Increased Ultrasound Knowledge Among Medical Residents Through Focused Ultrasound Training

Ultrasound is a relatively cost-efficient imaging modality without harmful effects of radiation exposure. With technological advances, ultrasound has become more portable and user-friendly and is utilized in variety of medical fields. Ultrasound is heavily operator-dependent and requires sufficient training to obtain and interpret images properly, but ultrasound training for resident physicians is still lacking.

A study on 437 obstetrics and gynecology residents across 93 programs in 2016 showed that 30% of residents reported not having any ultrasound didactics, and of those who did, 40% reported having it annually or less [5]. A more recent study from 2015-2016 on 110 otolaryngology residents noted that 76% residents had no exposure to formal ultrasound education, 44% did not feel comfortable with ultrasound-guided procedures, and 78% wished they had more exposure to ultrasound [6].

An increasing number of residency programs are becoming aware of the usefulness of ultrasound and starting to incorporate ultrasound education in some form or another. obstetrics and gynecology residency, for example, is one of the fields that has traditionally incorporated ultrasound education into their training given the integral part ultrasound has in the field. Historically, this has been through informal, educator-dependent training, however in 2018, the American Institute of Ultrasound in Medicine and its task force developed a formal standardized curriculum with competency assessment to be incorporated into ob-gyn residency training [7]. The curriculum provides varying levels of ultrasound education depending on the postgraduate year, starting from the fundamentals of ultrasound to a more advanced, procedural ultrasound training. It also requires that the residents personally obtain proper images and clips themselves as part of the assessment. Having such structured curriculum can be applied in various fields including internal medicine and strengthen postgraduate education.

Incorporating ultrasound in internal medicine has many advantages, including timely and efficient diagnostic evaluation that can guide management for the patient. In Netherlands and other European countries, a formal ultrasound training has been developed for internal medicine residents that is similar to the International Federation for Emergency Medicine’s ultrasound curriculum [8,9]. Nonetheless, there is no formalized curriculum for internal medicine residency programs in the U.S. The Alliance of Academic Internal Medicine recently published a position statement in 2019 on point-of-care ultrasound within the field of internal medicine and stated that ultrasound does indeed provide clinical benefit to patient care and supports longitudinal ultrasound training in internal medicine residency [10]. Through robust ultrasound training, internal medicine residents can acquire higher efficiency in ultrasound-guided procedures and tests as they care for acutely sick patients, performing a quick point-ofcare ultrasound to obtain central vascular access and to assess for retroperitoneal bleed or cardiogenic shock.

There are limitations to this study, namely the small sample size. Given that this was solely based on a voluntary basis, this was the maximum number of busy residents we were able to recruit, however one way to overcome this is to incorporate it as an elective rotation in which the residents would have dedicated time for learning and expand it to a multicenter study for a larger sample size. Another limitation is that this was only focused on the hepatobiliary system, largely for efficiency. While our lecture does discuss the specific indications that would warrant a right upper quadrant ultrasound, the participants were made aware that working through the hepatobiliary system alone is not sufficient for patients presenting with abdominal discomfort, and that this may not necessarily be generalized to the overall efficacy of all ultrasound training curriculums. Our study also does not incorporate the actual scanning aspect of ultrasound teaching. This is due to the limited participation of the residents (this was offered as an adjunct but many had schedule conflicts). If a formal curriculum is incorporated with a set allotted time, this would be very feasible and will exponentially enhance ultrasound learning.

One of the major obstacles in incorporating a formal ultrasound curriculum seems to be the lack of time and trained faculty [11]. Nonetheless, our study demonstrates that even just one 45-minute educational session on ultrasound enhanced residents’ knowledge and comfort level on ultrasound. This in turn has considerable clinical implications for more efficient and effective patient care. This study shows that incorporating ultrasound teaching in graduate medical education in the field of internal medicine is feasible and has a favorable outcome. An ultrasound simulator software program that can be used with a phone and a laptop has been shown to work effectively among residents [12], and a systematic review on simulation-based training on abdominal ultrasound highlights its effectiveness [13]. This type of software can help ameliorate difficulties associated with lack of dedicated ultrasound educators or faculty time across residency programs.