Point-of-Care Ultrasonography: Visually Satisfying Medicine or Evidence-Based Medicine?

Eden Bernstein; Tracy Y. Wang

doi:10.1001/jamainternmed.2021.5831

Editorial

October 11, 2021

Point-of-Care Ultrasonography: Visually Satisfying Medicine or Evidence-Based Medicine?

Eden Bernstein, MD¹; Tracy Y. Wang, MD, MHS, MSc²

Author Affiliations Article Information

¹Cleveland Clinic Foundation, Cleveland Clinic Community Care, Cleveland, Ohio
²Duke University, Duke Clinical Research Institute, Durham, North Carolina

JAMA Intern Med. 2021;181(12):1558-1559. doi:10.1001/jamainternmed.2021.5831

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Point-of-care ultrasonography (POCUS) is the use of ultrasonography by clinicians to augment the physical examination and guide clinical decision-making at the bedside.¹^,2 It has become the standard of care for most common bedside procedures. However, while endorsed by the American College of Physicians and the Society of Hospital Medicine, its use for diagnostic purposes is not as firmly grounded in evidence demonstrating net benefit on patient outcomes.¹^,3

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3 Comments for this article

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October 12, 2021

The Benefit sof POCUS

Fiore Mastroianni, MD | Northwell Health

In my view, POCUS is useful in the emergency room, intensive care unit, ward, or outpatient office to rapidly assess patients with a variety of cardiopulmonary complaints. The authors complain about a lack of reproducibility, recording of images, and training but the same can be said for any physical exam maneuver.

Complex studies are not needed for POCUS or the stethoscope. The rationale, to drive training, archiving of images and formal instruction is out of date. Software such as QPathe, and PACS can be used to record an essentially limitless archive of POCUS images and clips. Regarding training and certification, the American College of Chest Physicians is one of many organizations that provide this through in-person didactics, self-directed learning and accumulation of an imaging portfolio to reviewed and critiqued by content experts. The degree of training, documentation, and certification for POCUS is already more rigorous than for any physical exam maneuver or interpretation of EKG, both of which are skills expected of emergency medicine and internal medicine physicians, among others.

When I am called to see a patient with COVID-19 and worsening dyspnea I can assess the patient for pneumothorax, pleural effusion, worsening pneumonia, right and left ventricular dysfunction, pericardial effusion, and DVT within a few minutes. I can then use those findings to provide appropriate treatment and disposition. Is it reasonable to do what I do or, alternatively, be randomized to wait 15 minutes for an X-ray technician and 2-9 hours for an echocardiogram and vascular study? Or risk moving an unstable patient for CT through several hallways and an elevator before a stabilizing intervention can be done? Further, "formal imaging" is often difficult to obtain during the evening and on weekends and holidays, while I can perform POCUS at any time of day or night.

CONFLICT OF INTEREST: Dr. Mastroianni has been a POCUS instructor for Northwell Health and the American College of Chest Physicians in the past but has received no compensation for POCUS teaching in the last year.

October 14, 2021

Excellent Commentary, but...

Steven Simpson, MD | University of Kansas School of Medicine

I read this commentary with interest, and I will disclose that I have similar thoughts to the author's. However, as I read the commentary it occurred to me that one could substitute the words "physical examination" everytime one reads POCUS, and the document would be substantially no different. I am of a generation that bemoans the loss of examination skills among the younger generation(s!). It hurts tremendously to say this, but variation in examination skill has always existed, while physical examination as a basis for treatment has remained little questioned. Additionally, one must wonder why we consider POCUS anything other than an extended physical examination skill. I am wondering whether Laennec's contemporaries thought him audacious when he proposed a stethoscope for listening to a chest. Surely, one should not use that thing without being properly trained!

