Integrating Point-of-Care Ultrasonography Into Nephrology Fellowship Training: A Model Curriculum

Point-of-care ultrasonography (POCUS) is a relatively easy-to-learn skill that can be incorporated into day-to-day clinical practice and the trainee curriculum to enhance patient care. POCUS is primarily intended to address focused clinical questions at the bedside and serve as an adjunct to physical examination. More recently, POCUS is being increasingly adopted by health care professionals from various medical specialties. However, most general nephrology training programs have not yet fully embraced the rapidly evolving field of POCUS.1Quigley L. Salsberg E. Mehfoud N. Collins A. The American Society of Nephrology survey of 2017 nephrology fellows.https://www.asn-online.org/education/training/workforce/Nephrology_Fellow_Survey_Report_2017_Highlights.pdfDate accessed: February 4, 2019Google Scholar We have previously reported our experience with the development and implementation of a renal POCUS curriculum for the internal medicine residents at our institution, which resulted in substantial increase in reported confidence level of the learners.2Koratala A. Bhattacharya D. Kazory A. Helping patients and profession; nephrology-oriented point-of-care ultrasound program for the internal medicine residents.Clin Nephrol. 2018; https://doi.org/10.5414/CN109652Google Scholar We propose a model curriculum as an educational platform to integrate focused ultrasonography pertinent to the care of patients with kidney disease into nephrology fellowship training programs. Although the core concepts would apply to any fellowship program, the topics and time slots could be customized to the specific needs, interests, and resources of the trainees and the institutions. We also discuss practical aspects and barriers to the development and implementation of such a curriculum. With the exception of a few training programs, the application of POCUS for nephrologists has until recently been limited to procedural guidance for vascular access and kidney biopsy.3Moore C.L. Copel J.A. Point-of-care ultrasonography.N Engl J Med. 2011; 364: 749-757Crossref PubMed Scopus (1087) Google Scholar With the rapidly expanding use of POCUS, diagnostic renal sonography, and determination of fluid volume status by focused sonographic assessment of the inferior vena cava (IVC), lung, and heart are now considered well within the scope of contemporary nephrology practice.4Kaptein M.J. Kaptein E.M. Focused real-time ultrasonography for nephrologists.Int J Nephrol. 2017; 2017: 3756857Crossref PubMed Scopus (15) Google Scholar, 5Mullangi S. Sozio S.M. Segal P. et al.Point-of-care ultrasound education to improve care of dialysis patients.Semin Dial. 2018; 31: 154-162Crossref PubMed Scopus (14) Google Scholar Some experts propose that nephrology fellows should be trained to perform and report comprehensive renal ultrasound examinations similar to a radiologist. That said, the utility of IVC sonography in assessment of volume status is controversial and while it can offer a coarse estimation of central venous pressure, several limitations exist.6Via G. Tavazzi G. Price S. et al.Ten situations where inferior vena cava ultrasound may fail to accurately predict fluid responsiveness: a physiologically based point of view.Intensive Care Med. 2016; 42: 1164-1167Crossref PubMed Scopus (91) Google Scholar Even limited echocardiograms and lung water are still a “work in progress” in this context; despite numerous observational studies, lung ultrasound has only been studied in 1 clinical trial.7Siriopol D. Onofriescu M. Voroneanu L. et al.Dry weight assessment by combined ultrasound and bioimpedance monitoring in low cardiovascular risk hemodialysis patients: a randomized controlled trial.Int Urol Nephrol. 2017; 49: 143-153Crossref PubMed Scopus (40) Google Scholar Although there are short-term training opportunities in POCUS for practicing nephrologists, fellowship-based longitudinal training has been proposed to provide better results with regard to long-term skill retention.8Sliman S. Amundson S. Shaw D. Phan J.N. Waalen J. Kimura B. Recently-acquired cardiac ultrasound skills are rapidly lost when not used: implications for competency in physician imaging.J Am Coll Cardiol. 