February 28, 2024

Sono Hot Seat

Sono Hot Seat with Rachel Liu

What experiences first led to your interest in getting involved with POCUS on the national and international level?

I had the chance as a green junior faculty member (1-yr. out from fellowship) to co-lead an SAEM AEUS pre-conference workshop at the same time as I was volunteering for the newish SonoGames© committee. I confess I wasn’t interested in national-level involvement at that time, but found that I really enjoyed being part of curricular creation teams and designing fun/crazy things with fun/crazy people, all in the spirit of education. So when I was asked to step into a vacancy as the AEUS Education Officer, I accepted my first national role. This then launched a string of leadership positions across several organizations that had weightier responsibilities, but the root of all that stemmed from being excited by educational innovation.

More valuable than any of the opportunities I initially had are the innumerous friendships I made, and continue to make, by getting to know our POCUS community – it only happens through the choice to become nationally involved. I now have many people to thank for the advice, mentorship and sponsorship I’ve received throughout my career. Taking on national or international projects works to accomplish a task, but the thing that keeps me engaged is continuing to collaborate with amazing people.

Biggest accomplishment? Lessons learned?

One of the things I’m most satisfied with is publishing the Appropriate Use Criteria for Handheld / Pocket Ultrasound guideline during my term as ACEP EUS Chair. It may not seem that mighty to read, but we anticipated a need for a referral document before handheld devices exploded on the market. It was written to protect us against potential barriers, since there had been prior challenges to reimbursement based on size and weight of a machine. Also at that time, IT departments did not know how to handle on-premises storage of cloud-based images or security of cloud-based image storage, so we worked with vendors on this simultaneously. The whole effort and purpose was completely community-driven, and I feel it has helped solidify our relationships across vendors and hospital IT. Having a culture of open and frank communications with our vendors has also led to more meaningful discussions with them in current and future work.

I feel I learned a lot the year I was ACEP EUS Chair. For some reason, that year had a lot of external issues that required urgent responses, ultimatums and subsequent peace-keeping meetings. Probably most lessons were internal about strategies used in different circumstances, but the big take home is that there isn’t a way to please everyone. There are methods to tactfully disagree and hold your ground without making enemies. Then sometimes you just have to resort to fisticuffs (j/k!).

What advice would you have for junior faculty members looking to expand their portfolio to leadership roles in national organizations?

The first step is to be active. Find one or two subcommittees in areas you’re really interested in and join! It might take a couple meetings to get familiar with their objectives and goals, but the subcommittee leadership will outline ongoing or anticipated projects. Choose 1-2 of those to contribute to, even if they involve just small tasks initially.

Once you join a project, the most important thing to do is to execute – do what you say you’re going to do, in a timely fashion. When people see you accomplish the tasks set before you (without prompting), they’ll recommend you for progressively higher level roles. It sounds obvious, but you’d be surprised how often it doesn’t happen. Not everything is successful - I’ve had plenty of initiatives fall flat, and I haven’t met all my deadlines either.  Regardless, your efforts are visible and appreciated by those who can sponsor you in the future.

You have been centrally involved in writing several position statements and guideline papers related to POCUS. What battles and obstacles do you envision the next generation of US fellows will face and overcome?

We still have the same challenges that our pioneers faced regarding true acceptance of our skills and incorporation of our findings, reimbursement, scope of practice, safety, etc. They may be quieter or less frequent now, but they still arise occasionally and sometimes unexpectedly at the national level. I think that we sort of need to add POCUS history lessons to the fellowship curriculum because there has to be ongoing memory of how these issues surfaced, then resurfaced, as well as the strategies the leadership groups used to deal with them. We’ve actually been meaning to start this program for a while (it’s been delayed), and will eventually!

Future generations are also going to need to continuously think of how new technologies are incorporated into healthcare systems. This leads to POCUS policies on a system-wide level, and likely guidelines regarding incorporation of non-physician POCUS operations or administration. The framework for those guidelines currently exist, but will need to expand as those entities evolve.

You have worn many hats related to POCUS over the years. What words of wisdom would you share with mid- or late-career faculty who feel things have gotten stale and are looking for the next new thing to get involved with?

I feel like this is where I am now and looking for advice myself! We know that our day-to-day POCUS jobs have given us multidimensional skills in departmental and hospital administration, operations and throughput, quality and safety, reimbursement, negotiations, human resources, IT and security, technology, education and design, research, etc. Usually, at least one of these areas is something that we can cultivate more of in a non-ultrasound way, even if the basis of our interest affects POCUS implementation. We heard a lot about this during last year’s Maine SCUF conference. Several of my mentors and friends have transitioned to departmental, hospital or system leadership roles. Others have moved to industry.  The skills we have are transferrable in many ways other than the traditional hierarchy of POCUS jobs, so it’s worth reflecting on the kinds of work that you find exciting or meaningful. 

For me, one of the things I’ll always get excited about are gadgets, toys and tech. So I’ve continued involvement with the ACEP Emerging Tech and Industry Roundtable (IRT) group, who are doing some incredible work right now. But I’m also part of a newly formed innovation group at Yale that evaluates new products and brainstorms ideas for potential student implementation. It’s small, but that’s just one example of re-purposing my geekiness for a new cause.

Where do you see the future of POCUS and industry/tech lining up? What novelties are on the horizon? What are barriers to their implementation?

Thinking about POCUS and tech is both exciting and overwhelming. We’ve seen rapid evolution in just the last 5 years, with a proliferation in handheld devices and the near-marriage of handhelds with AI or guidance tools. These tools are now expanding into the cart-based systems as vendors standardize their fleet families. While clinical POCUS AI incorporation isn’t quite mainstream yet and there are a lot of things we physicians need to come to grips with when making the decision to implement, this field will continue to grow exponentially over the next several years.

If I were to guess about the next upcoming novelty, I’d say it’s further incorporation of wearable devices, both on-patient and on-physician. Wearables aren’t a new idea but are gradually becoming more realistically feasible.  Institutions are getting interested in augmented reality headsets not only for education, but also for surgical planning. We’re only at the beginning of determining how this could affect our POCUS education and operations besides being an expensive voice-activatable heads-up display. Sticker-like wearable transducers have been developed too, and who knows? Maybe we’ll see continuously wearable cardiac probes replace EKG stickers in our lifetimes (ahem, ALARA).

What is your favorite memory or experience in POCUS? Your funniest? Darkest?

I can’t list all the great times I’ve had, and there have been many. I’ll just say that SonoGames© is probably the source of most of my emotional extremes. Y’all, I’m getting too old to pull these all-week all-nighters (thanks to everyone who came back at 10 pm last year to help!!!). But it’s very rewarding for us when we get through the glitches and all participants (+ spectators) have a fantastic time. It’s been amazing to help other countries put on their versions of SonoGames© too. I won’t ever forget the contestants in Turkey who had to put a US PIV into a moulaged trauma patient in the back of a moving ambulance. And I’ll also never forget the pivotal moment in round 3 of our first AIUM SonoSlam© when radiologists and sonographers collectively realized the impact of our teaching to medical students.

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