Feasibility and acceptability of a structured curriculum in teaching procedural and basic diagnostic ultrasound skills to internal medicine residents

Implementation and Evaluation of a Longitudinal Flipped-Classroom Point-of-Care Ultrasound Curriculum at an Internal Medicine Residency Program

BACKGROUND

Point-of-care ultrasound (POCUS) has extensive clinical utility in internal medicine, but formal and uniform curricula in internal medicine are lacking.

OBJECTIVE

To determine the effectiveness of a longitudinal, flipped-classroom, academic half-day curriculum on internal medicine resident confidence, utilization, and changes in clinical management.

METHODS

We implemented an asynchronous, flipped-classroom, academic half-day curriculum from November 2020 to November 2021 and conducted an evaluation with a prospective, before-after cohort study. Curriculum included 4 rotating sessions comprised of 20 to 30 min of image interpretation followed by 1.5 to 2 h of image acquisition. Confidence was rated via Likert scale. Utilization was reported via indicating never, 1 to 2, 3 to 4, 5 to 6, or >6 times per month (recorded as 1-5, respectively). Image interpretation was assessed via a 6-question, multiple-choice video assessment.

RESULTS

Nineteen of 99 potential residents (19%) completed a pre- and post-curriculum evaluation. Residents attended a median of 4 sessions. Confidence improved from 2.47 to 3.53 (P = .002). Utilization did not improve overall (2.11-2.42, P = .22), but utilization of left ventricular function assessment (1.53-2.00, P = .046) and pulmonary assessment (1.53-2.00, P = .039) increased. The percentage of residents that had ever changed their clinical management by POCUS increased from 47% to 84% after implementation of the curriculum. Cardiac, pulmonary/pleural, volume assessment, and abdominal free fluid exams were reported as the most clinically useful.

CONCLUSION

Implementation of a longitudinal, academic half-day curriculum for POCUS resulted in improved confidence, increased POCUS utilization for the cardiac and pulmonary examination, and changes in clinical management based on POCUS.

A prospective randomized study to compare standard versus intensive training strategies on long-term improvement in critical care ultrasonography proficiency

BACKGROUND

Critical care ultrasonography (CCUS) has become a daily diagnostic tool for intensivists. While the effective training measures for ultrasound novices are discussed widely, the best curriculum for the novices to retain a long-term proficiency is yet to be determined.

METHODS

Critical care medicine fellows who underwent an introductory CCUS workshop were randomly allocated into the standard training (ST) or the intensive training (IT) group. The IT group received an 8-h training besides the standardized fellowship education that the ST group received. Participant improvement in CCUS proficiency tests (maximum score, 200) after a 6-month training intervention was compared between the groups. CCUS examinations performed in patient care were observed over 2 years.

RESULTS

Twenty-one fellows were allocated into the ST (n = 10) or the IT (n = 11) group. No statistically significant difference was observed in the median (interquartile range [IQR]) improvement in CCUS proficiency tests between the ST group and the IT group: 18 (3.8-38) versus 31 (21-46) (P = .09). Median (IQR) test scores were significantly higher in postintervention than preintervention for both groups: ST, 103 (87-116) versus 124 (111-143) (P = .02), and IT, 100 (87-113) versus 143 (121-149) (P < .01). Participating fellows performed 226 examinations over the 2 years of observation.

CONCLUSIONS

Fellows improved their CCUS proficiency significantly after 6-month training intervention. However, an additional 8-h training did not provide further benefits.

Development of a Point-of-Care Ultrasound Track for Internal Medicine Residents

BACKGROUND

Point-of-care ultrasound (POCUS) training has been increasing among internal medicine (IM) residency programs, but few programs can provide longitudinal training due to barriers such as lack of trained faculty.

AIM

Describe the development of a longitudinal POCUS track for IM residents using local and external resources, including a national POCUS certificate program.

SETTING

University-based IM residency program affiliated with a public and veterans affairs hospital.

PARTICIPANTS

Twelve IM residents from 2018 to 2021.

PROGRAM DESCRIPTION

Residents complete a national POCUS certificate program by attending live courses and completing online modules, an image portfolio, and final knowledge/skills assessments. Locally, residents participate in 1-month procedure and diagnostic POCUS rotations and provide peer-to-peer POCUS teaching of residents and medical students.

PROGRAM EVALUATION

The POCUS track increased residents' use and comfort with diagnostic and procedural applications. All residents rated being satisfied or very satisfied with the track and would recommend it to prospective applicants (100%). The most commonly reported barriers to utilizing POCUS per residents were time constraints (83%), lack of available ultrasound equipment (83%), and lack of trained faculty (58%).

DISCUSSION

IM residency programs with limited faculty expertise in POCUS can leverage external resources to provide longitudinal POCUS training to its residents.

