This is John Miller with Heart Rhythm Society Core Concepts in Electrophysiology and Board Review Course. I'm going to talk to you about how to succeed in the board examination process. Here are my disclosures. The ABIM exam, I know a thing or two about this. I served with the board for almost 20 years. I don't know about the collaborative pathway so well, but I know about how this process has worked over the years. The way the exam is constructed is that the immediate prior exam, the administration so-called of the exam, is reviewed and old questions that have done well on the exam. That is people who scored the highest on the examination got those questions correct. People who scored lowest missed them. That's a good question. Separates good from or able candidates from less able candidates. Those questions are accepted for subsequent use on another exam. They may be modified to update them time-wise or medication-wise, dosage-wise, things like that. Or they may be discarded, just too old. Some that were great questions that had electrograms from devices that are no longer used, they're not relevant, so they were discarded. The ideal question will be one in which about 55 to 85 percent of candidates answered correctly and has a good correlation with overall exam performance. That is the ones who got it right, did well on the exam, and that's a good question. One that's that only five percent get correct, well, that shows how smart the really, really good candidates are, but it doesn't really help differentiate because you don't want to be that exclusive. Questions have a trial in their first use. The third module or the fourth module that's given during the certification exam is not really counted on the exam. It's actually to test the questions to see if they're going to make it, if they perform well or not. So they're not counted in the score. If they perform as well, it goes into the pool for subsequent use on another examination. Each question is assigned a degree of difficulty by the team of committee members that are adjudicating this, and an absolute passing standard is calculated prior to the exam. We'll get through that process in a second here. About 65-70 percent correct is a pass on the exam overall. Very few get more than 90 percent of the questions correct. It's a little humbling. The actual passing score may be about 55 percent correct in some administrations. It's pretty humbling. Performance outlines are reviewed before the final result. So, for instance, when I was chairman of the exam committee, we'd get two, three, four questions that just didn't perform well. Some of them were questions where a lot of candidates choose A and C. We had to look back and say, what was it about A that people thought was correct and we thought C was correct? It was just a splay all over the place, and sometimes we would have to count those questions. All are correct or none are correct. It makes a difference to some individuals whether they pass exam or not, so we had to be pretty careful about that, but there was always a couple of those. The way the exam is constructed is it tries to sort of match what happens in electrophysiologist life. There is some understanding of basic science and pharmacology that has to be there. Anatomy, invasive diagnosis and therapy, catheter ablation, EP studies is a big part of what we do. Device management is also a large part. Interpreting non-invasive tests such as monitors, ECGs and so forth. Then figuring out what your patient has, syncope syndromes, WPW, inherited arrhythmia syndromes. Questions are devised with the test is made up of roughly these proportions. Some things cross boundaries such as what's the CCG suggestive of, and it's a Brugada pattern. Well, that's a clinical syndrome plus an ECG non-invasive recognition thing. These questions should test knowledge, synthesis and judgment. Judgment ones are the most valuable ones because you have to know not only what you're seeing, but you have to make a judgment and then come to a plan of action. This is a further breakdown. Initial certification is a little bit stronger on the basic concepts. Maintenance and certification now seems like we're over that and more out into the humdrum world of electrophysiologic practice. The initial exam is offered once a year in the fall certification. Recertification is in the fall and spring has been that way. I think it's that way still. Actually, I think this year they're both in the fall as I think of it. How is the pass rate set? Who passes this exam? There is not an established, you have to get so many questions correct to pass the standards are set using this so-called modified Angoff method by which is meant. A question is analyzed by all the members of the committee, the examination test committee, and each member is asked to think about a minimally competent candidate taking this examination. Maybe one of their trainees, somebody who's just going to pass, what's the likelihood they would get this question correct? And then that's put into a formula and the sum of the item ratings, which is what that ends up being, represents the passing cut score. You get that many questions correct, you pass, you get one less than that, you don't pass. This is a distribution of the passing score in one recent year of the examination. You see that the passing score was 376 out of 800 standard. That's not too good. Most people passed. This is one of my trainees here. I chided him for not being up here, but it's okay. The mean score is here. So my trainee, of whom I'm quite proud, did pretty well in this exam. This is how many people have been taking it. The first administration was in 1992. A lot of folks pent up demand, took it that year. It was only given every other year because of lack of number of questions and lack of number of candidates. And then about 99, we started