Extra POCUS training - worthwhile?

[Green_Goose]

My IM program offers a dedicated track for residents interested in learning more about POCUS. All residents here develop a basic level of familiarity with POCUS, either through learning sessions or on the wards/unit, but a smaller group have the chance to join a separate track with more in depth learning. It's not an extra year or anything like that, but it is of course a time commitment, as are most worthwhile things. I am interested in pursuing cardiology fellowship after residency, and cardiac POCUS is very obviously relevant to that field. Is POCUS important enough where I should pursue more extensive training now, or is it something that I can anticipate I'll get adequate training on while in fellowhsip, if I do end up doing cards? Would love to hear y'alls thoughts.

---

Members don't see this ad.

 

[gutonc]

I suspect that you'll get all the US training you need during fellowship. Feel free to get ahead of the curve with this if you want, but I doubt you're going to be doing a bunch of echos and dopplers in the POCUS training.

Now, if you told me you were interested in going into rural primary care or hospitalist work, I think it would be helpful. Out here in the sticks it can sometimes take a divine act to get and urgent US or a US-guided procedure like a para or a thora or an FNA. If you rolled up to the exam room or bedside with your Butterfly iQ and a long-ass needle, you'd be a hero some of these places.

 

[DrMetal]

My IM program offers a dedicated track for residents interested in learning more about POCUS.

A great example of where GME is disconnected from the real world.

In the real world, we get formal US studies (a tech does it, a radiologist reads it and puts her name on it).

This helps fend off the lawyers

 

[Green_Goose]

A great example of where GME is disconnected from the real world.

In the real world, we get formal US studies (a tech does it, a radiologist reads it and puts her name on it).

This helps fend off the lawyers

That's a good point. I figured everyone gets a formal echo anyways, as I wouldn't want to be on the hook for missing something on an informal POCUS. But I was more thinking along the lines of situations that arise on weekends/evenings when there might not be time for a tech to come in, like seeing if someone has a big pericardial effusion, or even just getting a quick assessment of volume status. But I'm not sure that competency with evaluating that sort of thing requires any extra training beyond what the average IM resident will eventually learn in 3 years anyway.

 

[Green_Goose]

I suspect that you'll get all the US training you need during fellowship. Feel free to get ahead of the curve with this if you want, but I doubt you're going to be doing a bunch of echos and dopplers in the POCUS training.

Now, if you told me you were interested in going into rural primary care or hospitalist work, I think it would be helpful. Out here in the sticks it can sometimes take a divine act to get and urgent US or a US-guided procedure like a para or a thora or an FNA. If you rolled up to the exam room or bedside with your Butterfly iQ and a long-ass needle, you'd be a hero some of these places.

You mention hospitalist work - this is only semi-related, but do you think that POCUS will become an integral part of running codes in the future? I've only seen it done on rare occasions but I've heard that some hospitalist attendings swear by it.

 

[DrMetal]

That's a good point. I figured everyone gets a formal echo anyways, as I wouldn't want to be on the hook for missing something on an informal POCUS.

Yep.

In the real world, if you're doing any procedure (US counts as a procedure, even if just diagnostic), you better be credentialed, and your malpractice insurance better cover you for it.

To get credentialed, you have to be trained in it, have done many, and continue to do many on a regular basis (maintaining competency). It's just not practical (nor safe) unless your specialty directly incorporates it into practice. (The intensivist uses US and places lines all the time . . .the hospitalist not so much).

 

[Radetzky]

But I was more thinking along the lines of situations that arise on weekends/evenings when there might not be time for a tech to come in, like seeing if someone has a big pericardial effusion, or even just getting a quick assessment of volume status.

At the risk of sidetracking the discussion.. there is very little on echo that tells you anything about a patients volume status.

Most often cited reason for doing pocus and actually the lowest yield

 

[dozitgetchahi]

I suspect that you'll get all the US training you need during fellowship. Feel free to get ahead of the curve with this if you want, but I doubt you're going to be doing a bunch of echos and dopplers in the POCUS training.

