ultrasound certification in residency

hello. I am curious about programs that say "by the time our residents finish their training, they have enough US scans for certification." That sounds good to me and seems like it would look great on a resume. However, when I asked a PD about 'do residents in your program do enough ultrasounds to get certified?' he said 'there is no certification for ultrasound.' and I felt pretty dumb. I didn't want to argue though. But at other programs obviously I've heard this said.

I checked the archives and from what I understand there, there is no board certification for ultrasound as a subspecialty of EM, during fellowship, but I think I knew that already. My question is about during residency, doing a larger number of ultrasounds than what people are required to do and getting some sort of credit for that. What's the deal?

There is a certification for U/S. It's called the ARDMS (which I believes stands for "American Registry of Diagnostic Medical Sonographers") and it's not a physician specific certification, so that is probably why the PD gave you the answer he did.

EDIT: Here's a link: http://www.ardms.org/

Here's how I understand the whole "certification" thing for ED ultrasound. Basically, its a matter of priveleges at whatever hospital you're eventually going to work at. Each place can set the list of things that EP's are allowed to do at their facility, including ultrasounds. For example, there are some (albeit few) places where EP's are doing their own DVT and RUQ ultrasounds. At other places, we are much more limited in priveleges, usually because of a turf war w/ radiology. (Where I am, for example, we're only granted priveleges to do FAST, AAA, and pelvic u/s for IUP vs ectopic and FHT's).

Either way, in order for any physician to be allowed to do a certain procedure at a hospital, whether its a surgeon doing something like a lap chole or hernia repair, or an EP doing ED ultrasound, you have to apply and be granted priveleges. In order to do that, you must demonstrate that you have some proficiency in the procedure in question. So... when that residency PD says that you'll get enough scans for "certification", what you're basically being told is that you'll have done enough to be granted priveleges to do ED ultrasound in your practice at whatever hospital you end up at.

I don't think the PD was referring to the ARDMS certification. It's a credentialling process for the techs, and from what I hear is lots of $$$ and time.

Generally, from what I gather, when PD's say that residents meet the requirements for ultrasound by graduation, it means that they've fulfilled the criteria set by the ACEP Emergency Ultrasound Guidelines. Credentialling is done by individual hospitals, rather than any national organization. http://www.acep.org/NR/rdonlyres/8024079E-28E8-4875-93E6-6867EA705A2A/0/ultrasound_guidelines.pdf

hornste said:

I don't think the PD was referring to the ARDMS certification. It's a credentialling process for the techs, and from what I hear is lots of $$$ and time.

Generally, from what I gather, when PD's say that residents meet the requirements for ultrasound by graduation, it means that they've fulfilled the criteria set by the ACEP Emergency Ultrasound Guidelines. Credentialling is done by individual hospitals, rather than any national organization. http://www.acep.org/NR/rdonlyres/8024079E-28E8-4875-93E6-6867EA705A2A/0/ultrasound_guidelines.pdf

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Well, I know at least two hospitals that will not let a doc shoot detailed studies (beyond like a FAST or something similar) unless they are credentialed through ARDMS or CCI (the latter being another echocardiography credentialing organization).

Actually, a doc who has shot X number of studies and has some other education can sit for the exam. Take a look at the application form for it. I fully intend to take my exam once I'm eligible (I'm already boarded for echocardiography).

ARDMS is certification/registration.

Hospitals credential individuals to perform procedures.

You can be credentialled and not certified, but you cannot be certified and not credentialled to perform ultrasounds. In other words, certification is great, but it is credentialling that actually gives you the priviledge to do an ultrasound in a particular hospital. Certification will generally allow you to get credentials to perform ultrasound a little quicker and easier.

So, when discussing credentialing v. certification, it's important to use the appropriate terms to avoid any confusion.

Here is a something I wrote for the ACEP US Section newsletter that should put this issue into greater light.
Paul

Defining and Clarifying Differences between “Certification” and “Credentialing” in Emergency Ultrasound

Paul R. Sierzenski, MD, RDMS
Immediate Past-Chair, Emergency Ultrasound Section ACEP

Disclaimer: Before you read this article I suggest you prepare some strong coffee, or your caffeinated drink of choice!

As a continuation from my discussions earlier in this newsletter, it was felt that a description of “certification” and “credentialing” is in order. Before the days of Google, I’m sure this would be extremely difficult to research, now with over 1500 hits it is breeze. My first observation is that both terms begin with “C” and have thirteen letters, but that is where the similarity ends.

As with many aspects of medical care, a legal verdict changed how staff appointments would occur forever. The verdict of the case of Darling vs. Charleston Community Memorial Hospital in 1965 culminated with hospitals determined as liable for the qualifications of its medical staff. The hospital based credentialing “process” was established.

