In order to become competent in critical care ultrasonography (CCUS), the intensivist must access effective training, as competence is the goal of training. This chapter summarizes some aspects of training in CCUS that may be useful to two distinct groups: the frontline clinician who has decided to develop competence in CCUS and the faculty who are responsible for providing training to their colleagues.

Individual intensivists who seek training face different challenges depending on their function within the medical hierarchy. Physicians in training, such as residents or fellows, are in a good position, as they have the time and assignment to acquire a wide variety of skills intrinsic to critical care medicine, one of which includes CCUS. Only if there are no capable faculty available to provide them with training will they have difficulty in achieving this goal. Unfortunately, this is still the case in many fellowship training programs both in North America and Europe and will only be remedied in coming years by faculty development aided by the establishment of requirements for provision of training in CCUS at the fellowship level.

The attending level intensivist faces the challenge of obtaining training in CCUS while balancing the demands of the workplace, family life, and economic pressures. Some attending level intensivists come from an adverse training environment. They may work in a geographically isolated hospital surrounded by unfriendly colleagues from other specialties who are not interested in helping a co-worker develop a new skill. Others may be more fortunate and work in a hospital where knowledgeable radiology and cardiology colleagues are interested in providing local expertise for supervision of training.

There are several approaches that are effective when considering training. If a resident or fellow is in a program that provides formal training in CCUS, competence is achieved as a normal part of critical care training. If the program is not able to provide this, the fellow is in the same position as the attending who seeks training following their fellowship years. This group frequently develops competence using an “on the job” approach. In this case, the clinician works in a friendly training environment where they are supported by an informal network of colleagues.

Training in CCUS requires skills in image acquisition, image interpretation, and mastery of the cognitive elements of the field. Mastery of image acquisition is a key skill required for CCUS, as the frontline intensivist personally performs all parts of the ultrasound examination. Training in image acquisition requires partnering with a skilled ultrasonographer in combination with regular deliberate practice, initially on normal models followed by the scanning of patients. For “on the job” training, the learner may seek the help of highly skilled ultrasound technicians who, particularly in the United States, perform much of cardiology and radiology image acquisition. Widespread use of ultrasound technicians is common in the United States, while in Europe it is common for the physician to perform both image acquisition and interpretation. For training in image interpretation, the intensivist may partner with local experts from the disciplines of radiology or cardiology side. The cognitive elements required for competence in CCUS are now widely available in course materials, articles, and textbook formats. A self-designed program at the local level is both feasible and effective as a training option, but cannot be achieved if the intensivist works in an adverse training environment. The main obstacle to the “on the job” approach is that it is relatively inefficient compared to engaging in an organized training program that is specifically designed for mastery of CCUS.

A clear definition of competence is a key element for training, as it defines the goals of training. If the goals of training are explicitly defined, this facilitates the development of a training program designed to provide competence. A definition of competence establishes specific learning objectives for both course design and bedside training, it leads to a definition of scope of practice and it is needed for the development of competency based testing.

In 2009, a working group from the American College of Chest Physicians (ACCP) and the Societe de Reanimation de Langue Francaise (SRLF) defined the elements of CCUS that were required for competence in CCUS.¹ The Statement on Competence in Critical Care Ultrasonography provides a roadmap for faculty who are tasked with developing training programs and for the individual intensivist who is interested in training in CCUS. While other working groups have developed important summaries of the field,^2,3,4 the ACCP/SRLF document is instead designed to address a basic question in developing training standards: what constitutes competence in CCUS. The Statement on Competence sets out the goals of training in a simple and user friendly manner, and is useful both for the individual who seeks training for competence in CCUS and for faculty who are responsible for the design of training systems. The document fills the need for an explicit definition of competence, so that it is designed to be used as a practical guide for goals of training.

The Statement on Competence describes a standard for competence that does not include many useful applications of ultrasonography that are discussed in this textbook. Instead, it defines a skill set that would meet the usual operational needs of a frontline intensivist. This should not discourage the learner from developing an advanced ultrasound skill that has utility to a specific practice situation.

In follow-up to the ACCP/SRLF Competence Statement, the European Society of Intensive Care (ESICM) organized an expert roundtable meeting to reach an international consensus on training in CCUS. Representatives from the Asia-Pacific, South America, the Middle East, and most countries of the European Union were in attendance. North America was represented by the ACCP, the American Thoracic Society, the Society for Critical Care Medicine (SCCM), and the Canadian Critical Care Society. The resulting document, entitled Training in Critical Care Ultrasonography, is designed to provide guidance to the critical care community in developing training in CCUS.⁵ The working group recognized that there was a relative paucity of definitive literature on the subject of training except for some related to critical care echocardiography (CCE). As a result, the recommendations were formulated as suggestions to help guide training effort. However, there was agreement on several issues:

1. 
   

   The ACCP/SRLF Statement on Competence was designated as the foundation document to guide training; i.e., the goals of training are explicitly defined in the Statement on Competence.

   
   
2. 
   

   CCUS should be a required part of critical care training.

   
   
3. 
   

   CCE should be divided into basic and advanced CCE. Basic CCE is a required part of general critical ultrasonography; advanced CCE requires an extensive course of study and is an optional component of training.

   
   
4. 
   

   General CCUS (including basic CCE) requires no formal certification process to establish competence.

   
   
5. 
   

   Advanced CCE requires a formal certification process to recognize competence.

The opinion of the working group was that CCUS should be considered as a routine part of the scope of practice of critical care, and so requires no special recognition through certification. The cost and complexity of developing the process of certification is prohibitive. Also, setting up a complex national level certification system would imply that other standard parts of critical care practice (e.g., vascular access, ventilator management, pleural access, and airway management) would logically be subjected to the same standard. This is not the case. As a result, it is unlikely that this type of certification will be developed in the United States or elsewhere.

Given the complexity of advanced CCE, this component of CCUS requires the development of a formal certification process. A certification process for advanced CCE would need to be developed and administered by a national level agency that is independent of any training group. In the United States, such Certification would be under the aegis of the National Board of Echocardiography. A process for certification in advanced CCE has already been developed in France and Australia. It is possible that this may occur in the United States. The Training Statement offers recommendations for the design of training in CCUS and advanced CCE that are summarized in Tables 4-1 and 4-2. These may helpful to both faculty and learners in the design of training.