The assessment of point-of-care ultrasound (POCUS) in residency: the benefits of a four-year longitudinally integrated curriculum

Methods

Results

The study encompassed a total of 104 participants that were divided between primary care (N=50, 48.1 %) and other medical specialties (N=54, 51.9 %). Primary care specialties, as designated by the Association of American Medical Colleges (AAMC), include internal medicine, family medicine, obstetrics and gynecology (OBGYN), pediatrics, and psychiatry. Responses from residents in a total of 14 different clinical specialties were obtained: pathology (n=1, <1.0 %), anesthesiology (n=9, 9.0 %), emergency medicine (n=20, 19.2 %), family medicine (n=18, 17.0 %), general surgery (n=10, 10.0 %), internal medicine (n=23, 22.0 %), neurology (n=4, 4.0 %), OBGYN (n=3, 3.0 %), ophthalmology (n=1, <1.0 %), orthopedic surgery (n=1, <1.0 %), pediatrics (n=3, 3.0 %), physical medicine and rehabilitation (n=6, 6.0 %), psychiatry (n=3, 3.0 %), and radiology (n=2, 2.0 %). A subset of respondents, approximately 14 % (n=15, 14.4 %), indicated nonutilization of POCUS during their residency programs. However, most respondents (n=89, 85.6 %) confirmed the utilization of POCUS in their clinical practice, occurring at varying frequencies: daily (n=28, 31.5 %), weekly (n=39, 43.8 %), and monthly (n=22, 24.7 %).

A specific inquiry within the survey aimed to ascertain the most extensively employed imaging modalities during residency training from a selection of 10 options: pulmonary, cardiac, abdominal Focused Assessment with Sonography for Trauma (FAST), musculoskeletal, procedures, ocular, thyroid, OBGYN, vascular/deep vein thrombosis (DVT), and dermatology-related. Results demonstrated that the top five modalities widely utilized across diverse specialties by residents are procedures (n=80, 89.9 %), cardiac (n=79, 88.8 %), pulmonary (n=73, 82.0 %), FAST (n=65, 73.0 %), and vascular (n=64, 71.9 %).

The survey also delved into why respondents incorporate POCUS into their practice. Among the 89 respondents who regularly utilize POCUS, 97.8 % (n=87) regarded POCUS as a beneficial diagnostic tool. Additionally, 52 respondents (58.4 %) recognized its role in enhancing their physical examination skills, and 55 respondents (61.8 %) believe that POCUS use contributes to their professional growth. Similarly, 40 respondents (44.9 %) reported utilizing POCUS to improve patient satisfaction. We chose to further dissect these responses by residency specialty to gain insight into specific POCUS uses of various specialties. Specialties commonly reporting POCUS as enhancing their physical examination skills include emergency medicine (n=13, 13.0 %), internal medicine (n=11, 11.0 %), family medicine (n=8, 8.0 %), and general surgery (n=8, 8.0 %). Specialties commonly reporting utilizing POCUS as a diagnostic tool include emergency medicine (n=20, 19.0 %), internal medicine (n=20, 19.0 %), family medicine (n=15, 14.0 %), and general surgery (n=10, 10.0 %). Specialties reporting POCUS use for professional growth and development include internal medicine (n=14, 14.0 %), emergency medicine (n=13, 13.0 %), and family medicine (n=11, 11.0 %). Specialties reporting POCUS use to increase patient satisfaction include emergency medicine (n=13, 13.0 %), internal medicine (n=8, 8.0 %), and family medicine (n=8, 8.0 %). This residency-specific data breakdown is represented in Figure 1.

Figure 1:

A specialty-specific breakdown of the reasons why MWU-AZCOM graduates utilize POCUS in their practice. Residents in emergency medicine, internal medicine, and family medicine comprise most POCUS users.

The survey also aimed to highlight factors facilitating the utilization of POCUS during residency training and offered respondents options including cost-effectiveness, diagnostic differentiation, ease of use, expedited patient care, meeting residency accreditation standards, safety, and a potential no-enablers option. Notably, respondents identified key factors enabling POCUS use, with cost-effectiveness (n=73, 82.0 %), diagnostic differentiation (n=70, 78.7 %), and safety (n=71, 79.8 %) being the most prominent. Other enabling factors included ease of use (n=64, 71.9 %), expediting patient care (n=65, 73.0 %), and meeting residency accreditation standards (n=35, 39.3 %).

