Point of care ultrasound: a hyperechoic future in Med Ed?

In Knowledge Translation by Chris Byrne5 Comments

A little over a year ago, I was working a shift in the emergency department when I noticed an enthusiastic consultant briskly wheeling a portable ultrasound machine to a patient’s bedside.  I introduced myself and asked if I could observe the scan.  Until this point, ultrasound had retained a certain mystique. However, that was quickly erased by a deep, yet efficient, bedside lesson in anatomy, physiology and clinical medicine that left a lasting impact.

Technological advancements perhaps too often remove the physician and learner from the bedside.  Subjectively, I couldn’t help but notice that this assessment advanced the therapeutic relationship in a positive, patient-centered way.  I also realized the tremendous untapped potential of the use of point of care ultrasound (POCUS) in medical education.  In my eyes, this modality safely removed the sometimes frustrating – yet often necessary – barrier between knowledge and experience that is all too familiar during our training.

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Image used with the permission of the Department of Radiology at the University of Texas Health Science Center at San Antonio

What is Point-of-care Ultrasound?

Point of care ultrasonography refers to ultrasonography performed, interpreted and integrated in to the patient care plan by the physician in real time at the bedside.  Images are obtained immediately and dynamically, permitting direct correlation with the patient’s presenting signs and symptoms.  In addition, POCUS can be quickly repeated if the patient’s condition changes.  Due to some comparable qualities to the physical exam, some authors have gone so far to call POCUS a “visual stethoscope.”

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POCUS in undergraduate medical education is generating passionate discussion.  As portable and handheld ultrasound devices become increasingly affordable, many institutions south of the border have already or are in the process of formally implementing ultrasound training in to their curriculums.  Some of these schools go as far as providing first-year students with these handheld devices in addition to the stethoscopes and reflex hammers we are accustomed to.

How should Point-of-care Ultrasound be taught?

While there are different views on how physicians should be trained in ultrasound, many believe that much like percussion, stethoscopy or fundoscopy, POCUS will evolve into a core competency of medical training.  Stated another way, you can think of POCUS as a modern extension of the physical examination as we presently know it.  POCUS has the benefit of providing supplemental, immediate and dynamic information at the bedside that helps address focused clinical questions.  However, as with any physical exam skill, we must be cautious and appreciate variation in quality and skill among different users at different levels of training.  Ultrasound images may be easily recorded and archived using programs such as SWS and Q-Path permitting asynchronous review of findings by supervisors and allowing a higher level of oversight and accountability compared to physical exam.

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Point-of-care Ultrasound in Canada

In Canada, POCUS training is typically limited to the resident level and above.  There are, however, some working groups at medical schools across Canada lobbying curriculum administrators to consider POCUS training at the medical student level.  At my home institution, pre-clerkship students were exposed to POCUS in the anatomy lab for the first time this academic year.  Most senior medical students have encountered bedside ultrasound assessments in action in at least one of their clinical rotations through the emergency department, intensive care unit or operating rooms.

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Follow @squartadoc, the Twitter account responsible for sharing this great image with the #FOAMed community!

Outside the classroom, a local and growing grassroots movement has many students excited for the future of medical education.  Great things are happening at Schulich, an institution aiming for the best curriculum on earth by directly involving students in the medical education discussion.  In September 2012, the POCUS interest group was launched within Schulich’s robust medical student club system.  The club has attracted over 100 students in its inaugural year.  We’ve hosted a number of hands-on events – from scanning for abdominal aortic aneurysms and pericardial effusions to inserting central lines – that have generated rave reviews and an increasingly passionate core of sonophiles.

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Of course, we could not have accomplished this without the support of keen residents, fellows and faculty members whose contributions to the interest group have been immeasurable.  This passion has persevered throughout the year, now culminating in the organization of an innovative two-day event, the Western Medical Student Ultrasound Symposium, to take place on August 24, and 25, 2013.  This symposium is the first of its kind in Canada and is attracting interest from faculty and medical students from institutions across the country.

In the coming weeks, the POCUS interest group will be having a discussion on ultrasound in medical education.  This topic will also be brought up at the August symposium.  There are some fantastic #FOAMed (Free Open Access Meducation) resources out there on ultrasound in medical education, two of my favourites being the Ultrasound Podcast (episodes 40, 41 and 42) and a written piece at SonoSpot.

Barriers to Ultrasound Integration

Experience from other institutions reveals some of the obstacles to integrating POCUS – or any new topic, really – into an established medical curriculum.  With limited classroom time and a breadth of evolving technologies and progress in medicine to represent, tough decisions regarding curricular content must be made.   Uniquely, ultrasound does not demand standalone course time.  Though destined to be a tool of clinical value to medical students in their clerkship years and beyond, introductory ultrasound training may occur through integration in to existing core curricular activities such as anatomy and physiology.  In this fashion, ultrasound enriches, rather than competes for, existing classroom or lab experiences.

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Conclusion

The past year has been a fun and rewarding ride, from the initial zeal on wheels of that consultant in the emergency department to a growing group of forward-thinking students who are a pleasure to work with. A final comment to my medical student colleagues, taken directly from the opening sequence of the Ultrasound Podcast: Get out there, ultrasound some hearts, some lungs, some IVCs and let others know how you feel about it!

I look forward to what I believe will be a hyperechoic future for medical education.

Peer reviewed by Robert Arntfield of Western Sono and Brent Thoma of BoringEM.

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Chris Byrne
Chris is a first year resident at the University of Toronto in the Royal College emergency medicine program. His interests include ultrasound, simulation and medical education.
Chris Byrne