The Society of Point of Care Ultrasound


Proving to Your Credentialing Committee that You are Competent to Perform Clinical Ultrasound 

"Do I need to be 'certified' to demonstrate competency?"

When it comes to POCUS, there is much confusion around the terms "certification" and "credentialing."  We commonly encounter questions on how clinicians (usually physicians and APPs) can become “certified” in POCUS.  This question leads us to further clarify 1) what the individual means by "certification" and 2) what the clinician's overall goal of certification might be. Most clinicians simply wish to use POCUS in their clinical practice (aka achieve privileging via local credentialing board), and believe certification is the means by which they can do so.  Unfortunately this isn’t necessarily true.  

            The purpose of any certification process should be the validation of a particular skill.  There are multiple methods that allow for the validation of competency.  Soni et al published a thoughtful paper in the Journal of Hospital Medicine that describes the nuance of demonstrating/validating POCUS competency.  It specifically outlines the differences between intramural certification (that which can be achieved locally through existing/institutional POCUS programs or infrastructure) and extramural certification (that which is commonly offered by third-party societies or external "non-profit" organizations at a cost to the individual).

A locally-validated log/repository of complete ultrasound exams, OSCE or SDOT logs of exams, focused professional practice evaluations (FPPE) all represent inexpensive, locally achievable intramural methods to validate competency.  Although they require the local presence of an appropriately trained POCUS-skilled clinician, the lack of availability of such an individual, throughout entire hospital systems, is rare considering the proliferation of POCUS training opportunities. In contrast, certification by external entities may often be costly, may remove individuals from their respective practice settings for preparation and maintenance of certification, and therefore has potential to act as a barrier to implementing clinical ultrasound in your practice.  Additionally, there is little data to support the notion that external certification leads to increased patient safety, or "excellent" patient care. 

SPOCUS believes that certification should be minimally burdensome, both financially and in terms of removing clinicians from their practice to take high-stakes exams.  Intramural certification should therefore be considered the ideal method, as it also allows the primary stakeholders to best evaluate competencies while considering the dynamic factors that are unique to each practice setting.   SPOCUS recognizes that some institutions may lack the POCUS infrastructure required to validate competency.  While we work to overcome this challenge through the expansion of training opportunities, it is imperative that clinicians understand that the more clinicians pursue extramural certification, there is a risk that it will become a standard that credentialing bodies, employers, and state medical boards demand of clinicians, thereby creating a barrier to POCUS employment.  It is also imperative to understand that most extramural certification bodies still require a local POCUS-trained peer to locally validate skills, which may understandably lead some to question the value and effectiveness of extramural certification.  While we recognize the desire of some to pursue "certification' of their skills as a means to demonstrate their proficiency it is imperative that those considering extramural certification understand that many of the claims (enhances patient safety, demonstrates excellence, improves professional competitiveness etc) are not at all substantiated with literature.

All clinicians undergo validation of their clinical skills throughout their training programs.  "Can you perform a physical exam?"  "Can you read an ECG?" "Can you interpret laboratory studies?" Each of these are examples of clinical skills that are operator-dependent, require various levels of training, are performed with various degrees of competency, and may be subject to human error. Competency in these clinical skills has been historically evaluated/is best assessed by educators/trainers that know the trainees best, or by clinicians who work closely with the individual in their respective practice settings.  Why should POCUS be any different?

Recognizing that pursuit of external certification is a personal choice, history has demonstrated that the decisions of individuals within a profession can collectively create momentum which has great potential to impact the future of POCUS certification and our respective professions. While we can no way influence the existence of such external certification, that momentum carries with it a risk that external POCUS certification may become yet another mandatory fee-based exam/case log that credentialing boards or employers require (think ATLS/ACLS/PALS), a process that could require regular renewal fees, takes them away from their practice, without demonstrably increasing patient safety or excellence.  While it may facilitate credentialing for a few clinicians in the near-term, it has potential to become a barrier to CUS utilization in the long-term.

SPOCUS believes that professional and specialty organizations are singularly and best prepared and qualified to cultivate and validate competency standards and methods that are minimally expensive and minimally cumbersome to clinicians.  Outsourcing governance of a clinician's professional role or capacity to external certification bodies can be tantamount to surrendering the right to professional self-determination, and abdicating the professional responsibility to act as an advocate for what is best for patients and clinical practice.

Further commentary on the topic can be found below:




Is clinical ultrasound safe for my patients?   

While the answer to this question initially appears to be somewhat nebulous, the reasoning behind the lack of a clear answer quickly becomes evident.  As of the writing of this material Google and Pubmed searches for "POCUS bad outcomes," "clinical ultrasound medical errors," "POCUS harm to patients" and "Point of care ultrasound negative outcomes" or any combination of those key terms doesn't return a single study demonstrating harm to patients.  While there many studies that don't show a benefit, none of the search terms demonstrate harm to patients.  In fact those search terms don't even return case reports where POCUS harmed patients. 

Presumably because of the lack of negative data Blaivas and Pawl wrote, "Analysis of lawsuits filed against emergency physicians for point-of-care emergency ultrasound examination performance and interpretation over a 20- year period" and a similar paper from 2008-2012, using law suits filed in state and federal court as a surrogate marker for bad outcomes.  They found that during that time period there were only 5 suits filed for ultrasounds performed at that point of care.  In each of the 5 cases it was alleged that the breach of duty was related to have occurred not because the ultrasound missed a finding which resulted in a bad outcome, but because the ultrasound was not performed when clinically indicated.(cit 1-3)  

The take-home point is that if leaders in our medical communities feel that not formalizing an ultrasound program will protect them from litigation, it appears that litigation is much more likely to be pursued if clinicians don't perform the bedside exam, as bedside ultrasound appears to be a standard of practice.

Summary

SPOCUS will always champion patient safety as a top priority. We need to ensure we are using POCUS effectively, accurately, and appropriately dealing with the second and third order effects such as "incidentalomas."  SPOCUS will therefore continue to support and advocate for well-validated methods of competency-based training and skill validation. Competency-based clinical skill validation has been (and continues to be) effectively employed by universities and hospital credentialing boards for decades. There is an abundance of literature to support competency-based skill validation, and it carries with it none of the financial burden associated with external certification.  

Clinicians in our medical system make life and death decisions every day. Only they, in collaboration with the local medical leadership, are best positioned to decide the clinician's scope of practice and utilization of clinical ultrasound. Certification and testing, which may test principles which may not be important to a providers practice, are not necessary for safe implementation of clinical ultrasound.

REFERENCES

  1. Blaivas M, Pawl R. Analysis of lawsuits filed against emergency physicians for point-of-care emergency ultrasound examination performance and interpretation over a 20-year period. Am J Emerg Med. 2012 Feb;30(2):338-41. doi: 10.1016/j.ajem.2010.12.016. Epub 2011 Jan 28. PubMed PMID: 21277134.
  2. Stolz L, O'Brien KM, Miller ML, Winters-Brown ND, Blaivas M, Adhikari S. A review of lawsuits related to point-of-care emergency ultrasound applications. West J Emerg Med. 2015 Jan;16(1):1-4. doi: 10.5811/westjem.2014.11.23592. Epub 2014 Dec 12. PubMed PMID: 25671000; PubMed Central PMCID: PMC4307691.
  3. Nguyen J, Cascione M, Noori S. Analysis of lawsuits related to point-of-care ultrasonography in neonatology and pediatric subspecialties. J Perinatol. 2016 Sep;36(9):784-6. doi: 10.1038/jp.2016.66. Epub 2016 Apr 14. PubMed PMID: 27078203.


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