2016; 67: 1569Crossref PubMed Google Scholar The American Society of Diagnostic and Interventional Nephrology (ASDIN) recommends devoting 6 weeks to ultrasonography during a 2-year fellowship training9The American Society of Diagnostic and Interventional NephrologyApplication for certification in renal ultrasonography.https://cdn.ymaws.com/www.asdin.org/resource/resmgr/Cert_Recert_Updates/Renal_Ultrasound_Application.pdfDate accessed: February 4, 2019Google Scholar (this recommendation does not include sonographic fluid volume status assessment). Based on our experience with the POCUS training of residents and fellows, we suggest that an 8-week period, spread out over 2 years, would be needed to accommodate both the didactic training and scanning experience required to achieve competence. Dedicated POCUS training beyond this duration might hamper the acquisition of core knowledge and skills required for the successful completion of the general nephrology fellowship, as well as compromising the time available for other elective rotations. Mullangi et al10Mullangi S. Sozio S.M. Hellman D.B. et al.Integrative point-of-care ultrasound curriculum impart diagnostic skills relevant to nephrology.Am J Kidney Dis. 2019; 73: 894-896Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar have recently described a 2-week multisystem diagnostic POCUS curriculum for nephrology fellows at Johns Hopkins University, which led to substantial improvement in trainees’ skills on both subjective and objective assessments. While this is an excellent initial step toward integrating POCUS training into fellowship curriculum, a longer duration is needed to acquire the broader yet essential skill set that we propose and to provide adequate time to practice the acquired skills. As more medical students and residents are trained in POCUS, it is conceivable that the focus of POCUS training during fellowship will shift from “performing” the examinations to “interpreting” them, and the required training time will decrease. To ensure uninterrupted longitudinal training, it would be preferable to have at least 2 nephrology core faculty fully trained and credentialed in POCUS in every fellowship program. The didactic sessions should include an overview of the ultrasound physics, instrumentation, and generation of image. The key ultrasound modes and functions used for image acquisition and optimization should be discussed in detail (eg, B- and M-modes, color Doppler, and depth/gain adjustment). In addition, characteristics of a normal renal sonogram and common sonographic abnormalities should be reviewed. In our program, we have divided the learning objectives/milestones on a 6-month basis (levels I, II, and III in the order of increasing skills) for the first 18 months of fellowship. The rest is reserved for continued practice of the acquired skills (Box 1). The applications listed include those commonly performed by internal medicine physicians.11Soni N.J. Schnobrich D. Matthews B.K. et al.Point-of-care ultrasound for hospitalists: a position statement of the Society of Hospital Medicine.J Hosp Med. 2019; 14: E1-E6PubMed Google Scholar Programs could incorporate an evaluation process to document trainees’ proficiency of ultrasonographic skills by maintaining an online database compliant with regulatory standards (eg, the Health Insurance Portability and Accountability Act [HIPAA]), with integration into the electronic medical record system when applicable.Box 1Learning Objectives of the Point-of-Care Ultrasonography Curriculum for Nephrology TraineesLearning Objectives/MilestonesLevel I•Renal⋄Acquire satisfactory images of the kidneys (native and allograft) and urinary bladder⋄Identify the characteristics of normal kidney and urinary bladder on grey-scale ultrasound•Pulmonary⋄Identify lung scanning zones and acquire satisfactory images⋄Identify normal structures: ribs, rib shadowing, intercostal space, and pleural line⋄Identify pleural sliding⋄Identify A lines•Cardiac⋄Acquire satisfactory images of the 4 views of the heart (parasternal long axis, parasternal short axis, apical 4 chamber, and subxiphoid) and the IVC⋄Identify visualized chambers and valves in each view⋄Differentiate IVC from the aorta⋄Appreciate respiratory variations in diameter of the IVC•Dialysis access⋄AVF: Assess patency, depth, and diameter⋄PD catheter: Identify and trace the tunneled portion, identify shadowing from a normal catheter cuff•Procedures⋄Acquire satisfactory images of central vessels (neck and groin)⋄Differentiate veins from arteries⋄Perform image-guided needle and guidewire placement in real-time for temporary dialysis catheter insertionLevel II•Renal⋄Recognize common abnormalities: hydronephrosis, stone, and cyst⋄Recognize normal anatomic variants that