Maintenance of Certification in Cardiac Electrophysiology: Taking the Stick

Shuzan, a Buddhist monk of the tenth century, once held up a bamboo stick before his disciples. "Call this a stick," he bellowed, "and you assert; call this not a stick, and you negate. Now, do not assert or negate, what would you call this stick? Speak! Speak!"

From out the ranks, a young monk ventured forth, grabbed the bamboo, and, breaking it in two, exclaimed to Shuzan, "What is this?"*

After coughing up thousands of dollars and enduring months of test preparation for the third time to “maintain” my designation as “board certified” in my specialty according to a group I do not know called the American Board of Internal Medicine (ABIM), I have decided to do as the young monk has done in the passage above and take the stick. We need a different paradigm.  

So why not create our own, free and publicly vetted "certification?"  As part of this effort, I will ask for help from my physician colleagues who frequent this blog: please serve as test content providers.

While this will be a work in progress, there are a few rules (we must have rules, you see, to maintain legitimacy).  The rules for this high calling include the following:

1)      This certification process must, and always should be, free.  It is for doctors, by doctors.

2)      The development of this test and its scoring will be transparent.

3)      The content of questions created will always be relevant to clinical practice and apply to disease processes that occur with a prevalence of greater than one in a million of the population (no zebras allowed).

4)      Content created here can be re-used, reprocessed, and pureed without restriction and without cost, anywhere worldwide.  Any attempt to sell content created herein for purposes other than the support of patient care will be disclosed. (Enticements like "free" iPad Airs are particularly discouraged, especially when the content for a weekend course is sold for $1695.)

No conflicts of interest, period.

Here are my first two example questions so others get the point (I encourage others to add their own questions in the comments):

1. You are about to begin a permanent pacemaker implant on an 85 year old woman with a serum creatinine level of 3.2 who presented with complete heart block and a wide complex escape rhythm of 35 to your emergency room.  Her vital signs are otherwise stable.  You know you don't receive payment for placement of a temporary pacemaker wire before the permanent pacemaker is implanted.  Your patient is right-handed, so an IV is started in her left arm in anticipation of an ipsilateral pacemaker implant.  She receives appropriate skin prep (another question in this, perhaps?) and prophylactic antibiotics (maybe another on this?) before her procedure.  The next best approach before proceeding would be:

A.) Place a temporary pacing wire via the right femoral venous approach before proceeding anyway.
B) Use vascular ultrasound to carefully identify the precise location of the axillary vein before attempting a blind stick based on classic subclavian access techniques.
C) Withdraw the stylette approximately 2 cm before advancing the RV lead in the patient's ventricle to minimize the chance of ventricular perforation.
4) B and C above.
5) A, B, and C above.

2.  The new "pacemaker in situ" ICD-10 code to minimize patient hassles receiving payment for your services is:

A) 996.01
B) V43.3
C) Z95.0
D) 996.04

There, Questions 1 and 2 for our OWN new certification process are in.

Now, who's got some more?

-Wes