Advancing Point-of-Care Ultrasound (POCUS) Utilization and Education: A Comprehensive Analysis Among Postgraduate Physicians in a Tertiary Teaching Hospital

Abstract

Background

Point-of-care ultrasound (POCUS) is increasingly recognized as a vital skill in various medical specialties. Its integration into postgraduate medical training enhances diagnostic accuracy and clinical decision-making. Despite its growing importance, the implementation of a structured POCUS curriculum in postgraduate medical education remains challenging.

Methods

A pilot study was conducted at the National Cheng-Kung University Hospital to evaluate the introduction of a POCUS curriculum tailored to postgraduate-year physicians. The curriculum included basic and advanced courses with hands-on training sessions held during weekends across 2020. Participants’ pre-course and post-course proficiency were assessed through questionnaires and skill evaluations.

Results

The study included 116 physicians, revealing a broad spectrum of prior ultrasound training and varied frequency of clinical ultrasound use. The structured curriculum significantly improved participants’ POCUS skills, particularly in cardiac ultrasound, in which most participants achieved high proficiency levels. The program was successful in addressing the existing gap in ultrasound education and practice among postgraduates.

Conclusion

Integration of a structured POCUS curriculum within postgraduate medical education significantly enhances the ultrasound proficiency of physicians. Continuous and comprehensive training programs, supported by adequate resources and expert instruction, are crucial for the widespread adoption and effective use of POCUS in clinical settings.

Introduction

Point-of-care ultrasound (POCUS) is an essential tool in modern medicine that has revolutionized the way clinicians diagnose and manage patients. POCUS is a non-invasive, real-time imaging technique that allows clinicians to visualize internal organs and structures at the bedside without the need for expensive and time-consuming imaging studies. POCUS can be used to diagnose a wide range of conditions, including cardiac, pulmonary, abdominal, and musculoskeletal disorders. It can also guide invasive procedures, such as central line placement, thoracentesis, and paracentesis, and is particularly useful in emergency and critical care settings, in which rapid diagnosis and treatment decisions are critical. The incorporation of POCUS into medical education has also been shown to improve clinical decision-making and patient outcomes. Overall, POCUS is an invaluable tool that has transformed the practice of medicine and has become an essential skill for clinicians in various specialties.

As POCUS has been incorporated into clinical practice for physicians in various specialties, including emergency medicine, pediatrics, critical care, internal medicine, and surgery, 1 , 2 many residency programs and fellowship training programs have started to introduce POCUS into their curricula. In addition, there are numerous continuing medical education (CME) courses and workshops available for postgraduate physicians to improve their POCUS skills and knowledge. The American College of Emergency Physicians (ACEP) and the Society of Critical Care Medicine (SCCM) are among the organizations that offer POCUS training and certification programs for physicians. 1 These national guidelines or training programs define training, image storage, documentation, quality assessment, and credentialing.

To promote the general medical competence of physicians in Taiwan, the Department of Health proposed postgraduate medical education reform with a particular focus on general medicine and then launched the “Postgraduate General Medical Training” program in 2003. After several attempts to reform it, a “6+2” system, comprising six-year undergraduate medical education plus two-year postgraduate general medical training, was finally developed and is currently implemented. For their training in holistic medical care, it is mandatory that the physicians undergo two years of training in certain specialties, including general medicine, general surgery, general pediatrics, general obstetrics/gynecology, and emergency medicine. To better evaluate a patient’s condition in general clinical settings, bedside POCUS is believed to be a good tool for early diagnosis to initiate treatment in ward emergencies, and postgraduate-year (PGY) training of physicians in this skill is especially appropriate. 3 Overall, the incorporation of POCUS into postgraduate medical education is an important step in improving patient care and outcomes.

Therefore, the primary objective of this study was to investigate the current use and cognitive aspects of POCUS among postgraduate physicians. Additionally, the study aimed to establish and enhance POCUS curriculum education within a tertiary teaching hospital and to analyze the outcomes and findings from implementation of the curriculum in 2020.

Methods

This was a pilot study conducted to assess the feasibility and student response of introducing a basic and advanced POCUS curriculum into PGY education. The course curriculum was conducted by the National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Taiwan (NCKU) from January to December 2020. It was structured as a half-day course equivalent and was implemented during weekends as an elective course targeting mainly PGY physicians. Each course was offered to a maximum of 30 participants.

