doi: 10.1097/ALN.0000000000000311

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Kumar, Priya A. M.D.; Bortsov, Andrey V. M.D., Ph.D.; Arora, Harendra M.D.

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We would like to thank Drs. Fletcher and Sharma for their interest in our study.1 We are aware of their study that was published in June 2013 to assess the benefits of transesophageal echocardiography (TEE) simulation training in cognitive skill acquisition among anesthesiology residents in the United Kingdom.2 However, in April 2013, at the time of the initial submission of our article, the above study was not available. We apologize for the omission.
Image acquisition is indeed a technical skill that evolves on a continuum starting with knowledge in basic physics, probe manipulation, and anatomic/spatial orientation. This progresses on to supervised hands-on training on actual patients. Advanced levels of expertise are then achieved by on the job experience, which may not reach a plateau for years. Undoubtedly, there is no substitute for an actual patient and only parts of the skill sets can be taught in a classroom. However, different methods of classroom teaching may affect the acquisition of technical skills. To maximize image acquisition skills in the privileged operating room environment, it becomes necessary to prepare the trainees by relying on didactic and Web-based training using anatomic heart models and video clips, similar to what was used in our control group. A majority of training programs do not have access to mannequin-based TEE simulation. Our goal was to compare this current reality, the traditional method of teaching, with mannequin-based teaching on practical image acquisition skills.
We also appreciate the critique of our image scoring system. We agree that in the current literature, there are no validated scoring systems to assess image quality. There has been only one other study published simultaneously with ours to evaluate clinical TEE imaging skills with simulation training.3 Because ours is among the first attempts to grade the quality of TEE images, we agree that further refinement and validation of the scoring system is needed. We, however, disagree with Drs. Fletcher and Sharma that no validity of the scoring system was demonstrated. In our study, the experts blinded from the identity of the study subjects graded the imaging angle, overall clarity, and visibility of clinically important anatomical structures. Therefore, we strongly believe that the scoring system has intrinsic face and content validity. In addition, in our study, the images obtained by the attending anesthesiologists received significantly higher scores than images obtained by residents, and images obtained by residents with prior TEE experience received significantly higher scores than images obtained by residents without such experience, demonstrating the construct validity of our scoring system. We therefore strongly believe that in the absence of a definitive standard, our effort to objectively measure TEE image quality was successful.
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Competing Interests

The authors declare no competing interests.
Priya A. Kumar, M.D., Andrey V. Bortsov, M.D., Ph.D., Harendra Arora, M.D.
The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (P.A.K.).
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1. Ferrero NA, Bortsov AV, Arora H, Martinelli SM, Kolarczyk LM, Teeter EC, Zvara DA, Kumar PA. Simulator training enhances resident performance in transesophageal echocardiography. ANESTHESIOLOGY. 2014;120:149–59

2. Sharma V, Chamos C, Valencia O, Meineri M, Fletcher SN. The impact of internet and simulation-based training on transoesophageal echocardiography learning in anaesthetic trainees: A prospective randomised study. Anaesthesia. 2013;68:621–7

3. Damp J, Anthony R, Davidson MA, Mendes L. Effects of transesophageal echocardiography simulator training on learning and performance in cardiovascular medicine fellows. J Am Soc Echocardiogr. 2013;26:1450–1456.e2

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