Point-of-care ultrasound for general practitioners: a systematic needs assessment

Does point-of-care ultrasound examination by the general practitioner lead to inappropriate care? A follow-up study

BACKGROUND

The use of point-of-care ultrasound (POCUS) in general practice increases, but little is known about potential unintended findings and harms to patients. Information regarding such unwanted effects may be obtained by evaluating the medical records of patients who have been scanned by their general practitioner.

OBJECTIVE

To identify and characterize re-consultations related to POCUS use in general practice, potential misdiagnosis, overdiagnosis, and incidental findings, and to compare potentially troublesome cases to GPs' scanning competence and type of ultrasound device.

DESIGN AND SETTING

Professors in general practice with extensive experience in both research and quality assurance in general practice did a blinded review of prospectively collected routine electronic medical record data combined with cross-sectional data collected in relation to POCUS examinations.

SUBJECTS

Twenty general practitioners collected data on 564 patients examined with POCUS in primary care.

MAIN OUTCOME MEASURES

International standards for the classification of adverse events and incidental findings were used. First, research assistants identified all re-consultations described in the medical records that were related to the primary health complaint at the index consultation. Second, these re-consultations were classified by the medical experts in terms of seriousness and relation to the POCUS examination performed at the index consultation. In addition, the experts identified possible misdiagnosis, possible overdiagnosis, and incidental findings. Finally, identified cases were discussed in terms of appropriateness and described narratively.

RESULTS

Medical records of 564 patients were reviewed. A low risk of possible misdiagnosis (5.3%), potential overdiagnosis (0.7%), and incidental findings (0.7%) were found. Eleven POCUS-related re-consultations were identified and described.

CONCLUSION

POCUS scanning performed by general practitioners was generally safe, but it can result in unnecessary examinations and potential harm in a few cases. Certain areas, e.g. pelvic scans that included the ovaries, may especially be prone to misdiagnosis.

TRIAL REGISTRATION NUMBER

NCT03375333.

'Shades of grey': a focus group study on diagnostic uncertainty among general practitioners using point-of-care ultrasound

BACKGROUND

Point-of-care ultrasound (POCUS) has long been a diagnostic tool in family medicine, although most Norwegian general practitioners (GPs) who use POCUS, scans infrequently. The broad scope of family medicine, the relatively low prevalence of illnesses and infrequent use of POCUS imply that GPs may experience diagnostic uncertainty regularly.

AIM

To explore how GPs perceived and managed diagnostic uncertainty when using POCUS.

DESIGN AND SETTING

A qualitative focus group study among Norwegian GPs using POCUS.

METHODS

Four focus group discussions were conducted. Total number of participants were 21. The interview guide was piloted, the focus group discussions were audio-recorded and transcribed, and Systematic Text Condensation, a thematic cross-case analysis, was used to analyse the data.

RESULTS

Diagnostic uncertainty using POCUS was considered as aligning to the general clinical uncertainties in family medicine, but there were also POCUS-specific uncertainties in clinical decision-making. We generated six themes: emotional, cognitive, and ethical uncertainty using POCUS, communicating uncertainty to patients, interaction with specialists when using POCUS, and coping strategies of participants. POCUS results were the only results the participants sometimes withheld when communicating with other specialists. POCUS itself stimulated a renewed interest in family medicine. Scanning enough patients was the recommended coping strategy.

CONCLUSION

POCUS-using GPs experienced diagnostic uncertainty when using POCUS that aligned with other diagnostic uncertainties they experienced in everyday practice. However, they did not treat the results like other findings, as the GPs at times withheld their POCUS findings when interacting with secondary care specialists. This requires further investigation.

Ultrasound education, competencies and expected future use among medical interns in Denmark: a national cross-sectional study

BACKGROUND

Point-of-care ultrasound is increasingly used across medical specialties, calling for timely and relevant ultrasound education in specialty training. To enable customizing such education, we aimed to explore medical interns' received ultrasound education during medical school and internship, perceived scanning competencies, evaluation of received education, future expectations for using ultrasound, and tendencies for perceiving ultrasound competence.

METHODS

This was a national cross-sectional study. We developed a questionnaire based on a theoretical conceptual model, individual interviews with medical interns and focus groups with medical students, followed by pilot testing. The questionnaire was distributed to all medical interns in Denmark (N = 1231). Data were summarized with descriptive statistics. Differences between universities and tendencies for perceiving ultrasound competence were analyzed with Fisher's exact tests and modified Poisson regression, respectively.

RESULTS

Responses from 420 (34.1%) interns were included. Although varying across medical schools, 95.7% received formal ultrasound training and 86.0% encountered ultrasound examinations through clinical rotation. During internship, 44.2% received formal training, while 68.5% had to pursue it independently. Ultrasound examinations during clinical work were observed by 73.2% and performed by 47.6%. Common ultrasound usage barriers were insufficient scanning routine, supervision, knowledge, confidence and mental surplus. Ultrasound competence gain from medical school and internship was reported by 75.2% and 55.3%, respectively, but mainly to lesser/some extent. Most desired more training, expected to use ultrasound in the future (71.0%) and considered it a core competence (73.0%). Perceived ultrasound competence was significantly associated with receiving practical (RR: 4.08) or both practical and theoretical education (RR: 4.34) in medical school, and practical training on patients (RR: 1.09), required number of performed scans (RR: 1.06), competence test(s) (RR: 1.07), and/or consulting books/encyclopedia (RR:1.07) during internship.

