Point-of-care ultrasound as a competency for general internists: a survey of internal medicine training programs in Canada.

BACKGROUND
Point-of-care ultrasound (POCUS) is increasingly used on General Internal Medicine (GIM) inpatient services, creating a need for defined competencies and formalized training. We evaluated the extent of training in POCUS and the clinical use of POCUS among Canadian GIM residency programs.


METHOD
Internal Medicine trainees and GIM Faculty at the University of Toronto were surveyed on their clinical use of POCUS and the extent of their training. We separately surveyed Canadian IM Program Directors and Division Directors on the extent of POCUS training in their programs, barriers in the implementation of POCUS curricula, and recommendations for POCUS competencies in IM.


RESULTS
A majority of IM trainees (90/118, 76%) and GIM Faculty (15/29, 52%) used POCUS clinically. However, the vast majority of resident (111/117, 95%) and GIM Faculty (18/28, 64%) had received limited training. Of the Program Leaders surveyed, half (9/17, 53%) reported POCUS clinical use by their trainees; however only one quarter (4/16, 25%) reported offering formal curricula. Most respondents agreed that POCUS training should be incorporated into IM residency curricula, specifically for procedural guidance.


CONCLUSIONS
A considerable discrepancy exists between the clinical use of POCUS and the extent of formal training among Canadian IM residents and GIM Faculty. We propose that formalized POCUS training should be incorporated into IM residency programs, GIM fellowships, and Faculty development sessions, and identify POCUS skills that could be incorporated into future IM curricula.


Introduction
Point-of-care ultrasound (POCUS) refers to ultrasonography performed in real-time by the care provider at the patient's bedside. 1 POCUS has been demonstrated to improve diagnostic and procedural accuracy and improve patient care in cardiology, [2][3][4] intensive care, 5,6 rheumatology, 7,8 respirology, 4,9 endocrinology, 1 and nephrology. 10,11 Other clinical specialties such as Emergency Medicine, Critical Care, and Trauma Surgery have successfully established curricula to train residents to perform bedside diagnoses and procedures under ultrasound guidance. 1,12,13 General Internists practicing in inpatient settings have also increasingly adopted the use of POCUS as an aid in clinical assessment and procedural guidance. 1 Evidence suggests that clinicians can acquire "focused" ultrasound skills with directed training. 3,[14][15][16][17][18][19] POCUS has the potential to improve diagnostic accuracy by allowing the collection of more precise and timely clinical data, as well as increasing the procedural success rate and patient safety for procedures such as central vascular access, thoracentesis, paracentesis, and arthrocentesis. 6,[20][21][22][23][24][25][26] In the CanMEDS 2015 Patient Safety and Quality Improvement Expert Working Group Report, POCUS guidance is cited as one of the potential skills, or competencies, in residency training to improve safety in diagnostic and therapeutic procedures. 27 However, there are a paucity of published guidelines or formal curricula for POCUS training in Internal Medicine (IM) programs. 28,29 To the best of our knowledge, no studies have looked at the current state of clinical use of POCUS by Canadian residents and General Internal Medicine (GIM) Faculty. If the clinical use of POCUS has outpaced formal training on its safe applications, ultrasound studies performed by inexperienced users may result in harm to patients from inaccurate diagnoses, unnecessary additional tests, and procedural complications. 1 In support of this concern, the Canadian Association of Radiologists developed a position statement in 2013 on POCUS asserting that, "Sonography equipment in the hands of an operator who is not well versed in the specific scope of examinations that are to be performed, has an increased likelihood of being more harmful than beneficial." 30 This study aimed firstly to identify the prevalence of POCUS use amongst IM residents and GIM faculty in Canada. Secondly, we identified the amount of formal training that respondents had received. Subsequently, we examined for discrepancies between the amount of formal training and the current clinical use of POCUS in Canada due to the implications of inadequate training on the unsafe use of POCUS in clinical care. Lastly, we identified potential barriers to the implementation of POCUS curricula in Canadian IM programs.
In this aim, we conducted two local and one national survey. The local surveys, conducted at the University of Toronto, aimed to establish the extent of clinical use and the level of POCUS training among IM residents and GIM faculty in Canada.
Respondents were also asked their opinions on POCUS skills that would be valuable to the clinical practice of internists. With the national survey, we examined the current use of and training for POCUS in Canadian IM residency programs and aimed to understand potential barriers to the implementation of POCUS curricula in these programs. All three surveys examined for potential discrepancies between the formal training on POCUS and the current clinical use of POCUS.

