Point of Care Ultrasound Curriculum in an Internal Medicine Residency Program: 9 Years of Experience From a Teaching Hospital in the United States

Abstract

Background

The growing availability of portable ultrasound devices enables clinicians to enhance physical examination, improve diagnostic accuracy, promote safer procedures and reduce costs. In the United States, ultrasound education is increasingly integrated into medical training with growing demand for structured training in residency programs. Beginning in 2016, we implemented a POCUS curriculum in the Internal Medicine residency program at the University of Miami/Jackson Memorial Hospital.

Objective

To describe the design and outcomes of a structured POCUS training curriculum aimed at developing resident proficiency.

Methods

We conducted a prospective educational study over nine years including 314 Internal Medicine residents, who completed a two-week POCUS elective. Participants were assigned a unique code to ensure data de-identification. The curriculum comprised two sequential components: the first week consisted of didactic lectures, simulation based learning, and supervised interactive hands-on scanning: the second week offered supervised clinical real time ultrasound use. Outcomes were assessed using pre-and post-course multiple-choice tests, procedural skills checklists, and structured evaluations.

Results

Faculty-assessed image acquisition and technical skills were high (mean checklist score 96.65%, SD = 4.22), demonstrating competency across ultrasound domains. Faculty ratings exceeded learner self-ratings (4.19 vs 3.69; Z = 14.09, P < .001). Knowledge scores improved from 63.83% (SD = 16.18) pre-course to 92.11% (SD = 8.79) post-course (Z = 15.36, P < .001, r = 0.87). Residents’ feedback was excellent.

Conclusions

Our nine-year experience suggests that a structured two-week POCUS curriculum is a feasible and effective approach for standardizing POCUS education in Internal Medicine residency programs.

Introduction

Advances in portable ultrasound technology enable physicians to augment the traditional physical examination and improve real-time clinical decision-making in a wide range of clinical settings. ¹

Point-of-Care Ultrasound (POCUS) has therefore emerged as an increasingly important bedside tool with a broad range of diagnostic and procedural applications. ²

Multiple studies demonstrates that POCUS improves diagnostic accuracy across multiple clinical scenarios,^3,4 contributing to enhanced patient safety and more efficient utilization of healthcare resources.^4,5

In the United States, ultrasound education is rapidly expanding within undergraduate medical education ⁵ and there is growing demand for structured POCUS training within Internal Medicine residency programs, ⁶ as well as among practicing physicians.

Although POCUS is not yet a mandatory requirement for Internal Medicine residency training according to the Accreditation Council for Graduate Medical Education (ACGME), it is increasingly recognized as valuable clinical competency (^6-8). In a randomized controlled study of internal medicine residents, incorporation of supervised ultrasound scans into a structured curriculum improved practical performance compared to curriculum alone. ⁹

Despite its recognized role, the structure, intensity, and implementation of POCUS curricula remain highly variable across institutions, and standardized models for effective training and competency assessment are still evolving. In response to this need, we developed a structured, simulation-based bedside ultrasound curriculum for the Internal Medicine Residency Program at the University of Miami/Jackson Memorial Hospital (JMH).

The curriculum was designed in response to learner feedback, institutional educational needs, and emerging evidence supporting simulation-based and mastery-learning approaches in ultrasound education.^4,7,10,11,12

In this manuscript, we describe our nine-year experience of training more than 300 residents, and we describe the curriculum structure, educational objectives, and longitudinal outcomes based on pre- and post-course assessments and participant evaluations.

Methods

Setting and Participants

The target audience for this curriculum included interns (first year’s residents, PGY-1) and residents (from the second year up, PGY2-4) of the Internal Medicine Residency Program at Jackson Memorial Hospital/University of Miami Miller School of Medicine. The primary goal of the rotation was to introduce POCUS to residents and ensure acquisition of foundational theoretical knowledge and practical skills necessary for integration into routine clinical practice.

The first cohort began training in November 2016. Data were collected and analyzed through May 2025. The course was paused from March 2020 to January 2021 due to the COVID-19 pandemic, with temporary transition to limited remote instruction. The course was conducted primarily at the Center for Patient Safety at UM/Jackson Memorial Hospital, a state-of-the-art simulation facility equipped with high-fidelity simulators and ultrasound machines.

Curriculum and Course Structure

This study is a multi-cohort, quasi-experimental educational study conducted over nine years, employing a single-group repeated-measures pretest–posttest design to evaluate educational effectiveness and participant satisfaction.