Now, if you told me you were interested in going into rural primary care or hospitalist work, I think it would be helpful. Out here in the sticks it can sometimes take a divine act to get and urgent US or a US-guided procedure like a para or a thora or an FNA. If you rolled up to the exam room or bedside with your Butterfly iQ and a long-ass needle, you'd be a hero some of these places.

Yep.

In the real world, if you're doing any procedure (US counts as a procedure, even if just diagnostic), you better be credentialed, and your malpractice insurance better cover you for it.

To get credentialed, you have to be trained in it, have done many, and continue to do many on a regular basis (maintaining competency). It's just not practical (nor safe) unless your specialty directly incorporates it into practice. (The intensivist uses US and places lines all the time . . .the hospitalist not so much).

My exact thoughts.

Getting a bunch of training in a procedure doesn’t mean much if you’re not credentialed to do it. Even if you are, if you miss something/screw it up, you’re going to get hung out to dry if you don’t really have the expertise to safely do it.

 

[dgdg]

We used bedside POCUS for all our central lines and thoracenteses in residency over 20 years ago. It's absolutely amazing to view the anatomy in real time with the procedures. If the unit were available, I'd scout out the area for a paracentesis too.
Then I got a job as a hospitalist and I had to go back to using landmarks and physical exams again. Spoke with administration about what really was the standard of care. They thought it was a good idea and did nothing.

 

[DrMetal]

We used bedside POCUS for all our central lines and thoracenteses in residency over 20 years ago. It's absolutely amazing to view the anatomy in real time with the procedures. If the unit were available, I'd scout out the area for a paracentesis too.
Then I got a job as a hospitalist and I had to go back to using landmarks and physical exams again. Spoke with administration about what really was the standard of care. They thought it was a good idea and did nothing.

I click on 'IR guided thora/para/LP orderset' in Epic, then it happens, it's amazing. Love medicine in 2024.

 

[NewYorkDoctors]

You only really need POCUS skills if you are emergency medicine or critical care.
In certain cases you cannot wait for a formal study or report you need to jump in there and do it to see real time what is going on while waiting for a formal study (to stave off the lawsuits)

you really dont need this as a primary care provider or hospitalist. Besides no one would believe you anyway (lawyer wise)

if you are doing cardiology, you will get all all the echo skills you need from cards fellowship. The cards fellows are the one doing overnight urgent TTE studies anyway.

However I see a niche in which this might be useful. If you want to be a Cardiology / CCM doctor one day to run a CCU and be able to handle all the medical issues outside of the heart, this track might give you some extra knowledge and familiarity. but aside from this career path, you dont really need to go into this. Learning the other organ systems might detract from your cardiology learning later on. You only have "so much time anyway" in residency to do your cards research and connections.

If you have your own NPI already, go buy the butterfly IQ pocket ultrasound. i dont work for them. but if you get the probe and the annual subscription, it comes with an education / video series. no better way to learn than probe yourself, your friends, and your sig other everywhere (lol that didnt come out right)

 

[Green_Goose]

You only really need POCUS skills if you are emergency medicine or critical care.
In certain cases you cannot wait for a formal study or report you need to jump in there and do it to see real time what is going on while waiting for a formal study (to stave off the lawsuits)

you really dont need this as a primary care provider or hospitalist. Besides no one would believe you anyway (lawyer wise)

if you are doing cardiology, you will get all all the echo skills you need from cards fellowship. The cards fellows are the one doing overnight urgent TTE studies anyway.

However I see a niche in which this might be useful. If you want to be a Cardiology / CCM doctor one day to run a CCU and be able to handle all the medical issues outside of the heart, this track might give you some extra knowledge and familiarity. but aside from this career path, you dont really need to go into this. Learning the other organ systems might detract from your cardiology learning later on. You only have "so much time anyway" in residency to do your cards research and connections.

