Novice to Competence to Understanding Our Role as POCUS Educators

Nights at the VA medical ICU could get lonely sometimes. When the hubbub of the day had drawn down and the critical care fellows had gone home, the work in the ICUs slowed.Headshot_kevin piro

I figured that I would make use of the time that had seemingly stopped. I grabbed the ultrasound and went to scan and chat with a friendly gentleman whom I had admitted the previous night. It became readily apparent that I was still a struggling learner at this point in my training. There was something that looked like cardiac motion, but not resembling anything like the diagrams and videos I had looked at on my own. It was an uncomfortable place to be.

I imagine that is where a lot of people get frustrated and stop, especially when they don’t have someone to encourage and nurture their continued practice. I had a different luxury. Just a few weeks prior, I had received an inquiry about participating in a new general medicine POCUS fellowship at Oregon Health & Science University, and I was instantly sold on its potential. Here was a chance to carve out a new path and to invest in a skill that offered me a skillset that could improve my patient care. And I knew that I would have the benefit of POCUS experts literally holding my hand as I learned the skill. What a luxury!

So, I kept scanning in the ICU prior to my fellowship. You know what I found? Patients are much more forgiving than we might imagine them to be. Most understand that hospitals are frequently places of learning and like to be engaged in the process and, as I stumbled through my next few exams, I was reminded of my Dad’s words of encouragement, “the only difference between you and an expert is that they have done it once or twice.” So I kept at it. I was terrible the next times too. But, it got easier and I felt less intimated with each scan I performed. By the time I hit fellowship, I was already moving in the right direction.

When I started my POCUS fellowship, I was fortunate to work with all sorts of supportive colleagues that allowed me to continue to grow. Where I had struggled to build a foundation on my own, colleagues collected from internists, sonographers, and EM physicians provided me with the scaffolding. They provided me with lessons. “Remember, air is the enemy of ultrasound” and “ultrasound does not give you permission to turn your brain off. It is a problem-solving tool.” They entertained clinical application questions. They gave back when I leaned in. These colleagues were an amazing support network and would help me construct the mosaic that I teach from now.

A few months into the fellowship, I could complete a competent exam comfortably. It came together one day for me when I completed a Cardiovascular Limited Ultrasound Exam (CLUE) on a pleasantly demented older man, who had shortness of breath likely representing heart failure. As I looked at his lungs, taking stock of the bilateral B-lines and pleural effusions that confirmed his diagnosis, I discussed and showed the findings with his daughter.

“This makes so much sense now!” she remarked. The lightbulb went on for her as I democratized her father’s clinical information. The lightbulb came on for me too as I had a sense of satisfaction of both feeling confident in my diagnosis, but also being better able to teach and engage a family in their medical care. My transformation from novice to competency was mostly complete.

Now, a little more than 2 years removed from my fellowship, I have a little more perspective on the road from novice to competency, not only from my personal experience but also from my opportunity to network with an amazing group of enthusiastic (IM) POCUS educators.

These educators are largely trained by their own curiosity, their attendance at POCUS CME courses, or by latching onto experts from peripheral medical departments. In essence, these educators are pulling themselves up by their own bootstraps in a time when there is a distinct scarcity of POCUS educators within Internal Medicine, which can leave the supposed “all-knowledgeable” physician in an uncomfortable place of vulnerability. They have shared the angst that POCUS is a particularly challenging skill to learn due to its humbling nature – we may not know how badly we were hearing murmurs as medical students, but I bet most learners can guess by looking at a picture how poorly they are doing when they are scanning. It was a feeling I shared back in the ICU as a resident, but our experiences diverged when I had mentors who invested in me learning this valuable skill.

But, these physicians who learned POCUS independently are now at the next, even harder, part. As new leaders, we must reach behind us and pull up the trainees, whether that be by creating the next POCUS fellowship, starting or improving a residency POCUS program, or simply training your fellow colleague. We are tasked with making new learners feel supported and encouraged, and to make this technology accessible in fields where POCUS is not the standard of care. We need to foster these learners’ growth so that they can arrive at their own lightbulb moment and so they keep scanning on the ICUs in the effort to improve the care they deliver.

 

What was your defining moment in your decision to go into ultrasound? Have you had a unique learning experience? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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Kevin M. Piro, MD, participated in and helped build a point-of-care ultrasound fellowship at Oregon Health & Science University (OHSU), becoming only the second general medicine-focused ultrasound fellowship in the nation. Dr Piro is now a hospitalist at OHSU.

Who Owns POCUS?