Curriculum Development

Several ultrasound guidelines for emergency POCUS training programs in different countries were referred to as the basis for the curriculum design. 4 , 5 The education program covered didactic and hands-on training and assessment of knowledge and skills. To meet the needs of learners at different levels of training, a questionnaire was developed to better understand the PGY physicians who participated in the POCUS curriculum. When developing a standardized POCUS curriculum, the working group needs to collect inputs from experts in POCUS, medical education, and clinical practice, as well as stakeholders such as medical students, residents, and faculty.

Faculty Education

POCUS faculty education is an essential component of a comprehensive POCUS curriculum. Faculty education aims to increase POCUS use and undergraduate and postgraduate teaching by varied faculty across the colleges or hospitals. Faculty education includes multiple CME accredited training sessions for faculty, which are designed to increase confidence and knowledge with POCUS and give the faculty the tools to teach POCUS to medical students. The training sessions include didactics and hands-on instruction covering multiple examination types. Faculty education also involves the creation of laboratory facilitator guides, which include objectives of the laboratory, required images to obtain, and tips for acquiring images. These guides, in addition to the training modules, are available online and can be reviewed by proctors prior to laboratory training. Development and support of the POCUS faculty are necessary to ensure the sustainability of POCUS education. Faculty education is designed to increase the faculty’s confidence with and knowledge of POCUS, improve their ability to teach POCUS to medical students, and provide them with the tools to incorporate POCUS into their clinical practice.

Hands-on Instruction

Hands-on instruction refers to the practical training that PGY physicians receive in POCUS. This type of instruction involves using ultrasound machines to obtain images and interpret them, as well as applying the results of a POCUS examination to a patient’s clinical care. Hands-on instruction is an essential component of a comprehensive POCUS curriculum as it allows learners to apply their knowledge and skills in a clinical context. Hands-on instruction is integrated into the POCUS curriculum according to previous knowledge of anatomy, and clinical experiences including anatomy, physical examination skills, clerkships, and emergency medicine. During these classes, POCUS laboratory training is required, and depending on the resources available at campus or simulation centers, these laboratory training sessions can be held either multiple times as primary ultrasound training programs or combined with other training for different subspecialties.

Equipment

Physical space and POCUS equipment are the key components in planning a longitudinal POCUS course. Diagnostic POCUS machines are expensive, and finding physical space to house them can be challenging. Ancillary equipment required for hands-on scanning laboratories, such as ultrasound gel, tables for models to lay on, cleaning solution, towels for draping, etc., is also an important consideration in budgeting and planning.

After different types of POCUS equipment were explored, it became evident that handheld POCUS equipment offered several advantages over larger cart-based imaging systems. Handheld POCUS equipment could be purchased at a fraction of the cost, and secure storage of these devices required little space. Handheld equipment could also be checked out to individual users for several days at a time, thus allowing equipment to be used outside of dedicated laboratory time. The handheld POCUS devices and tablets were securely stored in locked cabinets at each site, along with other necessary supplies such as gel and cleaning solution.

In addition, the SonoSim LiveScan ultrasound simulation tool (SonoSim, Inc., Santa Monica, CA) was incorporated into the physical examination course in the hands-on laboratory for second-year students in a case-based format to illustrate pathology and for students to get comfortable incorporating POCUS into their clinical practice.

Study Questionnaire

At the beginning of the POCUS course, participants were asked to evaluate their prior ultrasound training, frequency of ultrasound use in daily clinical practice, and the equipment available to them. After the course, participants were invited to provide feedback on their satisfaction with the POCUS training through a set of questions.

Statistical Analysis

Total scores and means were calculated. Statistical analysis was conducted using SPSS version 17.0.

Results

Characteristics of Participants

The study involved 116 physicians to evaluate the impact and use of POCUS across various levels of medical training and clinical settings. ( Table 1 ) This diverse cohort included 77 PGY physicians (66.4%) and 39 resident physicians (33.6%), demonstrating a broad interest in POCUS at different stages of medical careers. The single attending physician initially included in the study was excluded from the subsequent statistics to maintain focus on the primary study population of PGY and resident physicians.

Table 1 . Characteristics of participants (N = 116) .

