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

Adding POCUS education to an already dense IM curriculum can be a challenging task, and its timing and length may be influenced by the extent of the curriculum to be delivered as well as practical considerations such as the number of available trained faculty, amount of time learners are accessible, and access to resources such as simulation for task training and scanning practice. While some programs have described their brief experiences teaching one discrete POCUS application, numerous IM programs teaching more comprehensive skills have dedicated roughly a 1- to 2-week period to introductory training followed by intermittent reinforcing sessions [3, 4]. In one report, Schnobrich et al. described a 30-h introductory course delivered over 5 days during intern orientation in which learners showed a statistically improved subjective and objective assessment of their ultrasound knowledge and skills in a wide range of skills [5]. Similarly, programs affiliated with Case Western Reserve, Boston University and Oregon Health & Science University have briefer introductory components of ultrasound use during or after intern orientation, but offer subsequent PGY2/3 electives. In all four programs, resident response to these formal curricula have been very positive and demands for more further formal instruction have been universally very strong.

A more frequent longitudinal component to didactic instruction may be beneficial, if sometimes more challenging to implement. Kelm et al. described IM-based training with a shorter initial training period (~ 4 h), but with a subset of residents participating in a longitudinal component involving monthly ultrasound-based morning reports and afternoon ultrasound rounds [6]. The authors found that the group participating in the ongoing training was more likely to correctly identify ascites, renal pathology and pleural effusion on static ultrasound images, and concluded that the addition of a longitudinal component to ultrasound education may result in improved knowledge retention. Regardless of how introductory and basic didactics are delivered, subsequent opportunities to scan patients on the ward or in clinic, integrate findings into management, and receive feedback are highly important to all programs.

A comprehensive POCUS program can be most effective when involving a variety of teaching methods. Many programs utilize some combination of online/in person didactic lectures, pre- or post-course quizzes, live models, simulation task trainers, dedicated ultrasound trainers, and direct patient scanning (Table 1). In several studies, residents were asked to rate the helpfulness of each of the above teaching modalities. IM residents found scanning live models and/or hospitalized or clinic patients, along with didactic lectures to be most helpful. Interestingly, taking and reviewing quizzes were rated as a less effective educational strategy [1, 5].

Many medical specialties perform POCUS tailored to their practices, and each is responsible for defining adequate training, competency, and quality assurance in their fields. The American Medical Association (AMA) policy H-230.960 specifically states that the use of ultrasound is not the intellectual property of any one specialty, and each specialty must define for themselves their scope of practice. With this guidance, a comprehensive ultrasound program for IM residencies should include defined, IM-specific competencies with subsequent regular assessment. Like other ACGME patient care-related milestones, this should involve direct trainee assessment, often including the creation of a portfolio for image review and approval. In its current state, many programs will “sign off” on resident ability to use POCUS for procedural guidance, however, diagnostic POCUS is more nuanced, and rigorous quality assurance systems need to be in place prior to granting residents the ability to make clinical decisions on their own.

It is the responsibility of all teaching programs to provide adequate supervision to medical trainees for all of their professional activities. This supervision may be direct or indirect, and is ideally tailored to the learners’ demonstrated proficiency, the activity being performed, and institutional resources. This supervision may often be quite challenging for internal medicine training programs, as the majority of teaching faculty are not likely to be proficient themselves. We are aware of a variety of mechanisms employed by teaching programs including partial delegation of supervisory roles to chief residents or other trained educators, the use of image review middleware to provide learners rapid feedback away from patient care, and formalization of entrustment using tools such as the CLUE-CEX exam or a formal entrustable professional activity [7].

As technology has evolved, POCUS equipment options have increased. Lower priced units have become available, including hand-held units to purchase or lease. These hand-held units are popular for their ease of transportation and use, however, present challenges for early learners given reduced screen size. Many suggest machines designed specifically for POCUS clinicians, as they often have a more approachable interface while losing little important functionality compared to machines designed for sonographers. Many manufacturers offer discounted educational pricing for educational-designated machines.

At a minimum, each program needs one dedicated machine configured with a linear, phased array and, if cost permits, a curvilinear probe. Maximizing access to POCUS machines encourages more frequent use, for example providing a cart-based unit for each floor and a hand-held for each resident team.

Some programs have access to simulation centers or ultrasound labs with machines that can be used by all learners. These spaces, when available, provide an arena for alternating didactics and hands-on sessions with normal models for the early learning phases. As learners progress, access to machines in clinical spaces is paramount for ongoing image acquisition and interpretation skill development, as actual patients provide both technical practice and the benefit of developing clinical integration skills.

Finances are often a limitation, and various methods have been used to acquire machines, including using medical school or hospital simulation centers (CWRU, UMN, OHSU, BU), noting the necessity of equipment if residents are expected to perform procedures (CWRU, UMN, OHSU, BU), quality improvement grant awards (UMN), use of machines destined for surplus from other divisions, group purchasing discounts when large departments/divisions are buying new machines, and making a return on investment (ROI) business case for ultrasound training later producing increases in billing or savings from enhanced patient safety (CWRU, BU).

Once machines are accounted for, there are other equipment considerations. If the assessment or quality assurance plan includes image portfolio collection and review, there should be a process to offload images in a HIPAA compliant fashion. Many machines come capable of connecting via wireless internet and archiving directly to image archival systems or the electronic medical record, however, others are not and require a “middleware” solution to sync images/clips to a secure on-site or cloud-based server. Some sites with student and resident learners decide not to have every educational image uploaded to the clinical spaces, and instead use “middleware” to differentiate between clinical and educational images. To save images, on-site requires the existence of a secure and sizeable server, which may already exist in other departments. Alternatively, a cloud-based server option can be added along with the “middleware” as a monthly operational cost.

The availability of ultrasound-skilled faculty to lecture provides hands-on education and creates ongoing curricula which can be a challenge. It is imperative to have a faculty “champion” who leads the development and maintenance of the program. Several successful programs have appointed a “Director of IM Ultrasound Education” or similar role with protected time, averaging 0.15–0.25 FTE.

Besides having a faculty champion, other faculty must become involved to continuously promote the program. Reaching out to other willing educators is critical as hands-on scanning sessions require at most 5 learners per teacher, and ideally 3–4. Interdepartmental and interprofessional collaboration have been invaluable at each of our institutions in this effort. Sonographers and echocardiographers have been excellent teachers for image acquisition skills. Several universities have found dedicated Educational Sonographers to be a core asset for their programs. In addition, we encourage growing programs to collaborate with other POCUS users within their institutions, in departments such as EM, Pulmonology/Critical Care, Cardiology, Family Medicine, Rheumatology and Anesthesiology, amongst others.