The debate over point-of-care ultrasound (POCUS) governance was rekindled recently when the Canadian Association of Radiologists published a POCUS position statement. The statement rankled some prominent POCUS leaders who hotly debated the statement’s merit via Twitter. This is a debate certainly worth having, but it is hardly a new one. Some likened it to the “turf battles” that emergency physicians successfully overcame well over a decade ago. To be clear, there is a governance problem, largely the result of technology/machine availability outpacing the development of POCUS training, credentialing, and employment guidelines and standards. Referring to the POCUS realm as the “wild, wild west” as Zwank and colleagues did, is somewhat apropos. But to develop the best solutions, we must first define the problem.empty conference room

The problem – “who”…or “how”? The statement seems to frame the problem around who is best qualified to govern POCUS. Most would agree that radiologists are imaging experts with the most training in interpreting ultrasound. But if using Bahner’s popular I-AIM framework, the image interpretation that most radiologists practice is only one aspect of POCUS. POCUS is a separate entity from consultative ultrasound. Clinician-performed at the point of care, POCUS has different goals, primary of which is to answer focused questions that guide and expedite proper definitive care. Its versatility allows it to be employed well outside of the domain of traditional diagnostic ultrasound, enhancing the safety of bedside procedures, improving the physical exam, and directing further testing & timely care. But when did you last see a radiologist at the bedside of a patient outside of the interventional radiology (IR) suite…one willing to personally “clinically correlate” the image findings rather than just include the phrase in their report?

Rhetorical questions aside, if we lived in a perfect and resource-rich world, we might all be able to dedicate a full year to the performance of ultrasound, or even better, radiologists would come to the bedside to perform the exam within minutes of the order. But we don’t. Fortunately, there’s already quite a bit of data suggesting that the requisite training for non-radiologists to safely employ POCUS isn’t as extensive as some might have us think. Additionally, the American Medical Association’s resolution (AMA HR. 802) long ago recommended that training and education standards for the employment of ultrasound be developed by each physician’s respective specialty society, effectively recognizing the importance of self-governance of this modality. I would argue that the problem, therefore, centers less around the “who” and more around the “how” of governance.

Practical solutions – Interprofessional collaboration is key: The desire to ensure patient safety is the common ground here. We all want to ensure POCUS is safely employed, but how do we best do so? Training and utilization standards can ensure this, but overly restrictive standards can create unnecessary barriers that limit POCUS employment and prevent patients from reaping the demonstrated benefits of POCUS. The radiology specialty undoubtedly has a wealth of valuable expertise to contribute to this debate. Their well-established and validated training and imaging standards could well-serve as a framework upon which POCUS standards could be built and certainly makes them deserving of a seat at the table. But given how and where POCUS is employed, surely the clinicians doing so deserve a seat also. To suggest that “non-imagers” are incapable of developing rigorous, evidence-based training and utilization standards that allow for the safe employment of POCUS simply isn’t fair, nor is it well-substantiated, if we’re using emergency physicians as an example.

Furthermore, unilaterally developed statements such as this are what drive us to remain in our respective silos and can hinder the progress still required in this realm. The solution is a collaborative one, considerate and respectful of the diagnostic ultrasound knowledge and experience of imaging experts, the setting in which POCUS is employed, and the variety of ways clinicians can capably employ it to enhance patient care at the bedside. This collaborative concept isn’t mine, nor is it new, thankfully (more thoughtful discourse on the topic can be found here and here). It’s time that we recognize and leverage the talent that each discipline can offer toward the safe, effective employment of POCUS. It’s time to embrace interdisciplinary and interprofessional collaboration.

The inherent value of POCUS lies in its ability to transcend clinical specialties, settings, and practice scopes. It is distinctly different from consultative ultrasound and therefore shouldn’t be bound by standards created long before POCUS existed. It is a valuable, patient-centered adjunct that demands new standards that are 1) considerate of both its versatility and the multitude of settings in which it can be employed, 2) considerate of the experience of those who have previously employed US, and 3) created by all those actively employing it to enhance the care they directly provide at the bedside. But rest assured, ultrasound no longer belongs only to radiologists, or any one specialty/profession for that matter, and that’s a good thing.

 

Have you integrated a collaboratively developed approach to POCUS training and/or utilization?  Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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Jonathan Monti, DSc, PA-C, RDMS, is an Associate Professor of the US Army / Baylor EMPA Residency Program at Madigan Army Medical Center and President of the Society of Point-of-Care Ultrasound (SPOCUS). He is actively engaged in research that assesses POCUS training and its unconventional employment by a myriad of users.