Characteristics	Number (%)
Level of medical training
Postgraduate-year	77 (66.4)
Residency	39 (33.6)
Previous ultrasound training
Self-practice	41 (35.3)
Never	15 (12.9)
Less than 10 hours training	56 (48.3)
More than 10 hours training	4 (3.5)
Frequency of clinical ultrasound use
Several times a year	24 (20.7)
Several times a month	50 (43.1)
Several times a week	31 (26.7)
Everyday	6 (5.2)
Seldom	5 (4.3)
Equipment available in clinical work
Sufficient, and it is readily available	19 (16.4)
Available, but a short wait is required	70 (60.3)
Available machines but it takes a long time to wait	11 (9.5)
There are machines but not enough	14 (12.1)
No machines at all	2 (1.7)

Prior ultrasound training varied significantly among the participants, with a substantial number having limited exposure: 56 physicians (48.3%) reported less than 10 hours of training, underscoring a potential gap in ultrasound education. In contrast, 41 participants (35.3%) had engaged in self-practice, thus demonstrating proactive efforts to acquire ultrasound skills. Notably, only a small fraction (4 participants, 3.5%) had received more than 10 hours of training, suggesting the need for more comprehensive, structured ultrasound education programs.

In terms of ultrasound use in clinical practice, frequencies varied widely, reflecting diverse levels of integration and accessibility of POCUS in different settings. A significant proportion of physicians used ultrasound several times a month (50 participants, 43.1%), whereas others reported usage several times a week (31 participants, 26.7%) or daily (6 participants, 5.2%). These data indicate a growing reliance on ultrasound for diagnostic and patient management purposes.

The availability of ultrasound equipment in clinical settings significantly impacted POCUS utilization. Most respondents (70 participants, 60.3%) indicated that while ultrasound machines were accessible, a short wait was often necessary, pointing to generally adequate but improvable access. A smaller portion of participants encountered more pronounced access issues, with 14 (12.1%) reporting insufficient machines and 11 (9.5%) facing long wait times. These findings underscore the need to enhance the availability of ultrasound equipment to support more widespread and effective POCUS use in clinical practice.

Design of Courses

The curriculum for advancing POCUS use among postgraduate physicians included both basic and advanced courses designed to cater to a broad range of clinical applications ( Table 2 ). The basic course covered the foundational aspects of diagnostic ultrasound, including its history, principles, and common image artifacts. It also included practical workshops on chest, abdomen, cardiac, and trauma ultrasound, focusing on identifying key structures and pathologies. The advanced course delved into more specialized applications, such as ultrasound-assisted procedures, puncture techniques, airway applications, shock management, and the urinary system, with each module combining lectures and hands-on workshops to enhance skill acquisition. This structured approach aimed to provide a comprehensive understanding and proficiency in POCUS, from basic operations to complex clinical applications.

Table 2 . Curriculum development and content of the program (basic courses and advanced courses) .

Session	Objective	Characteristics
Basic course
Introduction	Introduces the development history and principles of diagnostic ultrasound, common ultrasound image artifacts and applications, as well as ultrasound machine modes and probe selection and operation methods	Lecture
Chest	Identify the timing and scope of chest ultrasonography, foundational structures of the rib cage, ultrasound features of pneumothorax, characteristics of pleural effusion on ultrasound, and ultrasound features of pulmonary edema and parenchymal consolidation.	Workshop
Abdomen	Identify the relationship of intra-abdominal organs, including liver, gallbladder, kidney, Morrison’s pouch, diaphragm, spleen, aorta, and vena cava	Workshop
Cardiac	Identify basic cardiac view, including apical 4-chamber, parasternal long-axis, and short-axis views, showcasing heart structures from different angles for comprehensive assessment of cardiac anatomy and function.	Workshop
Trauma	Quickly identify and evaluate potential life-threatening injuries, particularly in the abdominal and pericardial areas. Identify the timing and extended applications of trauma ultrasonography, focusing on four areas: the right upper quadrant (liver and kidney), left upper quadrant (spleen and kidney), suprapubic region (bladder), and pericardium (heart).	Workshop
Advanced course
Introduction	Introduce the concepts and the indication of ultrasound assistance procedures, including central venous catheter placement, scanning and aspiration of body cavity fluid, and scanning and aspiration of joint effusion.	Lecture
Puncture	Introduction to basic puncture methods, needle control techniques, optimization of ultrasound imaging, and principles of sterility and safety in ultrasound-guided puncture procedures.	Workshop
Airway application	Identify neck respiratory tract structures, auxiliary applications during intubation, and emergent use of cricothyroidotomy procedures.	Workshop
Shock	Introduce the application of the RUSH exam, abdominal aorta scanning, assessment of deep vein thrombosis in the lower extremities, ultrasound features of pericardial tamponade, and ultrasound characteristics of severe pulmonary embolism.	Workshop
Urinary system	Identify the basic structures of kidney and bladder, detect and assess the severity of hydronephrosis, and calculate residual urine in the bladder.	Workshop

Characteristics of Instructors

The instructors responsible for delivering the POCUS curriculum were distinguished by their extensive clinical experience and diverse specialties, which added depth and practical insight to the program. With an average age of 40.1 years and a range of clinical practice spanning 11 to 25 years, these instructors brought a wealth of knowledge to the courses. Their backgrounds varied and included emergency medicine, cardiology, gastroenterology, and genitourinary specialties to ensure comprehensive coverage of POCUS applications. This diversity in expertise not only enriched the learning experience but also highlighted the multidisciplinary nature of POCUS in clinical practice.