can mimic above pathologies, such as extrarenal pelvis⋄Recognize renal parenchymal abnormalities such as variations in cortical echogenicity and thickness⋄Recognize urinary retention by performing postvoid residual urine assessment⋄Perform basic Doppler scan of the kidney and bladder; appreciate sonographic representation of major vessels and blood flow; identify ureteral jets•Pulmonary⋄Recognize common abnormalities suggestive of hypervolemia: B lines and pleural effusion•Cardiac⋄Able to qualitatively assess cardiac chamber size (left and right ventricles and atria)⋄Able to qualitatively assess left ventricular global and segmental motion⋄Recognize pericardial effusion⋄Measure the maximal diameter of IVC, effectively use M-mode to measure respiratory variations•Dialysis access⋄AVF: Determine access flow using pulsed wave Doppler⋄PD catheter: Recognize common pathologies such as tunnel abscess and pericatheter fluid collections•Procedures⋄Identify appropriate sonographic window and perform transplant kidney biopsy under real-time image guidanceLevel III•Renal⋄Recognize less common abnormalities such as renal mass, angiomyolipoma, etc⋄Assess bladder wall irregularities and abnormal findings in the bladder lumen⋄Perform and interpret pulsed wave Doppler examination of kidney allograft; calculate and understand the limitations of resistive indexes•Pulmonary⋄Recognize pneumothorax, consolidation, and atelectasis⋄Use M-mode to identify presence or absence of pleural sliding•Cardiac⋄Perform M-mode examination to evaluate of the motion of mitral valve leaflets, including E-point septal separation⋄Assess fractional shortening of the left ventricle using M-mode to estimate ejection fraction⋄Assess right ventricular function by determining TAPSE•Procedures⋄Identify appropriate sonographic window and perform native kidney biopsy under real-time image guidance⋄Use ultrasound guidance for cannulation and needle repositioning in patients with difficult arteriovenous accessRequired Number of Studies for Certification/Unsupervised Practicea•ASDIN7Siriopol D. Onofriescu M. Voroneanu L. et al.Dry weight assessment by combined ultrasound and bioimpedance monitoring in low cardiovascular risk hemodialysis patients: a randomized controlled trial.Int Urol Nephrol. 2017; 49: 143-153Crossref PubMed Scopus (40) Google Scholar⋄Performance of at least 80 renal ultrasound studies and interpretation of 125 studies•ACEP Policy Statement11Soni N.J. Schnobrich D. Matthews B.K. et al.Point-of-care ultrasound for hospitalists: a position statement of the Society of Hospital Medicine.J Hosp Med. 2019; 14: E1-E6PubMed Google Scholar (endorsed by AAFP17American Academy of Family PhysiciansRecommended curriculum guidelines for family medicine residents in point of care ultrasound.https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint290D_POCUS.pdfDate accessed: February 4, 2019Google Scholar)⋄At least 25 documented and reviewed cases in each of the core applications with a range of 25-50 cases (urinary tract, cardiac, and thoracic are included in core applications)•ACCP Critical Care Ultrasound Certification18American College of Chest PhysiciansCritical care ultrasonography certification requirements.http://www.chestnet.org/Education/Advanced-Clinical-Training/Certificate-of-Completion-Program/Critical-Care-UltrasonographyDate accessed: February 4, 2019Google Scholar (endorsed by SHM19Society of Hospital MedicinePoint-of-care ultrasound certification requirements.https://www.hospitalmedicine.org/clinical-topics/ultrasonography-cert/Date accessed: February 4, 2019Google Scholar)⋄Abdominal: 4 studies each for left kidney, right kidney, and urinary bladder⋄Lung: 4 studies each demonstrating pleural effusion, lung sliding, and consolidation⋄Cardiac: 10 studies each for the 4 standard views of the heart (parasternal long axis, short axis, apical 4-chamber, and subcostal) and IVC•APCA POCUS Certification Academy20POCUS certification academy by the Alliance for Physician Certification and Advancement.https://apca.org/Pages/default.aspxDate accessed: February 4, 2019Google Scholar⋄20 renal/genitourinary, 20 lung, and 30 cardiac POCUS examinations within the last 2 yearsAbbreviations: AAFP, American Academy of Family Physicians; ACCP, American College of Chest Physicians; ACEP, American College of Emergency Physicians; APCA, Alliance for Physician Certification and Advancement; ASDIN, American Society of Diagnostic and Interventional Nephrology; AVF, arteriovenous fistula; IVC, inferior vena