"Fun slipping into the doctor's role"-The relationship between sonoanatomy teaching and professional identity formation before and during the Covid-19 pandemic

The various psychological dimensions of professional identity formation (PIF) are an important aspect of the study course for undergraduate medical students. Anatomical learning environments have been repeatedly shown to play a critical role in forming such an identity; however, relevance of PIF during sonoanatomical training remains underexplored. At the end of their basic anatomy studies, third-semester medical students took part in a four-day block course on anatomy and imaging. Anatomical content was revised in small groups using peer teaching and imaging methods, including one hour of hands-on sonoanatomy sessions each day. On-site sonoanatomy was identified as an excellent format to support students' transition from the pre-clinical to clinical phase as medical experts-to-be. Students enjoyed practical exercises and the clinical input, which increased their interest in the medical profession and their academic studies. This study further examined the effects of the transition into an online-only format, necessitated by the current Covid-19 pandemic. A comparison was made between the quantitative and qualitative evaluation data, and the written results of examinations of several on-site (n = 1096, mean age = 22.4 years ± 2.18), and online-only cohorts (n = 230, mean age = 22.6 years ± 2.21). The online-only transition led to a reduction of all PIF-related variables measured, losing identity-related variables, increasing students' stress levels, and reducing their long-term academic performance. Together, this study demonstrates presence of PIF in undergraduate sonoanatomy teaching, and cautions against the uncritical online-only substitution of hands-on learning environments.

A Blueprint for an Integrated Point-of-Care Ultrasound Curriculum for Nephrology Trainees

Point-of-care ultrasonography (POCUS) is a limited ultrasound study performed by the clinician at the bedside as a component or an adjunct to physical examination. POCUS has multiple applications in nephrology practice, including evaluation of obstructive uropathy, objective assessment of volume status, arteriovenous access assessment, and procedural guidance. However, unlike specialties such as emergency medicine, POCUS training is not yet integrated into most nephrology fellowship curricula, and the sonographic applications taught vary widely among fellowship programs. In this article, we have used our institutional experience to provide a roadmap or blueprint for nephrology programs looking to create a POCUS program. We provide an overview of the curriculum, including the basic organization, applications taught, online resources, milestone development, and quality assessment. We also discuss the nuances of POCUS workflow and perspectives on billing for these limited studies. In addition, we share the evaluation forms and sample documentation we use in our program. Future support, in the form of endorsed nephrology society guidelines, is needed before POCUS training is universally incorporated across nephrology fellowship programs.

Novel Internal Medicine Residency Ultrasound Curriculum Led by Critical Care and Emergency Medicine Staff

INTRODUCTION

Point-of-care ultrasound (POCUS) is an integral aspect of critical care and emergency medicine curriculums throughout the country, but it has been slow to integrate into internal medicine residency programs. POCUS has many benefits for internal medicine providers, guiding diagnostic decisions and aiding in procedures. Additionally, POCUS is a convenient and portable resource specifically for internal medicine providers in the military when practicing in deployed or critical care settings. Critical care and emergency medicine clinicians are excellent resources to lead these courses. We sought to develop a new POCUS curriculum for internal medicine residents within the Naval Medical Center Portsmouth Internal Medicine Residency program with the support of emergency medicine and critical care medicine staff to lead and oversee the training. The project's aim was to increase internal medicine resident confidence with POCUS by 20% and proficiency with POCUS as evidenced by pretest and posttest analysis by 10%.

MATERIALS AND METHODS

The program consisted of a 2-day, 9-hour, introductory course, combining lecture with hands-on scanning taught by emergency medicine physicians who had completed emergency ultrasound fellowship-level training. This was followed by a longitudinal component of hands-on scanning throughout the academic year built into the residents' schedules. Emergency and critical care medicine ultrasound staff reviewed all studies for quality assurance (QA). The residents were given both precourse and post-course knowledge tests and confidence surveys, which utilized a 5-point Likert scale. The knowledge assessments were analyzed with a paired t-test, and the Likert scale data were analyzed using the Wilcoxon signed-rank test. The Naval Medical Center Portsmouth Institutional Review Board deemed this project nonhuman subjects' research.

RESULTS

Twenty participants were enrolled, with 10 (50%) of those enrolled completing all course requirements. The average precourse knowledge assessment score was 76.60%, and postcourse assessment score was 80.95% (+4.35%, P = .33). The confidence survey scores were initially 73.33% and improved to 77.67% (+4.34%, P = .74).

CONCLUSIONS

A curriculum comprised of a 9-hour workshop followed by a longitudinal hands-on experience can provide improvement in internal medicine resident POCUS knowledge and confidence. This model emphasizes the benefit of emergency and critical care cooperation for ultrasound training and provides an emphasis on medicine-relevant scans and longitudinal training.

Development and Evaluation of Resident-Championed Point-of-Care Ultrasound Curriculum for Internal Medicine Residents

Introduction: Point-of-care ultrasound (POCUS) is a powerful clinical tool that has seen widespread adoption, including in Internal Medicine (IM), yet standardized curricula designed by trained faculty are scant. To address the demand for POCUS education at our institution, we created a resident-championed curriculum with support from skilled faculty across multiple specialties. Our objective was to teach postgraduate year (PGY)-3 IM residents the basics of POCUS for evaluation of the pulmonary, cardiac, and abdominal systems through resident-developed workshops. The goal of acquisition of these skills was for resident education and to inform decisions to pursue further patient testing. Methods: Three half-day workshops were created to teach residents how to obtain and interpret ultrasound images of the pulmonary, cardiac, and abdominal systems. Workshops were comprised of didactic teaching and practical ultrasound instruction with expert supervision of clinicians within and outside of IM. Residents were asked to complete a written survey before and after each workshop to assess confidence, knowledge, and likelihood of future POCUS use. Results: Across the three workshops (pulmonary, cardiac, and abdominal), 66 sets of pre- and post-workshop surveys (32 pulmonary, 25 cardiac, and 9 abdominal) were obtained and analyzed. Confidence in and knowledge regarding POCUS use increased significantly across all three workshops. Likelihood of future use increased in the cardiac workshop. Conclusions: We implemented a resident-championed POCUS curriculum that led to improved attitudes and increased knowledge of POCUS for PGY-3 IM residents.