The course was offered as a two-week elective rotation for Internal Medicine and Medicine-Pediatrics residents and interns. A minimum of one ultrasound-trained Internal Medicine faculty member was present during every training session as instructor. The maximum number of learners per group was seven, allowing for an optimal faculty-to-learner ratio. The curriculum was guided by a mastery learning framework, in which progression to subsequent modules required satisfactory completion of prior learning objectives. ¹³

The first week focused on foundational knowledge and image acquisition skills through a blended learning model consisting of didactic lectures, simulation-based training, online resources, instructional videos, and supervised hands-on ultrasound scanning. Five core modules were covered: (1) General Principles of ultrasound; (2) Vascular ultrasound; (3) Cardiac ultrasound; (4) Abdominal ultrasound; (5) Lung and pleural ultrasound. Each module lasted approximately three hours and was typically scheduled in the morning.

Each module followed a standardized educational structure designed to integrate knowledge acquisition with hands-on skill development. The session started with a pretest assessment. Residents then attended a didactic lecture covering core concepts relevant to the module. Following the lecture, learners participated in a simulation-based training session. During this phase, they were exposed to ultrasound simulators programmed with both normal findings and pathological conditions allowing controlled exposure to clinically relevant scenarios and reinforcement of diagnostic interpretation skills.

After simulation training, residents transitioned to supervised hands-on scanning using ultrasound machines on SP (standardized patients), where they applied acquired skills in a supervised setting. This step reinforced technical proficiency, image acquisition and interpretation.

An introductory overview of ultrasound-guided procedures was also included. However, formal procedural ultrasound training (e.g., paracentesis, thoracentesis, central venous access, lumbar puncture) is addressed separately through another dedicated rotation in the residency program.

During the second week, residents participated in supervised clinical experiences, including shadowing radiology technicians, attending radiology reading sessions, and participating in the echocardiography laboratory with one-on-one mentoring by echocardiography technicians and faculty. At the end of the rotation, residents have the option to submit recorded ultrasound images and corresponding clinical cases to faculty mentors. An overview of the structure of the course is summarized in Figure 1.

Figure 1.

Curriculum Structure. Diagram and overview of the course

Assessment and Evaluation

We analyzed the data pertaining to the first week of training only since the recording of the images during the second week was not mandatory. Each participant was assigned a unique code to allow deidentification (encryption) of the data. Since the course was a voluntary elective, there was no formal grading or pass/fail assessment, and it did not affect residents’ performance in the residency program.

Participants’ performance was evaluated as follow:

• a) pre-and post-course multiple-choice examinations

• b) Skills performance checklists

• c) Self-reported confidence and faculty assessments

• d) Course evaluation surveys.

The course started every morning with a pre-test assessment of 15 questions about the module covered that day. At the conclusion of the module, participants completed a post-test to assess knowledge acquisition. In addition, a skills checklist evaluation was conducted. The skills performance checklist (b) consists of a multi-step evaluation in which trainees must demonstrate the correct execution of several skills. Each step is scored as completed, partially completed, or missed, corresponding to 2, 1, or 0 points, respectively. Each checklist includes 17 steps, resulting in a maximum possible score of 34 points. Performance was tested through both learner self-evaluation and direct supervisor assessment on a scale from 0-5. Figures 2 and 3 provides an example of the checklist used and the parameters for Self-evaluation and supervisor evaluation. For the Skills checklist b) and for the faculty evaluation c), we set the passing score at a high pass of 80% with correct completion of all critical safety steps, indicating achievement above expected competency. However, there is no universal cutoff, as programs often combine percentage ranges with faculty judgment of technique, efficiency, and overall clinical performance.^14,15

Figure 2.

Performance checklist. Basic point-of-care ultrasound(pocus). UM-JMH center for patient safety. Checklist 1

Figure 3.

Performance checklist. Abdominal point-of-care ultrasound(pocus). UM-JMH center for patient safety. Checklist 2

At the conclusion of the course, residents completed a comprehensive evaluation of the course, instructors, and the learning environment. The residents also evaluated the course as part of the educational offering of the residency program. We analyzed paired pre- and post-module multiple-choice test scores, including only participants who completed both assessments within a module. Exclusion criteria for the review of our data were the absence of either the pre-test or post-test for any of the five modules.

The primary educational outcome was faculty-assessed technical performance and image acquisition competency using standardized skills checklists. Knowledge examination scores, learner self-assessment, and course evaluations were also considered.

