CON: Physician- Performed Ultrasound: The Time Has Come for Routine Use in Acute Care Medicine

several cases, both hypothetical and taken from Australian case which illustrate how liability may be determined. In one A with little experience and training in echocardiography decides to perform an echocardiogram on a patient with acute onset dyspnea and hypotension. The are reported to be normal and later the patient dies of tamponade. a missed or wrong diagnosis itself is not necessarily a breach of duty, a ‘sub-standard’ procedure is. In this case, as soon as the doctor holds the transducer, is professing to be fluent in the technique. thinking that he is experienced in the field, may not doubt his skills and may rely on his findings in managing the patient . In their con-clusion, they that both the practitioner and hospital may be liable for breach of duty if a ultrasound if of the if is not difficult cases.

D iagnostic ultrasound (including cardiovascular ultrasound) has the potential to contribute much to patient care, and restricting its use is neither feasible nor fair to patients. On the other hand, used poorly, it has the potential to contribute to misdiagnosis, needless downstream testing or treatment and possible patient harm. Hence, it needs to be used wisely and with sufficient expertise. It is easy to see in an image what you already expect to see, and without some knowledge of how the images are made, the opportunity for misunderstanding is real.
In their Core Review article " Physician-Performed Ultrasound: The Time Has Come for Routine Use in Anesthesiology and Acute Care Medicine," Royse et al. make a compelling argument for the use of point-of-care ultrasound and echocardiography by nontraditional specialties, such as anesthesiology, intensive care medicine, emergency medicine, and surgery. 1 As they point out, the traditional specialties, specifically cardiology and radiology, historically challenged this paradigm, fearful of the use of this technology by variably trained individuals and the potential to act on unsubstantiated information with resultant harm.
In a provocative article in the Harvard Business Review, 2 Christensen et al., commenting on the field of medical diagnostics, argue that innovation from below, although disruptive, could lead to "less costly equipment which is user friendly to a broader base of practitioners, but only if the entrenched powers get out of the way and let market forces play out." Drawing a parallel with point-of-care ultrasound is hard to resist.
The American Society of Echocardiography issued its first report on hand-carried ultrasound in 2002. The prescience was unmistakable; as portable, compact, and inexpensive equipment became more widely available, it was predicted that "further progression of cardiovascular ultrasonography beyond the cardiovascular specialist will likely occur," but that " User-specific training will be essential to the success of this evolution in technology application." 3 Subsequently, a joint statement from the American Society of Echocardiography and American College of Emergency Physicians on focused cardiac ultrasound was published. 4 As seen in Table 1, the consensus was that life-threatening hemodynamic disturbances could be addressed and urgently treated guided by focused ultrasound. Once again it was stressed that adequate training was essential, and that guidelines were the purview of the governing bodies of the respective specialties.
What should be the paradigm, then, to ensure that expanded ultrasound utilization produces qualified practitioners? The best scenario would be for graduating medical students to have a grasp of the fundamentals of ultrasound physics, how images are generated, and how artifacts are created. The specialties and subspecialties where ultrasound is likely to have an important role should have appropriate instruction built into residency and fellowship programs. We would also propose that certification standards be set forth, either as part of the base residency examination, or in a separate venue, with a requisite number of studies and success in a written examination as components.
Members of the critical care and emergency medicine community have been especially proactive in this regard. In a widely endorsed review of practice, training, and accreditation in critical care ultrasound, 5 an ambitious curriculum is presented, placing the onus on postgraduate programs in intensive care unit medicine to produce trainees with specific skill sets (Fig. 1). With the recognition that not everyone will become an expert, there is a move in some quarters to establish different strata of competence. In most anesthesia programs in the United States, although there is formal instruction in ultrasound for nerve blocks and central line placement, there really is none for transthoracic echocardiography (TTE).
What is the downside to a more liberal strategy? Inadequate training may lead to inadequate practice, with the potential for misdiagnosis. Unlike major teaching institutions, where numbers of staff and house staff abound, the implications for busy solo practitioners are quite profound. Doing an adequate study and reporting it may be constrained by the time available.
The authors have not addressed the issue of liability. In a paper entitled "Do We Need A Critical Care Ultrasound Certification Program? Implications From an Australian Medical-Legal Perspective," 6 Huang and Mclean present several cases, both hypothetical and taken from Australian case law, which illustrate how liability may be determined. In one example, A doctor with little experience and training in echocardiography decides to perform an echocardiogram on a patient with acute onset dyspnea and hypotension. The findings are reported to be normal and later the patient dies of tamponade. While a missed or wrong diagnosis itself is not necessarily a breach of duty, a 'substandard' procedure is. In this case, as soon as the doctor holds the transducer, he/she is professing to be fluent in the technique. Others, thinking that he is experienced in the field, may not doubt his skills and may rely on his findings in managing the patient. In their conclusion, they stress that both the practitioner and hospital may be liable for breach of duty if a substandard ultrasound examination is performed, if the knowledge of the operator is not up to date, or if help is not sought in difficult cases.
Canty et al. 7 observed preoperative TTE in patients scheduled for emergency noncardiac surgery, performed by anesthesiologists and found a significant number of anesthetic modifications subsequently ensued. Cowie 8 also demonstrated a large number of anesthetic alterations that resulted from anesthesiologists-driven perioperative TTE. What are lacking, as the authors acknowledge, are outcome data that argue for broader acceptance of a liberal strategy of ultrasound practice.
There is a wide body of literature that Royse et al. 1 cited, which demonstrates that teaching basic ultrasound to novices can be achieved. We believe there is little doubt about the validity of this statement. However, it must be ensured that before taking it to the next level, practitioners are minted in a manner that achieves excellence.
Where do we then stand on the "ultrasound for everyone" model? The range of programs and training varies considerably among specialties and institutions, which often makes it difficult to determine a particular individual's competence. The way this is achieved in medical specialties around the world is that after an accredited residency, certification by examination is requisite. The National Board of Echocardiography certification in perioperative transesophageal echocardiography is familiar to most cardiac anesthesiologists, and now offers both basic and advanced pathways to certification.
Because ultrasound is ubiquitous in medical practice, from cardiac and lung ultrasound to the guidance of nerve blocks and invasive line placement and the assessment of acute surgical emergencies, we agree the best place to start is the teaching of basic principles in medical school. Integration of ultrasound training into all 4 years has been described at several institutions 9,10 and should serve as a template to build on.
We firmly believe that residencies that incorporate ultrasound training should be held to a high standard when it comes time for accreditation. We would also propose that certification examinations be created, either as part of the base residency examination, or in a separate venue. After certification, quality assurance programs, and the need for continuing medical education are mandatory. As is the case with perioperative transesophageal echocardiography, current certification may become a prerequisite for hospital privileges in diagnostic ultrasound.
The issue of certification of individuals already in practice will vary among countries and specialties, and would require an alternate pathway. For the National Board of Echocardiography, there are caseload and continuing medical education requirements and an examination.
As Royse et al. 1 stress, research into outcomes is needed. Opposing the wider use of ultrasound is not appropriate or