Development and implementation of competency-based assessment for urological ultrasound training using SonoSim: A preliminary evaluation

INTRODUCTION

Urology residents are encouraged to learn ultrasound (U/S) imaging, yet there are few tools available for teaching and assessing a resident`s competence. The aim of this study was to test the new SonoSim LiveScan® and to propose a competency-based assessment model for the urology graduate medical education.

MATERIALS AND METHODS

Urology residents attended an interactive training session covering the urological U/S techniques guided by the assessment model developed by the authors. Faculty members evaluated the residents using defined objectives, and the residents were surveyed on their comfort level for performing each of the model tasks. A subset of the residents then underwent a structured testing using the SonoSim LiveScan device 6 months following the training. The model developed assessed: general U/S setup, structure identification, and pathologic clinical scenarios.

RESULTS

The residents felt most comfortable in identifying the bladder (4.73/5) and the kidneys (4.53/5) during the training sessions. They felt least comfortable while testing for total ureteric obstruction (3.13/5). All the residents were confident that additional U/S training sessions would improve their comfort level in performing the assessed objectives. Resident`s assessment performed at 6 months had a median test score of 15.5/20 and the assessment scores increased with resident seniority. Self-reported comfort, however, did not seem to correlate with seniority. In general, the residents felt that the SonoSim device was highly functional (4.4/5) and the pathologic assessments in particular were very helpful (4.4/5).

CONCLUSIONS

Through pilot testing, we propose that a competency-based assessment used with the SonoSim LiveScan could guide the resident`s education through the acquisition of U/S skills and warrants testing in a larger cohort.

Introduction of an academic medical center's point-of-care ultrasound curriculum to internal medicine residents at a community-based teaching hospital

Background

Despite its proven utility, integration of point-of-care ultrasound (POCUS) into internal medicine (IM) residency training has been inconsistent. Due to their unique constraints, community-based teaching hospitals may face particular challenges in providing POCUS training to IM residents.

Objectives

To evaluate short-term educational outcomes of an academic center’s POCUS curriculum following its adaptation and delivery to IM residents at a community-based teaching hospital.

Methods

A needs assessment (NA) regarding POCUS training was distributed to PGY-2 and PGY-3 IM residents at a community-based teaching hospital in 2017. Based on the NA results, a POCUS curriculum from an academic center was modified and a revised course was offered to the same residents. Participants completed cognitive assessments before and after three of the four didactic sessions. Observed placement of an ultrasound-guided peripheral IV before and after the training program comprised the skills assessment.

Results

17 of 28 (61%) residents completed the NA; eleven participated in the course. Of 33 possible quiz pairs, 15 (45%) were completed. Average quiz scores rose after the first and third sessions. Skills assessment scores increased after course completion.

Conclusion

Adaptation of POCUS curricula from academic centers may be a feasible instructional strategy for community-based IM residency programs.

[Focused cardiac ultrasound in anesthetic practice: technique and indications]

The use of ultrasonography is well established in several anesthesia sub-specialties. Recently, there has been a major expansion of the POC (Point-Of-Care) ultrasound technique in intensive care, surgery, and emergency medicine, corroborating that USPOC in perioperative medicine has a much more comprehensive capability for both providing improved hemodynamic monitoring and early diagnosis of complications. The objective of the present article was to describe the use of a USPOC modality (focused cardiac US) that can be used for bedside assessment of unstable patients. Within a specific list of diagnoses, clinical treatment for a given situation can be tailored according to ultrasound findings, and by using binary and simple questions. Perioperative focused cardiac US use by the anesthesiologist has been related to lower rates of complications and mortality in high-risk patients.

Focused cardiac ultrasound in anesthetic practice: technique and indications

The use of ultrasonography is well established in several anesthesia sub-specialties. Recently, there has been a major expansion of the POC (Point-Of-Care) ultrasound technique in intensive care, surgery, and emergency medicine, corroborating that USPOC in perioperative medicine has a much more comprehensive capability for both providing improved hemodynamic monitoring and early diagnosis of complications. The objective of the present article was to describe the use of a USPOC modality (focused cardiac US) that can be used for bedside assessment of unstable patients. Within a specific list of diagnoses, clinical treatment for a given situation can be tailored according to ultrasound findings, and by using binary and simple questions. Perioperative focused cardiac US use by the anesthesiologist has been related to lower rates of complications and mortality in high-risk patients.