getting 70 or so per year. Now it's topped out just a little over a hundred graduates each year. And the passing rate is pretty good. It was a pretty hard exam back in the day. It's gotten a lot easier. The soft guys and ladies on the exam committee, I guess, I don't know. And research has actually gotten a little bit harder just as last year. I'm researching this year. The question types, as I said, are knowledge. This is just which of the following drugs ends in OL. Sotolol would be one of those. Do you know it or do you not know it? No controversy there. Synthesis is combining bits of knowledge to come to a straightforward conclusion. This is like most tracings you would analyze. What does it show? Do you have to know what you're looking at? And it's a hysterectomy PVC that advances the judgment is making a decision based on the information provided. And the distractors, which are the choices for your exam, are supposed to be worthy of your thought and consideration. It shouldn't be just a silly thing. But because there quite often be a couple that are pretty close, but one of them is definitely the most correct. And this applies to most treatment decisions you would do. Judgment questions will hopefully be up to about 40% of the exam. The hardest ones to write well without tipping your hand and giving the answer away. There's a separate committee for the recertification module there has been in the past. Questions are circulated to select diplomats, people who passed the exam in the past for their comment. And the candidate can use resources to look up the relevant data and on the practice exam and to keep you current. This is updated annually based on literature review. And so stuff that is relatively recent will be represented on exam. It is by its nature more, this is the practice exam, an open book exam there. But when you show up on the day, it's not, you have to know what you're doing. No, no additional resources available. The overall pass rate is, I'm not sure how that is set. I was part of that committee for some time, but I've been off for so long. I don't know how it's done anymore. Recertification first time test takers don't take the same exam. There's basic sciences decreased substantially on the recertification exam. The design of an individual question is complex. There are only a limited number of arrhythmias with which we have to deal. And most of these will be covered at least in regard on any of an examination. The content of an exam is not proportional to the prevalence in the incidence of an arrhythmia. So for instance, most exams will have an atrial fascicular on it. And many electrophysiologists might not see one in their actual practice. They may only see it on the examination, but it's full of physiology and therefore has lots to offer as far as testing considerations. The questions try to be generic, especially with devices. There should not be anything shows up that is a manufacturer specific algorithm. There might be some things that minimize the amount of ventricular pacing, but it won't be, it'll be the concept. It won't be how does this particular manufacturer implement this. Controversial topics are completely off limits. There must be an agreed upon right answer. If you think about the use of adenosine in atrial flutter or atrial fibrillation, pulmonary vein isolation assessment, you know the physiology, but you can't really construct a question on what do you do with that information? Because it's just not settled science. Everybody has to agree on what the correct answer is to be able to be an appropriate question. Older questions may linger on the exam. They worked on prior administrations. Let's keep it around. It's a good question. Some get a little bit long in the tooth, especially device questions and should be discarded. Onscreen electronic calipers have worked well in the past. They find a little bit, and I haven't heard too many complaints about these in recent years. Use them. They're a tool to be accessed. Don't overthink questions. Don't try to get inside the heads of those WISNT test committee members who write the exam and say, well, what are they really after here? No, just read the question. It's asking you a specific piece of information from you and get that. All questions are multiple choice. Single best answer. There will be no true false questions. There'll also be no negative questions, such as which is the least likely or all of the following except that's just a, they try to be positive questions. You may get some funky wording about with that. A couple of parts. There's the stem, the 70 year old woman has this and that and the other thing. Then there's the question line, which is which of the following would you do next? And then the distractors are your choices, A, B, C, D, and E or however many there are. At least 50% of the questions on this exam will have figures to them. It may be ion channel recordings, intracardiac recordings, device recordings, all sorts of things. The stem, as I said, is a description of the case and will not have such words as the least likely or all of the following except. They should all be positive, usually including the something that is called face validity. A five-year-old Asian person, if that's important, for the rest of the question will be included. There won't be any run-on cases, such as the following applies to the next 15 pages of figures. Each question is independent. Some might have a couple of figures, but they won't be scattered over several pages in the vast majority of cases. Clinical questions will only about U.S. market-released drugs and devices. There might be some experimental drug questions that everybody should know. An old drug that's been used for a while, adjuvalent or something like that, that's not available in the U.S. Basic science questions can be anything, anything. It's