CONCLUSIONS

Ultrasound training is part of medical school curricula but varies in type and extent. While most encounter and many use ultrasound during internships, formal training is less integrated. Most desire more training and attitudes towards future ultrasound usage are positive. Filled curricula pose dilemmas for prioritization and several barriers prevail for using ultrasound, representing missed opportunities for competence development and maintenance. Training governance and scaffolding continuous learning may be needed.

TRIAL REGISTRATION

None.

Structured POCUS education for primary care physicians: the transition from short workshops to sustainable longitudinal learning

The use of point-of-care ultrasonography in primary care is increasing. Primary care physicians are introduced to ultrasonography at short workshops with little guidance for implementation of the technology in clinical routines and medical decision-making. This article introduces a framework for longitudinal ultrasound education tailored for office-based general practice, building on the best available evidence and established teaching principles. The framework includes three teaching seminars over three months, a curriculum of 10 ultrasound applications, an online learning platform providing educational support before, during, and after the teaching seminars and continuous support and feedback from allocated mentors. The framework aims to reduce primary care physicians' absence from the clinic, scaffold the learning process to build a solid and sustainable foundation of knowledge, and support implementation and appropriate use of the technology in the unselected patient population in primary care setting. Evaluation of the framework demonstrated high satisfaction with the educational elements among both participants and teachers.

Is it worth trying? A cross-sectional study on the implementation of point-of-care ultrasound in Hungarian primary care

BACKGROUND

Although the number of point-of-care ultrasound devices available in Hungarian primary care practices are increasing due to government funding, their use in day-to-day patient care is limited and unregulated. Our study aimed to evaluate the attitudes and needs of general practitioners (GPs) and patients in Hungary regarding the introduction of bedside ultrasonography in primary care practices.

METHODS

As a part of a cross-sectional study, an anonymous, self-administered questionnaire was distributed to GPs and patients on a social media platform. Data collection was carried out from August 2023 to October 2023. Chi-square test was used to determine the associations between categorical variables.

RESULTS

The survey was completed by 415 GPs (mean age 53.8 ± 11.1 years, 54.9% female, mean 19.5 ± 11.9 years of practice) and 693 patients (mean age 45.5 ± 12.3 years, 95.2% female). There was a statistically significant increase in interest in PoCUS among young and middle-aged GPs (age 28-59; p = 0.02). In addition, this population of GPs was also more likely to undertake training in PoCUS than their older colleagues (p < 0.0001). An inverse relationship was found between the duration of practice and training willingness (p = 0.0011). Even with the government's financial support, only 8.2% of GPs currently use PoCUS in a daily basis, and 59.5% of GPs are unfamiliar with the indications and the ways of using it. Patients would even pay to have the examination done in a primary care setting, even though only 45.9% of patients would pay a GP who is not certified in PoCUS, but the willingness to pay increased to 99.4% for those with formal training (p = 0.024).

CONCLUSION

Our findings indicate a significant interest in adapting PoCUS in primary care from both GPs and patients. Based on the fact that a significant proportion of Hungarian GPs are unaware of PoCUS and its indications, it is particularly important to develop educational frameworks, and practical guidelines for the effective incorporation of PoCUS in Hungary.

Geospatial Point-of-Care Testing Strategies for COVID-19 Resilience in Resource-Poor Settings: Rural Cambodia Field Study

BACKGROUND

Point-of-care testing (POCT) generates intrinsically fast, inherently spatial, and immediately actionable results. Lessons learned in rural Cambodia and California create a framework for planning and mobilizing POCT with telehealth interventions. Timely diagnosis can help communities assess the spread of highly infectious diseases, mitigate outbreaks, and manage risks.

OBJECTIVE

The aims of this study were to identify the need for POCT in Cambodian border provinces during peak COVID-19 outbreaks and to quantify geospatial gaps in access to diagnostics during community lockdowns.

METHODS

Data sources comprised focus groups, interactive learners, webinar participants, online contacts, academic experts, public health experts, and officials who determined diagnostic needs and priorities in rural Cambodia during peak COVID-19 outbreaks. We analyzed geographic distances and transit times to testing in border provinces and assessed a high-risk province, Banteay Meanchey, where people crossed borders daily leading to disease spread. We strategized access to rapid antigen testing and molecular diagnostics in the aforementioned province and applied mobile-testing experience among the impacted population.

