An increasing number of point-of-care ultrasound applications are now required components of training in certain specialties, and training standards for attaining competency are being developed for trainees and providers in practice.
Even though different professional societies have stated explicit goals for training in point-of-care ultrasound, specific training methods or standards to achieve these goals have not been published because few studies have addressed requirements to achieve competency.
A national standard for certification in point-of-care ultrasound has yet to be established; however, several training pathways exist that can assist providers in obtaining institutional privileges to use point-of-care ultrasound.
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.
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.
There are two major pathways to obtain competency in ultrasonography, well described in the ACEP guidelines for emergency physicians but applicable to all providers seeking to incorporate ultrasound into their practice:
Residency/Fellowship-based pathway: The ACGME has delineated minimal education requirements for general ultrasound training in certain specialties with a broad scope of practice, including emergency medicine and critical care medicine, and for specific ultrasound applications in certain specialties with a narrower scope of practice, including obstetrics/gynecology, pulmonary disease, ophthalmology, urology, colorectal surgery, vascular surgery, and rheumatology. This requirement may extend to other specialties as point-of-care ultrasound is incorporated further into clinical practice. Thus far, specific and detailed training requirements have been developed only for Emergency Medicine programs.
Practice-based pathway: Recommendations have been made by ACEP for minimal education requirements and competency assessment for physicians who completed Emergency Medicine residency training without ultrasound training. Competence in critical care ultrasound has been defined in a statement by ACCP and SRLF, but guidelines on how to achieve this standard have yet to be delineated.
Competency-Based Education in Ultrasound
An introductory ultrasound training course should include didactics, image interpretation practice, and hands-on image acquisition practice. The course should review core applications of ultrasound specific to each provider’s field.
The amount of time needed to attain minimal competency standards for core applications is unknown. However, multiple studies have shown that brief, focused training sessions ranging from several hours to multiple sessions over several days, with or without a requirement for proctored exams, can effectively train providers in several core applications, including lung/pleural, vascular diagnostic, and cardiac ultrasound. Despite the success of such focused training approaches, competency cannot always be determined using absolute cutoffs for number of examinations performed. Further study is needed on learning curves and minimal amount of training required for achievement of competency.
Residency/Fellowship-based pathway: A course may be offered by the training program as a series of lectures and hands-on practice sessions, or trainees can attend a regional or national training course in their specialty.
Practice-based pathway: Providers can attend regional or national courses developed by professional societies. If a number of providers at one institution require training, a course can be planned locally. Alternatively, some introductory didactic knowledge and image interpretation can be obtained via online tutorials and websites and through DVD tutorials. Hands-on experience and practice is mandatory.
Deliberate practice with supervision and the goal of achieving mastery has been shown to be a successful method of obtaining competency in several procedures, including ultrasound-guided vascular access and thoracentesis. Deliberate practice or repetition with focused feedback is an important adjunct to review techniques in image acquisition, diagnostic accuracy, and clinical application.
Residency/Fellowship-based pathway: This is best achieved by having ultrasound-trained faculty members guide deliberate practice with trainees and review saved ultrasound examinations. ACEP has defined specific requirements for the number and type of ultrasound examinations for emergency medicine residents.
Practice-based pathway: Ideally, providers should pursue deliberate practice with experienced sonographers. This may be difficult if the provider is the first one in a group to pursue ultrasound training. If experienced sonographers are unavailable at a provider’s home institution, remote review of ultrasound examinations is provided by some professional societies. Another approach is to initially order a confirmatory exam from the requisite subspecialty to self-identify and correct shortcomings in the provider’s acquisition and interpretation skills.
Competency in each core ultrasound application should be assessed rigorously. Limited data exist on the best way to determine competency; however, methods include written testing, objective structured clinical exams, simulation-based testing, video review, and bedside observation of skills (i.e., American Board of Internal Medicine Mini-Clinical Evaluation Exercise).
Residency/Fellowship-based pathway: This may be determined at a national level. For example, the ACGME requirement for obstetrics/gynecology residency training is minimum performance of 50 obstetric and 50 transvaginal ultrasound exams. ACEP recommends at least 25 documented and reviewed cases for each core application and a minimum of 150 total emergency ultrasound examinations for Emergency Medicine. Specific requirements do not yet exist for most other specialties, including Pulmonary Diseases and Critical Care Medicine, and should be determined by the individual program director.
Practice-based pathway: A similar standard for competency assessment exists for providers learning ultrasound after completing graduate medical education. ACEP recommendations are similar to that required of residents ; however, minimal requirements will depend on individual institutions for providers in other fields. The Certificate of Completion in Critical Care Ultrasonography is a training pathway offered by ACCP for critical care providers. Although not designed to serve as a certificate of competency, it instead serves as an opportunity for providers to gain and demonstrate considerable skill and experience in the field.