they need to work in integrated teams with colleagues who have the same concentrated area of focus. Cardiothoracic anesthesiologists are integral members of the multidisciplinary team, contributing to the body of basic science and clinical research that defines the specialty. We collaborate with the American Heart Association and Society of Thoracic Surgeons to publish guidelines for cardiac surgical patients, and we collaborate with the American Society of Echocardiography to create practice parameters in echocardiography. An entire journal is dedicated to the field of cardiothoracic and vascular anesthesia (the Journal of Cardiothoracic and Vascular Anesthesia) and the earliest “journal within a journal” in Anesthesia and Analgesia was the Cardiovascular Anesthesiology section.
Although TEE certification is an excellent metric by which to validate a skill set, it has become the surrogate marker by which we measure expertise in cardiac anesthesiology. Since 2006, cardiothoracic anesthesiology has been an ACGME-accredited subspecialty. In this past year, approximately 200 cardiothoracic anesthesiology fellows entered training in 63 fellowship programs. To our dismay, however, fellows in training may excessively focus on learning echocardiography and studying for an echocardiography examination, often without learning other aspects of anesthesiology and critical care medicine. Are we vulnerable to losing the forest for the trees?
Practicing cardiothoracic anesthesiologists (we!) represent another important demographic whose needs should be addressed. Some may rebuff the concept of certification, either because they do not wish to pursue it or they cannot meet the criteria set forth. The former will be a difficult group to satisfy. However, the latter represent an interesting cohort. Curiously, data from 2016 indicate that since the inception of the Perioperative Transesophageal Echocardiography Examination, there have been approximately 5300 testamurs of the examination, yet only 50% of these testamurs have applied for certification. This is a disappointing statistic. Do 50% of testamurs not wish to certify, or do they not meet the certification criteria? Finding the answers to these questions could help us explore the creation of a certification process in cardiothoracic anesthesiology that is both discerning and yet eminently attainable.
Without question, there is a distinct body of knowledge in cardiothoracic anesthesiology for which mastery entails a directed educational focus and an additional level of expertise. Our patients should receive the high standard of care delivered by those practitioners with this expertise. If recognition of an advanced scope of practice is realistically attainable, then it will be desirable, and we will be “certifiable.”
Linda Shore-Lesserson, MD