Taking the IBHRE Exam: Interview with Charles Love, MD, IBHRE President

When was the original International Board of Heart Rhythm Examiners (IBHRE) exam created? For what purpose? The original exam, which was previously called the NASPExAM, was first delivered in 1986. At the time NASPExAM was born, there was no way to assess the competency of physicians and associated professionals in the rapidly growing area of pacing (ICDs were just being placed experimentally at that time).  There was no board certification for electrophysiology at that time, either. In addition, the usual pathways towards board certification would not work for pacing, in that people from many specialties were (and are) involved with devices. In the early and mid 1980s, this included Cardiac Surgeons, General Surgeons, and a few adult Cardiologists and pediatric Cardiologists. Thus, a single subspecialty exam would not work. This was the reason that NASPExAM was born. The exam has been highly successful, and is now considered the standard when considering the competency of people in our field. When did you become involved with the IBHRE board? When did you become President? I became involved in the writing committee for the NASPExAM about a decade ago, and became a board member about three years ago. About a year and a half ago, IBHRE's second president (the first president being Seymour Furman, MD), David Steinhouse, left his cardiology practice and went to work as one of the medical directors at Medtronic. Because of the fact that he went to work for industry, he felt he had to relinquish his position on the board; as a result, he asked me if I would be interested in serving as President. I said yes, and was later approved by the Heart Rhythm Society (HRS) board. I have been serving as President for about a year and a half now. Explain the differences between the two AP exams (i.e., the Examination of Special Competency in Cardiac Electrophysiology for the Associated Professional and the Examination of Special Competency in Cardiac Pacing and Cardioversion Defibrillation for the Associated Professional). Who should take either exam? Let me first mention the third exam available, which is the Examination of Special Competency in Cardiac Pacing and Cardioversion Defibrillation for the Physician. The associated professional examination for competency in pacing and defibrillation is very similar to the MD exam, except there are a few questions that appear on the MD exam that do not appear on the associated professional exam; this has to deal with issues that were felt by the writing committee to be more appropriate for physicians only. Therefore, this AP examination is really geared towards someone who has spent a lot of time with devices, predominantly in a follow-up setting, but also in an implant setting. In addition, a lot of the questions have to do with troubleshooting, identification of electrograms, and malfunctions of the devices, etc. Thus, there is a strong emphasis on troubleshooting and on basic function of pacemakers and defibrillators. The other examination, which is the examination for competency in cardiac electrophysiology for associated professionals, is geared towards the technologists or nurses in the EP lab who spend their time working with arrhythmias, ablation, and electrophysiologic studies. It's a very different examination from the one delivered for competency in pacing and defibrillation. Approximately how many people will take these exams this May? This May, I believe we have close to 1,000 associated professionals taking the pacing examination. I'm not 100 percent sure how many people are taking the other exam, but I'd say approximately 100 or so people will be taking the EP examination. How long does the exam take? In addition, I hear that computer-based testing will become available next year. Can you tell us more about this? The exam is 4 and a half hours long. Currently we are delivering these as paper-based examinations; however, this will be the last year they will be delivered in a paper-based format. Starting in 2008 we will be using a company called Prometric, which has testing centers throughout the United States and the world, and all of our examinations will be delivered through computer-based testing. Therefore, on a given day when the exam is delivered, anyone wanting to take the exam can go to their local Prometric center and take the examination, thereby not having to travel and incur all of the expenses associated with going to another city or state to take the exam. In fact, this is one of the things I have been pushing very hard for as President. Computer-based testing will make it more available to everyone, not just to people in the United States, but around the world. In addition, as you know we've changed our name from the North American Society of Pacing and Electrophysiology examination (NASPExAM) to the International Board of Heart Rhythm Examiners (IBHRE). IBHRE is a subsidiary of the Heart Rhythm Society, but we maintain an arms-length relationship with HRS, because you can't have both the exam and the society that does all of the education as part of the same entity, for a number of legal reasons. What is considered a passing score? How long after the test do people find out their score? They usually find out within 60 - 90 days whether they've passed or not. Generally, the passing score for the AP exams is about 61 - 62 percent; I'm sure that sounds kind of low to you, but we score this way for several reasons. First, we have many different types of people taking the exam engineers from pacemaker companies, nurses, technicians these are people who have very different training backgrounds, and some may have great strengths in certain areas. For example, an engineer may have better knowledge in the basic functioning and electronics of the device, whereas the nurse may have a much better command of practical troubleshooting and patient management issues. Because of that, we don't expect everyone to know everything, but we do expect them to have a very good core knowledge, and that is reflected by the passing score that has been chosen. What are the best ways one can study for the exam? What are some of the basic topics generally covered in the exams? For a list of the topics