Online preceptor for non-clinical ultrasounds?

[FamilymedMD]

A few of us independent solo or small group family docs in our area are working on adding Point of Care Ultrasound (POCUS) but are having a hard time hiring a local or online preceptor to review scans we've done so we can get enough precepted scans to satisfy our med mal carrier.

We've already had courses, have the equipment (mostly Butterflys) and are piling up scans but have yet to find a preceptor to review them with us. These are scans that we've done for our own training, not clinical decision making, often with later imaging or clinical outcomes for comparison and reviewed at a later date so state licensing and med mal shouldn't be an issue.

Any EM or FM faculty that would be interested in helping us get POCUS going in our area? Once we have enough of us "competent", we can train each other.

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[septoplasty]

So indirectly related, but how do ya'll plan on using this? Will you be billing for it? Will you be able to interpret with enough detail to be able to bill for it? Or is this just a prelim scan you're doing prior to a formal radiology read? And if you are not getting them read by Radiology, is your medmal covering this scenario?

Just thoughts because I haven't seen this type of scenario, but would love for PCP's to get into this sort of thing (with Radiology oversight of course).

 

[FamilymedMD]

So indirectly related, but how do ya'll plan on using this? Will you be billing for it? Will you be able to interpret with enough detail to be able to bill for it? Or is this just a prelim scan you're doing prior to a formal radiology read? And if you are not getting them read by Radiology, is your medmal covering this scenario?

Just thoughts because I haven't seen this type of scenario, but would love for PCP's to get into this sort of thing (with Radiology oversight of course).

I plan on using it somewhat like it's been used for years in the ED but hopefully with less trauma cases. I expect I'll be scanning a lot more lungs soon, the data suggest it's more accurate than chest x-ray for pneumonia.

I own an affordable Direct Primary Care (DPC) practice and we typically don't bill for most things done in office but whether or not to bill for Point of Care Ultrasound is up to each practice. What the payers will do is beyond our control.

Depending on the clinical circumstances and my patient's preferences, I wouldn't think most scans would need to have a comprehensive ultrasound at radiology. Like EKGs, I'll send them out if unclear or if the case warrants it.

This whole issue came up because I asked my medmal about coverage and I'm the first primary care doc here to ask them (Maine's a small state) so we negotiated this based on evolving Family Med standards which mostly copy the ACEP guideline.

"with Radiology oversight of course" - Why would you assume or want that? Does radiology oversee ED point of care ultrasound? Should a surgeon oversee my skin biopsies or cardiology my office EKGs?

 

[septoplasty]

"with Radiology oversight of course" - Why would you assume or want that? Does radiology oversee ED point of care ultrasound? Should a surgeon oversee my skin biopsies or cardiology my office EKGs?

Well, biggest reason is your liability. Should you miss something (which happens to be the #1 reason PCPs get litigated*), the jury of your peers (most of whom don't do PoC US) and a radiologist will come and say "oh, that's easy, I would have caught that on the scan".

This is similar to you interpreting your own radiographs. Yea, we can all ready CXR's very well, but does that mean its as good as a Radiogist in the eyes of the court? (The answer is, no), thus, we still send it off for a formal read.

*Reference: AAFP

 

[FamilymedMD]

I'm well aware of the liability risk, that's why I contacted my medmal to ensure coverage, etc.

Defensive medicine is real but EM physicians have somehow been doing POCUS for years without radiology overreads.

I was intrigued and looked for data on POCUS and medmal. There are only a few studies but, given the huge changes and expansion in POCUS, there will likely be more in the next few years. In these two studies, failure to perform POCUS generated more lawsuits than misinterpreting.

West J Emerg Med. 2015 Jan;16(1):1-4. doi: 10.5811/westjem.2014.11.23592. Epub 2014 Dec 12.
A review of lawsuits related to point-of-care emergency ultrasound applications.

We conducted a retrospective review of all United States reported state and federal cases in the Westlaw database.
We identified five cases. All reported decisions alleged a failure to perform an ultrasound study or a failure to perform it in a timely manner. All studies were within the scope of emergency medicine and were ACEP emergency ultrasound core applications. A majority of cases (n=4) resulted in a patient death. There were no reported cases of failure to interpret or misdiagnoses.

In a five-year period from January 2008 through December 2012, five malpractice cases involving EPs and ultrasound examinations that are ACEP core emergency ultrasound applications were documented in the Westlaw database. All cases were related to failure to perform an ultrasound study or failure to perform a study in a timely manner and none involved failure to interpret or misdiagnosis when using of POC ultrasound.

J Perinatol. 2016 Sep;36(9):784-6. doi: 10.1038/jp.2016.66. Epub 2016 Apr 14.
Analysis of lawsuits related to point-of-care ultrasonography in neonatology and pediatric subspecialties.

Our search criteria returned 468 results; 2 cases were determined to be relevant to the study objective. The two cases alleged a failure to perform a diagnostic test and implicated POCUS as an option. There were no cases of neonatologists and PSS being sued for POCUS performance or interpretation.
This study of a major legal database suggests that POCUS use and interpretation is not a significant cause of lawsuits against neonatologists and PSS.

 

[VA Hopeful Dr]

This quarter's SCAFP magazine had something that might be helpful for you. It might take some doing since you aren't in state, but its worth looking into:

SOM Library: ICARED Rural Primary Care Ultrasound Training: About

SOM Library: ICARED Rural Primary Care Ultrasound Training: About

uscmed.sc.libguides.com

 

[FamilymedMD]

Thanks, actually I took a course at their institute last year and have spent most of this year working with or waiting for them as they contemplate online precepting. Nice docs and good instructors but with all the institutional inertia and IT Dept. hassles you might expect from a combined VA and university setting.

 

[VA Hopeful Dr]

Thanks, actually I took a course at their institute last year and have spent most of this year working with or waiting for them as they contemplate online precepting. Nice docs and good instructors but with all the institutional inertia and IT Dept. hassles you might expect from a combined VA and university setting.

The VA is what it is, but believe it or not the USC part used to be better (I graduated from there a few years back). It all went south when the university medical group merged with a local hospital system which itself then merged with a hospital system in a different part of the state.

Prior to that, things actually got done pretty efficiently.