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.