Saturday, November 09, 2013

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?



  1. 3. A healthy 28 year old male with no significant PMHx, comes to the ED with salvos of symptomatic tachycardia. One of the salvos was witnessed. It is a LBBB tachycardia at 180 bpm, that started with a PAC. The tachycardia easily terminated with a 6mg bolus of adenosine. Bedside echo revealed normal LV systolic function and no significant valvular pathology. There is no famhx of SCD or inherited arrhythmias. Baseline ecg is normal. The MOST LIKELY diagnosis is:

    a. ARVD VT
    b. Fascicular VT
    c. Mahaim related tachycardia
    d. AVNRT

    The answer is avnrt. yes its LBBB, but an AVNRT with LBBB aberration is still a GAZILLION TIMES MORE COMMON than a freaking Mahaim...which most of us will NEVER see in practice.

    fair? reasonable? or just a bit jaded?

  2. 4. The next morning after implanting a PPM it is discovered that the A and V leads were installed in the wrong ports of the can. In explaining the situation to the patient and family, you should?

    a. Shrug your shoulders and say, "what difference does it make?"

    b. Blame the Youtube video that you watched the night before showing how to place PPMs

    c. Blame the device manufacturer for not making the system FOOL proof.

    d. Use this failure as evidence during the trial to sue your training program

    e. Tell the hospital CEO that you will do any or all of the above unless you are promoted.

  3. This is exactly what needs to happen! And there are many physicians in the country who feel the same way. Check out

  4. And be wary..ABIM is looking for people to post questions so they can say you cheated. BE VERY CAREFUL!

  5. Check out this as well:

  6. Wes: Why make a "better" bad idea. MOC is not board Certification, which was conceived as a lifelong status awarded to those who "attained consultant status" as is printed on my 1989 original certificate. MOC is a subscription program designed to "capture" all physicians into a CME monopoly for the ABMS and affiliates. This is a $2.5 billion industry whereas ABMS is "only" a $350 million industry in 2011 (last IRS documents available). Nothing wrong with lifelong certification and lifelong learning, I have the problem iwth extortion of all physicians by a handful of "colleagues" who rarely practice medicine at the bedside but hope to expand their industry profits at great cost to all physicians and patients, when healthcare must get cheaper, not MORE expensive. Drop me a line @ and visit for more discussion or information!