Introducing point-of-care ultrasound through structured multifaceted ultrasound module in the undergraduate medical curriculum at the University of Hong Kong

Incorporation of point-of-care ultrasound in the undergraduate medical curriculum is of great importance to ensure early exposure and safe use of the modality. We aimed to assess the students' learning experiences following implementing an ultrasound module in the medical curriculum at the University of Hong Kong. Medical students in semester 6 (n = 221) were enrolled in the module in 2018. It consisted of 1 hour of didactic lecture, followed by 3 hours of hands-on session. The students had the opportunity to enroll into a four-week Special Study Module to further practice their skills. The students had access to an e-learning platform to assist in their learning. Outcome measures include task-based performance, quizzes, feedback, and round-table discussion to assess the learning experiences. The module was highly rated by over 90% of students (response rate of 96%). Students practiced on peer subject on upper abdominal scanning. Post-training assessment showed an increment of 16% in their understanding of the modality. Students were motivated to enroll into the Special Study Module, where they were trained and became proficient with Focused Assessment with Sonography with Trauma. More than 86% of the students found the e-learning platform easy to use and assisted the training session. Round-table discussion suggested more simulated clinical cases to be added and expansion of future modules. Ultrasound module was successfully implemented into the undergraduate medical curriculum at the University of Hong Kong through new pedagogical approaches. This integration was highly rated by the medical students with improved awareness and better understanding of point-of-care ultrasound.

The Master Clinician's Elective: Integrating Evidence-Based Physical Examination and Point of Care Ultrasonography in Modern Clinical Medicine

Background: Many internal medicine residency programs have incorporated ultrasonography into their curriculum; however, its integration with physical examination skills teaching at a graduate medical level is scarce. The program's aim is to create a reproducible elective that combines physical exam and bedside ultrasound as a method for augmenting residents' knowledge and competence in these techniques with the ultimate goal of improving patient care. Methods: We designed and implemented a two-week elective rotation for senior internal medicine residents, combining evidence-based physical examination with diagnostic bedside ultrasonography. The rotation took place in an inpatient setting at Denver Health Hospital. Program evaluation data was collected data between February 2016 to March 2019. IRB approval was waived. Results: Since its inception in 2016, 19 residents completed the rotation. Residents performed a pre-test and a post-test under direct observation by course faculty. Each resident was measured on the ability to perform pre-determined physical exam and point-of-care ultrasound (POCUS) skills. In the pre-test, participants correctly performed an average of 40% of expected physical exam maneuvers and 32% of expected POCUS skills. At elective conclusion, all participants were effectively able to demonstrate the highest yield physical exam and ultrasound maneuvers. Discussion and Conclusion: An elective designed specifically to integrate POCUS and physical exam modalities improves the ability of resident physicians to utilize both diagnostic modalities.

Developing and Evaluating a Remote Quality Assurance System for Point-of-Care Ultrasound for an Internal Medicine Residency Global Health Track

Background: A quality assurance system is vital when using point-of-care ultrasound (POCUS) to ensure safe and effective ultrasound use. There are many barriers to implementing a quality assurance system including need for costly software, faculty time, and extra work to log images. Methods: With minimal funding or protected faculty time, we successfully developed an effective remote quality assurance system between residents rotating internationally and faculty in the US. Results: 270 total exams were logged using this system (41 per resident over a 7 week period). Over the course of the implementation period, a significant increase was seen in average image quality (p = 0.030) and percent agreement with reviewer (p = 0.021). No significant increase was seen for percent images with quality rating 5/5 (p = 0.068) or for studies per resident per week (p = 0.30). Discussion/Conclusions: A quality assurance system for remote review and feedback of POCUS exams was successfully developed with limited available funding, using consumer-level software and an educational collaboration. Residents used the system regularly and demonstrated improvement in reviewer-rated image acquisition and interpretation skills. A similar system can be applied for physicians in any geographic area looking to learn POCUS, in partnership with local or international POCUS mentors. We detail a step-by-step approach, challenges encountered, and lessons learned, to help guide others seeking to implement similar programs.

Reliability of focused cardiac ultrasound performed by first-year internal medicine residents at a community hospital after a short training

The use of bedside ultrasound over the past few decades has created a new wave of options for visualizing pathological processes allowing for faster and better detection of disease. We aimed to evaluate the reliability of focused cardiac ultrasound (FCU) performed by first-year internal medicine residents at a community hospital after a short period of training. They received a two-hour lecture and initially performed a supervised FCU followed by ten unsupervised/independent FCUs each. The four parameters that were assessed were left systolic ventricular function, right systolic ventricular function, presence of pericardial effusion, and presence of IVC dilation. Interpretation and analysis of ultrasound images were then carried out by both the residents and an attending physician with expertise in FCU analysis and interpretation. Cohen's Kappa values were obtained comparing the results found by the interns versus the attending. Our findings indicate that more training is required for reliable analysis of FCU by first-year medical residents. Our results also emphasize the need to carefully evaluate the medical residents' FCU skills after the training.

Hospitalist-Operated Compression Ultrasonography: a Point-of-Care Ultrasound Study (HOCUS-POCUS)

BACKGROUND

Venous thromboembolism includes deep vein thrombosis (DVT) and pulmonary embolism. Compression ultrasonography is the most common way to evaluate DVT and is typically performed by sonographers and interpreted by radiologists. Yet there is evidence that ultrasound examinations can be safely and accurately performed by clinicians at the bedside.