Survey development
In

Statistical analysis
All data were extracted from the online survey software into Microsoft Excel (2011). All data were summarized using descriptive statistics.

Table 2. Internal medicine resident and GIM faculty responses on clinical use of POCUS, amount of POCUS training, and comfort in use of POCUS for procedures n (%)
Residents n =118 Faculty n =29

Amount of Training in POCUS
Received formal general POCUS training 2 (2) 2 (7) Received formal training in specific POCUS assessments or procedures 4 (3) 8 (28) Received informal training in specific POCUS assessments or procedures 37 (32) 4 (14) No  (Table 3).  (Table 4). procedural rotation mixed with POCUS teaching from a radiologist or practical teaching with or without online modules (Table 5).

Discussion
In the 2013 position statement on the use of POCUS, the Canadian Association of Radiologists asserts their concern that ultrasound use by inexperienced providers may portend harm to patient care. 30  The findings from our study have several potential limitations. The two local surveys that were administered to the IM residents and GIM staff had modest response rates and are subject to sampling bias. 32 Further, there is the possibility that residents and GIM Faculty with documented clinical use of POCUS may overestimate the extent of their formal training, subjecting this study to potential response bias. Based on the small sample size, and with the aim to preserve anonymity of respondents, we were unable to correlate the amount of reported training in POCUS of an individual respondent with the extent of their clinical use. As such, we were unable to determine if there was an association between the amount of POCUS training and the individual respondents' comfort or clinical usage of POCUS. Furthermore, the local surveys sent to the residents and GIM Faculty differed on questions related to demographics. As such, there is the possibility of error in comparing data between these two surveys.
To limit this potential source of error, comparisons between these surveys were only made for identical questions. Lastly, these surveys were administered locally at the University of Toronto and the findings may not generalize to other Canadian IM residents' or GIM Faculty members' experiences with POCUS.
The national survey included responses from the majority of IM Program Leaders in Canada [17/32]. Nonetheless, the number of respondents is small and it is difficult to determine whether these data accurately reflect the current usage and training for POCUS across Canada. In addition, we surveyed GIM Program Directors, GIM Division Directors, and Core Internal Medicine Program Directors. As such, it is possible that we received multiple responses from a single IM program. Due to the anonymity of data collection, we did not determine the respondents' University affiliations and we were unable to account for this. The low response rate and the chance of multiple data from one program create the risk of sampling bias. 32 In particular programs without POCUS curricula may not have participated in the survey, which would overestimate the prevalence of POCUS usage and teaching in IM programs in Canada. The findings of both the local and national surveys relate to the IM education system and the practice of General Internists in Canada, which is largely hospital-based. These findings may not generalize to other countries such e58 as the United States where Internal Medicine has a larger role in ambulatory primary care. Lastly, this study provides a representation of the prevalence of POCUS in clinical use and the extent of POCUS training at the time of the study. POCUS is rapidly evolving within the medical community and a followup study would help elucidate changes in our findings.
Despite these limitations, this study highlights several important issues. There is an increasing need for formal training on POCUS within IM programs.
IM competencies for ultrasound training should be well defined and focus on targeted clinical assessment skills and bedside procedures, relevant to the scope of practice of an Internist. More research is needed to establish a competency-based training framework and to develop validated assessment tools.
Following the findings of this study, the IM program at the University of Toronto has developed and launched a competency-based curriculum to teach focused diagnostic and procedural POCUS skills to IM trainees. This curriculum includes on-line modules followed by hands-on training with direct observation. Trainees will be able to electronically log POCUS studies and receive feedback on their sonographic skills and diagnostic accuracy. Residents subsequently undergo a structured standardized assessment to evaluate POCUS competency in specific competencies.