The Place of POCUS in Prevention of Physician Burnout

Doctors’ jobs, in the hospital or clinic, have been getting more demanding and less rewarding in the last several years. Well-meaning changes including the rise of electronic medical records and attempts to improve how we do our jobs through quality measures have made us sad and tired and supply none of the joy that we can get from a satisfied patient or a diagnostic puzzle cleverly solved. We may find ourselves aging, with multiplying frown lines and receding hairlines, sitting at our computers finishing our documentation, while our families have vacations and parties without us. Although we make enough money, strangely, it doesn’t buy happiness.

When we are tired and sad; we lack the creativity to make job changes. Fear eclipses courage.

IMG_9919Sometimes we do stupid things involving alcohol or indiscretions, or buying something expensive on credit… family members give us “that look.”

We feel inadequate.

We get grumpy and stop doing that extra little bit to connect with the patient or unravel the mysterious illness. The precious little job satisfactions of working well with our team or taking our patients’ point of view become rarer.

We are burning out. There’s that telltale smell of smoke as our soul shrivels and our dreams fry.

What do we need? Probably a vacation, maybe even a stint working in global medicine, to change our perspective. Counseling and confiding in friends can help. If we keep doing the same job, perhaps we need a scribe to take care of the paperwork. Also learning a new skill could make us wake up and love medicine again. Enter point-of-care ultrasound.

I don’t want to trivialize the pain of burnout. It can be devastating, making us depressed, ending marriages, wrecking careers and friendship, collapsing us inward, and sometimes leading to suicide. Somehow we need to jump off of that horrific course and better sooner than later. I got close to burning out early in my career and ever since that time I’ve done everything I can to stay in love with my job. For me, learning to do point-of-care ultrasound enriched my practice and, along with a major career adjustment, kept me from getting all charred and crispy.

Doing point-of-care ultrasound, for a physician who is already skilled in practice but has no ultrasound experience, can be life-altering. As I matured in my practice, some of my physical exam skills improved but others atrophied for lack of use and because I knew that I couldn’t trust them. A fluid wave doesn’t predict ascites. Dullness in the base of the lung doesn’t lead me to suspect a pleural effusion. Splenomegaly, if not massive, is so hard to detect in my super-adequately nourished patients. Learning basic point-of-care ultrasound brought me back to paying good attention to my patients’ bodies. And they were fascinated and appreciated the extra care. I also was able to more quickly solve their medical mysteries and shorten previously prolonged evaluations. Seeing patients got more fun.

Burnout is an awful feeling and is preventable. It happens when we get ourselves into situations that are not sustainable and don’t feed our souls. We physicians have vast options and we need to recognize when we are trying to do a job that is wrong for us. And before we quit the profession entirely, we need to try learning something that makes it fun again. Point-of-care ultrasound, for instance.

 

How do you avoid burnout? Do you have your own experience to share? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Janice Boughton MD, FACP, RDMS, is an internist  Moscow, Idaho. She practices hospital medicine and rural primary care as well as teaching point of care ultrasound techniques in the US and Africa. She also writes about healthcare economics in her blog (www.whyisamericanhealthcaresoexpensive.blogspot.com.)

Dr. Boughton graduated from the Johns Hopkins School of Medicine in 1986 and completed residency training at the Johns Hopkins Hospital and the University of Washington. She started doing bedside ultrasound in 2011.

POCUS in Pediatrics

Do you work in a children’s hospital? Do you perform POCUS? Do you ever wonder if other divisions in your hospital are using POCUS as well?

Point-of-care ultrasound (POCUS) is growing quickly across all medical specialties, including pediatrics. Within pediatrics, POCUS is being utilized in the emergency department, intensive care unit, operating room, clinic as well as on the inpatient floor. While the scope of practice may differ across sub-specialties, the issues pertaining to education, training, credentialing, equipment procurement, and workflow solutions are universal.A Abo

At Children’s National Medical Center (CNMC) in Washington, DC, we have established a hospital-wide oversight committee for POCUS, which is a multi-disciplinary effort throughout the institution. Our aim is to standardize the use of POCUS across the hospital with respect to
1) education/training/credentialing,
2) documentation/image archival, and
3) maximizing the financial benefit.

Education, Training, and Credentialing

Each division who uses POCUS should have a champion who is responsible for the education and training of both trainees and faculty within the division. Many faculty in pediatrics, and pediatric sub-specialties, were not trained in POCUS as part of their residencies and fellowships; therefore, the opportunity to learn POCUS as a faculty member is incredibly important. Once competent in POCUS, faculty should have the ability to become credentialed in POCUS. A hospital-wide POCUS initiative can promote POCUS education across divisions through collaboration. Divisions can share POCUS curriculums with one another in addition to sharing resources. For example, divisions can bring their resources together and host a hospital-wide POCUS course. Furthermore, at CNMC, we recently received a grant to establish an ultrasound simulation program, which will be incorporated into our hospital-wide simulation program.

