Point-of-care ultrasound training in low-income countries: a need of time

Abstract

Point of care ultrasound (POCUS) is “an ultrasonography performed at the bedside in real-time by the treating physician.” It is a powerful imaging modality used as an adjunct to physical examination and has gained momentum to become the future stethoscope. By using POCUS, the treating physician performs all image acquisition and interpretation and uses the information immediately to address specific hypotheses and guide the ongoing therapy. There is a shred of solid evidence that POCUS improves the diagnosis and management of acutely unwell patients is expanding rapidly. Due to the rise in the practice of POCUS in clinical medicine, the use of consultative ultrasonographic services has been reduced. The widespread availability of portable ultrasound machines and training an adequate number of clinicians to become competent in performing POCUS is a great challenge. The development of effective competency levels, curriculum, and assessment methods is imperative for the training of POCUS.

Point-of-care ultrasound (POCUS) is “an ultrasonography performed at the bedside in real-time by the treating physician”1 It is a powerful imaging modality used as an adjunct to physical examination and has gained momentum to become the future stethoscope2. POCUS is different from conventional ultrasonography, in which the test is ordered by the treating physician, performed by a technician or trainee physician, and interpreted by another physician not directly involved in the patient’s care3. By using POCUS, the treating physician performs all image acquisition and interpretation and uses the information immediately to address specific hypotheses and guide the ongoing therapy. Due to the rise in the practice of POCUS in clinical medicine, the use of consultative ultrasonographic services has been reduced4.

Many clinical subspecialties have widely used POCUS, especially emergency medicine and critical care. It is used to aid in the diagnosis and management of a variety of medical and surgical conditions, ranging from acute appendicitis to undifferentiated shock, respiratory failure, and cardiac arrest5–8. Many studies have shown the positive impact of POCUS on clinical decision making, which resulted in a decreased emergency department and hospital length of stay9,10. Moreover, the use of POCUS is also associated with a measurable reduction in planned referrals11. In low-income countries like Pakistan, where overcrowding in the ED is a major problem, training POCUS in our healthcare providers can play a major role in mitigating this issue.

The use of POCUS is also cost-effective. The literature shows that using POCUS eliminates safety issues and reduces costs associated with invasive and conventional testing like computed tomography scan and MRI12. A study done by Peris et al.13 showed that the use of lung ultrasound has been shown to reduce the use of chest radiographs and computed tomography scans in critically ill patients by 26% and 47%. In Pakistan, we have limited healthcare resources. Only 27% of the population receives free health care services, mostly government employees and members of the armed forces. The remaining 73% of the population must pay from their pockets14. The incorporation of POCUS training and diagnostic protocols will not only improve clinical decision making but also lower the costs associated with diagnostic workups.

Performing POCUS requires adequate training and competency. Physicians not adequately trained in performing POCUS may cause harm to patients by making an inaccurate diagnosis. The Joint Commission on Accreditation of Healthcare Organizations identified using POCUS without adequate training as a major risk from health technology15. The widespread availability of portable ultrasound machines and training an adequate number of clinicians to become competent in performing POCUS is a great challenge. The development of effective competency levels, curriculum, and assessment methods is imperative for the training of POCUS. Many health care systems in the world have incorporated ultrasound training not only at the postgraduate but also at the undergraduate levels. In the USA, 35% of the 222 medical schools have implemented POCUS training at the undergraduate level16,17.

Currently, there is no formal training in POCUS available in our country. The authors recommend adapting the existing curriculum recommended by the Accreditation Council for Graduate Medical Education (ACGME), the American College of Emergency Physicians (ACEP), the Australasian Society for Ultrasound in Medicine (ASUM), and other accreditation societies and involving our trained radiologists to develop the national curriculum and competency levels.

In summary, there is a shred of solid evidence that POCUS improves the diagnosis and management of acutely ill patients and that its use is expanding rapidly. National training committees need to consider how it can be routinely integrated into postgraduate and undergraduate curricula. In addition, there needs to be a commitment to support the development of trainers with both time and resources to ensure adequate training can occur, as opposed to the ad-hoc approach, which relies primarily on the goodwill of trainers to deliver training to a select few. The authors fully support the integration of POCUS into the existing undergraduate and postgraduate core curriculum.

Ethical approval

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Sources of funding

None.

Author contribution

Dr N.A.: conceptualization and supervision. Dr S.W. and S.M.S.: writing, reviewing, and editing.

Conflicts of interest disclosure

The authors declares no conflict of interest.

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Corresponding author is the guarantor.

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Not commissioned, externally peer reviewed.