Equally significant was the identification of barriers hindering regular POCUS utilization within residency programs. All 104 participants were presented with 10 potential barriers, and the commonly indicated barriers included the lack of trained faculty (n=29, 27.9 %), absence of necessary equipment (n=28, 26.9 %), and cost of equipment (n=23, 22.1 %). Additional barriers included discomfort with image interpretation (n=17, 16.3 %), insufficient training (n=13, 12.5 %), lack of administrative support (n=11, 10.6 %), lack of support from the radiology department (n=5, 4.8 %), image acquisition issues (n=6, 5.8 %), and lack of internet access (n=1, 1.0 %). These data are visually expressed in Figure 2. Further evaluation of the data indicated that specialties citing a lack of training in residency as a barrier (n=13, 12.5 %) included internal medicine (n=5, 38.4 %), family medicine (n=4, 30.8 %), and anesthesiology (n=4, 30.8 %). Common specialties citing a lack of trained faculty (n=23, 27.9 %) at their respective programs were family medicine (n=10, 34.5 %), internal medicine (n=9, 31.0 %), and emergency medicine (n=4, 13.8 %).

Figure 2:

MWU-AZCOM graduates commonly report a lack of trained faculty, a lack of necessary equipment, and the cost of equipment as the most prohibitive factors against POCUS use within their residency programs.

A Likert scale was implemented to gauge respondents’ perceptions of their POCUS skill sets resulting from their MWU-AZCOM education. Among those indicating POCUS use in their residency practice, a considerable portion agreed or strongly agreed that their exposure to POCUS during medical school directly enriched their clinical practice (n=80, 76.9 %). Moreover, this exposure was positively associated with increased confidence in performing POCUS evaluations (n=77, 74.0 %) and interpreting POCUS imagery (n=79, 76.0 %). Furthermore, a notable subset of participants (n=45, 43.3 %) perceived that their medical school’s POCUS training increased their attractiveness as residency candidates. These data are represented in Figure 3. Respondents suggesting that their training in medical school was a factor in successfully matching into residency (n=45, 43.3 %) mainly went into emergency medicine (n=11, 24.4 %), family medicine (n=7, 15.5 %), and internal medicine (n=7, 15.5 %). Additionally, most participants (n=71, 68.3 %) maintained that their POCUS training aligned well with their subsequent clinical practice.

Figure 3:

Most MWU-AZCOM graduates are comfortable performing and evaluating POCUS scans and agree that their POCUS training in medical school benefits them in their current residency program.

In the survey’s optional free-response section for improvement and additional comments, 22 respondents (21.1 %) provided input. Within the Improvement section, comments encompassed suggestions to fine-tune educational strategies to better equip participants for residency. These recommendations included fostering greater familiarity with procedures, “use without having to think,” and greater emphasis on pulmonary and cardiac POCUS. In the Additional Comments section, most respondents expressed positive regard for their POCUS medical education. Notably, one comment highlighted how POCUS “helps solidify anatomy” and “highly recommend continuing for future students.” Moreover, a respondent conveyed appreciation stating, “AZCOM has a well-thought-out ultrasound curriculum that is beneficial regardless of the specialty the student chooses.” There were also two respondents who utilized this section of the survey to highlight another perceived barrier preventing residents from utilizing POCUS: time. These respondents stated that residents “simply do not have the time to use POCUS” because “residents are already busy learning the hospital system, writing various notes (H&P, progress note, and discharge/death summary), putting orders, etc…. I end up relying on an ultrasound tech to complete the exam instead….”

Discussion

As POCUS has become an increasingly versatile tool across various medical specialties, and the benefit of immersing medical students from an early stage is evident [9]. Our survey shows that 85.6 % of AZCOM graduates regularly employ POCUS in their practice, with 75.3 % utilizing it daily or weekly. Given that most of these graduates consistently utilize ultrasound during their residencies, current medical students would benefit from developing a solid foundation in ultrasound training through a comprehensive 4-year longitudinal program. High levels of confidence in both performing POCUS (74.0 %) and interpreting POCUS (76.0 %) among our surveyed graduates underscore the benefits of introducing this modality in the didactic phase and continuing it through clinical rotations.

