A recent article on cardiorenal syndrome in a leading nephrology journal set out to address pathophysiology and strategies for decongestion. At first glance, it seemed like a welcome read. That was until I reached the brief and rather dismissive mention of point-of-care ultrasound. The authors stated that POCUS, including VExUS, is “helpful, but caveats exist with its inherent operator and organ-specific assumptions and limitations.” That was the extent of it! To a reader unfamiliar with POCUS or with terms like VExUS, that sentence likely plants more skepticism than curiosity. And that is a missed opportunity.
Let’s talk about this. The “operator dependency” critique has become a convenient go-to whenever people want to discredit POCUS. But operator dependency is not unique to ultrasound. It applies to nearly every aspect of clinical care—history taking, physical examination, interpreting lab results, and communicating with patients. That’s exactly why there’s a difference between good and not-so-good clinicians. If a physician misses ST-elevation on an ECG, we don’t blame the ECG itself. We recognize the need for better training.
The issue of “organ-specific assumptions” is just as vague. Hemodynamic POCUS relies on physiologic relationships between flow, pressure, and volume. These are not absolute, but when interpreted within a clinical context, they provide valuable insights. That is, of course, assuming the operator is doing more than just waving the probe over the IVC and self-declaring as a ‘POCUS expert’. Again, the key is to focus on training physicians in how to clinically integrate POCUS, rather than placing blame on the tool itself. After all, echocardiography operates under the same assumptions and limitations, yet it is widely accepted as a standard tool. The irony is that clinical decisions are often shaped by the cardiologist’s impression at the end of the report, even when the treating physician may not fully grasp the underlying findings/numbers or their relevance to the case. Everything has its limitations. Even pulmonary artery catheter readings are not infallible. Those of us who work in ICUs have often encountered errors in leveling and zeroing.
In nephrology, skepticism around POCUS often comes from lack of exposure. Studies show that once nephrologists are introduced to POCUS, they tend to pursue further training. That is because it adds real value at the bedside, providing repeatable, real-time assessments that support better clinical decisions. As nephrology societies continue to recognize multi-organ POCUS beyond just kidney imaging, it is frustrating to see major journal articles continue to minimize its role. Knowing how to titrate diuretics is important. But doing it without any objective hemodynamic data often turns into guesswork. It is ironic that we emphasize treatment so much, but shy away from improving how we diagnose. That should still be the foundation of what we do as physicians. POCUS enhances diagnostic precision. It should not be held to an unrealistic standard of outcome-based validation. Nobody asks a stethoscope to prove a mortality benefit!
I (IAPN team) submitted these thoughts as a letter to the editor. It was rejected because the original article did mention POCUS. Apparently, that one-liner was considered sufficient! I hope nephrology journals will eventually have editors who understand the relevance of physical examination (= POCUS). Until then, we’ll keep scanning, teaching, and speaking up. Realistically, more young and next-generation nephrologists are likely reading NephroPOCUS.com than those journals. Apologies if that sounds egoistic, it’s just the truth.
I’m putting this post under the program development section, as these points may be useful when discussing support for your POCUS program with division leadership.