In conversation | Dr Sandeep Hothi, TOE Lead

Dr Sandeep Hothi, Consultant Cardiologist at The Royal Wolverhampton NHS Trust, started examining over five years ago, is one of our few crossover examiners (TTE, TOE) and has completed three accreditations.

Sandeep found his way through clinical standards and exam writing and has delivered an updated TOE accreditation pack, a TOE practical assessment under COVID conditions. He is a consultant cardiologist with specialty interest in multimodality cardiac imaging (echo, cardiac MRI, CT) and is currently leading the TOE committee and working on further developments. He sat down with our Accreditation Manager, Ms Jo Vashishta got to find out a little bit more about Sandeep. 

Jo: When did it all start for you in medicine and echo?

Sandeep: When I came out of medical school, I knew I wanted to be a physician and early on, cardiology was one of my top choices. I just had excellent mentors and people I had worked with as consultants, especially when I was an SHO. I was in London for one of my jobs, my cardiology job in the Royal Brompton. I remember working with some good people there, registrars and consultants. One was Dr Derek Gibson, now long retired, and a big name in many aspects of clinical cardiology – echo, haemodynamics, cardiac physiology and adult congenital heart disease. He did it in the olden days where you had phonocardiograms and B mode echo. He showed us how you can diagnose someone with complex cardiac, congenital problems purely by physical examination and then would talk about echo afterwards. He still did some complex echo lists; I would have to go down there as an SHO and ask for complex cases. He was very accommodating, and it grew from there. When I was a registrar, again, it was key to have good mentors. So I was lucky; I met lots of people who were good at General cardiology, but echo. Some of the interventionists also told me incredibly early on, before I knew what I wanted to focus on, how important understanding cardiac structure and anatomy and function from echo is, whether you are going into interventional, EP, heart failure or devices. At first, echo looks complicated when you start, and it does not immediately make sense when you look at the images. I think the difficulty is trying to get a 3D understanding of what you are seeing on the screen. Working out why the probe is being put on the chest in certain spots, and there are all the movements people do which can be hard to notice and make sense of. Once I learnt how to do it, I enjoyed it, and when you start to enjoy something, I think it becomes fun to learn more.

Jo: So that enjoyment of learning something new paved the way to achieving a hattrick of accreditations? 

Sandeep: Yes, I enjoyed the accreditation process. The last one (Stress echo) was more interesting because I was in the early stages of being a consultant. The experience grounds you; it takes you back to your days of being a student, so that was enlightening.

Jo: I noticed that your TTE and TOE were achieved in the same year; how did you manage that?

Sandeep: So I started my training in echo purely in TTE at the beginning of my first year as a registrar; I had done a lot of that. By the end of the second year, I was ready for the accreditation process. But I did move hospital, to another unit where I was for the remainder of my training. So that little bit of pause probably just slowed me down again, somewhat, because I was in a new unit getting access to echo. With TOE, I was fortunate that I got to start quite early, So I observed TOE from the beginning. But in terms of hands-on TOE, it started towards the end of my first year as a registrar. I was competent, independently, very early in cardiology training, just because I had access to the list I had in that hospital and made every effort to attend. So they ended up growing together, and the accreditations fell really close because of that. 

Jo: What encouraged you to pursue TOE?

Sandeep: It seemed like a mysterious art at first. From seeing the TOE probe going into the gullet then, trying and working out how you can get pictures and different angles from a transducer at the end of the probe, and controlling the imaging plane from a distance seemed like a challenge to solve. The images were beautifully clear for most cardiac structures. So it became a goal to work out how do you get these pictures? How do you get them when it is a complicated case? Then how do you analyse these pictures? And then how do you draw a conclusion? Because it seems so central, you knew when you were doing a TOE that it was important to decide if, for instance, surgery is needed or if they need antibiotics. Is there is a significant problem with a valve or not? So it is an important test for the patient’s clinical pathway. I think that this central clinical importance of a TOE, combined with good teachers and constructive learning I enjoyed it highly. Putting that all together with TTE, it becomes more fulfilling for an echo practitioner. So if you start to become valuable to your department before you become a consultant, and you genuinely enjoy it, everyone benefits. That is what happened to me. It continued to get better when I became a more senior registrar, and more doors opened leading to periprocedural TOE. In that setting you realise that things are getting faster. You have to obtain images and form an opinion quickly and communicate to a surgeon or interventionist who is waiting on your opinion. That was in the earlier era of TAVI, when it was common to have TOE during the procedure. TOE during TAVI is now much less common but will be vital to the newly arriving era of percutaneous mitral and tricuspid valve intervention. It is also central to the congenital heart disease teams that I worked with for ASD closure and other congenital procedures. 