RESULTS

COVID-19 outbreaks were difficult to manage in rural and isolated areas where diagnostics were insufficient to meet needs. The median transit time from border provinces (n=17) to testing sites was 73 (range 1-494) minutes, and in the high-risk Banteay Meanchey Province (n=9 districts), this transit time was 90 (range 10-150) minutes. Within border provinces, maximum versus minimum distances and access times for testing differed significantly (P<.001). Pareto plots revealed geospatial gaps in access to testing for people who are not centrally located. At the time of epidemic peaks in Southeast Asia, mathematical analyses showed that only one available rapid antigen test met the World Health Organization requirement of sensitivity >80%. We observed that in rural Solano and Yolo counties, California, vending machines and public libraries dispensing free COVID-19 test kits 24-7 improved public access to diagnostics. Mobile-testing vans equipped with COVID-19 antigen, reverse transcription polymerase chain reaction, and multiplex influenza A/B testing proved useful for differential diagnosis, public awareness, travel certifications, and telehealth treatment.

CONCLUSIONS

Rural diagnostic portals implemented in California demonstrated a feasible public health strategy for Cambodia. Automated dispensers and mobile POCT can respond to COVID-19 case surges and enhance preparedness. Point-of-need planning can enhance resilience and assure spatial justice. Public health assets should include higher-quality, lower-cost, readily accessible, and user-friendly POCT, such as self-testing for diagnosis, home molecular tests, distributed border detection for surveillance, and mobile diagnostics vans for quick telehealth treatment. High-risk settings will benefit from the synthesis of geospatially optimized POCT, automated 24-7 test access, and timely diagnosis of asymptomatic and symptomatic patients at points of need now, during new outbreaks, and in future pandemics.

The use of diagnostic ultrasound by primary care physicians in Switzerland - a cross-sectional study

BACKGROUND

Diagnostic ultrasound has become a bedside tool widely available to many primary care physicians (PCPs) in Europe. It is often used as point-of-care ultrasonography (POCUS) in this setting. In Switzerland, certain POCUS examinations are listed as learning objectives in existing ultrasound training programs (we defined these examinations as swissPOCUS = sPOCUS). Ultrasound performed by PCPs can lead to faster diagnostic workup and reduce referral to secondary care units. However, adequate training is crucial to guarantee high quality. To guide the development of ultrasound training programs for PCPs, this study explores the use of ultrasound in primary care in Switzerland.

METHODS

This was a cross-sectional study. We invited PCPs from the Swiss practice-based research network "Sentinella" to collect data on the first 5 daily ultrasounds they ordered or performed themselves. Participating PCPs collected data for 3 months - divided into 4 groups to account for seasonal differences.

RESULTS

Out of 188 PCPs invited, 81.9% provided data through an initial questionnaire. 46.8% provided data on 1616 ultrasounds. 56.5% of PCPs had access to ultrasound machines, while 29.8% had completed formal training. 77% of the reported ultrasounds were self-performed; 27% of the reported scans (35% of all self-performed scans) were performed by PCPs with incomplete or no formal training. The main areas of interest were the abdominal (57.9%) and the musculoskeletal (22%) region. 36.9% of reported examinations were sPOCUS exams. Among PCPs with access to US machines, the percentages of referred examinations were similar for sPOCUS (11.9%) and non-sPOCUS (11.3%) indications. However, some sPOCUS musculoskeletal ultrasounds were often referred (e.g. tendon/ligament/muscle injuries or cutaneous/subcutaneous tumour).

CONCLUSION

Most Swiss PCPs had access to ultrasound equipment and performed a majority of both sPOCUS and non-sPOCUS scans themselves, often without or with incomplete training. This reflects the fact that POCUS was only recently introduced in Switzerland. There is a need for easily accessible POCUS training programs aimed at PCPs in Switzerland. Training courses for PCPs should focus on abdominal and musculoskeletal ultrasound, because these were the most common sites for scans, and because some sPOCUS musculoskeletal examinations showed a particularly high percentage of referral.

Consensus on relevant point-of-care ultrasound skills in General Practice: a two-round French Delphi study

CONTEXT

Point-of-Care Ultrasound (POCUS) has become an important tool in the clinical practice of many specialties, but its use and impact in General Practice in France remains to be explored.

OBJECTIVE

The objective of this study is to obtain a consensus among experienced French general practitioners on a list of relevant POCUS skills in General Practice in 4 anatomical regions.

METHOD

We used a two-round Delphi method to obtain a consensus. An initial list of skills was drawn by conducting a literature review. To rate each skill, we used a nine-point Likert scale. An interactive meeting between experts took place between Delphi rounds. POCUS experts in General Practice were defined as general practitioners with theoretical training in ultrasound who regularly perform ultrasound, who have performed ultrasound for more than five years and/or are involved in providing ultrasound training.

RESULTS

11 French general practitioners screened 83 skills in 4 anatomical regions: abdominal, urogenital, vascular, gynecology and obstetrics. An agreement was obtained for 36 POCUS skills as to their appropriateness in General Practice. There were 17 skills with a strong appropriate agreement (100% of "7-9" ratings) and 19 skills with a relative agreement (100% of "5-9" ratings).

CONCLUSION

These skills could serve as a basis for guidelines on the use and curriculum of POCUS in General Practice in France as well as in other countries with similar healthcare systems.