If you have your own NPI already, go buy the butterfly IQ pocket ultrasound. i dont work for them. but if you get the probe and the annual subscription, it comes with an education / video series. no better way to learn than probe yourself, your friends, and your sig other everywhere (lol that didnt come out right)

Great answer, thank you! In the long run, I'm leaning towards doing my career in the outpatient setting anyway. Learning POCUS now would have some utility, but yeah there would be redundancy with learning it again anyways in fellowship, and if I enter the outpatient setting after fellowship it probably wouldn't be of much use once I'm done with training.

 

[dozitgetchahi]

Spoke with administration about what really was the standard of care. They thought it was a good idea and did nothing.

Across three jobs, I’ve lost count of the number of times I talked to admin and they thought something “was a really good idea”…and nothing happened. I’ve learned to never assume anything will happen until I see it before me with my own two eyes.

 

[NewYorkDoctors]

Great answer, thank you! In the long run, I'm leaning towards doing my career in the outpatient setting anyway. Learning POCUS now would have some utility, but yeah there would be redundancy with learning it again anyways in fellowship, and if I enter the outpatient setting after fellowship it probably wouldn't be of much use once I'm done with training.

right there is no real reason for an outpatient cardiologist to sono anything outside the heart anyway

exception might be learning lung U/S (which is super easy... and does not need much formal training anyway outside what of you learn in MICU as a resident) to assess pleural effusion and B lines for pulmonary edema. that can be helpful.

 

[NewYorkDoctors]

Across three jobs, I’ve lost count of the number of times I talked to admin and they thought something “was a really good idea”…and nothing happened. I’ve learned to never assume anything will happen until I see it before me with my own two eyes.

that's the beauty of self owned. I am the administrator. I just whip out my credit card or bank ACH and order away. Then do new things. Bill. Count the money all the way to the bank.

Non-physician administrators are total parasites who offer little of value other than to leech off of a doctor's NPI and ability to bill and collect money from insurances.

 

[dgdg]

I'd love to have POCUS in my outpt office for a quick DVT eval. New onset lower ext edema without overt volume overload is a not an uncommon presentation for me. The hardware kit should be cheap to build, but because it's medical probably expensive.
I'd get a formal outpt venous ultrasound regardless, which are often not same day anymore even if STAT, but with some basic credentialing I could start anticoagulation on the same day as my visit. If I can locate a carotid artery just superficial to the jugular vein and successfully watch my hands guide a large bore central catheter needle to the perfect venous location, scouting for venous compressibility can't be that difficult.

Would be nice too for ascites and pleural effusion office evals even if I am not doing an invasive procedure. Examination findings are not 100% sens and spec even with the best examiner. I had an older patient recently with subacute abdominal distention and shifting dullness. Obvious concern was the inevitable malignant ascites from an ovarian cancer, but she was just constipated. I didn't alarm her about my exam, but it alarmed me until the ultrasound report returned. Another patient had decreased breath sounds and dullness on exam, diaphragm still moved. Since he had cancer hx I was alarmed, but a chest xray was fine as well as a follow up CT scan for his esophageal cancer in remission.

 

[NewYorkDoctors]

just use the butterfly IQ to your iphone android. i dont work for them so I am not shilling for them. i just like how portable and easy it is and cheap it is you can save your images to a web portal like a PACS system.

you could bill for exams too... i bill 76604 for my lung U/S. the insruance companies sometimes needs a report from me. I give them a report templated. pays everytime. they have never asked for the actual images before.

of course if you are not self owned practice, the administrators will give you a hard time because they are all cowards (in addition to being parasites). in that situation, consider getting the butterfly IQ for your own use. just to give yourself some additional certainty about things.

 

[dgdg]

How do you get certified for POCUS?

 

[kacelius]

POCUS Certificate of Completion

The POCUS Certificate of Completion program offers a comprehensive, hands-on experience to learn the fundamentals of point-of-care ultrasound.

www.hospitalmedicine.org

 

[dozitgetchahi]

How do you get certified for POCUS?

It depends on specialty and what you are trying to image.

For MSK ultrasound in rheumatology, there are at least two programs: USSONAR and the ACR’s RhMSUS.