Study Design and Ethics

This study employed a multi-group pretest–posttest design to evaluate educational effectiveness and participant satisfaction. All data were de-identified prior to analysis. As the study involved evaluation of an educational intervention with aggregated, de-identified data, it qualified for an exemption and a waiver of informed consent. The reporting of this study conforms to the Equator guidelines as for the DOCTRINE check list. ¹⁶

Statistical Analysis

We analyzed paired pre- and post-module multiple-choice test scores, including only participants who completed both assessments within a module. Exclusion criteria for the review of our data were the absence of complete pre-post pairs of observations per participant within each of the five modules.

Each module’s knowledge test consisted of 15 questions, except for the cardiac module which had 14 questions. Scores were converted to percentages to allow for comparison across modules.

Normality of pre–post difference scores was assessed using the Shapiro–Wilk test. Paired t tests were used for normally distributed data and Wilcoxon signed rank tests otherwise. Primary comparisons examined differences by level of training (Interns vs residents), module topic, and academic year. Bonferroni correction was applied for multiple comparisons.

Exploratory analyses assessed interactions between testing time and training level, and between testing time and specialty. Because linear mixed-effects models showed non-normal residuals, interactions were analyzed using Aligned Rank Transform (ART) ANOVA for repeated measures. Post hoc comparisons used estimated marginal means with Holm adjustment. Trends in knowledge scores across academic years were evaluated using Jonckheere–Terpstra tests.

Descriptive statistics summarized ultrasound technique checklist performance and self- and supervisor-rated performance. Paired comparisons between self and supervisor ratings were conducted within modules. Differences in post-course technical skills confidence across modules were examined using Kruskal–Wallis tests with Dunn post hoc comparisons.

Statistical significance was set at P < .05. Analyses were performed using R version 4.5.0 (R Foundation for Statistical Computing, Vienna, Austria).

Results

Data were collected from November 2016 through June 2025. A total of 314 learners were included in the analysis.

Knowledge scores improved substantially following course completion. Mean scores increased from 63.83 (SD = 16.18) pre-course to 92.11 (SD = 8.79) post-course (Z = 15.36, P < .001, r = 0.87). Significant gains with large effect sizes were observed across all training levels, all five module topics, and all nine academic years (Table 1). Improvement over time was consistent across PGY-1 (interns) and PGY-2+ (residents) learners, with no difference between training levels and no interaction effect. When specialty was categorized as preliminary vs categorical, both groups improved significantly. Although there was no difference at baseline (P = .20), preliminary PGY1s scored modestly higher than categorical PGY1s at post-testing (94.88 vs 91.70; P = .002).

Table 1.

Knowledge Questionnaire Descriptives Statistics and Wilcoxon Signed Rank Test and Paired t Test Results

​	n	Observations, no. (%)	Pre		Post	Post - pre test statistic			Effect size		P
Variable			Mean	SD	Mean	SD	Z	t	r*	Cohen’s d
Training Level
Interns	108	1028 (34.68%)	64.15	15.72	92.73	9.50	9.02	​	0.87	​	<.001
Residents	206	1936 (65.32%)	63.65	16.43	91.78	8.38	​	34.64	​	2.41	<.001
Module topic
Principles	303	606 (20.45%)	68.21	15.95	94.06	7.72	14.71	​	0.85	​	<.001
Vascular	291	582 (19.64%)	65.68	15.53	90.63	8.72	14.34	​	0.84	​	<.001
Cardiac	294	588 (19.84%)	58.37	17.54	90.51	10.30	​	29.80	​	1.74	<.001
Abdominal	300	600 (20.24%)	65.54	14.84	92.78	8.61	14.69	​	0.85	​	<.001
Lung	294	588 (19.84%)	61.18	15.07	92.49	7.93	14.75	​	0.86	​	<.001
Academic Year
2016-17	31	306 (10.32%)	54.60	13.95	92.07	7.60	​	20.98	​	3.77	<.001
2017-18	42	414 (13.97%)	62.71	14.95	92.66	7.95	​	28.71	​	4.43	<.001
2018-19	39	384 (12.96%)	58.14	11.73	90.76	6.32	​	28.63	​	4.58	<.001
2019-20	26	244 (8.23%)	63.66	12.89	94.48	6.10	​	20.46	​	4.01	<.001
2020-21	10	92 (3.10%)	65.51	11.00	92.17	6.93	​	12.32	​	3.89	<.001
2021-22	46	428 (14.44%)	67.94	15.85	93.59	9.36	​	18.42	​	2.72	<.001
2022-23	28	254 (8.57%)	70.45	15.26	91.72	9.67	​	12.03	​	2.27	<.001
2023-24	48	436 (14.71%)	66.66	18.10	92.03	10.22	13.11	​	0.87	​	<.001
2024-25	44	406 (13.7%)	65.49	19.30	90.19	10.65	​	12.88	​	1.94	<.001

Abbreviations: SD, standard deviation.