Using geographic rescue time contours, point-of-care strategies, and spatial care paths to prepare island communities for global warming, rising oceans, and weather disasters

OBJECTIVES

To perform geographic contour analysis of sea and land ambulance rescue times in an archipelago subject to super typhoons; to design point-of-care testing strategies for medical emergencies and weather disasters made more intense by global warming and rising oceans; and to assess needs for prehospital testing on spatial care paths that accelerate decision making, increase efficiency, improve outcomes, and enhance standards of care in island nations.

METHODS

We performed needs assessments, inspected healthcare facilities, and collected ambulance rescue times from professionals in the Bantayan Archipelago, Philippines. We mapped sea/land ambulance rescue routes and time contours. To reveal gaps, we statistically compared the fastest and slowest patient rescue times from islands/islets and barangays to the District Hospital on Bantayan Island. We developed spatial care paths (the fastest routes to care) for acute myocardial infarction, community care, and infectious diseases. We generated a compendium of prehospital diagnostic testing and integrated outcomes evidence, diagnostic needs, and public health goals to recommend point-of-care strategies that build geographic health resilience.

RESULTS

We observed limited access to COVID-19 assays, absence of blood gas/pH testing for critical care support, and spatial gaps in land and airborne rescues that worsened during inclement weather and sea swells. Mean paired differences (slowest-fastest) in ambulance rescue times to the District Hospital for both islands and barangays were significant (P < 0.0001). Spatial care path analysis showed where point-of-care cardiac troponin testing should be implemented for expedited care of acute myocardial infarction. Geospatial strengths comprised distributed primary care that can be facilitated by point-of-care testing, logical interisland transfers for which decision making and triage could be accelerated with onboard diagnostics, and healthcare networks amenable to medical advances in prehospital testing that accelerate treatment.

CONCLUSIONS

Point-of-care testing should be positioned upstream close to homes and island populations that have prolonged rescue time contours. Geospatially optimized point-of-need diagnostics and distributed prehospital testing have high potential to improve outcomes. These improvements will potentially decrease disparities in mortality among archipelago versus urban dwellers, help improve island public health, and enhance resilience for increasingly adverse and frequent climate change weather disasters that impact vulnerable coastal areas. [350 words].

Building Consensus on the Point-of-Care Ultrasound Skills Required for Effective Healthcare Service Delivery at District Hospitals in South Africa: A Delphi Study

BACKGROUND

Despite the widespread availability of ultrasound machines in South African district hospitals, there are no guidelines on the competency in point-of-care ultrasound (POCUS) use required by generalist doctors in this setting. This study aimed to define the required POCUS competencies by means of consensus via the Delphi method.

METHODS

An online Delphi process was initiated in June 2022, using the existing American Academy of Family Physicians' ultrasound curriculum (84 skillsets) as the starting questionnaire. Panelists were selected across the country, including two from district hospitals in each province and two from each academic family medicine department in South Africa (N = 36). In each iterative round, the participants were asked to identify which POCUS skillsets were essential, optional (region-specific), or non-essential for South African district hospitals. This process continued until consensus (>70% agreement) was achieved on all of the skillsets.

RESULTS

Consensus was achieved on 81 of the 84 skillsets after 5 iterative rounds (96.4%), with 3 skillsets that could not achieve consensus (defined as <5% change over more than 2 consecutive rounds). The final consensus identified 38 essential, 28 optional, and 15 non-essential POCUS skillsets for the South African district hospital context.

CONCLUSIONS

The list of essential POCUS skillsets provided by this study highlights the predominance of obstetric- and trauma-based skillsets required for generalist healthcare workers in South African district hospitals. The findings will require priority setting and revalidation prior to their implementation across the country.

Using Kane's framework to build an assessment tool for undergraduate medical student's clinical competency with point of care ultrasound

INTRODUCTION

Point-of-care ultrasonography (POCUS) is a portable imaging technology used in clinical settings. There is a need for valid tools to assess clinical competency in POCUS in medical students. The primary aim of this study was to use Kane's framework to evaluate an interpretation-use argument (IUA) for an undergraduate POCUS assessment tool.

METHODS

Participants from Memorial University of Newfoundland, the University of Calgary, and the University of Ottawa were recruited between 2014 and 2018. A total of 86 participants and seven expert raters were recruited. The participants performed abdominal, sub-xiphoid cardiac, and aorta POCUS scans on a volunteer patient after watching an instruction video. The participant-generated POCUS images were assessed by the raters using a checklist and a global rating scale. Kane's framework was used to determine validity evidence for the scoring inference. Fleiss' kappa was used to measure agreement between seven raters on five questions that reflected clinical competence. The descriptive comments collected from the raters were systematically coded and analyzed.

RESULTS

The overall agreement between the seven raters on five questions on clinical competency ranged from fair to moderate (κ = 0.32 to 0.55). The themes from the qualitative data were poor image generation and interpretation (22%), items not applicable (20%), poor audio and video quality (20%), poor probe handling (10%), and participant did not verbalize findings (14%).

CONCLUSION

The POCUS assessment tool requires further modification and testing prior before it can be used for reliable undergraduate POCUS assessment.

