For a hospitalized patient who is experiencing shortness of breath, time is of the essence. There could be many potential causes — the patient's heart may not be pumping well, there could be an infection, or there might be fluid in the lungs, to name a few. To find out what is happening, doctors may order numerous tests, including blood tests, X-rays, and CT scans, which can be costly and take time. Recent evidence suggests ultrasounds can be better than some of the traditional tests for making a correct diagnosis, and equally important, ultrasounds can help clinicians find answers faster.
Traditionally, the patient would have to wait for a specialized radiology technician to perform the ultrasound. Because these technicians are not physicians, they are not supposed to disclose what they see, leaving the patient in quiet anticipation during the ultrasound.
"As a patient, you're sitting there wondering, 'Is anything wrong?' And you won't find out for a while," says Amiran Baduashvili , MD, a hospitalist and associate vice chair for education at the University of Colorado Anschutz Department of Medicine .
However, thanks to a medical imaging technique called point-of-care ultrasound , or POCUS for short, more physicians are learning how to use a portable ultrasound machine so they can perform the ultrasound themselves and deliver real-time information to patients.
"This pocket-sized device allows me to look inside a patient's body so I can identify the issue and make a diagnosis faster," says Baduashvili, an associate professor of hospital medicine and director of the Advanced Hospital Medicine Clinical Scholars Program . "And by sitting next to my patients at the bedside, examining them with POCUS, and explaining to them what I see, I've found that I form stronger bonds with my patients."
Despite the benefits of POCUS, not all institutions teach this technique to physician trainees. Of those that do, the skills they teach can vary, leading to inconsistencies in how physicians learn about and implement POCUS.
As a result, Baduashvili worked alongside other physicians, mostly those at CU Anschutz , to identify the POCUS skills, teaching methods, and evaluation strategies that leaders across the nation agreed are the most important. The resulting study, published in the Annals of Internal Medicine journal, found consensus on more than 50 skills and various teaching methods and evaluation strategies.
"POCUS is a really important tool for delivering better care, but it is also a complex technique that requires practice and skill development to do it safely and efficiently," he says. "With that, there is a need to standardize POCUS education."
The value of POCUS
Oftentimes, POCUS is used in high-stakes scenarios that call for quick decision making to help a patient, Baduashvili explains, whether it be in emergency departments, intensive care units (ICUs), or general hospital wards. The portable tool allows physicians to assess a patient's cardiac function, abdominal pain, and fluid status, among many other conditions.
For example, if a patient has low blood pressure, they may need more fluids; on the other hand, for some patients, giving them extra fluids could be harmful because their heart is weak. A physician can use POCUS to quickly assess what is happening and determine whether fluids can be lifesaving or cause significant harm.
"The most value that POCUS adds is when we need to make rapid decisions and don't have time to wait," he says. "POCUS helps us act right away."
Studies have shown that POCUS not only decreases the amount of time it takes to make a diagnosis — it also increases the likelihood of making a correct diagnosis. This can lead to patients getting the treatment they need sooner.
"It's also a great tool for patient education," he says. "In my experience, patients appreciate when I sit down and show them what I see inside their bodies, explaining what parts are normal versus abnormal. I think that improves their trust in physicians and helps them better understand what is happening."
Teaching POCUS
Baduashvili realized the value of POCUS during his third year of residency training when he observed ICU physicians using the tool. Getting trained in POCUS, however, was a unique journey because it was not formally taught in his residency program. Instead, he sought out mentors and attended conferences and workshops to learn the skills.
Now, as director of the Advanced Hospital Medicine Clinical Scholars Program, Baduashvili helps train others on POCUS. The clinical scholars program has a POCUS track in which two clinical scholars receive additional training in POCUS. Two of those scholars were physicians Leela Chockalingam, MD, and Dagan Hammar, MD, who are the lead authors of the POCUS consensus paper.
"About three years ago, they raised a simple yet profound question: How do you decide what trainees need to know for POCUS?" Baduashvili recalls. "I told them I've been teaching what I was taught by my colleagues, and I wasn't sure where that originated."
After some digging, the physicians realized there was no formal consensus on what skills should be taught, how those skills should be taught, or how those skills should be evaluated — all key elements of a strong curriculum. It sparked an idea to conduct a study aimed at building a consensus on all three of those elements, helping establish a foundation for future training to build upon.
Finding consensus
One of the first steps of the study was identifying national leaders in POCUS education, defined as people who either hold a POCUS leadership position in a national internal medicine society, have taught national or regional POCUS courses, or have a publication record in POCUS education. Ultimately, the investigators reached out to 36 leaders, and 21 participated in a multi-round survey.
In the first round of the survey, the investigators shared a list of skills, teaching methods, and evaluation strategies with the leaders and asked if there was anything they believed should be added to the list. By the end of the first round, the list went from 44 skills to 103.
In the second round, the leaders rated each skill, teaching method, and evaluation strategy on a five-point scale from not important to very important. At the end of the third round, the investigators found agreement among the leaders on 53 skills, 14 teaching methods, and five evaluation strategies. For example, the leaders agreed that trainees should learn how to identify and diagnose simple versus complex pleural effusion, which is fluid around the lungs.
Among the teaching methods, the leaders agreed it is important to use image portfolios to teach POCUS, which is where a trainee obtains an image of their ultrasound scan. That way, an educator can look at the image and provide feedback on the image quality and determine whether the trainee used the machine correctly. Leaders also agreed there needs to be a longitudinal curriculum, which means that trainees will learn POCUS periodically throughout their training rather than during a one-week workshop, for instance.
"On a national level, there's increased recognition that POCUS is really important, it adds value, and we need to have evidence-based curricula," he says. "I think this research is a step toward achieving that."
Putting the findings into action
At CU Anschutz, beyond the training happening in the clinical scholars program, POCUS is also being taught in the Internal Medicine Residency Program . The residency program's POCUS co-directors, Michelle Fleshner , MD, and Carolina Ortiz-Lopez , MD, were both involved in this research, allowing them to compare what the study found to how they are approaching teaching residents.
"When we compared what we do at CU Anschutz to our study's findings, we found that, for the most part, we were already delivering the majority of the items," Baduashvili says. "There were a few items we were not doing, so this nudged us to make sure we're including everything that we reached consensus on in our curriculum."
Outside institutions have also recognized the value of this study, he explains. The Society of General Internal Medicine, for example, will have Baduashvili and his colleagues present their findings during its national conference next year, helping spread the results to other POCUS educators.
Overall, Baduashvili hopes that by sharing these findings with other educators, it will help align POCUS curricula across different training programs in the nation, as well as spark further investigations on how to best teach physicians to use this important tool.
"I'd love for researchers to look at how to best implement and teach POCUS in resource-limited areas, such as at a location that cannot afford multiple machines or is limited in faculty," he says. "And in the bigger picture, I'd like to see internal medicine societies, like the American Board of Internal Medicine, to recognize POCUS as an important evolving competency for internists, because I think that would have significant downstream effects on the wide adoption of POCUS education."
Special note: Baduashvili would like to recognize two other co-authors for this study, Division of Hospital Medicine Data and Analytics Team members Angela Keniston, PhD, MSPH and Lauren McBeth, BA. He says they were instrumental in helping develop robust study methods, creating and deploying the survey, and helping analyze the results, expressing gratitude for their guidance.
