Our review article on VExUS, where we dive deep into common pitfalls of technique and interpretation, was just named the Best Review of 2024 by the journal. A pleasant surprise? Sure. A shock? Not so much, it turns out people find it genuinely useful.

This got me thinking about the “status” of review articles and case reports in academia. You know, those forms of scholarship that some of our so-called “elite” colleagues tend to look down on. The same crowd that thinks a faculty member asking for time to build a POCUS program should just “put out some data and get a grant” to earn protected time. Easy, right? Except it’s not.

Building a meaningful multi-organ POCUS program is nothing like setting up a glomerulonephritis or kidney stone clinic. Those are already part of fellowship training, and by the time someone graduates, they’re expected to have at least a baseline level of competence. This means a research-oriented faculty member can often launch small-scale studies right from day one.

POCUS, however, is a different beast. Most fellowship programs barely scratch the surface. First, you have to learn it yourself, properly, which takes time, practice, and yes, a fair bit of humility. Next comes the work of developing teaching materials and running hands-on sessions. Even if the starting point is curated online resources rather than content created from scratch, filtering out the noise and distilling the useful elements still requires considerable effort. From there, the focus shifts to advanced applications, and this is where reliance on low-quality handheld machines, so often favored by administrators, begins to fall short. Without proper spectral Doppler and an ECG module, mastering VExUS or advanced Doppler cardiac is extremely challenging. Worse, training on substandard equipment can breed false confidence, the surest way for bad habits to become entrenched. So, obviously, POCUS faculty need TIME and resources!

In today’s “publish or perish” climate, that is exactly how we end up with studies that are, frankly, pointless. Like the one that set IVC collapsibility cutoffs for hyponatremia without accounting for the fact that strength of breath varies among patients. Or the study that documented POCUS findings in hospitalized patients without any plan to act on them, then concluded that POCUS doesn’t affect outcomes. Or my personal favorite, papers where the representative image itself is mislabeled or incorrectly measured, making you question whether the operators even knew what they were looking at.

There are numerous examples of this, which is why it bears stating clearly: principal investigators and co-investigators undertaking POCUS research should possess some sort of formal credentials that demonstrate genuine competence. This involves more than a certificate on the wall; it requires substantial time devoted to understanding the principles of image acquisition, interpretation, and clinical integration. Put simply, data collection shouldn’t start the moment someone first picks up a probe or walks out of an introductory workshop, even if it’s one I’m running (no exceptions 😊).

This whole situation reminds me of the fate of pulmonary artery catheter (PAC) research, which was arguably ‘killed’ in part by a lack of understanding among physicians. When clinicians vary wildly in how accurately they obtain and interpret PAC readings, it’s no surprise that research results are shaky. Poor technique in catheter placement, calibration, and waveform acquisition can make the data itself unreliable. Add in cognitive errors like misidentifying pulmonary artery occlusion pressure or misinterpreting oxygen transport variables, and you end up with studies that misclassify patients, use flawed inclusion criteria, and draw the wrong conclusions.

The same principle applies to POCUS, particularly in newer areas like VExUS. While case reports may rank low on the traditional evidence pyramid, in this field they are invaluable for demonstrating individualized applications and real-world utility. They also serve as an excellent way to build confidence and strengthen literature review skills among nephrology fellows and early-career faculty. I have shared some of my own cases in the past, and I would argue that these illustrative reports are often far more useful than certain observational studies I have come across. This is not to diminish the importance of RCTs and outcome-based research – they remain essential. However, in POCUS, especially while the field is still developing, the guiding principle should be clear: learn before you leap. Do not overlook training in the rush to publish. And yes, well-crafted review articles also remain vital for communicating cautions and research ideas to the wider community, and I hope nephrology organizations and journals recognize this and invest in supporting training.