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

Internal medicine (IM) physicians are increasingly incorporating point-of-care ultrasound (POCUS) into patient care for procedural and diagnostic applications.¹ POCUS use to guide bedside procedures improves patient safety by increasing procedural success rates, reducing complications, and avoiding unnecessary attempts and has evolved to become the standard of care for certain bedside procedures.^2‐7 Diagnostic POCUS applications can improve diagnostic accuracy, prognostication, patient satisfaction, and shared diagnostic understanding.^{6, 8, 9} By guiding clinical decision-making, POCUS can contribute to more efficient and cost-effective medical care.¹⁰

The Alliance for Academic Internal Medicine (AAIM) has endorsed POCUS training in IM residency programs, and programs have been seeking creative ways to implement POCUS training.¹¹ Despite the high demand^12‐14, incorporation of POCUS curricula by IM residency programs has been slow, increasing from 25% to 37.5% between 2012 and 2016.^{15, 16} Major barriers to incorporating POCUS training in IM residency programs include lack of faculty with POCUS expertise, time and cost of training faculty, and time required to train residents.^15‐19

To meet the demand for POCUS training, some IM residency programs have created POCUS electives or held workshops that provide an immersive experience.^{13, 18, 20‐22} However, longitudinal POCUS training has been shown to increase knowledge and skills retention among IM residents better than stand-alone workshops, but few programs currently can offer longitudinal POCUS training.^{23, 24} Among the IM residency tracks in hospital medicine in 2017, only one included a rotation in ultrasound diagnostics, and none was dedicated to POCUS training.²⁵

In 2018, we created a unique IM residency track, the POCUS track, that utilizes both local and external resources through a national certificate program in order to provide a 3-year longitudinal POCUS training experience. Here, we describe the development of our POCUS residency track including resources required, perspectives of residents and residency program leadership, and barriers to establishing a POCUS track.

We developed a POCUS track for our IM residency, a university-based program with 95 categorical residents that is affiliated with a public and veterans affairs hospital. Candidates apply for the POCUS track through a separate NRMP number. Our program accepts 4 residents per year with a total of 12 residents in all three years on the POCUS track.

POCUS track residents receive longitudinal ultrasound training during all three years (Supplemental Table 1).

All POCUS track residents were surveyed in April 2021 with a response rate of 100% (Table 2). The project was reviewed by the IRB and deemed to be non-research. Characteristics of POCUS track residents are summarized in Supplemental Table 2.

Frequently reported reasons for choosing the POCUS track included the desire to obtain POCUS training and certification, teaching opportunities, and important skills for career development. All residents rated being satisfied or very satisfied overall with the POCUS track and would recommend it to prospective applicants. All third-year POCUS track residents successfully completed the SHM-ACCP POCUS COC program prior to graduation and felt participation in the track was advantageous for their job search or fellowship application. The most commonly reported barriers to utilizing POCUS per POCUS track residents were time constraints (83%), lack of available ultrasound equipment (83%), and too few faculty trained in POCUS to supervise scanning (58%).

Frequency of use and comfort levels for different diagnostic and procedural POCUS applications are shown in Supplemental Tables 3 and 4. In general, the reported frequency of use and comfort levels increased between the 1^st and 3^rd years of residency.

We have described the development of an IM residency POCUS track combining local and external educational resources to provide longitudinal POCUS training. Direct benefits to POCUS track residents included the attainment of POCUS knowledge and skills and completion of a certificate program. Indirect benefits included increased institutional capacity for POCUS training by creating additional POCUS instructors for peer-to-peer teaching of residents and medical students. Our experience revealed important barriers and challenges that can help an IM residency program interested in developing a POCUS track.

