Assessment of an Internal Medicine Residency Point-of-Care Ultrasound Elective

Background: Point-of-care ultrasound (POCUS) is an increasingly utilized diagnostic modality in internal medicine, and internal medicine residents desire training in POCUS. Residency programs across the country have... [ view full abstract ]

Background: Point-of-care ultrasound (POCUS) is an increasingly utilized diagnostic modality in internal medicine, and internal medicine residents desire training in POCUS. Residency programs across the country have implemented various strategies to teach POCUS applications, though a standardized modality to assess the effectiveness of these interventions has not been established.

Objective: Our aim is to describe the structure of a one-month POCUS elective offered to internal medicine residents at the University of California, San Francisco, the impact of the elective on POCUS knowledge as determined by a pre/post-elective online test, resident confidence in and use of POCUS after the elective, and resident feedback on the elective.

Methods: For our residency program we developed both a basic introduction to POCUS and an intensive POCUS elective. Because procedural ultrasound training is already established in our residency we focus on diagnostic POCUS. All first-year residents participate in a 2-hour hands-on training session focused on a comprehensive volume status assessment. Second and third-year residents are offered a month-long POCUS elective that employs a “flipped classroom” approach, such that all background learning is achieved online prior to the elective and elective time is used for hands-on experiences. We can accommodate two residents per month. Prior to the elective residents take an anonymous 26-question multiple choice online test of core POCUS knowledge and image interpretation. Guessing is strongly discouraged; test takers are instructed to choose the common fifth answer choice “not sure” unless they are certain of the correct answer. After taking the test residents are assigned chapters from a free electronic book; several educational websites are recommended as well.

During the elective residents spend 4-6 half-days per week on POCUS activities. They spend over half their time scanning with POCUS experts in three different emergency departments. They spend their remaining time shadowing echocardiography technicians, interpreting echocardiograms with cardiologists, scanning in intensive care units, and, if their schedule allows, attending a weekly dedicated POCUS image review session. One to three months after the elective residents take the same online test and answer survey questions about their elective experience and their post-elective use of POCUS. We compared mean test scores pre vs. post-elective and analyzed the survey results. Data involving feedback on specific elective experiences were supplemented by results of informal interviews of residents at the end of the elective.

Results: At the time of this writing, 23 residents have completed the pre-elective test and 16 residents have completed the post-elective test and survey. On average, residents answered 37% questions correctly on the pre-elective test, compared to 71% on the post-elective test.

69% of residents were “very likely” and 31% “somewhat likely” to recommend the elective to other residents. 23% of residents were “very confident” and 69% “somewhat confident” in their overall ability to use POCUS after the elective. Specifically, residents were confident assessing global left ventricular function and volume status via IVC and IJ scanning and identifying pleural and pericardial effusions, ascites, pulmonary edema, and pneumothorax. These were also the applications residents utilized regularly after the elective.

Residents highly valued emergency department scanning experiences (particularly when the student: teacher ratio was low) and image review sessions. Some residents felt that echocardiography reading room and scanning lab experiences were not useful. A majority of residents wished they had receiving additional training in ultrasound-guided peripheral IV placement.

Conclusions: Participation in a POCUS elective enhances internal medicine residents’ ultrasound knowledge and ability to interpret images, as demonstrated by improved performance on an online test. After the elective residents were fairly confident in their POCUS skills, particularly for cardiac and pulmonary applications, which were the applications they continued to utilize regularly. Residents highly valued the elective’s emergency department hands-on scanning time and image review sessions but desired additional training in ultrasound-guided peripheral IV placement.