POCUS Application in Real Clinical Practice

The application of POCUS in real clinical practice was assessed among 70 participants, revealing varied usage across different clinical needs. Bladder exams were most common, performed by 55.7% of participants. ( Table 3 ) Ascites assessments were next, at 31.4%, followed by the use of POCUS for central venous catheter (CVC) placements and focused assessment with sonography for trauma (FAST), each at 17.1%. Less common applications included evaluation of hydronephrosis (14.2%), pleural effusion (10.0%), inferior vena cava (IVC) (5.7%), intra-abdominal bleeding (4.2%), fetus (2.8%), pelvis (2.8%), and gall bladder (0.4%). This range demonstrated the critical role of POCUS in order to enhance patient care across various domains.

Table 3 . Point-of-care ultrasound (POCUS) application in real clinical practice (N = 70) .

^a Participants were allowed to select multiple choices, so cumulative percentages may exceed 100%.

Clinical purpose	Number (%) a
Bladder exam	39 (55.7)
Ascites	22 (31.4)
CVC	12 (17.1)
FAST	12 (17.1)
Hydronephrosis	10 (14.2)
Pleural effusion	7 (10.0)
IVC	4 (5.7)
Intra-abdominal bleeding	3 (4.2)
Fetus	2 (2.8)
Pelvic survey	2 (2.8)
Gall bladder	1 (0.4)

Evaluation of Participants’ Perceptions

Fig. 1 showed the self-reported proficiency levels of the participants across various POCUS disciplines on a scale from 1 to 10, before and after completing various ultrasound training courses. The wide range of scores before all POCUS training courses suggested an obvious variation in participants’ self-proficiency. The highest median scores are in Urologic and Hepatobiliary POCUS, suggesting that these areas may have received more focus or better training coverage. The lowest median scores were in cardiac POCUS, indicating cardiac POCUS was either less emphasized during training or that it is perceived as more challenging compared to other types of POCUS. The lower proficiency might also reflect a need for more focused training or practice in cardiac ultrasound to improve overall confidence and competency in this area. For post-course self-proficiency, it illustrated a significant improvement in skills in all POCUS training courses. This suggested that the training effectively enhanced their confidence and capability in key POCUS applications, reflecting the curriculum’s impact on advancing their ultrasound skills from foundational to more advanced levels.

Fig. 1 . This figure shows participants’ self-reported proficiency levels on a scale from 1 to 10, before and after completing various ultrasound training courses. The box plot illustrates the maximum, third quartile (Q3), median, first quartile (Q1), and minimum of the proficiency scores.

FAST: focused assessment with sonography for trauma; POCUS: point-of-care-ultrasound.

Discussion

Medical education across different specialties emphasizes the importance of POCUS as it influences the decision-making process during patient care. POCUS can be an adjunct to the physical examination and visualization of internal structures, leading to better patient care and safety when used appropriately. POCUS integration and implementation in medical education have been slow and challenging due to limited resources, lack of standardized training, and traditionalist resistance. As the importance of POCUS in clinical practice become increasingly recognized and widely adopted, curricula for POCUS have been developed for different purposes, specialties, and in-hospital or home care environments. 6 , 7 As with any clinical skill, the application of the POCUS curriculum requires standardized training programs and a certification process to ensure that all undergraduate and postgraduate physicians receive adequate training and are competent in POCUS.

Incorporating POCUS education into medical school curricula has been extensively discussed, with much literature available on the integration of ultrasound training for medical students. 8 The use of ultrasound can be seamlessly integrated into various fundamental medical courses, which encompass topics such as anatomy, physiology, physical examination techniques, and procedural methodologies. 9 , 10 The response from medical students towards these initiatives has been notably positive. The courses have effectively ensured that graduating medical students possess a certain level of proficiency in ultrasonography. 11

A significant gap in the theoretical understanding and practical abilities of PGY physicians to ensure user competency and patient safety has resulted in these physicians having limited transferable proficiencies in the clinical application of POCUS. This observation underscores the potential to significantly enhance knowledge and skill development through POCUS training.