OBJECTIVE

To measure the operating characteristics of hospital medicine providers performing point-of-care ultrasound (POCUS) for evaluation of DVT.

DESIGN

This is a prospective cohort study enrolling a convenience sample of patients. Hospital medicine providers performed POCUS for DVT and the results were compared with the corresponding formal vascular study (FVS) interpreted by radiologists.

PARTICIPANTS

Hospitalized non-ICU patients at four tertiary care hospitals for whom a DVT ultrasound was ordered.

MAIN MEASURES

The primary outcomes were the sensitivity, specificity, and predictive values of the POCUS compression ultrasound compared with a FVS. The secondary outcome was the elapsed time between order and the POCUS study compared with the time the FVS was ordered to when the formal radiology report was finalized.

KEY RESULTS

One hundred twenty-five limbs from 73 patients were scanned. The prevalence of DVT was 6.4% (8/125). The sensitivity of POCUS for DVT was 100% (95% CI 74-100%) and specificity was 95.8% (95% CI 91-98%) with a positive predictive value of 61.5% (95% CI 35-84%) and a negative predictive value of 100% (95% CI 98-100%). The median time from order to POCUS completion was 5.8 h versus 11.5 h median time from order until the radiology report was finalized (p = 0.001).

CONCLUSION

Hospital medicine providers can perform compression-only POCUS for DVT on inpatients with accuracy similar to other specialties and settings, with results available sooner than radiology. The observed prevalence of DVT was lower than expected. POCUS may be reliable in excluding DVT but further study is required to determine how to incorporate a positive POCUS DVT result into clinical practice.

Three-Dimensional Printed Cardiac Models for Focused Cardiac Ultrasound Instruction

BACKGROUND

Focused cardiac ultrasonography (FCU) is an increasingly integral component of routine medical training and practice. While various instructional methods have been described, few attempts have been made to incorporate a physical 3-dimensional (3D) instructional aid.

OBJECTIVE

The aim of this study was to determine if a 3D printed heart model workshop for FCU instruction leads to equivalent structure recognition and scanning ability compared to traditional didactic FCU instruction.

INTERVENTION

Twenty first-year medical students with no point-of-care ultrasonography experience were randomly assigned to a traditional lecture (n = 10) or a 3D printed heart model workshop (n = 10). Written examinations at 0 and 3 months as well as image acquisition at 3 months were compared.

RESULTS

The median scores from the initial written structure identification in the traditional and 3D heart groups were 74% and 90%, respectively (P = 0.7). The second written exam at 3 months yielded median scores of 56% and 58% in the traditional and 3D heart groups, respectively (P = 0.8). The average scores on the image acquisition practical at 3 months were 3.3 of 5 and 2.7 of 5 (P = 0.1) in the traditional and 3D heart groups, respectively.

CONCLUSIONS

Utilizing 3D heart models in an FCU workshop format results in similar skill acquisition and knowledge retention as traditional didactics. The 3D heart models are relatively inexpensive, portable, and reusable, enabling learners to practice repeatedly and at flexible intervals. The reduction in ongoing expenses and the ability to teach large groups may decrease training costs as well as the need for local faculty expertise.

Internal medicine residents' point-of-care ultrasound skills and need assessment and the role of medical school training

Introduction: Point-of-care-ultrasound (POCUS) as a useful bedside tool is growing. Few studies have examined residents' attitude towards POCUS or compared POCUS image interpretation skills between residents with and without POCUS training in medical school. Material and Methods: We distributed an anonymous survey and image interpretation test to assess residents' attitude towards POCUS, confidence, and skills in interpreting POCUS images and videos. Using independent samples t-tests, we compared mean confidence levels and test scores between residents with and without prior POCUS training. Results: Fifty-two residents responded to survey (response rate 68%) and 59 took the image interpretation test (77%). Most residents (90%) reported being interested in POCUS. Residents with prior POCUS training (n=13) were either PGY-1 (9) or PGY-2 (4). No PGY-3 resident had prior training. Most residents (83%) thought POCUS could be extremely useful in the inpatient setting compared to 29% for outpatient setting. PGY-1 residents with prior training had a higher mean confidence level than PGY-1 residents without prior training, but the difference was not statistically significant (3.26 vs 2.64; p=0.08). PGY-1 with prior training had a mean confidence level that was close to that of PGY-3 residents. PGY-1 residents with prior training scored significantly higher than PGY-1 residents without prior training in image interpretation test (10.25 vs 7; p=0.01). Residents felt most confident in interpreting inferior vena cava images (mean 3.7; max. 5), which also had the highest score in image interpretation test (correct response rate of 88%). Conclusion: Our residents seem very interested in POCUS. PGY-1 residents with prior POCUS training in medical school seem to have higher confidence in their POCUS skills than PGY-1 residents without prior training and outperformed them in image interpretation test. The study is very instructive in building our future POCUS curriculum for residents.

A road map for point-of-care ultrasound training in internal medicine residency

Background

Ever-expanding uses have been developed for ultrasound, including its focused use at the bedside, often referred to as point-of-care ultrasound (POCUS). POCUS has been well developed and integrated into training in numerous fields, but remains relatively undefined in internal medicine training. This training has been shown to be desirable to both educators and trainees, but has proven difficult to implement. We sought to create a road map for internal medicine residency programs looking to create a POCUS program.

