In conversation | Dr Anita MacNab, Stress Echo Lead

The British Society of Echocardiography (BSE) launched the world’s first accreditation programme in stress echocardiography in 2016, meeting the needs of echocardiographers both nationally and internationally.

Dr Anita MacNab, Consultant Cardiologist at Manchester University NHS Foundation Trust was instrumental in setting up the accreditation process and continues to serve as the BSE National Lead for Stress Echocardiography. She sat down with our Accreditation Manager, Ms Jo Thanjal, for something a little different than their usual conversation of candidate figures, exam content and practical assessments.

Jo: Tell us how you got into echo?

Anita: I have been doing echos since the mid-1990s. I was introduced to TTEs by a senior registrar when I was an SH,O but I learnt my skills from our wonderful sonographers. It was a combination of being in the right place at the right time and learning from the experts! I learned TOE from Simon Ray and stress echo from Jane Hancock. Not many people were doing them to their high standards so I was extremely lucky to have them as my supervisors. Lots of inspiring people have helped along the way, and I have been an echo consultant for 17 years now. As a registrar, I only learnt the basics; as a consultant, you fine-tune your skills.

Jo: How has echo changed over the last 17 years?

Anita: There have been many changes in echo. As a consultant, I have had to learn interventional TOE, which you can't learn from books. It is a modality that takes a lot of practice. Especially in the last ten years, I have been going into the cath lab and guiding challenging intervention procedures such as mitraclips. We could always do pre-procedural planning with echo but intra-procedural planning is another level. Another big change in my practice is integrating echo with other modalities such as CT and MRI. Multi-modality imaging is an important cog in a bigger diagnostic wheel. Registrars now can learn CT and MRI but their basics are still grounded in echo. Those like myself who did their training before those modalities were around, have had to learn to integrate with them to help us understand things better - it has been an amazing movement to be a part of. The humble transthoracic echo will remain the bread and butter of cardiac diagnostics but interventional echo and multi-modality imaging (CT and cardiac MRI) working together will drive the next ten years. 

Jo: How did stress echo accreditation come about?

Anita: During a BSE meeting, Dr Rick Steeds, Past President came up to me and said, "You do a lot of stress echos… Congratulations on being elected to council, now I have a job for you - your task is to develop a stress echo exam." So I took on the challenge! It was very important because stress echo is such a subjective modality; It's an eye-balling modality and you can’t measure much. Many people can spot normal and very abnormal stress images, but the parts in the middle are hard to spot. So the accreditation process was an opportunity to get some experts together and set some acceptable thresholds of competency for the modality. The problem was that there was no blueprint as it was never done before in the world. I remember those early meetings with experts like Reinette Hampson, Benoy Shah, Roxy Senior and others to work on how to translate our knowledge base into an accreditation process. But we had to start somewhere and take a leap of faith. Although it would never be as big as TTE/TOE, it was important to pitch the exam as well as we could. Everybody who has gone through this process have reported that they have learnt a lot, so it has been worthwhile - although a bit scary at times.

Jo: How did you go about setting up the accreditation?

Anita: The theory test was relatively easy to figure out. Jane Lynch (who was Chair of Accreditation at the time) helped a lot with the setup; even though she was not from a stress echo background, her knowledge of the other accreditations was vital. For the practical exam, Station 2 was the one that needed the most careful thought. Stress echo can be dobutamine but that clearly was not an option for the exam. We could not give a volunteer drugs - not even pretend drugs! We obviously had to choose exercise as the stressor; this could be replicated in a real-life volunteer and developing this station was fun. 

Jo: Did you get any criticism when setting up the accreditation?

Anita: We came into some criticism from some stress echo gurus in the UK, who felt that the accreditation didn't go far enough. They were worried that the accreditation could give somebody an inflated badge of expertise. Our counterargument was that accreditation measures competency and safety, not expertise. This is a level 2 accreditation, not level 3. It is not designed for experts leading high volume departments. This is a badge that can be earned by sonographers, senior registrars, and new consultants to show that they are competent and safe in performing these procedures. If I sat in a room with a group of experts, we would disagree on probably about 10% of the cases. That is the nature of the beast; it's a very subjective modality. However, hopefully, we would have a consensus decision on the severity of the problem rather than the minutiae of the problem. Who is an expert? An expert is someone who gets it right most of the time, has a track record of high volumes with good audit trails and outcomes. Level 2 accreditation doesn't make you an expert; your expertise comes after you have gained the initial competencies. Expertise comes with experience.

Jo: Do you have any advice for candidates pursuing stress echo accreditation?

Anita: If you are not doing stress regularly, it is not the right time for you to do the exam. You can pass the theory exam from a book. In general, the practical exam will expose you if you are not well practiced in the modality. I have to reiterate though that this exam is not there to catch you out; it's not there for the minutiae. If you are at a point where you can manage the room without direct supervision, then you are ready for the exam. It's a pragmatic exam; you have to be doing enough to get through, but you do not need to be an expert.

Jo: How has the BSE helped you with your career? What have been the benefits?

Anita: Joining the BSE council has given me a purpose; I hit the road running. The task of setting up stress accreditation helped me focus and feel useful. When you are doing work for the BSE, you become a part of a family. You make friends who have the same priority of pushing the agenda for quality and improving things for the echo community. The BSE opened my eyes to what was happening beyond my department, which in turn helped open my eyes and improve my department. 

Jo: During this unpredictable time, have you discovered anything new about yourself?

Anita: I thought I was a reasonable person who can look at things with a broader lens, good at making choices. But when the pandemic broke out, I couldn't believe how frightened I was… The scientist jumped out of my brain for a while, and the human took charge. I am ashamed to say that I was scared to go out to the wards and worried for my family. The fear went fairly rapidly when I got COVID at the end of March 2020. The pandemic has made me appreciate the team around me a lot more. Our sonographers have worked so hard in the department, those who don't get a mention - those who are going out facing COVID patients every day. They must have been terrified as well. As department leads we can become so focused on what the service needs it is easy to forget how everyone stepped up to make a difference. In our echo department the junior sonographers in particular were the real heroes during the pandemic.

If you were….
  • If you were the Minister for Health, you would… think more carefully about joining left and right hands of the health and social services. We have lost the links between hospital care and community care. This gap needs bridging again.
  • If you were to create a doctors uniform, you would… have everyone in scrubs… The pandemic has renewed my love of scrubs. I no longer have to choose what to wear every morning!
  • If you were not a doctor, you would… be in performing arts… Drama queen!

Thanks to Anita and Jo for this insightful discussion into stress echo accreditation. For more profiles, check out Behind the scenes in our ECHO archives.

ECHO archives