Common Sense

Development of a Focused Designation of Clinical Practice in Ultrasound

Issue:November/December 2019

Authors: Melissa Myers, MD FAAEM and Alexis Salerno, MD

 

Emergency physicians have been an essential part of the development of Point-of-Care Ultrasound (POCUS). In the 1970s, POCUS started as part of the trauma resuscitation. Since then, emergency physicians have expanded the boundaries of POCUS to evaluate and treat a wide range of medical conditions. As early as 1988, emergency physicians began publishing on the use of bedside ultrasound in the emergency department. Within a few years, in 1991, both the American College of Emergency Physicians (ACEP) and the Society of Academic Emergency Medicine (SAEM) published policy statements regarding the utility of bedside ultrasound in the emergency department.1

Emergency physicians have also led the way in developing curriculum. The first published curriculum in 1994 by Mateer et al has led to multiple well-developed curriculums based in educational research. Today, POCUS is considered an essential skill and was recognized as such in the 2013 Model of the Clinical Practice of Emergency Medicine. Modern emergency medicine residencies include rigorous and extensive training in POCUS with graduates performing a wide array of POCUS skills to diagnosis and treat their patients.

Some emergency physicians choose to pursue ultrasound training beyond that required during residency, by completing an emergency ultrasound fellowship. During one or two year fellowships, these physicians become experts in advanced ultrasound modalities and ultrasound education. The presence of ultrasound fellowship trained faculty at residency sites correlates with a higher number of faculty credentialed to perform ultrasound and may assist with quality assurance for ultrasound performed in the ED.2 Fellowship trained emergency physicians also continue to develop new ways to improve the use of POCUS and to study best practices for use on shift.

The Society for Clinical Ultrasound Fellowships (SCUF) currently lists 50 fellowships, though this list is not exhaustive, and does not include the military programs. Until recently, there has been no established way to recognize physicians who choose to pursue this extra training or to credential these fellowships.  While some have chosen to pursue recognition through the exams offered by the American Registry for Diagnostic Medical Sonography or other similar organizations, these exams were not developed by emergency physicians and do not reflect the use of POCUS in the emergency department. As noted by Dr. Gibbons in the May/June 2019 edition of Common Sense, emergency physicians do not need these merit badges to legitimize our training.3

Following an extended debate and vote, members of these fellowships and ultrasound societies nationwide felt that attempting to establish a subspecialty board could have unintended consequences for the practice of POCUS by those who did not choose to pursue a fellowship. The alternative chosen was a “Focused Practice Designation (FPD).”

The FPD, which is approved by the American Board of Medical Specialties, “recognizes physicians who devote a substantial portion of their practice to a specific area of a specialty.”4 This will hope to recognize emergency physicians with expertise in emergency ultrasound beyond the requirements for ABEM certification. It will be a recognition developed by emergency physicians which will be specific to the requirements of our specialty. There will be three pathways to obtain this designation, the fellowship training pathway, the training-plus-practice, and the practice-only pathway.5

In the fellowship training pathway, physicians will complete an Advanced Emergency Medicine Ultrasound (AEMUS) fellowship accredited by the Emergency Ultrasound Fellowship Accreditation Council (EUFAC). The Society of Clinical Ultrasound Fellowships (SCUF) will be charged with the creation of this council. For those who do not know, the current SCUF website helps potential fellows compare various ultrasound fellowships and complete fellowship applications. In the future, the EUFAC will release regulations to obtain fellowship accreditation and a curriculum for the fellows. The curriculum will expand on the basic emergency medicine ultrasound knowledge by including advanced measurements and views. Although the curriculum has not been released yet, potential topics may include muscular tendon assessment, arterial doppler assessment or even cardiac diastology. The curriculum will most likely also cover administrative topics such as billing and workflow solutions.  

In the training-plus-practice pathway, physicians must complete an acceptable non-EUFAC accredited fellowship. This pathway will most likely be for recent emergency ultrasound fellows who graduated prior to the date of the first accredited fellowship. The physician must also demonstrate 24 months of AEMUS practice including performing or supervising 300 studies per year and reviewing for quality assurance 500 studies per year. This pathway will only be available to physicians for five years from the date of the first EUFAC-accredited AEMUS fellowship. Those who are considering applying for this pathway, may wish to start logging ultrasound scans and QA’ed studies.

In the practice-only pathway, physicians must demonstrate 36 months of AEMUS practice with 300 performed or supervised studies and 500 reviewed studies. In addition, physicians will have to demonstrate additional knowledge in the area by prior work in leadership administration, publications, or teaching. This pathway will most likely be for more senior faculty that continue to have a strong interest in ultrasound. And just as in the training-plus-practice pathway, this will only be available to physicians for five years from the date of the first EUFAC-accredited AEMUS fellowship.

Physicians who meet the eligibility criteria will also need an appropriate verifier who can confirm the physician has the hand-eye-motor coordination to perform ultrasound tasks. Finally, physicians will be able to take a multiple-choice examination to gain FPD. The first exam is scheduled to be offered in 2022.

Through these pathways, emergency physicians who devoted significant time and attention to practicing point-of-care ultrasound will be able to obtain recognition of their expertise. This exciting development will likely continue to evolve over the next few years as ultrasound societies nationwide work together to develop the exam and fellowship credentialing guidelines. To keep updated on the progress of the AEMUS FPD check out the SCUF website at eusfellowships.com and don’t forget to check out EUS-AAEM newsletter, the POCUS Report.

References:

  1. Kendall, J. L., Hoffenberg, S. R., & Smith, R. S. (2007). History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Critical care medicine, 35(5), S126-S130.
  2. Das, D., Kapoor, M., Brown, C., Ndubuisi, A., & Gupta, S. (2016). Current status of emergency department attending physician ultrasound credentialing and quality assurance in the United States. Critical ultrasound journal, 8(1), 6.
  3. Gibbons, Ryan. “Emergency Ultrasound Merit Badges...There’s No Need.” Common Sense, May/June 2019.
  4. Focused Practice Designation. Focused Practice Designation | American Board of Medical Specialties. https://www.abms.org/board-certification/focused-practice-designation/. Accessed August 18, 2019.
  5. Advanced EM Ultrasonography. American Board of Emergency Medicine. https://www.abem.org/public/become-certified/focused-practice-designation/advanced-em-ultrasonography. Accessed August 18, 2019.

 

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