in the literature. The figures are edited but not retouched. I had to do a fair amount of this back in the day. If the coronary sinus recordings were arranged from distal to proximal as they were delivered to us, we had to flip them because we all wanted the candidate to not have to try to get in looking at the tracing and say, what am I looking at here? You should only see his proximal distal, CS proximal distal. All the formats should be consistent, surface ECG leads on the top, maybe a blood pressure recording if it's relevant. If it's not, sometimes that's taken out just as a distraction. If the coronary sinus or tricuspid annular catheters or other catheters are present, and it's important to know where they are deployed, you will have either a figure for that or a description that the proximal recordings on the coronary sinus catheter are at the ostium, something like that. There might be a couple of tracings per question as in our workshops. It might just be one. Single tracing might be used a couple of times on an exam. If it's a really good one, probably not. Artifacts are legitimate testing points. They occur in real life. You're supposed to be an expert to be able to figure this stuff out. It's not a waste of a question to have an artifact that you have to be able to tell that's what it is. The distractors are your choices, ABCD, so on. There might be as little as three, as many as six, mostly four or five. There's one best answer. There might be another one that's pretty close and you could say, yeah, on any given day, but there will be one that really fits best. And there shouldn't be any all of the above or none of the above A and C, D, E, F only or whatever, that sort of stuff. So here's an example. 13 year old girl, Caucasian girl is brought from a local school, complaining of palpitations, blood pressure is 118 over 80. She's aware of the rapid heart rate, but has no other complaints. Her ECG is shown. Which rhythm is the most likely shown on the ECG? And I'm not going to show you the ECG, but these are the possible choices here that you'll get. And it'll be pretty obvious which one it is. There is dissociation or there isn't or whatever. When you're analyzing these questions and the distractors think about patient safety and conservative measures first, reprogramming a device, giving a medication instead of doing an invasive procedure. You may need to revise a device. You may need to do an ablation procedure, but so don't avoid that if it's truly necessary, but don't jump to it. Remember that when it asks for the most likely diagnosis, it's not all, it's not saying the only conceivably possible diagnosis, just based on what you have, this is the most likely thing. Don't, don't be too, too fine-tuned about it. When it says, what is the next thing you would do? It doesn't mean, it's not the same as saying, would you ever do this? For instance, an ablation procedure, you might need to do an ablation procedure for somebody with an atrial tag that's causing ICD discharges, but maybe that's not the first thing that you would do. What's the next thing you would do to resolve the patient's problem? Percentages are hard to test like 65% success rate or 0% heart block rate. Those are hard to test and exam. So probably won't show up on questions. Questions are rarely based on one specific trial. There might be one land trial that everybody, this is not necessary to replicate. That's not going to be very common in our discipline. There might be questions about classic or super trials, which is cast trial or the affirmed trial, things like that, but probably not. Technical problems are fair game. For instance, if you don't do lead extractions or you don't do epicanthal ablation, you still are exposed to the literature. You still need to know about potential complications of these things. What's a good candidate, what's not a good candidate, preparation for it and so forth. So those are fair game, not necessarily minute technical details of some such procedure. Exam covers material that is what we call settled law. Everybody agrees his refractory PVC during tachycardia that prolongs the next atrial cycle is indicative of participation of a pathway. It's just, it's done. No question about it. No controversy. Everybody can agree on the right answer. That means that anything that is on the exam has been through it. An initial question writing has been tested on an exam where it hasn't counted for the score is then revised, then might appear on another exam. So the information that is on that is at least two years old. So anything that you find in the literature, that's less than a couple of years old. And you think, boy, did they know about that on the exam? No, it's been a couple of years out. Rarely will be there anything about brand specific stuff. As I said, you might see something on an algorithm to decrease the amount of ventricular pacing in a device, but it won't be a manufacturer specific. You won't have to know if you don't use manufacturer A, B, or C. And so you're not familiar with their algorithm, yet it is generic enough that you should be able to tell what's going on. Look at the, what does it say? Whole tracing. Look at the whole tracing. Look at the beginning of the tracing, look at the end, look at the whole thing and make your decision. Not just focusing on one part. Oh, I see a PVC. There might be something important at the other end of the tracing. So look at the whole thing. Changes in activation sequence in the atrium, there might be changes in VA interval that you might not be able to pick up from measuring any two consecutive cycles. Look at the, at the far left, look at the far right of the image and see if you can just difference there that it will, any minute changes will be amplified over the course of the tracing. Are pacing stimuli capturing consistently? Look