The devised training programs encompass a combination of informative lectures and immersive hands-on practice, and these initiatives fall within the framework of Kirkpatrick’s Levels 1 through 3 models of educational outcomes. 12 At Level 1, the focus is on learners’ initial reactions to the training, thereby gauging their sentiments and perceptions. Level 2 entails assessing the learning aspect and quantifying the extent of knowledge or skill advancement by comparing pre-course and immediate post-course scoring evaluations. Finally, Level 3 emphasizes the retention of newly acquired knowledge and the effective application and use of skills in practical scenarios.

In POCUS education, the use of versatile supplementary tools such as ultrasound simulators has proven to be highly valuable. These supplementary tools have effectively facilitated ultrasound training, especially when real patients or cadavers are not readily available. Within the literature on ultrasound education, ultrasound simulators, and phantoms have emerged as prominent tools frequently mentioned for instructional purposes. A multitude of studies have highlighted the effectiveness of these simulators, and the adoption of cost-effective teaching methods, such as online or e-learning technologies, has also gained prominence. This is particularly beneficial for educators dealing with constraints in resources. 13 , 14 However, when initiating ultrasound courses, certain challenges might arise, particularly in terms of access to ultrasound machines and simulators. The purchase of new machinery requires a larger budget, and a significant amount of the ultrasound equipment used for educational purposes is repurposed for clinical use.

During simulated patient examinations, PGY physicians can promptly apply their acquired skills. This application serves to enhance their learning experience and contribute to the sustained retention of skills. This highlights the potential for improving POCUS training programs by combining theoretical instruction and hands-on practice to enhance the competence of medical practitioners. Under such circumstances, the recourse to using standardized patients becomes imperative. Standardized patients offer a unique advantage, not only in replicating normal scenarios but also in emulating the dynamic and interactive patient-provider relationship. Moak et al. 15 found that students trained with live models demonstrated better scanning technique and image acquisition than those trained with simulators when undergoing training in transvaginal sonography.

Despite the technological nature of ultrasound training, effective communication skills remain pivotal, thus making the integration of standardized patients a powerful method for honing these skills within medical education. 16 , 17 These individuals, trained to portray specific medical scenarios, furnish medical students and professionals with a controlled yet lifelike setting to refine both their clinical and communication proficiencies. Beyond the acquisition of knowledge and skills within a workshop setting, encounters with standardized patients bridge the divide between theoretical understanding and real-world application. This results in students being better equipped to apply their skills in clinical settings. A notable example of this integration can be found in the work of Black et al., 18 in which they reached a consensus on developing a global rating scale for POCUS. This scale encompasses various dimensions, including patient interaction, rapport, patient comfort, and ensuring appropriate patient positioning and draping, all of which are evaluated during the initial stages of POCUS performance.

One of the most common barriers to the adoption of POCUS use in healthcare is the lack of training among healthcare providers. Continuous education is necessary to acquire and hone skills. For physicians already engaged in their profession, POCUS training is typically acquired through local, regional, or national CME courses that provide hands-on training. 19 , 20 For medical students and residents, evidence indicates that there is a decline in POCUS proficiency as early as four weeks following completion of a training course. 21 Implementing longitudinal educational plans has positively impacted skill retention. 22 Schott et al. 23 showed that practicing physicians retained their POCUS knowledge and skills and increased their frequency of POCUS use in clinical care 8 months after participating in a 2.5-day hands-on POCUS training course. Remarkably, participants who reported minimal or no post-course POCUS usage retained a considerable portion of their acquired skills after the 8-month interval. Establishing a consistent and continuous education and training regimen has the potential to increase physician comfort and confidence in incorporating POCUS into their practice.

Conclusion

This study underscores the transformative impact of a structured POCUS curriculum in enhancing diagnostic skills among postgraduate physicians. The positive outcomes observed, particularly in the mastery of cardiac ultrasound techniques, affirm the curriculum’s efficacy in bridging educational gaps and advancing clinical competence. As POCUS becomes increasingly integral to various medical specialties, it is imperative that training programs evolve to meet the diverse needs of healthcare providers. This will ensure that future physicians are well-equipped to leverage this technology in improving patient care outcomes, thereby fostering a higher standard of medical practice.

Funding

The research was supported in part by National Cheng Kung University Hospital Research Program [NCKUH-10903042].

Declaration of conflicting interest

The authors declare no potential conflicts of interests with respect to the research, authorship, and/or publication of this article.

Acknowledgements

We extend our gratitude to Professor Tina Tajima from St. Marianna University School of Medicine for her assistance in editing and revising the English of this article.