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The National Board of Echocardiography has developed an examination to assess echocardiography and ultrasound skills, which are required by many medical programs. Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, was joined by Sara Nikravan, MD, FASE, FCCM, at the 2023 Critical Care Congress to discuss advanced echocardiography and the National Board of Echocardiography examination. Sara Nikravan, MD, FASE, FCCM, is director of point-of-care ultrasound and associate program director of residency at the University of Washington in Seattle, Washington, USA. This podcast is sponsored by Echonous.
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This podcast is sponsored by Echonous, maker of the Cosmos Handheld Ultrasound. Cosmos is redefining point-of-care ultrasound by bringing the power of AI and advanced features like CW, PW, and auto VTI trace to a handheld device. Critical care practitioners can now do more with the handheld system than ever before. Cosmos uses trusted technology and works on compatible iOS and Android tablets. Learn more about Cosmos by visiting echonous.com/podcast.
Dr. McLaughlin: Hello, and welcome to the 2023 Critical Care Congress edition of the Society of Critical Care Medicine Podcast. I’m your host, Diane McLaughlin. Today, I’m joined by Sara Nikravan, MD, FASE, FCCM, to discuss advanced echocardiography and the NBE board exam. Dr. Nikravan is a director of point-of-care ultrasound and associate program director of residency at the University of Washington in Seattle, Washington. Welcome, Dr. Nikravan.
Dr. Nikravan: Thanks, Diane. Thanks for having me.
Dr. McLaughlin: Do you have any disclosures before we get started?
Dr. Nikravan: I don’t have any disclosures. But something I’m proud of, I was inducted last night as a fellow of the American College of Critical Care Medicine, so I’m now FCCM too, which is great.
Dr. McLaughlin: Awesome. Congratulations.
Dr. Nikravan: Thank you so much.
Dr. McLaughlin: I’m excited that we’re here to talk about the SCCM Critical Care Echocardiography Review Course. I think a lot of people don’t know that this exists yet. Can you talk a little bit about how it got started?
Dr. Nikravan: About, I would say, six or seven years ago, we were in this strange place with critical care echocardiography and ultrasound, where a lot of the faculty, a lot of the learners, didn’t have any kind of formatted way to assess their competency. A lot of programs were requiring that people be competent in ultrasound and echocardiography, but they didn’t have any structured learning in place. So a lot of the expert leaders from a number of different societies, American Society of Echocardiography, Society of Critical Care Medicine, American College of Chest Physicians, American College of Emergency Medicine, American Society of Anesthesiology, you name it, all of these societies basically had expert leaders who really wanted to help our learners understand their own competency and give a pathway for quality assurance, so we thought that there needed to be some sort of certification process in place. I think the National Board of Echocardiography really heard us and they answered the call by creating this critical care echocardiography examination to assess competency and provide some quality control.
Dr. McLaughlin: That’s a pretty impressive group of organizations, and that way it’s even across the board. So emergency medicine doesn’t have a different examination or competency process in critical care medicine or actual echocardiography from ASE.
Dr. Nikravan: Yeah, exactly. I think we really wanted to make sure that we pulled in the expertise of all these different thought leaders into creating something that would work for everybody. Yeah, it’s a pretty impressive list of societies and really exciting that we could get some level of agreement between them all.
Dr. McLaughlin: I don’t know that much about the examination itself, but I’ve picked up from colleagues and faculty at the ultrasound course that this is legitimately a difficult examination. Can you talk a little bit about that?
Dr. Nikravan: Yes, it is. I mean, it’s comprehensive, and, although there are some basic components to it, there is some advanced ultrasound and echocardiography as part of it. I took the test too, and I’ll tell you I studied for it. I think if you don’t study for it, you’re going to find yourself in a little bit of a challenging, maybe nerve-wracking situation when sitting down for the exam.
Dr. McLaughlin: Is there any particular area on the examination that you weren’t expecting? It sounds like you studied and did fine, but for somebody who’s just hearing about this and is like, Oh, I’ve been scanning patients for years, it’ll be fine, that they might be surprised to learn is on there?
Dr. Nikravan: It’s a comprehensive critical care ultrasound exam; what that means is it has components of all ultrasound as it relates to critical care medicine. It’s echocardiographically heavy, with advanced measurements and assessments. The other thing that I think is important to recognize is a lot of the questions are two-step deductive reasoning questions. So you may know what the image is, but then you have to pull in the clinical context from the stem of the question to come up with the ultimate answer. For example, you may know what the echocardiographic findings of tamponade are, but do you know how that may change when the patient has chronic right heart disease and pulmonary hypertension? It’s that two-step approach that a lot of these advanced exams are going for.
