The POCUS Imperative

• Scenario 1: You are a program director interested in offering a point-of-care ultrasound (POCUS) curriculum to residents, but you are unsure if it is feasible or where to begin.

• Scenario 2: A strong applicant from your institution's medical school took a keen interest in their ultrasound elective and asks what opportunities your program offers.

• Scenario 3: A resident in your program bought a handheld ultrasound device and has been using it on patients as they teach themself how to perform various scans with web-based resources. Your program has no faculty comfortable with POCUS, and it is unclear if the resident's use of ultrasound is informing their medical decisions.

Ultrasound has been a fixture of bedside evaluation in obstetrics, cardiology, and emergency medicine for several decades, and in critical care for at least a decade, with growing applications for multiple other specialties. POCUS entails real-time focused assessment at the bedside of patients with suspected pathology. It differs from consultative imaging in that the examination is hypothesis-driven, limited in scope, and meant to answer a binary or graded clinical question that could immediately impact care. Its use is affirmed by the American Medical Association,¹ yet based on the Accreditation Council for Graduate Medical Education Common Program Requirements, few specialties require trainees to learn POCUS or its performance, interpretation, and clinical integration.² A 2021 survey reported 73% of responding medical schools now have ultrasound curricula,³ a proportion that has more than doubled since 2014.⁴ Schools use ultrasound in a variety of ways, and there is a breadth of research evaluating the use of POCUS to enhance teaching of anatomy, physiology, physical examination, and procedures in undergraduate medical education.⁵ Graduates expect continued opportunities to learn and advance their POCUS skills in residency, and surveys of residents from pediatrics,^6,7 internal medicine,^8,9 family medicine,¹⁰ and neonatal/perinatal medicine fellows¹¹ demonstrate perceived shortfalls in the availability of this training. As access to ultrasound education and devices grows, and as more students enter postgraduate training with varying levels of experience, ignoring the need to train physicians in its use and judicious application feels imprudent. Graduate training programs and academic hospitals should familiarize themselves with specialty-relevant applications, develop POCUS curricula and policies to promote patient-centered care, and encourage responsible use among trainees.

Assessing the value of a diagnostic modality is complex and should factor in cost, diagnostic accuracy, contribution to clinical reasoning, and a range of patient-centered and clinical outcomes.¹² Evidence of the benefits of POCUS often takes the form of improvements in time to diagnosis, time to triage, and diagnostic accuracy relative to standard care. Its utility in undifferentiated patients can be especially profound, helping clinicians to provide more expeditious and accurate care.^13-15 Studies from emergency department settings demonstrated improvements in mortality among patients sustaining penetrating cardiac injuries¹⁶ and torso trauma patients¹⁷ when POCUS was performed early in the evaluation. The latter example also demonstrated reduced time to the operating room, fewer computed tomography (CT) examinations, decreased length of stay, fewer complications, and reduced expenses among the group of patients randomized to ultrasound examination.¹⁷ An economic analysis from an Italian internal medicine department forecasted potential cost savings at 406 days after implementation of POCUS, accounting for the costs of incidental findings, time to perform examinations, and the costs of the machines and training staff.¹⁸ A 2020 prospective study by Barchiesi et al demonstrated significant reductions in the ordering of chest x-rays, chest CTs, abdominal CTs, abdominal ultrasounds, and echocardiograms in elderly internal medicine patients when ultrasound machines were available to trained staff.¹⁹ Mozzini et al randomized 120 heart failure patients to standard care or lung ultrasound at admission, 24 hours, 48 hours, 72 hours, and discharge, reducing length of stay by 1 day in the ultrasound group.²⁰ A recent systematic review and meta-analysis of studies examining clinical endpoints in patients with acute dyspnea revealed improved time to diagnosis and treatment, increased odds ratio for receiving appropriate therapy, and decreased length of stay in intensive care settings.²¹

These studies were in emergency and internal medicine settings, but specialty-specific applications abound awaiting clever research designs to investigate safety and efficacy. Already, anesthesia, cardiology, emergency medicine, obstetrics and gynecology, endocrinology, sports medicine, and pulmonology/critical care include basic proficiency with ultrasound applications as training requirements.² In addition, revised ACGME Common Program Requirements for family medicine, which require experience in using POCUS in clinical care, will go into effect July 1, 2023.²² Examples of ultrasound applications in various specialties are outlined in the Table.