Results

Four internal medicine residency programs that have successfully integrated POCUS training describe their programs, as well as the principles and concepts underlying program development and execution. Review of educational teaching and assessment methods is outlined, as well as suggestions for integration into an already busy residency curriculum. Commonly reported barriers to POCUS implementation such as faculty development, equipment purchasing, resident supervision and quality assurance are addressed. Specific POCUS applications to target are touched upon, and a comparison of applications taught within these four programs suggest that there may be enough similarities to suggest a common curriculum. Finally, future needs are discussed.

Conclusions

POCUS can be successfully taught to internal medicine residents as a part of internal medicine training. Many common elements and principles are evident on review of these four described successful programs. Future support, in the form of endorsed medical society guidelines, will be needed before POCUS is universally incorporated across internal medicine residency training programs.

Considerations for Implementing Point-of-Care Ultrasound in a Community-Based Family Medicine Residency Program

BACKGROUND

Prior to implementing Point-of-Care Ultrasound (POCUS) training into our Family Medicine Residency Program, we sought to determine opinions on the most relevant applications according to current Family Medicine residents and recent graduates. As there are so many POCUS applications relevant to Family Medicine, it would be efficient to teach only the most relevant scans.

OBJECTIVE

Examine current POCUS use and the perception of future use among current residents and recent graduates of a Family Medicine Residency Program.

METHODS

In 2017, an electronic survey was used to examine differences in perceptions regarding the value of POCUS applications, benefits of use, and potential barriers to implementation.

RESULTS

Of the 88 surveys sent, 21 of 21 current residents (100%) and 28 of 67 recent graduates (41.8%) completed the survey with a total completion rate of 55.7%. The POCUS practices differed between groups. Current residents were significantly more likely than recent graduates to use POCUS for vascular procedural guidance and other procedural guidance. Recent graduates were significantly more likely to report POCUS use for abdominal aortic aneurysm screening and lower extremity Doppler screening for deep vein thrombosis. All P values were significant at the .05 level.

CONCLUSIONS

Point-of-Care Ultrasound training is generally desired by current residents. Some applications are perceived to be of sufficient utility by current residents and recent graduates. Findings would justify investment of time and effort required to implement POCUS training in Family Medicine Residency curriculums. Curriculum should focus on applications viewed as high priority based on usage rates.

Entrusting internal medicine residents to use point of care ultrasound: Towards improved assessment and supervision

Background: Internal medicine physicians and trainees are increasingly using, and seeking training in, diagnostic point of care ultrasound (POCUS). Numerous internal medicine training programs have described their curricula, but little has been written about how learners should be assessed, supervised, and allowed to progress toward independent practice, yet these practices are imperative for safe and effective use. Entrustable professional activities (EPAs) offer a practical method to assess observable units of professional work and make supervision decisions. Methods: An EPA for POCUS is used as a framework to assess and determine appropriate levels of supervision in an internal medicine residency program. Results: All learners have been able to advance to level 2 with a mandatory introductory boot camp course. Learners have been able to advance to higher levels of independence, often after taking formal elective programmatic coursework. However, not all learners taking the same coursework have been granted the same level of independence. Conclusions: It is feasible to assess and supervise internal medicine residents' ability to use diagnostic point of care ultrasound using an EPA.

Recommendations on the Use of Ultrasound Guidance for Adult Thoracentesis: A Position Statement of the Society of Hospital Medicine

Executive Summary: 1) We recommend that ultrasound should be used to guide thoracentesis to reduce the risk of complications, the most common being pneumothorax. 2) We recommend that ultrasound guidance should be used to increase the success rate of thoracentesis. 3) We recommend that ultrasound-guided thoracentesis should be performed or closely supervised by experienced operators. 4) We suggest that ultrasound guidance be used to reduce the risk of complications from thoracentesis in mechanically ventilated patients. 5) We recommend that ultrasound should be used to identify the chest wall, pleura, diaphragm, lung, and subdiaphragmatic organs throughout the respiratory cycle before selecting a needle insertion site. 6) We recommend that ultrasound should be used to detect the presence or absence of an effusion and approximate the volume of pleural fluid to guide clinical decision-making. 7) We recommend that ultrasound should be used to detect complex sonographic features, such as septations, to guide clinical decision-making regarding the timing and method of pleural drainage. 8) We suggest that ultrasound be used to measure the depth from the skin surface to the parietal pleura to help select an appropriate length needle and determine the maximum needle insertion depth. 9) We suggest that ultrasound be used to evaluate normal lung sliding pre- and postprocedure to rule out pneumothorax. 10) We suggest avoiding delay or interval change in patient position from the time of marking the needle insertion site to performing the thoracentesis. 11) We recommend against performing routine postprocedure chest radiographs in patients who have undergone thoracentesis successfully with ultrasound guidance and are asymptomatic with normal lung sliding postprocedure. 12) We recommend that novices who use ultrasound guidance for thoracentesis should receive focused training in lung and pleural ultrasonography and hands-on practice in procedural technique. 13) We suggest that novices undergo simulation-based training prior to performing ultrasound-guided thoracentesis on patients. 14) Learning curves for novices to become competent in lung ultrasound and ultrasound-guided thoracentesis are not completely understood, and we recommend that training should be tailored to the skill acquisition of the learner and the resources of the institution.