The current ultrasound curriculum at MWU-AZCOM involves hands-on POCUS training incorporated into the anatomy, physiology, and osteopathic clinical medicine courses in the first year (11 h total) and further training in the osteopathic clinical medicine courses in second year (4 h) as well as an optional 10-week annual ultrasound elective offered for 30 second-year medical students. Additional training is afforded during core clinical rotations in year 3 (family medicine, internal medicine, OBGYN, pediatrics, and general surgery) as well as one standardized Objective Structured Clinical Examination (OSCE), and in year 4 (critical care and emergency medicine), clinical faculty chairpersons have incorporated discipline-specific learning objectives pertinent to POCUS imaging along with providing hands-on, in-person ultrasound education. As students advance into audition rotations, there is a heightened emphasis on specialized focus, with faculty dedicating more time to this aspect of training. Notably, survey results indicate that 77.0 % of recent MWU-AZCOM graduates agree or strongly agree that their POCUS training in medical school directly benefits their clinical practice. These findings demonstrate the congruency of the medical education provided at MWU-AZCOM with the clinical practice undertaken by our recent graduates.

The survey data highlights that most POCUS applications by respondents are concentrated in clinical procedures (90.0 %), cardiac tests (89.0 %), and pulmonary examinations (82.0 %). One survey respondent specifically noted the greater utility of focusing on cardiac and abdominal ultrasound training by stating, “introduction to ultrasound is an excellent use of time, cardiac and abdomen should be done twice.” This feedback suggests that dedicating more curriculum time to these high-impact areas could further enhance the readiness of MWU-AZCOM graduates for their residencies. Research supports the efficacy of ultrasound training in significantly improving students’ skills in image acquisition and interpretation [17], bolstering the case for curriculum refinement.

While the foundation of medical education is crucial, ongoing education in residency is equally important. Although 43.3 % of respondents report no barriers to POCUS utilization, over one-third of respondents specifically cite a lack of training and trained faculty as an impediment, particularly within family medicine and internal medicine. Because both specialties were among the strongest reporters of utilizing POCUS diagnostically, the importance of increasing competency within these residencies cannot be overstated. This barrier within residencies, specifically family medicine, will be addressed soon by the ACGME, which recently announced that POCUS competency will be a requirement for accreditation starting in 2024 [3]. This could explain the reports of a lack of trained faculty from residents, because prior to this requirement, the only specialty formally required to provide residents with POCUS training by the ACGME was emergency medicine. Moreover, our study reveals that the primary facilitators for POCUS adoption are its cost-effectiveness (82.0 %), contribution to patient safety (79.8 %), and diagnostic utility (78.7 %). These factors reinforce the necessity of ensuring ultrasound competency in medical education to equip future physicians for success. The utility of a longitudinal POCUS curriculum is dual: It prepares new residents for their clinical responsibilities and allows medical students to distinguish themselves during clinical rotations. According to the survey, an impressive 43.3 % of participants believed that their POCUS training during medical school helped make them a more attractive applicant when applying to residencies.

Looking ahead, the next steps in advancing POCUS education should involve addressing the identified barriers, such as the shortage of trained faculty, financial constraints, and the obstacle of navigating medical students’ demanding schedules, all while exploring innovative ways to provide comprehensive, hands-on training. Identical barriers were also identified in the recent study by Slyvka and Gwilym [18]. By investing in ultrasound education at the medical school level, these barriers can be proactively tackled without major administrative overhaul at the hospital level, and the identified shortcomings with current POCUS use in practice can begin to be addressed. If integrated into the clinical years and audition rotations, POCUS training can enhance students’ proficiency and competitiveness prior to applying to residency. This approach would provide efficient and cost-effective means to strengthen POCUS in residency and beyond, because the students empowered by this education will themselves provide the foundational basis for the next generation of physicians. To this end, it is imperative that medical schools adapt their curricula to ensure that the future physicians they produce are well-equipped to leverage the potential of POCUS to augment patient care and comfort.

Conclusions

POCUS integration into medical education, particularly through a 4-year longitudinal curriculum, has provided significant benefits to current residents who have attended MWU-AZCOM. Our study highlights that recent AZCOM medical graduates who received POCUS training throughout their 4 years are now utilizing POCUS regularly, with the majority indicating a prominent level of confidence in both performing and interpreting ultrasound examinations. With the recent change in residency accreditation requirements, such as in family medicine, medical students must acquire proficient exposure to this modality to ensure their competitiveness. This showcases the importance of introducing POCUS as an integral part of medical school education because it enhances clinical skills and parallels the real-world integration of POCUS in medical practice.