This is made all the more poignant for me by a conversation I held last night with a fourth year medical student about a close friend of mine, hospitalized with sepsis. I expressed concern that my friend may have a hepatic abscess, and I hoped his physicians, in another city, would heed my request for a contrast CT. To which the student replied that it would be so much easier to take an ultrasound to the bedside, and he described to me the exact findings one should expect to see. I don't remember them and didn't try to remember them. But the fact that a student could rattle off 1, 2, 3 the findings of a hepatic abscess on ultrasound - during the course of a conversation that he had not studied for, nor knew was coming - tells me that our youngest generation, or at least some of them, are receiving excellent ultrasound training. The same way we received physical diagnosis training.

Had I read your commentary yesterday I would have shouted "Hear, hear!" As of today, my perspective has shifted, a bit. You'll probably never see me use POCUS on a routine basis, and I suspect that is a good thing, given what you have to say about it. But the times they are a changin'.

CONFLICT OF INTEREST: None Reported

October 15, 2021

In order to study POCUS, we need precision in understanding what POCUS is and what it isn't

Maitray Patel, M.D. | Mayo Clinic Arizona

I applaud Drs. Bernstein and Wang for their thoughtful editorial on the challenges in assessing the value of POCUS in patient outcomes, but the commentary it has engendered from Drs. Mastroianni and Simpson are emblematic of the confusion the term POCUS creates. This confusion stands in the way of understanding how and where POCUS can help in patient care.

Bernstein and Wang are right to highlight the need for research to understand the degree to which POCUS might increase testing due to false-positive findings, but fall into the trap of thinking that sonographic evaluation with the intent of establishing and grading disease states for purposes of subsequent follow-up or treatment beyond the immediate encounter are POCUS exams. Mastroianni is correct to refer to his use of ultrasound to help him decide the next step for his patient with worsening dyspnea as POCUS; Simpson’s medical student who wants to use ultrasound to establish a diagnosis of hepatic abscess is not using POCUS.

A recent article in the Journal of the American College of Radiology attempts to define POCUS as distinct from “Diagnostic Ultrasound” (DXUS), an important foundation needed to clarify the discussion. I encourage others to review that article for more thorough analysis (https://doi.org/10.1016/j.jacr.2020.09.013). POCUS is not defined by who is doing the study or where the study is done, it is defined by whether the study is being performed to inform the immediate next steps to be taken by that clinician for an evaluation encounter (POCUS) or whether it is being performed to establish and document the presence or absence of disease (DXUS) upon which the clinician or others might act.

DXUS can be performed at the bedside by clinicianss who are not primarily imagers; when appropriately trained and experienced, these non-imagers may do it well—yet, this is not POCUS, this is DXUS performed by non-imagers. Perhaps evidence will show that wide implementation of DXUS by non-imagers is more cost-effective than DXUS by radiology departments for some assessments; Bernstein and Wang are right to highlight this as a research topic. But that should not be misconstrued as an evaluation of POCUS, it is an evaluation of DXUS.

POCUS is diagnostic, but any meaningful evaluation of POCUS and its role in patient care must distinguish it from DXUS. Without a clearly defined difference, health systems struggle to build effective POCUS programs which become stalled amidst questions of organization, quality assurance, coding and reimbursement, and workflow.

Defining POCUS as a tool used by clinicians making decisions for “the next step” is the proper context that differentiates it from “DXUS performed by non-imagers.” Clinicianss use POCUS to decide what they are going to do next in their evaluation or treatment of the patient, not as assessment and documentation to potentially direct the actions of others or serve as reference for future evaluation. POCUS can help clinicians decide to pursue DXUS or other imaging to comprehensively characterize and record the presence, absence, and severity of a disease process at a point in time. Using POCUS, a clinician may decide to pursue an intervention such as thoracentesis, using ultrasound for guidance. POCUS may confirm a decision to not pursue further testing for conditions deemed unlikely after the evaluation.

These are examples of POCUS, and the benefit POCUS provides is worthy of investigation, using a framework that defines POCUS and DXUS as distinct activities, both with potential value.

CONFLICT OF INTEREST: Fellow and Past President of the Society of Radiologists in Ultrasound; member of the American College of Radiology US Commission

Point-of-Care Ultrasonography: Visually Satisfying Medicine or Evidence-Based Medicine?

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