Jo: How did you find your way to the BSE?

Sandeep: First, you are very aware of BSE right from the beginning when you start to train in echo. You're aware from the sonographers from your first day following BSE guidance on day-to-day imaging and reporting. For your training, and the accreditation processes, BSE gives an excellent scaffold, a good syllabus, a good guide. As I moved through the different accreditations, I was meeting people in the organisation like yourself and the accreditation examiners, people who were extremely interested clearly in different aspects of the organisation. After that, I worked more closely with the previous TOE lead - Dr Mahesh Prabhu, he taught me a lot about TOE examining. He gave me good guidance on the existing accreditation structure. After I accredited, I examined people with the other volunteers. I then worked with the past president, the current president of the BSE, the vice president, and many other colleagues and sonographers, doctors, physiologists, and anaesthetists. 

Jo: So this is what convinced you to give up your spare time and lead TOE accreditation?

Sandeep: Yes! It was a successful mission! It is rewarding and valuable. I think all of us do it because we want to. We want to use our spare time as we enjoy it, and in parallel it makes us better practitioners and keeps us informed of developments whilst meeting the Society’s goals, which is much more about the echo community and the trainees but it is definitely a bidirectionally beneficial relationship.

Jo: I have noticed that our examiners across the accreditations have a strong sense of community. Even when assessing, they are here to support colleagues through the accreditation process. 

Sandeep: Absolutely and just improving standards on an individual basis, it might be when you are helping someone with their logbook, or when you are marking their logbook, or when you are doing practical assessments. Then at a committee or organisational level, it is more about the standard of a population or where cardiac physiology in the country is going.

Jo: Looking at where the population is going raises the topic of COVID. How have you coped over the last twelve months?

Sandeep: So now we have a very different situation compared to the earlier phases of COVID-19. At the start, and then for many more months, both on an individual clinician level and as an echo operator, it was a big shock, as it was to the whole echo community. We were all very worried; this could affect us, staff as well as patients, and then your family, relatives or friends. By virtue of the physical proximity between sonographer and patient, whether TTE, Stress or TOE - that was a significant initial concern. We are all human and shared this very real concern alongside PPE issues that I need not bring up here – save to say that the advised PPE levels were wildly discrepant and inferior to that which echo practitioners felt was appropriate. Looking back now over the year, it felt like a long time before that level of concern went away. I was fortunate enough to be involved in discussions with a much wider number of people in the BSE guidance on performing TTE, Stress or TOE in the era of COVID-19. I found that rewarding because we aimed to help everyone. I am proud that we took a position where we clearly stated that focus on safety. 

Jo: What are your plans for TOE accreditation?

Sandeep: I am fortunate to receive an already mature accreditation process. There is no doubt that it is a great setup. For the theory exam and the practical exam, I'll be looking at finding new examiners to contribute and complement the existing highly experienced examiners who have already contributed a lot of their time. There are new people who are super keen; getting them on board will be helpful.

I am keeping on new clinical developments that will feature in the theory exams in due course, for instance, percutaneous valve interventions including tricuspid and mitral intervention, as these become more established, to bring an awareness of these into the theory exam and into the syllabus. So percutaneous interventions and 3D TOE are now very common. We don't want to catch people out and make them all have to do more complex TOE, but a bit more awareness will gradually be brought in steadily in a manner reflective of changing clinical practises. These are works in process to reflect the full range of TOE without making the ability to enter and accredit harder – watch this space.

Jo: What would your advice to those who are TOE accredited for three years and are thinking of assessing?

Sandeep: I think they should express their interest and contact your team in the accreditation office or myself. The first step would be to come and observe a practical assessment. If they enjoy the process, and if they have got the time to give at least a couple of days (usually falling on weekends) in the year, that would be a starting point. It is very rewarding. We welcome new, enthusiastic people as well as people who have done TOE for years but have not examined before.

Jo: What's your advice to candidates thinking of taking the autumn written exam?

Sandeep: If you have done the least 6 to 12 months in TOE and your supervisor thinks you are ready, then I think you should go for the exam. Passing the exam is an important step to motivate you to get through the rest of the process. So I think, go for it, but make sure you have taken your colleagues' opinions in your department to make sure that they think you’re ready and that the timing is right. For any candidates who felt that their training might have been slow down during COVID, it is a great time to get back into the system, whichever modality it is, and then open the window for the case collection. 

If you…

...woke up as Jimi Hendrix? I would be the greatest guitarist on the planet and would never go back to sleep again.

...had the power to change the world? I would go back to the Jurassic days and start over. 

...were not involved in medicine? I would have studied maths or physics.

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

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