cava; PD, peritoneal dialysis; POCUS, point-of-care ultrasonography; SHM, Society of Hospital Medicine; TAPSE, tricuspid annular plane systolic excursion.aAs recommended by a certification agency/professional organization. Items listed are in addition to other requirements, such as completing online modules and attending workshops. Level I•Renal⋄Acquire satisfactory images of the kidneys (native and allograft) and urinary bladder⋄Identify the characteristics of normal kidney and urinary bladder on grey-scale ultrasound•Pulmonary⋄Identify lung scanning zones and acquire satisfactory images⋄Identify normal structures: ribs, rib shadowing, intercostal space, and pleural line⋄Identify pleural sliding⋄Identify A lines•Cardiac⋄Acquire satisfactory images of the 4 views of the heart (parasternal long axis, parasternal short axis, apical 4 chamber, and subxiphoid) and the IVC⋄Identify visualized chambers and valves in each view⋄Differentiate IVC from the aorta⋄Appreciate respiratory variations in diameter of the IVC•Dialysis access⋄AVF: Assess patency, depth, and diameter⋄PD catheter: Identify and trace the tunneled portion, identify shadowing from a normal catheter cuff•Procedures⋄Acquire satisfactory images of central vessels (neck and groin)⋄Differentiate veins from arteries⋄Perform image-guided needle and guidewire placement in real-time for temporary dialysis catheter insertion Level II•Renal⋄Recognize common abnormalities: hydronephrosis, stone, and cyst⋄Recognize normal anatomic variants that can mimic above pathologies, such as extrarenal pelvis⋄Recognize renal parenchymal abnormalities such as variations in cortical echogenicity and thickness⋄Recognize urinary retention by performing postvoid residual urine assessment⋄Perform basic Doppler scan of the kidney and bladder; appreciate sonographic representation of major vessels and blood flow; identify ureteral jets•Pulmonary⋄Recognize common abnormalities suggestive of hypervolemia: B lines and pleural effusion•Cardiac⋄Able to qualitatively assess cardiac chamber size (left and right ventricles and atria)⋄Able to qualitatively assess left ventricular global and segmental motion⋄Recognize pericardial effusion⋄Measure the maximal diameter of IVC, effectively use M-mode to measure respiratory variations•Dialysis access⋄AVF: Determine access flow using pulsed wave Doppler⋄PD catheter: Recognize common pathologies such as tunnel abscess and pericatheter fluid collections•Procedures⋄Identify appropriate sonographic window and perform transplant kidney biopsy under real-time image guidance Level III•Renal⋄Recognize less common abnormalities such as renal mass, angiomyolipoma, etc⋄Assess bladder wall irregularities and abnormal findings in the bladder lumen⋄Perform and interpret pulsed wave Doppler examination of kidney allograft; calculate and understand the limitations of resistive indexes•Pulmonary⋄Recognize pneumothorax, consolidation, and atelectasis⋄Use M-mode to identify presence or absence of pleural sliding•Cardiac⋄Perform M-mode examination to evaluate of the motion of mitral valve leaflets, including E-point septal separation⋄Assess fractional shortening of the left ventricle using M-mode to estimate ejection fraction⋄Assess right ventricular function by determining TAPSE•Procedures⋄Identify appropriate sonographic window and perform native kidney biopsy under real-time image guidance⋄Use ultrasound guidance for cannulation and needle repositioning in patients with difficult arteriovenous access •ASDIN7Siriopol D. Onofriescu M. Voroneanu L. et al.Dry weight assessment by combined ultrasound and bioimpedance monitoring in low cardiovascular risk hemodialysis patients: a randomized controlled trial.Int Urol Nephrol. 2017; 49: 143-153Crossref PubMed Scopus (40) Google Scholar⋄Performance of at least 80 renal ultrasound studies and interpretation of 125 studies•ACEP Policy Statement11Soni N.J. Schnobrich D. Matthews B.K. et al.Point-of-care ultrasound for hospitalists: a position statement of the Society of Hospital Medicine.J Hosp Med. 2019; 14: E1-E6PubMed Google Scholar (endorsed by AAFP17American Academy of Family PhysiciansRecommended curriculum guidelines for family medicine residents in point of care ultrasound.https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint290D_POCUS.pdfDate accessed: February 4, 2019Google Scholar)⋄At least 25 documented and reviewed cases in each of the core applications with a range of 25-50 cases (urinary tract, cardiac, and thoracic are included in core applications)•ACCP Critical