POCUS skills are highly desired but inconsistently taught in IM residency programs across the country.^{15, 16} Longitudinal POCUS training has been shown to increase the frequency of ultrasound use and increase retention of knowledge and skills.^{11, 18, 23, 24} Creation of a POCUS track allowed residents with a deep interest in POCUS to receive comprehensive, longitudinal training and complete a certification endorsed by two national specialty organizations. POCUS track residents’ comfort and frequency of POCUS use increased and overall satisfaction with the program was positive. However, we recognize that our total sample size is relatively small, and future surveys will give us a better understanding of residents’ comfort level with different POCUS applications.

Several institutional benefits were realized by the creation of a POCUS track for IM residents. First, the lack of POCUS-trained IM faculty is a major barrier to POCUS implementation nationwide.^{15, 18, 19} For programs with limited local expertise, our POCUS track can serve as a model for providing longitudinal training by leveraging available external educational resources. We utilized the SHM-ACCP POCUS COC program, a nationally recognized POCUS certificate program, to overcome a shortage of local POCUS-trained faculty to provide feedback and assess the knowledge and skills of our POCUS track residents. Second, peer-to-peer instruction has been shown to be effective for POCUS education.^27‐29 POCUS track residents increased our institutional capacity to provide POCUS training by serving as instructors to teach residents and medical students. Third, our residency program anticipated attracting competitive candidates due to the uniqueness of the POCUS track. The number of candidates matching the POCUS track coming from the first quartile of our residency program’s rank list has been increasing since 2019. Fourth, POCUS track residents have increased the residency program’s scholarly output, including peer-reviewed publications and national conference presentations. Additionally, a POCUS track can provide early faculty development during residency and may better prepare residents for careers in academic medicine.³⁰ Thus far, one-third of our POCUS track residents have been recruited as academic hospitalist faculty or chief residents.

The most commonly reported barriers to POCUS use per POCUS track residents were time constraints, lack of available ultrasound equipment, and limited number of faculty trained in POCUS to supervise scanning. These barriers are consistent with past national surveys of POCUS training in IM residency programs.^{15, 16} Specific challenges per POCUS track residents were completion of the image portfolio (limited protected time to collect images; limited availability of faculty to review and provide feedback on images) and arranging schedules to attend required in-person courses. Lack of available ultrasound equipment presented challenges for both portfolio development and skills practice, and our IM residency program recently purchased two handheld ultrasound units specifically for the POCUS track residents to overcome this barrier.

We recognize our experience has limitations. First, core components of our POCUS track have been demonstrated to increase knowledge and skills of practicing clinicians, including participation in 2- or 3-day immersive POCUS CME courses^{31, 32} and collection of an image portfolio.³³ However, the impact of a POCUS track on IM residents’ long-term knowledge and skills retention, and changes to clinical practice is unknown. Furthermore, the current training paradigm provides limited experience in clinical integration of POCUS findings into bedside decision-making, but as more faculty become trained, residents will have more frequent supervised clinical integration in the future. Second, peer-to-peer POCUS instruction has been shown to be effective for medical student POCUS training,^27‐29 but its effectiveness among IM residents has not been well studied which we plan to evaluate in the coming years. Third, POCUS use is beneficial in outpatient settings to monitor high-risk patients for decompensation, expedite workups, and improve the availability of diagnostic resources for underserved populations.³⁴ Our POCUS track curriculum focuses primarily on inpatient applications, and additional training in outpatient applications, including skin, soft tissues, and joint ultrasound, shall be added to the curriculum in the future. Finally, the costs of the national certificate program and availability of a local POCUS faculty director may be limitations for residency programs desiring to start a POCUS track. Alternatively, institutions without local expertise could support interested faculty in completing the SHM-ACCP POCUS COC program. Investing in the development of institutional POCUS faculty champions could allow for the creation of a local certificate program for IM residents, similar to the SHM-ACCP POCUS COC program.

In conclusion, we have described the development of a dedicated POCUS track in IM residency that can provide longitudinal POCUS training and certification for a select group of IM residents. Our POCUS track leverages external educational resources to help overcome local barriers to POCUS training for IM residents. Our POCUS track may serve as a model for IM residencies interested in providing longitudinal training to its residents but lack the required resources or local expertise to offer such training.