Table.

Some Specialty-Specific Applications of Point-of-Care Ultrasound

Specialty	Specific Applications
Dermatology	Evaluation of potentially cancerous lesions with high frequency ultrasound23
Gastroenterology	Monitoring disease activity and treatment response in inflammatory bowel disease24
General surgery	FAST examination, evaluation of hepatobiliary disease, assessment of breast and thyroid pathology25
Hematology/oncology	Focused assessment for malignant effusion in cancer patients26 and hemarthrosis in patients with hemophilia27
Family medicine	Abscess detection, abdominal aortic aneurysm screening, identification of intrauterine pregnancy, assessment for joint effusion, focused cardiac and pulmonary assessment in the dyspneic patient28
Orthopedic surgery	Detection of tendon ruptures, tendonitis, tenosynovitis, ligamentous injuries, bursal pathologies, foreign bodies, necrosis, and soft tissue masses, injection procedural guidance29
Nephrology	Evaluation of fluid status and acute kidney injury30
Neurology	Enhancing examination in patients with suspected increased intracranial pressure31
Pediatrics	Procedural guidance for lumbar puncture, assessment of skin and soft tissue infection, evaluation of the acute abdomen and pulmonary pathologies while sparing radiation32

Abbreviation: FAST, Focused Assessment with Sonography in Trauma.

An effective ultrasound training program includes one or several ultrasound machines, trained faculty for teaching and supervision, and infrastructure that allows for image storage, documentation, and quality assurance programs. The best models are the ones that fit the particular facility and program. Unless details are specific in program requirements, each program will likely need to perform a needs assessment to determine the ideal design of their POCUS curriculum. There are no specialty-agnostic and universally recognized standards for accreditation or credentialing in POCUS, but credentialing³³ and curricular³⁴ roadmaps are available for adoption and adaptation. In addition, if no locally proficient faculty exist, institutions can lean on recognized training certification pathways like those offered by the Society of Hospital Medicine and the American College of Chest Physicians to help upskill champions to lead this endeavor.

Even with 1 or 2 champions, the lack of faculty comfortable with POCUS for overall clinical supervision is a commonly raised barrier to implementation of POCUS curricula at the resident level.^9,35,36 Anstey et al recently described a 3-pronged approach, including a curriculum that allowed faculty with limited exposure to at least supervise resident-performed scanning.³⁷ They additionally provided pathways for limited practice and credentialed independent practice, graduating more than 50 faculty through 1 of the 3 pathways over 3 years.³⁷ Image storage and quality assurance mechanisms serve educational and clinical roles by providing a means for feedback in addition to review of clinical images and outcomes.

Insufficient funds or limited access to machines are other commonly encountered barriers.³⁸ Before purchasing ultrasound units, programs are advised to speak with stakeholders from other groups using ultrasound, administration, biomedical engineering, and information technology to ensure compliance, avoid the same potential mistakes, and learn if group purchasing or other savings can be leveraged. These strategies and more are discussed in greater detail elsewhere.³⁹

Given the growth of POCUS in medical schools, broad accessibility of handheld devices, desire for additional training among residents from a variety of specialties, and encouraging clinical trial results in diverse settings, we believe that prioritizing ultrasound teaching and infrastructure is a matter of great importance for program directors. The lack of standards for POCUS training, competency assessment, and quality assurance practice is a call to action for specialties that have not yet participated in these discussions. Engaging various stakeholders and exploring the unique needs of faculty and residents at individual institutions is the way forward. As POCUS uptake continues to grow and applications increase, the question shifts from, “Should our program invest in POCUS training?” to, “How will our program invest in POCUS training?”