Care Ultrasound Certification18American College of Chest PhysiciansCritical care ultrasonography certification requirements.http://www.chestnet.org/Education/Advanced-Clinical-Training/Certificate-of-Completion-Program/Critical-Care-UltrasonographyDate accessed: February 4, 2019Google Scholar (endorsed by SHM19Society of Hospital MedicinePoint-of-care ultrasound certification requirements.https://www.hospitalmedicine.org/clinical-topics/ultrasonography-cert/Date accessed: February 4, 2019Google Scholar)⋄Abdominal: 4 studies each for left kidney, right kidney, and urinary bladder⋄Lung: 4 studies each demonstrating pleural effusion, lung sliding, and consolidation⋄Cardiac: 10 studies each for the 4 standard views of the heart (parasternal long axis, short axis, apical 4-chamber, and subcostal) and IVC•APCA POCUS Certification Academy20POCUS certification academy by the Alliance for Physician Certification and Advancement.https://apca.org/Pages/default.aspxDate accessed: February 4, 2019Google Scholar⋄20 renal/genitourinary, 20 lung, and 30 cardiac POCUS examinations within the last 2 years Abbreviations: AAFP, American Academy of Family Physicians; ACCP, American College of Chest Physicians; ACEP, American College of Emergency Physicians; APCA, Alliance for Physician Certification and Advancement; ASDIN, American Society of Diagnostic and Interventional Nephrology; AVF, arteriovenous fistula; IVC, inferior vena cava; PD, peritoneal dialysis; POCUS, point-of-care ultrasonography; SHM, Society of Hospital Medicine; TAPSE, tricuspid annular plane systolic excursion. aAs recommended by a certification agency/professional organization. Items listed are in addition to other requirements, such as completing online modules and attending workshops. After successful completion of POCUS training during fellowship, the trainees should be able to demonstrate optimal generation of ultrasound images using the transducer and imaging system and thoroughly interpret common sonographic pathologies encountered in renal, lung, and cardiac sonography, including IVC assessment. At the same time, they should be able to appreciate the limitations of a focused study and indications for follow-up studies and radiology consultation. To date, assessment of competency in POCUS has not been well established. Even among the emergency medicine residency programs in which POCUS training is almost universal, there exists substantial variation in the methods of competency assessment.12Amini R. Adhikari S. Fiorello A. Ultrasound competency assessment in emergency medicine residency programs.Acad Emerg Med. 2014; 21: 799-801Crossref PubMed Scopus (54) Google Scholar Even in terms of the minimum number of procedures required, guidelines vary significantly among professional associations. For example, the 2008 American College of Emergency Physicians (ACEP) policy statement on emergency ultrasound recommends at least 25 documented and reviewed cases in each of the core applications.13American College of Emergency PhysiciansEmergency ultrasound guidelines.Ann Emerg Med. 2009; 53: 550-570Abstract Full Text Full Text PDF PubMed Scopus (481) Google Scholar ASDIN certification in “comprehensive” renal sonography requires documented interpretation of at least 125 and performance of 80 renal ultrasound studies (including bladder and transplanted kidneys).9The American Society of Diagnostic and Interventional NephrologyApplication for certification in renal ultrasonography.https://cdn.ymaws.com/www.asdin.org/resource/resmgr/Cert_Recert_Updates/Renal_Ultrasound_Application.pdfDate accessed: February 4, 2019Google Scholar With further integration of POCUS into the training programs over time, more data on the minimum number of scans are likely to emerge. In our program, we use 40 scans per application as a standard (ie, renal, lung, basic echocardiogram, and IVC assessment). In addition, using ultrasound guidance for placement of 10 nontunneled dialysis catheters and at least 10 native and 5 transplant kidney biopsies would likely aid in achieving the desirable level of competence in programs that train fellows in these procedures. Having said that, competency is not just about the number of studies, and in our program, we monitor error rates through a quality assurance process that involves both providing feedback in real time by the bedside and retrospective review of the saved images performed by each trainee using standardized tools. The main barriers to the development and administration of a POCUS curriculum