Ultrasound in primary care: Consensus recommendations on its applications and training. Results of a 3-round Delphi study

BACKGROUND

The introduction of portable and pocket ultrasound scanners has potentiated the use of ultrasound in primary care, whose many applications have been studied, analyzed and collected in the literature. However, its use is heterogeneous in Europe and there is a lack of guidelines on the necessary training and skills.

OBJECTIVES

To identify the fundamental applications and indications of ultrasound for family physicians, the necessary knowledge and skills, and the definition of a framework of academic and pragmatic training for the development of these competencies.

METHODS

A modified 3-round Delphi study was carried out in Catalonia, with the participation of 65 family physicians experts in ultrasound. The study was carried out over six months (from September 2020 to February 2021). The indications of ultrasound for family physicians were agreed (the > = 75th percentile was considered) and prioritised, as was the necessary training plan.

RESULTS

The ultrasound applications in primary care were classified into seven main categories. For each application, the main indications (according to reason for consultation) in primary care were specified. A progressive training plan was developed, characterised by five levels of competence: A (principles of ultrasound and management of ultrasound scanners); B (basic normal ultrasound anatomy); C (advanced normal ultrasound anatomy); D (pathologic ultrasound, description of pathological images and diagnostic orientation); E (practical skills under conditions of routine clinical practice).

CONCLUSION

Training family physicians in ultrasound may consider seven main applications and indications. The proposed training plan establishes five different levels of competencies until skill in real clinical practice is achieved.

Consensus on communication curriculum content in Danish undergraduate medical education: A Delphi study

BACKGROUND

The acquisition of skills in patient-centered communication is a critical aspect of medical education which demands both resource-intensive instruction and longitudinal opportunities for learning. Significant variation currently exists in the content and timing of communication education. The aim of this study was to establish consensus regarding communication curriculum content for undergraduate medical education (UME) within the country of Denmark.

METHODS

This study employed a Delphi process which is a widely accepted method for establishing consensus among experts and can be utilized to guide planning and decision-making in education. For this study, consensus was based on greater than 60% agreement between participants. Diverse stakeholders, representing all four universities with medical schools in Denmark, participated in an iterative three-round Delphi process which involved: (1) identifying key curricular elements for medical student education, (2) rating the importance of each item, and (3) prioritizing items relative to one another and rating each item based on the level of mastery that was expected for each skill (i.e. knowledge, performance with supervision, or performance independently).

RESULTS

A national sample of 149 stakeholders participated with a 70% response rate for round 1, 81% for round 2, and 86% for round 3. The completed Delphi process yielded 56 content items which were prioritized in rank order lists within five categories: (1) establishing rapport, engaging patient perspectives and responding to needs; (2) basic communication skills and techniques; (3) phases and structure of the encounter; (4) personal characteristics and skills of the student; (5) specific challenging patient groups and context-dependent situations.

DISCUSSION

Using a Delphi process, it was possible to achieve consensus regarding communication curriculum content for UME. These findings provide an important foundation for ensuring greater uniformity in UME, as well as supporting the important longitudinal goals of communication skill development across medical training.

Head and Neck Ultrasound - EFSUMB Training Recommendations for the Practice of Medical Ultrasound in Europe

Different surgical and medical specialists increasingly use head and neck ultrasound and ultrasound-guided interventions as part of their clinical practice. We need to ensure high quality and standardized practice across specialties, and this position paper of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) describes the training requirements for head and neck ultrasound. Traditionally, a minimum number of ultrasound examinations indicates competence, but this is unreliable, and a general shift towards competence-based training is ongoing. For each EFSUMB level, we will outline the theoretical knowledge and skills needed for clinical practice. The recommendations follow the three EFSUMB competency levels for medical ultrasound practice. Level 1 describes the skills required to perform essential head and neck ultrasound examinations independently, level 2 includes ultrasound-guided interventions, while level 3 involves the practice of high-level neck ultrasound and use of advanced technologies. Our goal is to ensure high quality and standardized head and neck ultrasound practice performed by different clinical specialists with these recommendations.

Protocol for a Delphi Consensus Study to Determine the Essential and Optional Ultrasound Skills for Medical Practitioners Working in District Hospitals in South Africa

With increasing access to point of care ultrasound (POCUS) at district hospitals in South Africa, there is a lack of standardisation of skillsets among medical practitioners working at this level of care. This study protocol aims to use the Delphi process to achieve expert consensus on the essential and optional ultrasound skills required for medical practitioners working in district hospitals in South Africa. In alignment with the Delphi method, several iterative rounds will be implemented from June to November 2022. Purposive sampling will be conducted, through the recruitment of two representatives from each academic department of family medicine and two medical doctors working in district hospitals in each province in the country (N = 36). The POCUS skillsets published by the American Academy of Family Physicians will be circulated in the first iterative round, following which participants may suggest further additions. Once a consensus target of 70% has been achieved, the Delphi process will be finalised. The Delphi process and data analysis will be facilitated by an online Delphi platform. Findings from the study will provide insight into the design of the curriculum for POCUS training for medical practitioners in district hospitals and registrars in family medicine departments across the country.