Therefore; credentialing is a pathway and process for which a hospital can delineate the qualifications of a physician to be recommended to be a member of the hospital medical staff. The hospital, and their department should delineate specific “privileges” for the staff member’s clinical practice within the hospital, e.g. procedural sedation, intubation, and emergency ultrasound.

In 1999, AMA HR 802.99.2001 (Privileging for Ultrasound Imaging) affirmed that “privileging of the physician to perform ultrasound imaging procedures is a hospital setting should be a function of hospital medical staffs, and should be specifically delineated on the Department’s Delineation of privileges form…that each hospital medical staff should review and approve criteria for granting ultrasound privileges based upon…training and education standards developed by each physician’s respective specialty.”

So there we have it, credentialing is a process by where hospitals essentially can do their do diligence as to whether you should be allowed onto their medical staff, and that there are specific clinical privileges that are defined by the hospital as well as the department. The privileges must have been approved by the hospital credentialing committee and subject to medical staff and department bylaws.
Potentially of even greater importance is that the 2001 ACEP Ultrasound Guidelines were developed to exist as the “specialty specific training/education/criteria/standards” that AMA HR 802 speaks to, and thus can and should serve as the credentialing criteria road map for emergency physician privileging and credentialing in EUS.

“Certification” is defined best as “ a written attestation”. This is vastly different than the process of credentialing as described above, however in modern medicine these terms seem to be used interchangeable.

Allow me to be perfectly clear, there is no organized, national, or ACEP recognized “certification” in emergency ultrasound. Furthermore, ACEP clearly discourages the use of “certification” exams beyond that of the certification in emergency medicine by the American Board of Emergency Medicine (ABEM) or the American Osteopathic Board of Emergency Medicine (AOBEM) [see the ACEP policy supplement at the end of this newsletter.]

To my surprise, I noted that several emergency residency programs state that they “certify” residents in emergency ultrasound. What does this mean? My answer…I have no idea. I presume that the goal here is to assist graduates through the hospital “credentialing” process, but since emergency ultrasound IS delineated by the RRC-EM as mandated in residency training, is the concept of “certification” necessary? More importantly, “certification” is not supported by ACEP when existing outside ABEM, AOBEM or their subspecialties.

Is the reality that the process of hospital “credentialing” seems so convoluted and confusing, that having a form that is a “written attestation” seems beneficial. Do the residencies that provide certification for EUS provide them for central access, intubation, and procedural sedations?

There clearly seems to be the need, for improved communication, and understanding by EPs of their rights and the processes as pertains to staff privileging and credentialing. ABEM includes emergency ultrasound testing, both on the ABEM exam and within the LLSA.

Simply put, emergency ultrasound IS within our scope of practice. ACEP and the US section have worked diligently to promote and support a recognized and endorsed pathway for EP’s to gain “EUS hospital credentialing”, and a separate “EUS certification” is not endorsed either by ACEP, ABEM, or the Emergency Ultrasound Section at this time.

References:
AMA Policy Finder http://www.ama-assn.org

ACEP Emergency Ultrasound Guidelines Document (policy # 400327, Approved June 2001)

Best advice when you are given this statement by a PD is to ask them to translate that for you.

As peski so adequately stated, the terminology is convoluted at best. And its incredibly confusing.

For example, our residents are required to be ACEP level III U/S providers. This means that they ahve to have 170 (? or there abouts) scans that meet the appropriate requirements of quality (you can't scan your belly button and call it a heart..).

I became ARDMS eligible when I was a second year, meaning I had completed 800 scans and had a letter of support from an RDMS certified person. (however, as an md, you must be done with residency before you can sit for the exams) so I now have to take a course and sit for two exams. Obviously this is waaaaaaaaay beyond what is required in residency. (there were two others in my class who met the 800 scans). You can get 'credit' towards rdms, depending on the situation.

Despite being RDMS eligible, as a resident, I was not 'credentialed' in my institution, despite having many more scans than many of my attendings. The minute I graduated, I become 'credentialed' in my institution.

So, as peski so adequately pointed out, the terminology is convoluted. Don't get swayed by the language. Ask them how many scans thier residents are doing and what kind of time they get dedicated to ultrasound. It also is a good idea to ask how many or what percentage of attendings utilize ultrasound in the department (indirect assessment of ultrasound prevelance).

peksi said:

References:
AMA Policy Finder http://www.ama-assn.org

ACEP Emergency Ultrasound Guidelines Document (policy # 400327, Approved June 2001)

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Peksi,

What about the AIUM certification? When we were working through this, I got the impression that it was the closest thing to physician certification that was universally accepted. I also concluded that while the 500 proctored exam thing might be doable, it was unlikely that any 3 year EM residency could devote the required minimum 3 months to US only.

BNK,
AIUM offers "accreditation" not "certification". They have recommended training guidlines for physicians as noted on their website. They imbed the requirment to meet physician training standards that they promote within the process of practice accreditation (systems, lab, documentation, reporting, staff etc.)

peksi said:

BNK,
AIUM offers "accreditation" not "certification". They have recommended training guidlines for physicians as noted on their website. They imbed the requirment to meet physician training standards that they promote within the process of practice accreditation (systems, lab, documentation, reporting, staff etc.)