Note: N = 314 participants; n = 2964 observations.

*Rank-biserial correlation.

Pre-course knowledge scores increased across academic years (P < .001), suggesting progressive improvement in baseline preparedness, whereas post-course scores remained consistently high over time (P = .63).

Image acquisition skills performance was high (M = 96.65, SD = 4.22). Faculty rated learners’ technical skills confidence higher than learners rated themselves (4.19 vs 3.69; Z = 14.09, P < .001, r = 0.93; (Table 2 and Figure 4).

Table 2.

Checklists and Self and Supervisor Ratings Descriptives per Module and Training Level

​	Training level
Evaluation metric	Intern (n = 109)		Resident (n = 218)
	Mean	SD	Mean	SD
Checklist (%)
Principles	95.90	4.69	96.65	4.48
Abdominal	96.10	4.60	96.96	4.09
Cardiac/Vascular	96.32	4.35	97.19	3.88
Lung	96.24	4.35	96.84	3.93
Self-rating
Principles	3.47	0.65	3.63	0.68
Abdominal	3.65	0.63	3.68	0.66
Cardiac/Vascular	3.83	0.71	3.75	0.70
Lung	3.77	0.68	3.72	0.66
Supervisor rating
Principles	4.05	0.72	4.13	0.68
Abdominal	4.15	0.76	4.23	0.69
Cardiac/Vascular	4.16	0.68	4.24	0.70
Lung	4.20	0.73	4.31	0.63

Abbreviations: SD, standard deviation.

Figure 4.

Supervisor minus self-ratings contrasts in technical skills confidence per topic and year

Post-course confidence ratings were high across all module topics, with consistently strong evaluations across academic years (Figure 5). We compared the residents’ evaluation of the POCUS elective to their rating of other courses within the residency program, and we observed that 76.7% of the residents gave a rating of excellence compared to 57.9% of other courses (Table 3). There was a significant positive association for the POCUS elective with greater odds of higher ratings compared to other courses (OR, 2.30;95% CI, 1.38-3.83; P=.001).

Figure 5.

Post course survey technical skills confidence per module topic and academic year

Table 3.

Comparison of Course Rating Distributions Between POCUS Elective and Other Internal Medicine Courses

​	No. (%)		Δ % points (POCUS − other)
Response	POCUS elective (n = 86)	Other internal medicine courses (n = 2031)
Excellent	66 (76.7)	1175 (57.9)	18.9
Fair	6 (7.0)	150 (7.4)	-17.7
Good	13 (15.1)	666 (32.8)	-0.4
Poor	1 (1.2)	40 (2.0)	-0.8

N = 2117 ratings. Chi-squared test results: χ²⁽³= 13.36, P= .004; Cramér V = 0.08.

Discussion

Point-of-care ultrasound (POCUS) is an increasingly recognized bedside tool that enhances diagnostic accuracy and clinical decision-making. In response to growing educational demand we developed and implemented a structured curriculum for our Internal Medicine residency program.^1,2,5

This curriculum was designed to provide Internal Medicine residents with a structured and clinically focused introduction to bedside ultrasound. Emphasis was placed on both theoretical understanding and practical skills acquisition, followed by integration into real-world clinical decision-making.^10,12,17

We intentionally refer to the curriculum as “Clinical Ultrasound” to emphasize that each ultrasound examination should be driven by a specific clinical question aimed at confirming or excluding a diagnostic hypothesis. This approach reinforces ultrasound as an extension of the physical examination rather than a standalone test. ¹⁸

Key elements of the curriculum included mastery-based learning, small-group instruction, a low faculty-to-learner ratio, and extensive use of simulation and real-time ultrasound technology. Dedicated one-on-one faculty supervision facilitated acquisition. These components may have contributed to effective skill acquisition and learner engagement.

Over the duration of the course, learners showed significant gains in theoretical knowledge, as evidenced by improvements in pre- and post-test scores (Table 1). More importantly, faculty assessments demonstrated consistently high levels of competency in image acquisition and technical performance, suggesting successful translation of knowledge into practical ultrasound skills (Table 2). The favorable course evaluations (Table 3) and higher course ratings compared with other Internal Medicine residency rotations, confirmed the positive educational impact for the residents.