Point-of-care ultrasound: An emerging clinical tool to enhance physical assessment

ABSTRACT

Point-of-care ultrasound (PoCUS) is a cost-effective diagnostic technology that, with training, is accessible, portable, and a convenient diagnostic modality to complement physical assessments. PoCUS is beneficial in that it can reduce the number of imaging tests required, while also mitigating barriers to healthcare for rural and remote communities.

Simulation-based procedure training (SBPT) in rarely performed procedures: a blueprint for theory-informed design considerations

Simulation-based procedure training is now integrated within health professions education with literature demonstrating increased performance and translational patient-level outcomes. The focus of published work has been centered around description of such procedural training and the creation of realistic part-task models. There has been little attention with regards to design consideration, specifically around how simulation and educational theory should directly inform programme creation. Using a case-based approach in cardiology as an example, we present a blueprint for theory-informed simulation-based procedure training linking learning needs analysis and defining suitable objectives to matched fidelity. We press the importance of understanding how to implement and utilise task competence benchmarking in practice, and the role of feedback and debriefing in cycles of repeated practice. We conclude with evaluation and argue why this should be considered part of the initial design process rather than an after-thought following education delivery.

Learning strategies of general practitioners striving to achieve point-of-care ultrasound competence: a qualitative study

BACKGROUND

Point-of-care ultrasonography (POCUS) is increasingly used in general practice despite the lack of official educational programmes or guidelines for general practitioners (GPs).

AIM

To explore how GPs have learnt to use POCUS and which barriers they have encountered in their learning process.

DESIGN AND SETTING

Qualitative study conducted in office-based general practice in Denmark.

METHODS

Semi-structured interviews were conducted with 13 GPs who had implemented POCUS without supporting guidelines or regulations. Analysis was carried out using systematic text condensation. The interview data for this study were collected along with data used in a previous study.

RESULTS

The participating GPs described having composed their own ultrasound education following a continuous learning process. Basic POCUS competences were achieved through formalized training sessions at hospital departments or courses. The GPs further developed and expanded their scanning skills through additional courses and continuous self-study practice on patients often while consulting internet sources, textbooks or colleagues. Lack of available ultrasound courses, supervision, and clinical guidelines together with time constraints and financial aspects were mentioned as barriers to their ultrasound training.

CONCLUSION

This study showed how GPs had composed their own ultrasound education individually and differently, guided by their own experiences and beliefs about good clinical practice. Formalized ultrasound training was considered a prerequisite for achieving basic ultrasound competences while continuous practice was considered paramount to develop and maintain scanning skills. There were several obstacles to overcome in the learning process including lack of supervision, guidance, and opportunity for practicing skills.Key pointsLittle is known about the educational needs of general practitioners striving to achieve ultrasound competences.General practitioners described using formalized training to achieve basic scanning competences and continuous self-study and practice to further develop their skills.Lack of time, supervision, clinical guidelines and ultrasound courses were considered barriers in the learning process together with financial aspects.

2021 international consensus statement on optical coherence tomography for basal cell carcinoma: image characteristics, terminology and educational needs

BACKGROUND

Despite the widespread use of optical coherence tomography (OCT) for imaging of keratinocyte carcinoma, we lack an expert consensus on the characteristic OCT features of basal cell carcinoma (BCC), an internationally vetted set of OCT terms to describe various BCC subtypes, and an educational needs assessment.

OBJECTIVES

To identify relevant BCC features in OCT images, propose terminology based on inputs from an expert panel and identify content for a BCC-specific curriculum for OCT trainees.

METHODS

Over three rounds, we conducted a Delphi consensus study on BCC features and terminology between March and September 2020. In the first round, experts were asked to propose BCC subtypes discriminable by OCT, provide OCT image features for each proposed BCC subtypes and suggest content for a BCC-specific OCT training curriculum. If agreement on a BCC-OCT feature exceeded 67%, the feature was accepted and included in a final review. In the second round, experts had to re-evaluate features with less than 67% agreement and rank the ten most relevant BCC OCT image features for superficial BCC, nodular BCC and infiltrative and morpheaphorm BCC subtypes. In the final round, experts received the OCT-BCC consensus list for a final review, comments and confirmation.

RESULTS

The Delphi included six key opinion leaders and 22 experts. Consensus was found on terminology for three OCT BCC image features: (i) hyporeflective areas, (ii) hyperreflective areas and (iii) ovoid structures. Further, the participants ranked the ten most relevant image features for nodular, superficial, infiltrative and morpheaform BCC. The target group and the key components for a curriculum for OCT imaging of BCC have been defined.

CONCLUSION

We have established a set of OCT image features for BCC and preferred terminology. A comprehensive curriculum based on the expert suggestions will help implement OCT imaging of BCC in clinical and research settings.

The unmet demand for point-of-care ultrasound among general pediatricians: a cross-sectional survey

BACKGROUND

Point-of-care ultrasound (POCUS) is a noninvasive bedside tool with many pediatric applications but is not currently a formal part of pediatric training and practice. Formal surveys of general pediatricians regarding POCUS training are lacking. We aimed to quantify the baseline ultrasound experience and training needs of general pediatricians and pediatric residents across different practice settings.

