Background

The American Medical Association (AMA) has long recognized that ultrasound has diverse applications and is used by a wide range of physicians and disciplines. The AMA states “that ultrasound imaging is within the scope of practice of appropriately trained physicians.” Point-of-care ultrasonography includes a subset of ultrasound applications, albeit an increasing number, practiced by different clinical specialties, most notably emergency medicine and critical care medicine.

In recognition of its utility and widespread use, point-of-care ultrasound has become a required component of training by the Accreditation Council for Graduate Medical Education (ACGME) in several residency and fellowship programs. As a result, many providers, particularly those trained prior to the inclusion of ultrasonography in graduate medical education, have sought local and national training courses organized by professional societies and private education companies.

Specialty-specific guidelines for point-of-care ultrasound applications, training standards, and competency assessments are undergoing rigorous evaluation. The American College of Emergency Physicians (ACEP) published a compendium to establish emergency ultrasound imaging standards and practice guidelines to better define training, proficiency, and credentialing of providers using emergency ultrasound. The American College of Chest Physicians (ACCP) and the Société de Réanimation de Langue Française (SRLF) defined the specific components of competency in general critical care ultrasound, basic critical care echocardiography, and advanced critical care echocardiography in 2009. More recently, combined professional society guidelines have emerged that mention training and competency, such as the American Society of Echocardiography (ASE) and ACEP consensus statement on focused cardiac ultrasound in emergent settings. Although these statements may give explicit goals for training in ultrasound, specific training methods or standards to achieve these goals are often broadly defined. Our understanding of learning curves for various applications of point-of-care ultrasound, minimal requirements for competency and expertise, and need for ongoing training to maintain competency is currently limited.

Definitions

The processes of both attaining and confirming possession of the requisite knowledge and skills of physicians using ultrasound require an understanding of four important terms.

Competence is the inherent state of possessing the cognitive and technical skills necessary to perform a specific task or range of tasks. The criteria that constitute competence are often difficult to determine. Criteria for the professional competence of physicians have typically been set by ACGME, American Board of Medical Specialties, and professional societies. Individual professional societies have also determined criteria for competence in many specialty-specific procedures.

Competency-based education (CBE) is a framework for training that has not been well defined until recently. Frank et al. define CBE as “an approach to preparing physicians for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies derived from an analysis of societal and patient needs. It deemphasizes time-based training and promises greater accountability, flexibility, and learner-centeredness.” For point-of-care ultrasound, CBE assumes outcomes-based assessment to ensure that providers have a basic set of knowledge and skills that they can integrate into clinical practice as independent users of ultrasound.

Certification (or licensing) is the method by which an external organization formally recognizes the competence of a provider. In the United States, certification indicates that the provider has met the knowledge and skill requirements felt to be integral to the practice of his/her specialty. The ACCP offers a “certificate of completion” in critical care ultrasound, but it is not a “certificate of competency.” There is currently no formal certification pathway in critical care or point-of-care ultrasound offered by a licensing board.

Credentialing and privileging are governed by the rules and regulations of an individual provider’s hospital and department, where that entity grants an individual permission to practice a certain set of skills, duties, and procedures. Credentialing is the process by which a department or hospital verifies a provider’s qualifications, such as board certification and medical licenses. Privileging is the process by which an institution grants a provider permission to perform patient care activities within the provider’s scope of practice and competence. The determination of competence during this process often relies on the documentation of the provider’s fulfillment of society-specific competency criteria, testaments of superiors/colleagues, or achievement of formal certification, if available.

The following sections describe in detail current training standards for point-of-care ultrasound using competency-based assessment, as well as the differences between a residency/fellowship-based pathway and a practice-based pathway. Although there is not a current certification process for point-of-care ultrasound or a national standard for credentialing/privileging, we review models that may lay the groundwork for future certification requirements and credentialing.

Training Standards for Competency and Competency-Based Education

Point-of-care ultrasound includes many different organ- and disease-specific applications, and the relevance of each application differs for each provider’s practice. Use of ultrasound independently by a provider requires competency in several areas, including basic physics, machine controls, indications for each application, normal and abnormal anatomy, image acquisition, interpretation, and clinical application.