A NephMadness Special Commentary

This year’s NephMadness did something interesting. It gave POCUS a dedicated bracket. That, in itself, says a lot. It reflects a growing curiosity, maybe even a quiet shift, within the nephrology community.

And that makes this a good moment to pause and ask a simple question. Why aren’t we all leaning into this already?

The Comfort of Square Wheels

POCUS is, at its core, a bedside skill. It brings us back to the patient, something we all “claim to” value deeply.

Yet, many of us are still holding on to “square wheels” – Comfortable habits, familiar workflows, and long-standing practices simply because they are what we know. Perhaps part of it is the quiet sense of pride we derive when empiric decisions happen to be correct, reinforcing the illusion that we do not need better tools. Meanwhile, someone is offering us a round wheel, and we are politely declining.

Why?

Because it is new. Because it is unfamiliar. Because we did not train with it.

That is understandable, but it is not sustainable. We now have a tool that is radiation free, repeatable, bedside accessible, and demonstrably more accurate than the physical examination alone, and often more informative than a chest radiograph. At this point, resistance looks less like caution and more like inertia.

The Next Generation Is Already There

Medical students are learning POCUS. Residents are learning POCUS. The training is heterogeneous, but the direction is clear. The next generation of nephrology fellows will not be impressed by an IVC-only assessment. They already know how to look at the IVC.

And if the attending physician cannot interpret, confirm, or challenge their findings, we introduce something far more concerning than a knowledge gap. Clinical ambiguity. That ambiguity does not just affect teaching. It affects patient care.

The ICU Reality Check

Let’s talk about the ICU.

It is becoming increasingly common to see notes that read something like “Ultrafiltration per ICU team.”

Translation: we are outsourcing hemodynamics.

If nephrology steps away from hemodynamic assessment, what remains? CRRT orders? Let’s be honest. Modern EMRs have made those fairly straightforward. If our primary role becomes order placement, it will not be long before that role is absorbed elsewhere.

And if we cannot engage in meaningful discussions about hemodynamics with ICU teams, we risk becoming irrelevant.

The Pathology Paradox

Here is another curious observation.

We spend a considerable amount of time on renal pathology during fellowship and at meetings like ASN, and that is appropriate. But let’s be honest. Kidney biopsy findings are ultimately interpreted by an expert, the renal pathologist. As nephrologists, we do not need to be pathologists. We need to understand the basics, follow what the expert is telling us, and then incorporate that information into our clinical decision making and management algorithms.

Now contrast that with POCUS. Unlike biopsy interpretation, POCUS is an extension of the physical exam. Here, the clinician is the expert at the bedside.

So why don’t we approach it with the same structure and rigor? Where are the equivalent conferences where we review images, discuss interpretations, and refine our skills? Why aren’t we training our eyes with the same intentionality? And if this is truly part of the physical exam, who exactly are we deferring to?

AKI, Hemodynamics, and the Illusion of “Supportive Care”

In many ways, AKI management is optimizing hemodynamics.

Yes, there are structural causes. Yes, biopsies matter. But day-to-day decision-making is largely about flow and congestion.

And yet, “continue supportive care” often becomes a placeholder for doing less, while ongoing hemodynamic injury quietly continues. Fluid overload worsens outcomes. That is not controversial. Without POCUS, we are often guessing.

And if we reduce POCUS to a single parameter like IVC, we are not solving the problem. We are just refusing to acknowledge it. Respect the entire hemodynamic circuit – cardiac output, filling pressures, lung water, and venous congestion, rather than relying on isolated data points.

A Simple Example That Is Not So Simple

Take a common scenario – suspected hepatorenal syndrome.

Small IVC. Minimal edema. Albumin gets ordered.

But what if the cardiac output is already 10 liters per minute, which is not unusual in cirrhosis? What exactly are we achieving by increasing it further? Once terlipressin is started, that added fluid can end up in the lungs, leading to discontinuation “per protocol” due to hypoxemia. Without advanced hemodynamic POCUS, we risk treating numbers or appearances rather than physiology.

Performing POCUS Means Seeing What We Are Doing

When managing fluid overload, the key question is not simply whether fluid is being removed, but whether organ congestion is actually improving. This is where tools like VExUS become invaluable, allowing us to visualize decongestion process rather than assume it. Without this, we are often flying blind. There is now ample evidence that the clinical examination performs poorly in detecting congestion, and that subclinical congestion at hospital discharge or in dialysis patients is associated with worse outcomes.

Workshops Are a Beginning, Not a Badge

There is clearly growing interest in POCUS. Workshops fill quickly. That is encouraging.

But attending a workshop is not the end of the journey. It is the very beginning.

POCUS competency comes from repetition, feedback, pattern recognition, and clinical integration. Not from a certificate of attendance.

Where Do We Go From Here

This is not about replacing anything. It is about evolving.

If nephrology wants to maintain its identity as the specialty of fluid and electrolyte expertise, we need to own hemodynamics, not defer it.

POCUS is not a shortcut. It is a skill set. And like any meaningful skill, it requires time, humility, and deliberate practice.

The Dunning Kruger effect is always lurking, especially in skill-based domains. A weekend course can create confidence. Mastery takes much longer.

For a complementary perspective, you can also read my official NephMadness post on the AJKD Blog.