Ultrasound imaging in medical student education: Impact on learning anatomy and physical diagnosis

Ultrasound use has expanded dramatically among the medical specialties for diagnostic and interventional purposes, due to its affordability, portability, and practicality. This imaging modality, which permits real-time visualization of anatomic structures and relationships in vivo, holds potential for pre-clinical instruction of students in anatomy and physical diagnosis, as well as providing a bridge to the eventual use of bedside ultrasound by clinicians to assess patients and guide invasive procedures. In many studies, but not all, improved understanding of anatomy has been demonstrated, and in others, improved accuracy in selected aspects of physical diagnosis is evident. Most students have expressed a highly favorable impression of this technology for anatomy education when surveyed. Logistic issues or obstacles to the integration of ultrasound imaging into anatomy teaching appear to be readily overcome. The enthusiasm of students and anatomists for teaching with ultrasound has led to widespread implementation of ultrasound-based teaching initiatives in medical schools the world over, including some with integration throughout the entire curriculum; a trend that likely will continue to grow. Anat Sci Educ 10: 176-189. © 2016 American Association of Anatomists.

The path to ultrasound proficiency: A systematic review of ultrasound education and training programmes for junior medical practitioners

Background

Point-of-care ultrasound (POCUS) is a form of diagnostic ultrasonography, which has a defined role as a clinical adjunct in patient assessment and management. If it is to continue to develop as a core clinical skill, junior medical practitioners and trainees may benefit from dedicated ultrasound education and familiarisation early in their training. Controversy endures, however, as inappropriate use of this highly technical and operator-dependent imaging modality has negative clinical implications.

Aims

A systematic review was performed to assess the ability of doctors in training to perform clinically appropriate and beneficial diagnostic ultrasound after undergoing a formal training programme.

Methods

Studies meeting pre-defined inclusion criteria were identified in electronic databases MEDLINE, EMBASE, CINAHL, PUBMED and through Google Scholar. Methodological quality was assessed using an established series of indicators.

Results

Fifteen studies were included in the review. Ten of these were performed in the United States, and eight focused on emergency medicine trainees. After the teaching intervention, ten studies assessed overall ultrasound capacity by calculating the collective sensitivity and specificity of trainee-performed ultrasound. Five studies used a standardised objective assessment tool to evaluate ultrasound skills and technique. Studies varied in terms of the specific ultrasound use investigated, teaching programmes used and methodological quality. Consistently identified areas for further research included the definition of the trainee learning curve and what constitutes competency in ultrasound.

Conclusions

Ultrasound can feasibly be incorporated into junior medical practitioner training, but more research is required to assess its effectiveness and appropriateness.

Internal Medicine Residents' Retention of Knowledge and Skills in Bedside Ultrasound

BACKGROUND

The long-term retention of knowledge and skills in bedside ultrasound by internal medicine residents after ultrasound training is not well understood.

OBJECTIVE

We sought to determine whether knowledge and skills acquired from focused training in bedside ultrasound are retained over time, and whether retention is related to independent practice.

METHODS

We conducted a prospective observational trial of 101 internal medicine residents at an academic medical center who participated in a bedside ultrasound workshop followed by 12 months of independent practice. Performance was measured on image-based knowledge and skills assessment using direct observation, both before the workshop and 12 months later. Individual usage data were obtained along with a survey on attitudes toward bedside ultrasound.

RESULTS

Participants' mean knowledge assessment score increased from a baseline of 63.7% to 84.5% immediately after training (P < .001). At 12 months, mean knowledge score fell to 73.0%, significantly different from both prior assessments (P < .001). Despite knowledge decline, the mean skills assessment score improved from a baseline of 30.5% to 50.4% at 12 months (P < .001). Residents reporting more ultrasound use (> 25 examinations) had higher scores in baseline knowledge and skills assessments than those with lower usage (< 25 examinations). Change in knowledge and image acquisition skills between assessments was equal in both subgroups.

CONCLUSIONS

Residents' knowledge of ultrasound improved after brief training but decayed over time, whereas skills showed marginal improvement over the study, with minimal support. Growth and retention of ultrasound abilities were not impacted by usage rates.

Teaching the internist to see: effectiveness of a 1-day workshop in bedside ultrasound for internal medicine residents

Background

A growing body of evidence supports the use of bedside ultrasound for core Internal Medicine procedures and increasingly as augmentation of the physical exam. The literature also supports that trainees, both medical students and residents, can acquire these skills. However, there is no consensus on training approach.

Aim

To implement and study the effectiveness of a high-yield and expedited curriculum to train internal medicine interns to use bedside ultrasound for physical examination and procedures.

Setting

The study was conducted at a metropolitan, academic medical center and included 33 Internal Medicine interns.

Program description

This was a prospective cohort study of a new educational intervention consisting of a single-day intensive bedside ultrasound workshop followed by two optional hour-long workshops later in the year. The investigation was conducted at Oregon Health & Science University in Portland, Oregon. The intensive day consisted of alternating didactic sessions with small group hands-on ultrasound practice sessions and ultrasound simulations. A 30-question assessment was used to assess ultrasound interpretation knowledge prior to, immediately post, and 6 months post intervention.