Among the outcomes evaluated, faculty assessment of learner POCUS performance may represent the most educationally meaningful measure of curricular effectiveness: while improvements in knowledge examination scores and learner self-assessments are important indicators of educational impact (Kirkpatrick, level 1), faculty-observed performance provides more direct evidence of competency acquisition and skill application in clinical settings (Kirkpatrick level 2) and therefore represents our strongest endpoint in this study. ¹⁹

An interesting trend that emerged over the years is the steady improvement in pre-test scores. This suggests that incoming participants are increasingly exposed to ultrasound concepts during medical school. This observation is consistent with the broader expansion of point-of-care ultrasound (POCUS) training in undergraduate medical education.

When compared with POCUS curricula in other specialties, such as emergency medicine, ²⁰ training in that field is standardized, mandatory, and fully integrated into clinical decision-making, with formal competency assessment. In contrast, Internal Medicine training is more heterogeneous, frequently elective, and lacks consistent structure and evaluation. Accordingly, we designed our curriculum to be as standardized as possible, incorporating uniform longitudinal exposure for all residents with the same core faculties.

Our findings suggest that the course functioned similarly across trainee levels, with no significant differences between PGY-1 and more advanced residents, indicating a consistent learning experience across cohorts. This suggests that observed improvements are likely related to participation in the curriculum rather than differences in postgraduate year level.

When PGY-1 residents were grouped by training pathway (preliminary vs. categorical), both cohorts demonstrated improvement. Although the post-test scores differed slightly between groups, both achieved meaningful gains, suggesting that prior training background may influence learning trajectories and warrants further study.

We observed that trainees adapted readily to ultrasound technology and engaged actively in learning. However, this observation should be interpreted cautiously, as it was not formally measured.

Because POCUS is not yet a mandatory competency in Internal Medicine residency training, offering the course as an elective allowed for focused participation. In addition to skill development, the curriculum supported clinical reasoning and appropriate use of diagnostic testing. Scholarly activity, including case reports and research projects, was encouraged.

As the ACGME continues to expand ultrasound-related competencies, we plan to scale the curriculum through faculty development and increased access to simulation and ultrasound equipment.

Future work will include longitudinal follow-up of graduates to assess sustained ultrasound utilization, recognizing that practice setting and subspecialty choice may influence long-term use. We are also exploring the integration of artificial intelligence tools to support ultrasound training. ²¹

From an educational outcome’s perspective, the curriculum achieved more than improvements in knowledge acquisition and learner satisfaction alone. Faculty-observed performance assessments suggest that learners developed measurable technical competency in ultrasound image acquisition and interpretation. Such performance-based outcomes are particularly important because they more closely reflect the skills required for clinical application of POCUS and may provide a more meaningful measure of curricular effectiveness than knowledge check and self-reported confidence.

Course Evaluation

The Overall course evaluations were highly favorable, with 96% of Participant rating the course as “outstanding” and the remaining 4% rating it as “excellent”. When compared to other courses within the residency program 76.7% of the residents gave a rating of excellence compared to 57.9% for other courses. Residents highly rated the setting and simulation models, the instructors and small instructors: learner ratio. Residents often suggested that the course should be mandatory for everyone and recommended earlier exposure to POCUS for everyone. We reported the overall comments on our course (Figure 6).

Figure 6.

Course evaluation responses by item

Limitations

Limitations of this study include its single-institution design, variability in post-course clinical ultrasound exposure, and limited long-term outcome data on ultrasound use after residency graduation. Future efforts will focus on more robust longitudinal assessment, including the mandatory acquisition of a 50-clip ultrasound portfolio to better evaluate trainee proficiency, clinical application, and skill development over time.

Conclusion

Despite growing adoption of bedside ultrasound, standardized training in Internal Medicine residency programs remains variable.

Our nine-year experience suggests that a structured, faculty-led clinical ultrasound curriculum is feasible and associated with improved resident knowledge, skills, and confidence.

However, given the single-center design, absence of a control group, and partial reliance on self-reported outcomes, generalizability is limited. Within these constraints, this model offers a practical framework that may guide POCUS curriculum development in other residency programs.

N = 324 participants. General has 11 missing observations, abdominal has 13,cardiac/vascular has 24, and lung has 33 for the checklist and 38 for the self and supervisor ratings. Missing observations were excluded from calculations.

ORCID iDs

Maria A Mosetti https://orcid.org/0009-0002-5969-5049

Roxanna J. Araya https://orcid.org/0000-0003-0021-6824