LAUSR

TO THE EDITOR: Marbach and colleagues' review (1) and Flint and Siegel's editorial (2) note that the use of point-of-care ultrasonography (POCUS), including focused cardiac ultrasonography, has rapidly expanded in recent years and is of increasing interest to internists. Marbach and colleagues highlight how focused cardiac ultrasonography helps improve the identification of left ventricular dysfunction and clinically significant cardiac valvular abnormality compared with routine physical examination. Both their review and the editorial describe the potential for cost savings using ultrasonography at the bedside. I would add that internists are also successfully and increasingly using POCUS to augment the physical examination in other ways, such as by identifying urinary obstruction, ascites, pleural and joint effusions, venous thromboses, and abscesses (3). Point-of-care ultrasonography is often less complicated than a cardiac assessment and still provides timely, clinically relevant data that offer similar potential advantages in terms of cost and diagnostic accuracy. However, as Flint and Siegel's editorial reminds us, widespread adoption of POCUS by internists for cardiac and other examinations has been limited by unresolved issues (including lack of standardization and difficult-to-quantify benefits in cost and outcomes) (2). Add to these concerns the amount of time needed to learn and practice new applications, a lack of clear credentialing pathways, uncertainty about how best to show competency, and variable institutional support, and the reasons internists have been slow adopters become clear. These obstacles are not unique to our field; early users of POCUS in emergency medicine experienced similar challenges. Informed by their own body of literature, the American College of Emergency Physicians addressed these concerns through a series of guidelines that now outline POCUS applications, quality management, and training and credentialing pathways that have led to increasing POCUS utilization and outcomes-driven research by emergency medicine practitioners (4). We in internal medicine can do the same. Reviewing the available evidence and highlighting the obstacles to using POCUS as Marbach and colleagues and Flint and Siegel have done is a major step in the right direction. Their work should pave the way for further outcomes-based research to be undertaken and published and will ideally lead to guidance from our own internal medicine organizations on the best use of POCUS.