for nephrology fellows are lack of adequately trained faculty, financial limitations, and faculty time constraints. In addition to attending workshops organized by professional societies, a multidisciplinary approach in collaboration with other specialties with established POCUS programs (eg, emergency medicine physicians and critical care specialists) may prove beneficial in the initial stages of designing a curriculum. This would allow nephrology faculty to perform a higher number of procedures under supervision until they acquire competence and confidence in teaching trainees and also help with the certification and credentialing process. Lack of divisional resources for procuring the ultrasound equipment represents another potential obstacle. Sharing the costs with other interested divisions or departments could be helpful. In addition, billing for studies can help offset startup costs. Moreover, highly portable hand-held devices are being introduced to the market; while being more affordable than conventional machines, many offer most of the commonly used functionalities such as color Doppler. Incorporating relative value unit–based performance metrics or other incentive systems by the institutions would help ensure productivity and help procure reimbursement. Finding a room for training should not be a major hurdle. For instance, we use a regular office room with a computer and a foldable bed to store the machine and train our residents and fellows. Although liability due to missed diagnoses is often brought up as a barrier, this has not been reported as an issue in the experience of centers in which nephrologists routinely perform renal ultrasonography.14Niyyar V.D. O'Neill W.C. Point-of-care ultrasound in the practice of nephrology.Kidney Int. 2018; 93: 1052-1059Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar With mounting evidence on the impact of POCUS on increased patient satisfaction,15Lindelius A. Törngren S. Nilsson L. Pettersson H. Adami J. Randomized clinical trial of bedside ultrasound among patients with abdominal pain in the emergency department: impact on patient satisfaction and health care consumption.Scand J Trauma Resusc Emerg Med. 2009; 17: 60Crossref PubMed Scopus (30) Google Scholar, 16Howard Z.D. Noble V.E. Marill K.A. et al.Bedside ultrasound maximizes patient satisfaction.J Emerg Med. 2014; 46: 46-53Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar hospital administrators may realize the importance of incorporating POCUS into internal medicine and medical subspecialty practices and may help support these programs. This proposal reflects our perspective based on our experience and review of existing data, which primarily stem from the emergency medicine literature. As nephrology fellowship programs continue to incorporate POCUS into their curricula, more data on its impact on patient care will need to be gathered to guide the development of a comprehensive nationwide curriculum endorsed by professional and educational organizations such as the Accreditation Council for Graduate Medical Education (ACGME). Instead of reinventing the wheel altogether, it would be prudent to form a work group comprising nephrologists and emergency physicians to formally design the blueprint of a nephrology-oriented POCUS curriculum, oversee its implementation, and assess its outcomes. Abhilash Koratala, MD, Mark S. Segal, MD, and Amir Kazory, MD. None. The authors declare that they have no relevant financial interests. Received November 11, 2018. Evaluated by 2 external peer reviewers, with direct editorial input from an Associate Editor and a Deputy Editor. Accepted in revised form February 11, 2019. Integrative Point-of-Care Ultrasound Curriculum to Impart Diagnostic Skills Relevant to NephrologyAmerican Journal of Kidney DiseasesVol. 73Issue 6PreviewIn the past decade, point-of-care ultrasound (POCUS) has shown tremendous potential to supplement bedside patient assessment.1 POCUS provides real-time data in a timely manner without incurring high monetary costs, engages patients in understanding the complexities of their condition, and empowers physicians to educate, strengthening the patient-physician relationship. However, multisystem diagnostic POCUS education is not generally included in nephrology fellowship curricula. We developed a nephrology-specific POCUS curriculum designed to address common clinical scenarios encountered by nephrologists and implemented it in the Johns Hopkins University Nephrology Fellowship. Full-Text PDF