Ultrasound Certification

Certification vs Credentialing

Credentialing (privileging) for diagnostic point-of-care ultrasound (POCUS) is determined by each individual hospital. There is no national credentialling program nor standards for internal medicine. POCUS falls into a nebulous zone of hospital privileging. If POCUS is considered an extension of the physical exam, then any hospitalist credentialed to perform a history and physical can also perform POCUS in that hospital. If POCUS is considered more of a invasive or risk procedure like central lines, then additional privileging requirements may be needed. The Society of Hospital Medicine POCUS guidelines leave it up to each individual institution to determine their preference.¹

Certification of Competency

Certification refers to a process that ensures a doctor is competent to perform POCUS independently with out supervision. Documentation of certification can aid the credentialing process above. Certification can occur externally through organizations like Society of Hospital Medicine. External certification process often cost > $2,000. You can also get certified internally at your own institution via your Director of POCUS. All certification pathways should share similar criteria:

    1. Completion of a series of videos or lectures to provide a knowledge base that emphasizes
      • Fundamentals
      • Image interpretation
      • Clinical case integration
    2. Completion of hands on training that emphasizes
      • Image acquisition
    3. Completion of an image portfolio that emphasizes
      • Practice optimizing image acquisition
      • Verify correct image interpretation
      • Practice clinical case integration on real patients
    4. Summative assessment that ensures competency of the above domains

The field of emergency medicine has clearly defined their POCUS applications and the amount of training required for competency.² Internal medicine is in early of stages of this process, though there are discrepancies among some of the early recommendations.3-5 I recommend the following applications for hospital medicine based my personal experience which mirrors the curriculums from the American College of Physicians Foundational Skills Course and the Society of Hospital Medicine Certificate of Completion. 

Central Venous Pressure Exam (10 patients)
      • Jugular venous pressure
      • Inferior vena cava with CVP 0-5mmHg
      • Inferior vena cava with CVP 5-10mmHg
      • Inferior vena cava with CVP 10-20
Pulmonary (10 patients)
      • A lines
      • B lines
      • Pleural effusion
      • Consolidation
      • Lung sliding (including M mode)
      • Lack of lung sliding (including M mode)
Cardiac (25 patients)
      • Normal Heart
        • Parasternal long axis
        • Parasternal short axis
        • Apical 4 chamber
        • Subxiphoid
      • At least 1 of all of the following patholgoies
        • Hyperdynamic EF > 65%
        • Moderately reduced EF 30%-50%
        • Severely reduced EF < 30% 
        • Pericardial effusion
        • Right ventricular strain
Abdomen (10 patients)
      • Normal FAST exam (3 views)
      • Small volume ascites
      • Large volume ascites 
      • Normal kidneys (short and long axis)
      • Hydronephrosis
      • Bladder distension
Deep Vein Thrombosis (10 patients)
      • Normal lower extremity DVT Exam
        • Saphenous vein
        • Deep formal vein branch
        • Popliteal vein
      • Abnormal DVT exam with non-compressible thrombus
Musculoskeletal (10 patients)
      • Normal subcutaneous tissue
      • Normal suprapatellar bursa
      • Edema
      • Abscess
      • Large joint effusion

Prior to Certification of Competency

A critical step in POCUS skill development is practicing on real patients during the image portfolio phase. It takes months, if not years, of deliberate practice to become competent at PCOUS. Prior to competency during this pre-entrustment phase, you should not make major management decisions based on your POCUS exams.

You are not sensitive enough to rule out pathology. If you are considering canceling an echo because the heart “looks ok,” you should stick with your original instinct of ordering a formal echo to confirm your assessment. You exams lack the specificity to make high stakes decisions. If you think you see a deep vein thrombosis (DVT), instead of immediately starting anticoagulation, you should expedite formal  DVT ultrasound to confirm your findings. The power of POCUS in this early phase is recognizing potentially life threatening disease like tamponade and then expediting formal cardiology evaluation. 

Next Page: Fundamentals

References

  1.  Soni NJ, Schnobrich D, Matthews BK, et al. Point-of-Care Ultrasound for Hospitalists: A Position Statement of the Society of Hospital Medicine. Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 2019;14:E1-E6.
  2. Ultrasound Guidelines: Emergency, Point-of-Care and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med. 2017 May;69(5):e27-e54. doi: 10.1016/j.annemergmed.2016.08.457. PMID: 28442101.
  3. LoPresti, Charles M., et al. “Point-of-care ultrasound for internal medicine residency training: a position statement from the alliance of academic internal medicine.” The American journal of medicine 132.11 (2019): 1356-1360.
  4. Torres-Macho, J., et al. “Point-of-care ultrasound in internal medicine: A position paper by the ultrasound working group of the European federation of internal medicine.” European journal of internal medicine 73 (2020): 67-71.
  5. Ma IWY, Arishenkoff S, Wiseman J, Desy J, Ailon J, Martin L, Otremba M, Halman S, Willemot P, Blouw M; Canadian Internal Medicine Ultrasound (CIMUS) Group*. Internal Medicine Point-of-Care Ultrasound Curriculum: Consensus Recommendations from the Canadian Internal Medicine Ultrasound (CIMUS) Group. J Gen Intern Med. 2017 Sep;32(9):1052-1057. doi: 10.1007/s11606-017-4071-5. Epub 2017 May 11. PMID: 28497416; PMCID: PMC5570740.