Dr. McLaughlin: This is a didactic exam. How do you sign up for it? Is it offered multiple times per year?
Dr. Nikravan: Yeah, it is a didactic exam. It’s offered through the National Board of Echocardiography. You can go to their website, it’s echoboards.org. When you go to the website, there’ll be a tab that says exams. When you click it, all of the exams they offer pop up with the exam dates and exam fees, and you can pick the critical care echo exam. The exam is offered once a year. It’s usually in the wintertime, so it’s usually in January. This year it’s coming up in about a week or so. It’s January 31st of this year. It’s kind of a joint venture in that you have this exam that you can take. It is a didactic exam, but you also have to submit a log of the amount of exams you’ve done and they provide an example sheet of what that log should look like. I would encourage folks who are interested in taking the exam and getting board certified to go and take a look at that example sheet and start putting together their log in preparation for submission.
Dr. McLaughlin: Are there any other specific requirements? I’m just going to throw out there, I know as a nurse practitioner, I would love to take some of these things just to say, Oh, I know some of this, look, but I know that we’re not part of the group that can take it; it’s physicians. Any specialty or do you have to work in critical care?
Dr. Nikravan: It’s any specialty. I think you just have to have a medical license, if I’m not mistaken, like a medical doctorate.
Dr. McLaughlin: Then, minimum hours required with hands-on probe?
Dr. Nikravan: They don’t really say that there’s a minimum time required with hands-on probe, but they have different kind of requirements for board certification based on where you are in your career pathway. So as long as you have a medical license of some sort and you have been on a training pathway, they have different requirements for if you’re coming out of medical training from fellowship, for example, as opposed to if you’ve been in practice. I would just encourage folks to go online and review those different pathways in order to see where they would fit in within the process.
Dr. McLaughlin: I remember when we started talking about this, six or seven years ago on the ultrasound committee, and I know that we sent a lot of our leaders to be involved with the formation and development of this examination, and SCCM has now developed a course. Do you want to talk about the course at all?
Dr. Nikravan: Yes. Full disclosure: I’ve been the chairperson of this course for the last two years, and I really think it’s a wonderful course. We started it back in 2018 in response to the first NBE exam. We really had no idea what was going to be on the exam because the exam had never been offered; none of us had had the opportunity to take it or be involved in any way with question writing as that would obviously be a conflict of interest. The course occurs every November in Chicago. It’s also available online, but there is an in-person component of it. We just finished it this past November and we are holding it close to O’Hare, so it’s easy for people to come in and go out. It’s very comprehensive. It is advanced. I don’t really recommend it for someone without any experience in critical care ultrasound because it is advanced.
The teachers who are the faculty are expert leaders in critical care, in pulmonary critical care, in cardiology, in emergency medicine, and in surgery. We have one of the former past presidents of the American Society of Echocardiography as one of the faculty for the course, so it’s very high level. It’s about three days, and it starts on the more fundamental topics and then gets really more advanced, even talking about things like diastology, valvular disease, congenital heart disease, pericardial disease, things like that, because the exam is very echo-heavy. It’s offered once a year in November, but if you can’t make it in person, there’s, of course, the online component to it. I believe next year it’s going to be November 14th through 16th. We’re talking about 2023 in Chicago.
Dr. McLaughlin: That’s nice, because it’s only a month or, I guess, two months prior to the exam being offered, so it’ll be fresh.
Dr. Nikravan: That’s right. That was our goal in timing it the way that it was, not to overburden you right before but give you enough time to go over everything with a refresher.
Dr. McLaughlin: It’s not meant to be introductory, it should be a review for the people who are attending.
Dr. Nikravan: Absolutely. That’s a lot.
Dr. McLaughlin: It is a lot. How do you get there? If you’re just starting in ultrasound and echo, how do you go from that introductory to expert-level echocardiography, thinking about taking a certification course?
Dr. Nikravan: Some people say to me, How do I get started with critical care ultrasound or critical care echo? My answer is kind of dumb. It’s very simple. You just get started; you just have to do it. You have to find your patients who you think maybe the stakes aren’t super high, scan them, you need validation, you can always get a formal exam and then compare your findings to that formal exam if you don’t have an immediate proctor standing next to you to tell you what’s going on. So if you were planning on getting a formal exam anyway, get the formal exam, but also scan them beforehand so that you can compare your findings. That’s one way.