Results

Thirty-three interns served as their own historical controls. Assessment performance significantly increased after the intervention from a mean pre-test score of 18.3 (60.9 % correct) to a mean post-test score 25.5 (85.0 % correct), P value of <0.0001. This performance remained significantly better at 6 months with a mean score of 23.8 (79.3 % correct), P value <0.0001. There was significant knowledge attrition compared to the immediate post-assessment, P value 0.0099.

Conclusions

A single-day ultrasound training session followed by two optional noon conference sessions yielded significantly improved ultrasound interpretation skills in internal medicine interns.

Ultrasound Skill and Application of Knowledge Assessment using an Innovative OSCE Competition-Based Simulation Approach

BACKGROUND

Despite Point-of Care Ultrasound (PoC US) rapidly becoming an important tool in perioperative medicine structured education, PoC US is currently rarely integrated into the anesthesiology residency curriculum. The aim of this project was to assess the current ultrasound skills of anesthesiology residents at one institution and evaluate the needs for development of a formal ultrasound curriculum.

METHODS

A event containing 6 different OSCE PoC US stations was developed with following stations: vascular, peripheral nerve block, lung ultrasound, transthoracic echocardiography (TTE) human model, pathologic TTE (simulator), and inferior vena cava (IVC) evaluation (simulator). The ability to obtain an US image or to interpret the US information was evaluated using a checklist and global rating scale. After IRB approval, anesthesiology residents participated in this event (n=30; PGY 2-4).

RESULTS

All residents were able to identify vascular structures and demonstrated sufficient ultrasound skill for lung anatomy IVC assessment. The lowest scores were observed for performing and interpreting TTE. There were no differences in resident ultrasound skills for all OSCE stations except minor differences between PGY 2 and PGY 4 in TTE pathology station. While more advanced residents had more clinical exposure to ultrasound for procedures and point-of-care diagnosis, we did not find growth in ultrasound skill level. Despite performing sufficient ultrasound guided peripheral nerve blocks, PGY 4 residents were not able to consistently identify common nerve block targets.

CONCLUSIONS

Our findings indicate that exposure and clinical use of ultrasound for procedures and point-of-care diagnosis is not sufficient for developing competency in PoC US and that a formal curriculum throughout the entire anesthesiology residency is needed to ensure PoC US competency.

Point-of-care ultrasonography improves the diagnosis of splenomegaly in hospitalized patients

Background

It is important to detect splenomegaly as it can have important diagnostic implications. Previous studies, however, have shown that the traditional physical examination is limited in its ability to rule in or rule out splenomegaly.

Objective

To determine if performing point-of-care ultrasonography (POCUS) in addition to the traditional physical examination improves the sensitivity and specificity for diagnosing splenomegaly.

Methods

This was a prospective trial of diagnostic accuracy. Physical and sonographic examinations for splenomegaly were performed by students, residents and attending physicians enrolled in an ultrasound training course. Participants received less than 1 h training for ultrasound diagnosis of splenomegaly. The findings were compared to radiographic interpretation of gold standard studies.

Setting/patients

Hospitalized adult patients at an academic medical center without severe abdominal pain or recent surgery who had abdominal CT, MRI or ultrasound performed within previous 48 h.

Results

Thirty-nine subjects were enrolled. Five patients had splenomegaly (12.5 %). The physical examination for splenomegaly had a sensitivity of 40 % (95 % CI 12–77 %) and specificity of 88 % (95 % CI 74–95 %) while physical examination plus POCUS had a sensitivity of 100 % (95 % CI 57–100 %) and specificity of 74 % (95 % CI 57–85 %). Physical examination alone for splenomegaly had an LR+ of 3.4 (95 % CI 0.83–14) and LR− of 0.68 (95 % CI 0.33–1.41); for physical exam plus POCUS the LR+ was 3.8 (2.16–6.62) and LR− was 0.

Conclusions

Point-of-care ultrasonography significantly improves examiners’ sensitivity in diagnosing splenomegaly.

Bedside ultrasonography (US), Echoscopy and US point of care as a new kind of stethoscope for Internal Medicine Departments: the training program of the Italian Internal Medicine Society (SIMI)

In recent years, thanks to the development of miniaturized ultrasound devices, comparable to personal computers, tablets and even to smart phones, we have seen an increasing use of bedside ultrasound in internal medicine departments as a novel kind of ultrasound stethoscope. The clinical ultrasound-assisted approach has proved to be particularly useful in assessing patients with nodules of the neck, dyspnoea, abdominal pain, and with limb edema. In several cases, it has allowed a simple, rapid and precise diagnosis. Since 2005, the Italian Society of Internal Medicine and its Ultrasound Study Group has been holding a Summer School and training courses in ultrasound for residents in internal medicine. A national network of schools in bedside ultrasound was then organized for internal medicine specialists who want to learn this technique. Because bedside ultrasound is a user-dependent diagnostic method, it is important to define the limits and advantages of different new ultrasound devices, to classify them (i.e. Echoscopy and Point of Care Ultrasound), to establish appropriate different levels of competence and to ensure their specific training. In this review, we describe the point of view of the Italian Internal Medicine Society on these topics.