METHODS

In 2020, we sent an online survey to 485 current faculty, residents, and graduates from an urban pediatric academic medical center in Northern California. Pediatric subspecialists were excluded. Survey questions about baseline experience, comfort, and perceived usefulness of 20 common POCUS applications were developed by two POCUS experts using existing literature. Chi-squared analysis was used to compare residents versus attendings and to compare attendings practicing in inpatient versus outpatient versus mixed settings.

RESULTS

Response rate was 20% (98/485). Compared to attendings (n = 73), residents (n = 25) endorsed more exposure to POCUS in medical school (32% vs 5%, p = 0.003) and residency (12% vs 5%, p = 0.003). Respondents endorsed low comfort with POCUS (mean 1.3 out of 5 on Likert scale). Of 20 procedural and diagnostic applications, respondents identified abscess drainage, bladder catheterization, soft tissue, neck, advanced abdominal, and constipation as most useful. Overall, 50% of pediatricians (and 70% of pediatric residents) responded that there were opportunities to use POCUS multiple times a week or more in their clinical practice.

CONCLUSIONS

There is an unmet demand for POCUS training among general pediatricians and trainees in our study. Although the majority of respondents were not POCUS users, our results could guide future efforts to study the role of POCUS in general pediatrics and develop pediatric curricula.

Highlights of the development in ultrasound during the last 70 years: A historical review

This review looks at highlights of the development in ultrasound, ranging from interventional ultrasound and Doppler to the newest techniques like contrast-enhanced ultrasound and elastography, and gives reference to some of the valuable articles in Acta Radiologica. Ultrasound equipment is now available in any size and for any purpose, ranging from handheld devices to high-end devices, and the scientific societies include ultrasound professionals of all disciplines publishing guidelines and recommendations. Interventional ultrasound is expanding the field of use of ultrasound-guided interventions into nearly all specialties of medicine, from ultrasound guidance in minimally invasive robotic procedures to simple ultrasound-guided punctures performed by general practitioners. Each medical specialty is urged to define minimum requirements for equipment, education, training, and maintenance of skills, also for medical students. The clinical application of contrast-enhanced ultrasound and elastography is a topic often seen in current research settings.

Abdominal ultrasound image quality is comparable among veterinary sonographers with varying levels of expertise for healthy canine and feline patients

Abdominal ultrasonography is increasingly used as a standard diagnostic test in veterinary practices, however, there is little published information regarding the effects of operator experience on image quality. In this prospective observer agreement study, image quality was assessed for abdominal ultrasound examinations performed by nine sonographers (three general practitioners, three credentialed veterinary technicians, and three board-certified specialists). Each sonographer independently performed abdominal ultrasound examinations on the same group of 4 sedated clinically healthy animals (3 dogs, 1 cat) using the same model machine and standardized presets. Twenty-five organs and anatomical landmarks per exam (26 for male dog) were evaluated. Still images and cine loops were recorded for each one of the organs. The final scoring of image quality for each examination was performed by two board-certified veterinary radiologists in a randomized and blinded fashion. Semiquantitative scoring system was used for each reading: 0 - not seen, 1- seen but poor quality/partial seen, 2 - average/good quality, and 3 - excellent quality. The average score for each animal and sonographer was tallied and sonographer groups and individual sonographers were compared. Scores were assessed for normality and data were ranked transformed prior to statistical analysis. No significant differences were found regarding the completeness and quality scores of sonographers of different experience levels and disciplines when measuring specific standard components of a full abdominal scan. There were no statistical differences between individual sonographers or groups of sonographers. Although not statistically significant, the general practitioner's group showed the greatest variability of their individual scores.

Handheld transabdominal ultrasound, after limited training, may confirm first trimester viable intrauterine pregnancy: a prospective cohort study

OBJECTIVES

Handheld point-of-care abdominal ultrasound (POCUS) may be used by primary care physicians while vaginal ultrasound is limited to use in specialist care. We aimed to compare abdominal handheld ultrasound to vaginal ultrasound in determining first trimester viable intrauterine pregnancy and estimate gestational length.

DESIGN

Prospective cohort study.

SETTING

Gynaecologic outpatient clinic; women referred from GPs during early pregnancy. Handheld ultrasound using VscanExtend^® was performed by fourth-year medical students with limited training. Transvaginal ultrasound using high-end devices was performed by ordinary hospital staff.

SUBJECTS

Women in the first trimester of pregnancy referred for termination of pregnancy or with symptoms of early pregnancy complications.

MAIN OUTCOME MEASURES

Rate of confirming vital intrauterine pregnancy (visualizing foetal heart beats) and measurement of crown-rump length (CRL) using handheld abdominal versus vaginal ultrasound.