I think the first hard part about ultrasound is image acquisition and tactile ability. How do you get a view, what do you do to manipulate the probe to optimize that view? But what’s way harder than that—at first, you think that’s what’s hard, right? But what’s way harder than that is actually interpreting the findings that you have, knowing when to trust them, knowing when not to trust them, knowing how to incorporate them with all the other things that you’re doing. That is why reading, getting involved in courses, going to national conferences, going and watching cases, getting on Twitter even, listening to podcasts, seeing, getting information on cases and continuing that longitudinal learning is super important for this. It’s like all the things we do in medicine. We never just do something and say, Oh, we’re an expert, right?
Dr. McLaughlin: Yeah. You don’t sit down and start playing Rachmaninoff on the piano if you haven’t learned scales.
Dr. Nikravan: Exactly right. That’s the same thing. It’s a use-it-or-lose-it skill. If you stop doing it, you forget. So you just have to keep doing it. I think, for those of us who have been doing this a lot, we know that, in order to maintain your skills, you probably should be doing about 50 exams every year.
Dr. McLaughlin: That’s full exams?
Dr. Nikravan: That’s comprehensive to your clinical questioning. This is the beauty of ultrasound, and I think what we’ve endorsed through the study of critical care medicine is it can be basic if your questions are basic and the picture is basic. But if the patient’s very complicated, if you have a patient with sepsis and RV failure, that’s hard and you can’t be basic with that. But maybe you have a patient who comes in and they’re at the very beginning of sepsis or they’ve had some sort of traumatic injury and you’re just trying to decide whether you can give them fluids or not. That may be more basic at the very beginning than later after they’ve been in the ICU for three days and you’re trying to figure out, Will they tolerate the fluid? Not, Will they respond to it, but will they tolerate the fluid? And if they tolerate it, are you still going to be able to extubate them or not? That is where you have to be able to move on to the more advanced parts of ultrasound basically, critical care ultrasound, that is.
Dr. McLaughlin: I love the advice of doing an examination yourself and then getting the formal echo, because that’s a question that comes up frequently. You probably have this, where people want to send you all of their scans, like via text message or try to email these to you. But that’s probably the best way for people who don’t have resources in their home institution. I thought that was great advice. Moving forward, once you start to develop these skills, you’re doing 50 examinations a year. At what point do you see somebody transitioning to, I’m going to sit for this board certification?
Dr. Nikravan: I’ve had learners come to the board review course and say, I just came here to get more information, then after the board review course, say, I got a lot of information here and I think I’m ready to take this test. I think some of it is having a leap of faith in yourself, and some of it is not thinking you have to be perfect to take something. I think that if you’re getting the experience, you’re doing the scans, you want to get the certification, then you set the deadline and you work toward it. I think because we’re perfectionists, oftentimes we say, Well, I don’t know, I still don’t know this one little thing, I may not be ready. But you’ll be surprised. I do think, even with the disclosures I shared with you, that this board review course will prepare you for the exam. We have had learners come and tell us that.
Dr. McLaughlin: I’ve heard some chatter that there might be a hands-on portion added in the future.
Dr. Nikravan: Yes. We did a poll this past November because we thought it may be a really nice way to consolidate the learning. You’re getting the didactic learning, and then these are the folks who really want to be able to do the advanced assessments. Could we consolidate that learning by having them apply it hands-on? Everybody in the room pretty much raised their hands and said they wanted it. So we’re working to see if we can add a hands-on component to the course. Hopefully for this next year, I can’t really promise that yet, whether it’ll be this year or the following year, but I’m hopeful that we could get it done by this next year.
Dr. McLaughlin: We talked a little bit with Dr. Bain about what is in the advanced course, but I’m just going to have you repeat in case people listen to that one and not the other about what skills are offered.
Dr. Nikravan: There are a number of different skills. I think advanced hemodynamic assessments is one of the big ones that people go after, advanced left ventricular and right ventricular assessments. Transesophageal echocardiography is a big one that people want exposure to that we like to offer. For the advanced ultrasound course, and I think that’s maybe a little bit separate from this, what I’m talking about, there’s also neuro ultrasound, that’s a big component of it. I am not sure yet how much time we’ll have and all the things that we’ll be able to incorporate in the advanced assessment. When we took our poll, what people said they really wanted was advanced hemodynamics. They wanted advanced chamber assessment and they wanted transesophageal echocardiography.
Dr. McLaughlin: The truth is, it seems like, at least for me, the longer I’ve been involved in ultrasound, the more we’re able to do, that maybe 10 years ago we didn’t even know was something that we could ultrasound.