Documentation and Image Archival

Divisions that are using point-of-care ultrasound for medical decision making or procedural guidance should be documenting their findings in the medical record and archiving the appropriate images. In an ideal world, the ultrasound images would be accessible in the medical record, along with the documentation. The ability to view the POCUS images, by all clinicians providing care, improves the flow of knowledge among clinicians and in turn, improves patient care. From a workflow standpoint, the ability to archive the images in a centralized location, with the ability to connect the images to the electronic medical record, may be better accomplished as a hospital-wide initiative.

Maximizing the Financial Benefit

Collaboration among the divisions using point-of-care ultrasound can have a financial impact as well. For instance, when purchasing ultrasound equipment, the cost per machine is lowered when purchased in bulk. Furthermore, once the infrastructure is in place with respect to credentialing as well as the ability to document and store ultrasound images, clinicians may have the ability to bill for their services.

In order to accomplish the aforementioned aims, it is crucial to have hospital-wide support. To that end, we have strong partnerships with other clinical divisions, such as Radiology and Cardiology, who share their ultrasound expertise with the POCUS community. Furthermore, we have established relationships with other groups as well, such as information technology, purchasing, legal, biomed, and credentialing.

Are you interested in doing something similar at your institution? Wondering where to start? One suggestion is to send out a survey to all the division chiefs to better understand if POCUS is currently being used (or will be used in the future) in their respective divisions. Be sure to ask if the division has a POCUS champion. From there, plan a meeting with all the champions and start a discussion on how to improve POCUS at your institution. For a resource, check out the following reference.

Strony R, Marin JR, Bailitz J, et al. Systemwide clinical ultrasound program development: an expert consensus model. West J Emerg Med. 2018; 19:649–653.

 

Do you work in a children’s hospital? Do you perform POCUS? Do you ever wonder if other divisions in your hospital are using POCUS as well? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Alyssa Abo, MD, FAAP, FACEP, is Director of Clinical Ultrasound in Emergency Medicine, and Chair of the Hospital Oversight Committee for Point-of-Care Ultrasound at Children’s National Medical Center in Washington, DC, as well as Associate Professor of Pediatrics and Emergency Medicine at George Washington University School of Medicine and Health Sciences in Washington, DC.

Ultrasound Made Me the Doctor I Wanted to Be

I didn’t come into medicine knowing much about what doctors really did. I also didn’t graduate my emergency medicine residency really believing point-of-care ultrasound (POCUS) was all that useful. Maybe it’s just a fad, I remember thinking.Minardi, Joseph J.

There were two things I did come to enjoy about medicine: making interesting diagnoses and intervening in ways that helped patients. Those were the victories and they were always more satisfying when I got to do them as independently as possible. It was great to diagnose appendicitis with a CT scan, but I had to share at least some of the credit with the radiologist.

I remember sometimes being frustrated with the fragmentation of care in American medicine. Send the patient to another facility with these services, order this imaging study by this specialist, consult this specialist for this procedure, and so on.

A few cases early in my career really brought to light these frustrations.

One was a young woman who didn’t speak English who presented to our community hospital who appeared to have abdominal pain. It took hours after getting approval to call in a sonographer, consulting with the radiologist, and eventually calling in the gynecologist from home to take her to the operating room for her ruptured ectopic pregnancy. Hours went by while her condition worsened and I felt helpless, being uncertain about her diagnosis and relying on fragmented, incomplete information from others to make management decisions. Luckily, her youth allowed her to escape unscathed, but I was frustrated with what I didn’t know and couldn’t provide for her: a rapid, accurate diagnosis and quick definitive action.

In another case, a young boy was transferred to our tertiary care center for possible septic hip arthritis and waited nearly 24 hours to undergo more ED imaging, subspecialty consultation, then wait for the availability of the pediatric interventional radiologist to perform X-ray guided hip aspiration with procedural sedation. I remember again feeling helpless and seeing the hopelessness in the eyes of his parents after seeing so many doctors, spending so many hours far from home just waiting on someone to tell them what was wrong with their son and what was going to be done to help him.