RESULTS

In all 100 women were included; 86 confirmed as viable intrauterine pregnancies and 14 pathological pregnancies (miscarriages/extrauterine pregnancies). Handheld abdominal ultrasound detected fetal heartbeats in 63/86 (73% sensitivity) of healthy pregnancies and confirmed lack of fetal heartbeats in all pathological pregnancies, total positive predictive value (PPV) 100% and total negative predictive value (NPV) 38%. From gestational week 7, handheld abdominal ultrasound confirmed vitality in 51/54 patients: PPV 100% and NPV 79%. CRL (n = 62) was median 1 mm shorter (95% confidence interval 1-2 mm) measured by handheld abdominal versus vaginal ultrasound.

CONCLUSION

Handheld ultrasound has an excellent prediction confirming viable intrauterine pregnancy from gestational week 7. Validation studies are needed to confirm whether the method is suitable in primary care assessing early pregnancy complications.KEY POINTSWhen early pregnancy vitality needs to be confirmed, women will traditionally be referred to secondary care for transvaginal comprehensive ultrasonography performed with high-end devices by imaging specialists.In this study personnel with limited former training (fourth-year medical students) performed transabdominal POCUS using a handheld device, investigating 100 first trimester pregnancies for confirmation of viability.Using handheld ultrasound viable pregnancy was confirmed from gestational week 7 with 79% positive and 100% negative predictive value.If handheld ultrasound used in primary care confirms vital intrauterine pregnancy, the need for specialist referral could be reduced.

Introducing point-of-care ultrasound in Danish general practice-elucidating the use through a medical audit

BACKGROUND

Point-of-care ultrasonography (PoCUS) is increasingly used across the medical field. PoCUS is also being implemented in general practice despite a lack of clinical guidelines and training programs for general practitioners (GPs).

OBJECTIVES

This study aimed to elucidate the employment of PoCUS by Danish GPs following a short training program.

METHODS

Thirty GPs were enrolled in a short ultrasound training program and taught how to perform 22 selected scanning modalities. In the following 3 months, the GPs registered all performed PoCUS examinations according to the Audit Project Odense method. After 5 months, the GPs were invited to participate in an evaluation seminar, where questionnaires were distributed.

RESULTS

During the registration period, 1598 patients were examined with PoCUS. A total of 1948 scanning modalities were registered, including 207 examinations outside the taught curriculum. The majority of the ultrasound examinations were performed within 10 minutes (89%), most were considered to be conclusive (87%) and/or to increase diagnostic certainty (67%), whereas one in four examinations entailed a change in patient management. Most GPs attending the evaluation seminar continued to use PoCUS and found the scanning modalities included in the course curriculum relevant in their daily work.

CONCLUSION

The GPs found several indications for performing PoCUS following the attendance of a 2-day basic training program. The majority of examinations were registered to be conclusive and/or increase diagnostic certainty. However, few GPs used PoCUS on a daily basis and not all examinations were registered to have an impact on patient care.

Life after a point-of-care ultrasound course: setting up the right conditions!

Background

Point-of-care Ultrasound (POCUS) is becoming an important diagnostic tool for internal medicine and ultrasound educational programs are being developed. An ultrasound course is often included in such a curriculum. We have performed a prospective observational questionnaire-based cohort study consisting of participants of a POCUS course for internal medicine in the Netherlands in a 2-year period. We investigated the usefulness of an ultrasound course and barriers participants encountered after the course.

Results

55 participants (49%) completed the pre-course questionnaire, 29 (26%) completed the post-course questionnaire, 11 participants (10%) finalized the third questionnaire. The number of participants who performs POCUS was almost doubled after the course (from 34.5 to 65.5%). Almost all participants felt insufficiently skilled before the course which declined to 34.4% after the course. The majority (N = 26 [89.7%]) stated that this 2-day ultrasound course was sufficient enough to perform POCUS in daily practice but also changed daily practice. The most important barriers withholding them from performing ultrasound are lack of experts for supervision, insufficient practice time and absence of an ultrasound machine.

Conclusions

This study shows that a 2-day hands-on ultrasound course seems a sufficient first step in an ultrasound curriculum for internal medicine physicians to obtain enough knowledge and skills to perform POCUS in clinical practice but it also changes clinical practice. However, there are barriers in the transfer to clinical practice that should be addressed which may improve curriculum designing.

Ultrasound Definitions and Findings in Greater Trochanteric Pain Syndrome: A Systematic Review

Ultrasound (US) assists in the determination of the pathology underlying greater trochanteric pain syndrome (GTPS); however, there exists no consensus regarding the US criteria used to define these pathologies. We aim to explore these US definitions and their associated prevalence. "Trochanteric bursitis" was defined in 10 studies (13 included studies) and was heterogeneously described. "Tendinopathy" was defined in 4 studies, while 7 studies defined "tendinosis." "Tendon tears" were defined in 8 studies, 6 of which distinguished between "partial- and full-thickness tears." Tendon pathology was most frequent in 5 studies (prevalence: 7%-93%), and bursitis in 2 studies (prevalence: 10%-75%); 3 studies had equal distribution. Methodological quality was limited in the descriptions of GTPS and US approaches. Together, we document the lack of standardized US definitions of the pathologies underlying GTPS. This may explain the heterogenous prevalence of US findings. Standardized definitions are needed to improve the reliability of future GTPS studies.