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Ok, this is getting even more confusing the further I read.

So notwithstanding the obvious advantage with regard to patient care issues (which, in an ideal world, would be the sole driving factor for getting an increased skill set but sadly rarely is) I guess my question would be distilled down to this:

What certification/acreditation/watercooler braggadacio do I want if I am seeking a way to make myself more attractive to future employers in terms of being able to bill for ultrasounds for those indications that we frequently encounter in the ED (FAST, OB, Renal, biliary, AAA, line placement)?

Also, does my legal standing change, esp. with regard to malpractice coverage, etc. if I have one certificatfion/qualification vs. another?

What do you think, Paul?

What certification/acreditation/watercooler braggadacio do I want if I am seeking a way to make myself more attractive to future employers in terms of being able to bill for ultrasounds for those indications that we frequently encounter in the ED (FAST, OB, Renal, biliary, AAA, line placement)?


Answer: You at minimum want to meet ACEP US Guidelines for Basic applications. Some letter to attest that you meet or exceed the ACEP US Guidlines (may or maynot be application specific-depends on the hospital you are seeking credentialling at)

You could consider ARDMS certification as this may ease some pushback from small community hospital antagonists, although this is NOT required for hospital credentials at any institution that I am aware of

Also, does my legal standing change, esp. with regard to malpractice coverage, etc. if I have one certificatfion/qualification vs. another?

Answer: No-Not as yet. However porforming an EDUS in an are that you are not credentialed in leaves you wide open. Generally you are only covered by med-mal for procedures you are "credentialed in"

Paul

peksi said:

What certification/acreditation/watercooler braggadacio do I want if I am seeking a way to make myself more attractive to future employers in terms of being able to bill for ultrasounds for those indications that we frequently encounter in the ED (FAST, OB, Renal, biliary, AAA, line placement)?


Answer: You at minimum want to meet ACEP US Guidelines for Basic applications. Some letter to attest that you meet or exceed the ACEP US Guidlines (may or maynot be application specific-depends on the hospital you are seeking credentialling at)

You could consider ARDMS certification as this may ease some pushback from small community hospital antagonists, although this is NOT required for hospital credentials at any institution that I am aware of

Also, does my legal standing change, esp. with regard to malpractice coverage, etc. if I have one certificatfion/qualification vs. another?

Answer: No-Not as yet. However porforming an EDUS in an are that you are not credentialed in leaves you wide open. Generally you are only covered by med-mal for procedures you are "credentialed in"

Paul

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Thanks Peksi.

As I understand everything now, then, the common sense aim for residents could reasonably be summarized as:

1) Fulfill the required number and type of scans to conform with the ACEP ultrasound guidelines -- pay special attention to page 13

(available here: http://www.acep.org/NR/rdonlyres/8024079E-28E8-4875-93E6-6867EA705A2A/0/ultrasound_guidelines.pdf)

2) Obtain a letter attesting to #1 (I assume this means from your program director, perhaps ultrasound director, or some other member of faculty who is credentialed)

3) Get credentialed at your institution -- either where you're doing residency* or confirm the rules at the institution that you've accepted an appointment at.

* as noted from previous posters, this might not be allowed where you do residency regardless of how many scans you have done.



Anyone care to comment or revise?

Just wanted to say thanks to those who took the time to respond in such detail. Excellent answers! I am glad my question wasn't dumb and feel like I know more about this subject now than probably plenty of residents do.

bulgethetwine said:

Thanks Peksi.

As I understand everything now, then, the common sense aim for residents could reasonably be summarized as:

1) Fulfill the required number and type of scans to conform with the ACEP ultrasound guidelines -- pay special attention to page 13

(available here: http://www.acep.org/NR/rdonlyres/8024079E-28E8-4875-93E6-6867EA705A2A/0/ultrasound_guidelines.pdf)

2) Obtain a letter attesting to #1 (I assume this means from your program director, perhaps ultrasound director, or some other member of faculty who is credentialed)

3) Get credentialed at your institution -- either where you're doing residency* or confirm the rules at the institution that you've accepted an appointment at.

* as noted from previous posters, this might not be allowed where you do residency regardless of how many scans you have done.



Anyone care to comment or revise?

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That pretty much sums it up except for #3. As a resident, you won't be credentialed in anything...everything you do is supposed to be done under direct supervision. When you graduate your program usually tells your new employer how many central lines, intubations, ultrasounds, etc you have done....they (the new hospital) then credentials you to perform whatever procedures they decide you are qualified to perform. ACEP's numbers are recommendations and it is up to each facility to decide what they want to require for credentialing in utrasound just as they do for procedural sedation or intubation or whatever.