After I was asked to lead POCUS education for our residency program and began to embrace it as a clinical tool, I encountered similar cases, but now with much more satisfying experiences for me as a physician, and hopefully, presumably for my patients. Now, I routinely hear stories from my residents and colleagues that go something like Hey Joe, check out this ectopic case, ED to OR in 20 minutes with bedside ultrasound. We have had cases of suspected hip arthritis where we were able to provide a diagnosis and care plan from the ED in 2–3 hours by performing bedside US-guided hip arthrocentesis. These and numerous other cases where diagnoses are made in minutes independently by the treating clinician have convinced me that POCUS can help improve healthcare. My colleagues and I have performed diagnostic and therapeutic procedures that we never would have considered attempting before we could competently use POCUS, allowing us to provide immediate care right where and when the patients needed it.

The “passing fad” of POCUS has allowed me to make medicine and being a doctor more into what I wanted it to be: seeing patients, giving them a diagnosis, decreasing the anxiety over uncertainty, and providing relief for their suffering. I trained and practiced without the advantages of ultrasound and I have seen the positive impact it can have not only on patients but also on the health care system and my job satisfaction as well. The advantages of more immediate, efficient diagnoses, better availability of advanced procedures can all be provided in a less fragmented, more cost-effective manner when treating clinicians are armed with and properly trained to use POCUS. There’s no way I would ever go back.

If you learned how to use ultrasound after you completed your original medical education, how did it affect your career? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Joseph J. Minardi, MD, is Chief of Emergency and Clinical Ultrasound, and Associate Professor of Emergency Medicine and Medical Education at the West Virginia University School of Medicine.

The Future of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Pediatrics entices practitioners with its focus on treating illness in the youngest patients, for long-term outcomes of future growth and development. When I reflect on my own journey through Pediatrics and Pediatric Emergency Medicine, helping patients in real-time through providing the best quality care given limited information, drew me to Pediatric Emergency Medicine.

Lianne Profile FinalPediatric Emergency Medicine (PEM) focuses on providing acute care to patients from the newest newborns to teenagers. With this breadth of ages comes differing pathology, physiology, and of course differences in relative and absolute size. Integration of point-of-care ultrasound (POCUS) into PEM practice offers the clinician an added tool to provide the best possible care. Children are ideal patients for POCUS scanning as they often have slimmer body habitus, fewer comorbidities, and there is increasing interest in limiting ionizing radiation amongst all patients, especially the very young.

POCUS offers direct visualization for procedures such as endotracheal tube airway confirmation, central-line insertion, and intravenous and intraosseous access. Utilizing this clinical adjunct allows for accuracy in nerve block administration, reducing the volume used of local anesthetic and decreasing the need for systemic sedation. Visualizing fractures following reduction and assessing joints and soft tissue infections prior to decision of incision and drainage or aspiration can all be achieved using POCUS.

Because our patients vary in size, optimizing planning prior to starting procedures can help to maximize success. Risk in pediatric procedures is heightened due to variable sizing, risking too-deep insertion of needles and endotracheal tubes. Direct visualization helps to support the provider in making safe choices.

Beyond procedures, POCUS allows PEM providers to optimize resuscitation, through real-time monitoring of volume status, cardiac function, and pulmonary edema. Reassessment throughout resuscitation adds additional information to vital signs and end-organ markers as patients are treated.

As machines become increasingly accurate at more portable sizes, and as cloud storage is increasingly popular among organizations, the future of POCUS offers providers along the care-continuum the opportunity to share information and images. My hope for the future of acute POCUS would be to have pre-hospital POCUS, emergency POCUS, consultative radiology imaging, and follow-up POCUS imaging in community clinics on an integrated system allowing for shared images and progressive monitoring for long-standing conditions.

The future of POCUS is bright as innovation and technology disruption move ultrasound outside of the walls of the hospital, placing transducers in the hands of those at the bedside from the helicopter to the remote health clinic. For countries such as Canada, increased portability means increasing access for those populations most at risk of health inequity, those living in the far North and remote regions of my country, who have limited access to urban care. POCUS with added portability and technological integration can help improve access, and shared decision making between urban centers and remote regions with patient safety and privacy as a priority.

I’m excited to see where POCUS integration moves in the course of the rest of my medical career, as I look forward to being an advocate for access and clinical education in addition to being an expert that maintains clinical accountability, safety, and privacy. The promotion of these critical pillars will help determine the success of the POCUS-empowered clinical experience.

Do you use point-of-care ultrasound in pediatric practice? If so, how has it helped you? Is there another medical field you think should use ultrasound more? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Lianne McLean, MB BCh, BAO, FRCPC, is Assistant Professor at the University of Toronto; and Staff Physician and Chair of the Council of Informatics & Technology in the Division of Emergency Medicine at the Hospital for Sick Children in Toronto, Canada.