at the whole tracing. It says, do it. Do yourself a favor. Chronic problem areas on exams. We found over the years that ECGs, so embarrassing. Our candidates did not do well on reading ECGs. This is a no-no. You need to read, be able to read ECGs. So they will be tested. Also retrograde conduction. We just happened to notice on the exam and getting scores back that people did not understand retrograde conduction. We felt it was so important that there's a lecture in the board review course on just that. So make sure you understand that well. There are general principles for taking the exam. If you haven't started yet, I don't know when you're seeing this, but you better start soon if you're going to be taking the exam this year. Core concepts is an extremely good resource. Many of the lecturers on the core concepts and board review course were part of the exam committee. So they know a thing or two about how the exam is constructed. They have submitted questions for the, the workshops that are representative of what's on the examination. It's a very, very good resource. Take a general approach to all, a similar approach to all tracings. Remember that there are 50 questions in each of four modules. You have two hours per module that roughens out to 2.4 minutes per question. So don't get hung up on something that, Kai, I just can't figure this out. Move on. Mark it. Come back to it. Don't waste time on that. Answer every question. Even if you've got two minutes left and you've got 15 questions, just put an answer for all of them. There's nothing to lose for that. You might get them right. You might not, but positive, correctly answered questions come up to the total that gets you the passing grade. Take a general approach to the exam questions. Read all the questions carefully. All the information that you need to get the correct answer is there. Laboratory tests are included parsimoniously. They're not there just for flippantly. Device settings, programs, everything you need to get the correct answer is represented there. You need to develop a differential diagnosis as to what the tracing is that you're looking at. Read all the answers. There's one best answer. Evaluate them carefully. Look at the whole tracing. I said whole tracing. Yes. Don't focus on only one part. You might be distracted by something that is interesting, but not particularly relevant for your answer. Measure intervals with your calipers. Don't just estimate with your fingers. Use calipers. They're helpful. You won't be held to a standard of five milliseconds difference. Oh, you missed it by five milliseconds. No, it's going to be more obvious than that. Focus on zones of transition between going from sinus to an arrhythmia, from an arrhythmia back to sinus, from bundle branch block to not bundle branch block, from pacing to tachycardia, all kinds of things. Zones of transition are zones of ... Test each distractor. That's the choices of your answers. For goodness of fit, does it fit with the information I have here? Or you can work backwards and say, well, what if C is correct? Do the other things that I'm seeing on the tracing fit with that? Or is there something wrong? If there's something wrong, then it's probably not the correct answer. So here's a question. 45-year-old man presented with Y-carotid tachycardia and during EP study, the effect of an extra stimulus is shown in figure one. The best interpretation is ventricular tachycardia is present. Pre-excited avian artery entry is present. Antedromic tachycardia is present. Orthodromic tachycardia is present or no diagnosis can be made. And sometimes that is correct. You need more information. Don't make a call when it is not appropriate. Here's the tracing, but just go over it here. Here's a single extra stimulus from the hybrid atrium in a patient with a wide complex tachycardia. Why would you do that? Well, it turns out that it's important because this is antedromic tachycardia. If you look at this carefully, we have a QRS onset roughly about here. We have a HISS potential that's after the QRS onset. Well, that's not orthodromic SVT. Could be any of the other ones. Could be VT, could be pre-excited cardia, but it can't be orthodromic. And we have cycle length showing up here. We have a natural extra stimulus that advances the timing of a QRS complex. That can't happen in ventricular tachycardia. So this has to be a pre-excited tachycardia of some sort. What type? Is it pre-excited avian artery entry, pre-excited atrial tachycardia, pre-excited antedromic tachycardia. So here are our HISS and here we have our AA, our HH intervals here. We have our AA intervals and you see that the perinodal atrium, we know it's perinodal because we have a HISS potential there. Tell you know exactly where it is. So the perinodal atrium is not affected by this atrial extra stimulus. So the next V and the next HISS and the next A is brought in, but not by quite as much as the HISS is here. So this is going from atrium over an accessory pathway, a left side accessory pathway, because right bundle pattern and down to the retrograde up the HISS, retrograde up something, probably the AV node because this HA inferentially is a little bit longer than this HA here, because this interval here is 345 instead of 350. So this is probably going up the AV node, definitely going down accessory pathway. And that's why it's antedromic tachycardia. That's the one that fits the best. It doesn't exclude the possibility of a second accessory pathway as a retrograde limb, but that wasn't one of the possible choices, was it? You could say, well, we can't make a definitive diagnosis. I think we can be pretty definitive about this. Okay. Thank you for your attention. Do well on the exam.

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John Miller

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