that are covered, you can go to our Web site (www.ibhre.org) to get an extensive listing. Topics range from basic electronic function (of the devices, the batteries, the timing cycles, and the circuitry) to basic electrical concepts. They also include surgical issues that occur during implantation of a device, as well as follow-up and troubleshooting of devices. This particular area has become extremely important, especially with defibrillators, in terms of understanding different kinds of heart rhythms that would cause a defibrillator to discharge or detect an appropriate or inappropriate arrhythmia. One of the best ways to study for the examination is to look into the industry-sponsored and/or HRS-sponsored courses that are available. There are also a number of excellent textbooks to study from as well; I suggest reading the newest edition of Cardiac Pacing, Defibrillation, and Resynchronization Therapy. How has the exam changed over the last ten years? In addition, describe the new recertification rule that requires testing every 10 years. Who does this apply to? I believe everyone can see that our field has advanced incredibly in the last decade. Things that were not even thought of ten years ago are now commonplace. For example, we weren't even working with resynchronization therapy ten years ago, and now that includes more than a third of all devices we are putting in. It is the same thing with defibrillators ten years ago they were being used mostly for secondary prevention. They were much simpler back then in terms of algorithms that were available, but now all the primary prevention cases that we are handling have incredibly complex algorithms that include not just ventricular arrhythmia termination and detection but also atrial arrhythmia termination and detection. Therefore, we are part of a field that is moving very rapidly; as a result, it was felt that the examination needed to have a provision added that required that after a certain period of time, people would have to retake the exam. Technology has advanced so much that being competent in EP ten years ago does not mean you are still up-to-date today. We want to make sure that the exam keeps up with technology, and evolves to include all crucial content and topics. Another thing that I would like for your readers to know is that I have been working with the Heart Rhythm Society board on the concept of developing a career pathway for our associated professionals. In the past if you passed one of our examinations, you got the Testamur title, and those of us in the profession knew what that meant and were very proud of the fact that we had passed this examination (it's not an easy exam!); people who pass it garner a significant amount of respect for taking the examination. However, even though you may have passed it, your hospital or employer may not have recognized you in any monetary way or with a new job title. Therefore, what we are working on is to develop a tiered career pathway in which people take an initial EP examination (administered by Cardiac Credentialing International) to obtain a registry level credential, or a Registered Cardiac Electrophysiology Specialist (RCES). From there, they would take the IBHRE examination for electrophysiology to become a Certified Electrophysiology Specialist (CEPS). At that time, they would have both a registry level and a certification level, and as these staff members progress, the hospitals could recognize them as having developed a significant amount of expertise and thus create job classifications that are in line with their degree of expertise. The same thing would be true for the pacing exam; we would transition from the Testamur title to a Certified Cardiac Device Specialist (CCDS). Therefore, nurses and technologists who are involved in devices will carry this certification and be recognized by hospitals and employers as being at a higher level of expertise a level that we're hoping will be recognized by higher pay and a better title. Do you think the IBHRE should be required for everyone? It doesn't need to be required, but I will tell you this: when I refer a patient out-of-city or out-of-state to another pacemaker center, one of the things I'll look for is whether someone has taken this examination and passed it. That tells me two things: 1) this person has a real interest in device therapy this is not just a hobby for them, it is their passion; and 2) they have achieved a level of competency in regards to device therapy that is demonstrated by the fact that they passed this examination. It is very important when I refer patients elsewhere that I see that this person has taken and passed the exam. Do you think the exam will be required in the future? That is difficult to say. I think that as the career pathways become recognized and accepted through the work being done by HRS and IBHRE, it will become the standard. I think in the future people will be expected to have the certification, very much like how board certification for physicians is expected now in most places. I have heard that some people don't want to take the exam because of the costs associated with it. What would you tell these people to convince them otherwise? The cost is certainly an issue for many people, and although the cost is necessary, it is also very conservative, considering that none of the members of the writing committee or the board are paid for anything they do we all do this as volunteers. There are professionals that we have hired to handle the day-to-day administrative issues of the exam itself, but all of the people who work on the exam do it because we have a passion for it. Right now there is no financial upside for taking the examination, but we are working very hard to make changes so that in the future we will be able to offer people a certification credential that will translate into higher pay for them that is where we are going and what we are really pushing for. So yes, today you won't see a change in your salary, but you will see a change in the way people see you, because people do recognize those of us who have taken the examination and passed it as being a cut above the rest. They are recognized as knowing a lot about what they do, and prove it by taking and passing the examination.