Pulmonary Perspectives®

An update on the current standard for ultrasound education in fellowship


Point-of-care ultrasound (POCUS) is an essential part of ICU care. It has been demonstrated to improve patient safety and outcomes through procedural guidance (Brass P, et al. Cochrane Database Syst Rev. 2015 Jan 9;1:CD006962) and aid in accurate and timely diagnosis of cardiopulmonary failure (Lichtenstein DA, Mezière GA. Chest. 2008 Jul;134[1]:117-25). Due in part to increasing affordability and portability of ultrasound technologies, the use of POCUS has become seemingly ubiquitous and will continue to increase in coming years. According to expert groups representing 12 critical care societies worldwide, general critical care ultrasound and basic critical care echocardiography should be mandatory training for ICU physicians (Expert Round Table on Ultrasound in ICU. Intensive Care Med. 2011 Jul;37[7]:1077-83).

Dr. Lewis Satterwhite

Currently, POCUS is not universally taught to pulmonary and critical care fellows (PCCM); and when training does exist, curriculums are not standardized. This is in part due to the broadly worded requirements set forth from the ACGME for pulmonary disease and critical care medicine. The totality of ACGME common program requirements as it regards to ultrasound training are as follows: 1. “Fellows must demonstrate competence in procedural and technical skills, including ... use of ultrasound techniques to perform thoracentesis and place intravascular and intracavitary tubes and catheters”; and 2. “Fellows must demonstrate knowledge of imaging techniques commonly employed in the evaluation of patients with pulmonary disease or critical illness, including the use of ultrasound” (ACGME Program Requirements for Graduate Medical Education in Pulmonary Disease and Critical Care Medicine).

In comparison, recently updated ACGME common program requirements for ultrasound in emergency medicine and anesthesiology residencies are robust and detailed. Requirements for anesthesia residency training include: ” ... competency in using surface ultrasound ... and transthoracic echocardiography to guide the performance of invasive procedures and to evaluate organ function and pathology ... understanding the principles of ultrasound, including the physics of ultrasound transmission, ultrasound transducer construction, and transducer selection for specific applications, to include being able to obtain images with an understanding of limitations and artifacts ... obtaining standard views of the heart and inferior vena cava with transthoracic echocardiography allowing the evaluation of myocardial function, estimation of central venous pressure, and gross pericardial/cardiac pathology (eg, large pericardial effusion) ... using transthoracic ultrasound for the detection of pneumothorax and pleural effusion ... using surface ultrasound to guide vascular access (both central and peripheral) ... describing techniques, views, and findings in standard language” (ACGME Program Requirements for Graduate Medical Education In Anesthesiology).

Herein lies a stark contrast in what is required of programs that train physicians to care for unstable patients and the critically ill. Current requirements leave graduates of PCCM training programs vulnerable to completing ACGME milestones without being adequately prepared to evaluate patients in a modern ICU setting. Increasingly, hospitals credentialing committees expect PCCM graduates to be suitably trained in ultrasound. Regrettably, there is no assurance that is true, or standardized, with current PCCM fellowship training requirements.

There is not a national standard for competency assessment or requirements for credentialing in POCUS for critical care physicians at this time. However, multiple national and international critical care societies, including CHEST, have consensus statements and recommendations outlining the areas of competence expected in critical care ultrasound (Mayo PH, et al. Chest. 2009 Apr;135[4];1050-60, Expert Round Table on Ultrasound in ICU. Intensive Care Med. 2011 Jul;37(7):1077-83). The PCCM ACGME requirements should be updated to reflect such recommendations, thereby placing greater emphasis on ultrasound teaching requirements and standardized curriculums. Despite the current ACGME program requirements, it is incumbent upon critical care training programs to provide competency-based education of this now “standard of care” technology.

Barriers to universal POCUS training exist. Fellowship programs may lack trained, ultrasound confident faculty, time, and funding to successfully develop and sustain an ultrasound curriculum. (Eisen LA, et al. Crit Care Med. 2010;38[10]:1978-83; Patrawalla P, et al. J Intensive Care Med. 2019 Feb 12: [Epub ahead of print].)

Although access to adequate quality and quantity of ultrasound machines is less often a problem than in the past, many institutions lack archival and image review software that allows for quality assurance of image acquisition, and some still may not have a faculty member with expertise and ability to champion the cause.

In attempts to mitigate the local faculty gaps, national and regional solutions have been developed for ultrasonography education. CHEST has educated more than 1,400 learners in the Ultrasound Essentials course since 2013. Also, grassroots efforts have led to the development of courses specifically designed to teach incoming PCCM fellows. Using a collaborative and cost-effective model, these regional programs pool faculty and experts in the field to train multiple fellowship programs simultaneously. The first of these was created over a decade ago in New York City (Patrawalla P, et al. J Intensive Care Med. 2019 Feb 12:[Epub ahead of print].)

Currently, there are at least four regional annual ultrasound courses directed at teaching PCCM fellows. These courses are typically held over multiple days and encompass the basics of critical care ultrasound, including vascular, thoracic, abdominal, cardiac, and procedural imaging. By estimation, these four courses provide a basic ultrasonography education to approximately two-thirds of first year pulmonary and critical care fellows in the United States. In addition to training fellows, these programs also serve as a platform for the development of local faculty experts, so that training can continue at their institutions.

Introductory courses are highly effective (Dinh VA, et al. Crit Care Res Pract. 2015 Aug 5:675041 Patrawalla P, et al. J Intensive Care Med. 2019 Feb 12: [Epub ahead of print]), but ongoing education, assessment, and quality assurance is required to achieve sustained competence. Ideally, training in POCUS should entail a dedicated, intensive introduction to the competencies of critical care ultrasound (such as the above regional courses or CHEST ultrasound courses), followed by a formal curriculum within the PCCM fellowship programs. This curriculum should afford the trainee exposure to critically ill patients in an environment with adequate ultrasound equipment and a method to record studies. The trainee then interprets the acquired studies in clinical context. Preferably, the program will afford the trainee real-time quality assurance for image acquisition and interpretation by a program champion. Quality assurance can be provided on site or remotely using fixed interval review sessions. Lastly, the program should have internal milestones to evaluate when a trainee has reached competency to perform these tasks independently. The completion of training should include a letter to any future employee attesting to the trainee’s acquisition of these skills and ability to apply them safely while caring for the critically ill. This robust education is occurring in many centers across the country. PCCM fellowship programs owe it to their trainees, and patients, that competency-based critical care ultrasound training is robust, standardized, and supported.

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