by Dan Scullin, MD (PGY-3)

Point of Care Ultrasound (POCUS) has been increasingly used by internists for diagnostic purposes as well as to assist with invasive procedures. If you haven't heard, UAB has added a new interest group that focuses on ultrasound and its application. The interest group is headed by Dr. Rob Smola, an Assistant Professor of General Internal Medicine at UAB and an Academic Hospitalist at the Birmingham, VA. He was gracious enough to sit down and give some insight into the new POCUS Interest Group as well as his views on how POCUS has informed his practice.  

What originally got you interested in POCUS?

My initial interest in ultrasound started as a resident and was mainly focused on procedures. I always enjoyed the procedural ultrasound component of POCUS. Late in residency, I became more interested in the diagnostic component of POCUS while seeing it used frequently on my emergency medicine rotation and by cardiology and critical care fellows. During my chief resident year and first year as faculty, I participated in a couple of POCUS training courses and was hooked from there!

How much does a reliable pocket ultrasound cost?

Pocket ultrasound technology has greatly expanded over the last few years. This is great for us as clinicians, because it makes everyday use that much more convenient. Regarding cost and device selection, it really comes down to what you intend to use the device for. Costs can range from around $2,000 to $7,000-10,000.

How has POCUS changed your practice? How has it changed your approach to and view of the physical exam? Are there certain parts of the physical exam you leave out of your routine in lieu of ultrasound?

POCUS has reinvigorated me to get back to the bedside with patients. I particularly love using POCUS on my new hospital admissions to confirm or change my initial differential diagnosis. I view my ultrasound exam as an extension of my physical exam. My traditional hands and stethoscope exam is my "surface exam" and my POCUS exam is my "beneath the surface exam." My physical exam for ascites (fluid wave, shifting dullness, bulging flanks) is probably the main exam that has been completely replaced by POCUS exam because the sensitivity and specificity is so much greater with ultrasound than any other examination maneuver.

What's your view on people using POCUS without formal certification?

Like all skills in medicine, POCUS requires training to achieve competency. Currently, a few organizations and societies (such as CHEST and SHM) have a certification pathway to prove that you have received training and are competent in the use of POCUS. Do I think it is absolutely necessary all general internists and clinicians go through one of these certification pathways? No. However, I do think those clinicians that wish to use POCUS should receive training to ensure it is being used properly. Credentialing is totally separate from competency, and certification will be based on the individual health care system you work in.  

Do you see the potential for misuse of POCUS in certain situations, especially by a general internist as opposed to say a cardiologist?

When comparing general internist use versus other subspecialist use, I believe it comes down to what you are using the POCUS exam for and what clinical question you wish to answer with a POCUS exam. Can a general internist get a parasternal long axis view and globally assess for left ventricular systolic dysfunction and a pericardial effusion? Without a doubt! Can a resident improve their volume assessment by using a multifocal lung exam in combination with a subcostal/IVC exam? Absolutely! Can they use doppler ultrasound to calculate a LVOT VTI in order to calculate cardiac output? Only with additional advanced training or fellowship. 

Do you fear the next generation of physicians will rely too heavily on this tool, or do you think this tool in the right hands will give more accurate information in certain circumstances?

I do not fear that future generations of physicians will use or rely on POCUS too much. I truly think that POCUS is the way of the future and those not using it will be left behind. Does that mean we abandon our traditional physical exam? Absolutely not. But failing to advance our knowledge and skills of POCUS is the bigger fear for me.

What are good resources for the internist interested POCUS?

For training purposes, there are numerous courses out there for clinicians to grow their POCUS interest and skills. ACP, SHM, AIUM, CHEST and many more societies offer 2-3 day training courses that are phenomenal! They are not cheap and require travel, but I highly recommend attending these courses if you have interest. If that is not an option, find your local POCUS "champions" and learn from them. These people often love to teach POCUS and want others to get on board.  

For online resources, ACP offers numerous online modules that are free to ACP members and very well developed. Society for Ultrasound in Medical Education has free online learning modules. The University of South Carolina has free online youtube videos. Society of Hospital Medicine (SHM) has an online POCUS question bank that is free with a code (contact me for details!). The POCUS Atlas has phenomenal images to review and see tons of pathology.