Dr. Nikravan: Exactly.
Dr. McLaughlin: I remember when lung ultrasound was a big deal because air was the enemy of sound, and that eventually became a tool. Can you talk about where ultrasound might evolve to next?
Dr. Nikravan: Oh, there’s so much. We’re seeing the utility of ultrasound in neurologic illness. We’re seeing the utility of ultrasound in airway assessments. To be honest with you, we’re seeing a big move in the utility of artificial intelligence and its applications to ultrasound, so machine-based learning to help guide image acquisition or to help guide interpretation of exams to potentially put pathologies into pockets. This is what we’re seeing here most likely would fit in the pocket of this series of diagnoses as opposed to this series of diagnoses. This is all that stuff that’s happening with artificial intelligence as well. It’s a really exciting time for ultrasound and echocardiography in general.
Dr. McLaughlin: It’s incredible to see these new machines compared to where they started. Did you start with the standup machine that only had a linear probe?
Dr. Nikravan: Yeah.
Dr. McLaughlin: And now, you’re right, a lot of these machines make it much easier to just focus on getting a good image and it’ll start to give you an idea, these auto tools as to what your cardiac function is, what your volume status is.
Dr. Nikravan: It’s crazy. It’s funny because back when I was in fellowship, I remember seeing one of the first pocket or handheld devices and just being blown out of the water that I could flip up a screen and put this thing in my pocket and go and scan people. Just seeing the evolution of that, the image quality on those devices over time compared to what we had before, it’s pretty amazing.
Dr. McLaughlin: This is where I’d love to open it up. If you had anything that you would want to tell the world about the exam, the course, your love of ultrasound, what would it be?
Dr. Nikravan: I think, if you want to take the exam, I would suggest you take the course because it’s good, it’s comprehensive, it’s going to give you everything you need to know. I really think that if you prepared, if you knew everything on all of those slides, from top to bottom, you’d be able to pass the exam from the course basically. I think that that’s one thing I’d like to say. And I’d like to say, critical care ultrasound I think sometimes gets pooh-poohed by people who perhaps maybe don’t have a full understanding of what we’re trying to do. This is a skill set. It’s not meant to replace your clinical acumen. It’s meant to augment it or accompany it, and being able to understand the full breadth of it and what you can do with it and how you know your assessments changed based on chronic illness, where your limitations are, I think is really where the power of this is hidden.
Just remember, it’s hard. You can’t study ultrasound in a randomized controlled fashion. It’s really challenging. We don’t have a lot of people who say, Oh, there’s not a lot of data to support it. But there’s also not a lot of data to negate it. I would say that, clinically, as I’ve applied it in my practice, I have seen it save people’s lives. To me, that’s why I keep coming back every year, every year, every year. Because if there’s one person who could benefit from this, then I feel like we’ve done our due diligence.
I also want to go back to something I said earlier. I said, “You need a medical degree to take this examination.” It could be an MD, it could be a DO, you have to have some sort of medical license. We weren’t part of that process. I think that this is something that’s offered by the NBE because it’s a medical degree organization, but there are solutions outside the NBE for all providers, and that shouldn’t stop you from coming to the course. It shouldn’t stop you from doing the exams. I work with some amazing APPs and they are doing some super-cool high-level assessments and saving people’s lives. In the end, that’s really what this is all about.
Dr. McLaughlin: Yeah. I think SCCM does an excellent job with making sure everything is multidisciplinary and not turning anything away. I know from working with you on the ultrasound course and on the committee that you’re very welcoming of that. I think this has been great information and really we’re just getting started. I can’t wait to see what the future brings.
Dr. Nikravan: Thank you so much, Diane.
Dr. McLaughlin: Congratulations on your FCCM. Thanks for being here.
Dr. Nikravan: Thank you.
Dr. McLaughlin: This will conclude another edition of the Society of Critical Care Medicine Podcast. For the Society of Critical Care Medicine, I’m Diane McLaughlin.
Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, is a neurocritical care nurse practitioner at University of Florida Health Jacksonville. She is active within SCCM, serving on both the APP Resource and Ultrasound committees, and is a social media ambassador for SCCM.
This podcast was recorded during the Society of Critical Care Medicine’s 2023 Critical Care Congress. Access essential education online through Congress Digital. More than 120 sessions are available on an easy-to-use platform. Continuing education credit is also available. Some SCCM members receive complimentary access to Congress Digital. To learn more, visit sccm.org/congressdigital.
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