Proving to Your Credentialing Committee You a Competent to Perform Clinical Ultrasound
"Why clinicians don't need certification, and embrace competency"
You have taken your CME course, practiced your technique, done your 25-50 scans in each application, and have a total of between 150-300 total scans. How do you know if you can safely perform diagnostic and procedural ultrasounds on your patients?
Firstly, clinicians utilizing clinical ultrasound do not need certification, licensing, or permitting to perform CUS. In fact, there are only 4 states that require any licensing or certification for ultrasound techs to perform comprehensive exams. Clinicians may want to draw parallels between clinical ultrasound and the interpretation of EKGs. There are no special tests or certification that are required to interpret EKGs, it is simply part of our job. The decision on when and how a provider interprets EKGs is based on many factors to include state law, experience of the provider, the local culture, the disease burden, the relationship to the collaborating physicians and specialists and even the condition of the patient. EKG interpretation is never based on a certification.
Certification is costly, acts as a barrier to implementing clinical ultrasound in your practice, has never been proven to demonstrate proficiency, and surrenders your profession's right to self determination by outsourcing governance of skills that only you and your professional societies are best positioned to judge.
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.
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.
Out Patient Setting- (Clinics/urgent care) the clinician should only follow the pathway set forth in the CUS Guidelines for initial training, proctoring, continued CME and an established QA program (5-10% of studies are QA).
In Patient Setting- The key is documenting your proficiency and then obtaining privileging to perform CUS in your facility. Proficiency can be demonstrated through competency, which is gained through the time tested and well validated Ultrasound guidelines, first implemented by the American College of Emergency Physicians in 2001.
Summary- 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 test principles which may not be important to a providers practice are not necessary for implementation of clinical ultrasound.