Prevalence and structure of ultrasound curricula in emergency medicine residencies

Stethoscope of the 21st century: dominant discourses of ultrasound in medical education

CONTEXT

In recent years, point-of-care ultrasound (POCUS) has become a widely used clinical tool in a number of clinical specialties. In response, POCUS has been incorporated into medical curricula across the learning continuum, bolstered by enthusiastic appraisals of the technology's benefits for learners, clinicians and patients. In this project, we have sought to identify and understand the effects of dominant discourses influencing the integration of POCUS into medical education.

METHODS

We conducted a Foucauldian critical discourse analysis (CDA) to identify and analyse discourses that legitimise and privilege the use of POCUS in medical education. We assembled an archive of 473 texts published between 1980 and 2017. Each article in the archive was analysed to identify frequently occurring truth statements (expressing concepts whose truths are unquestioned within particular discourses) that we used to characterise the major discourses that construct representations of POCUS in medical education.

RESULTS

We identified three dominant discourses: (i) a visuo-centric discourse prioritising the visual information as truth over other clinical data; (ii) a utilitarian discourse emphasising improvements in patient care; and (iii) a modernist discourse highlighting the current and future needs of clinicians in our technological world. These discourses overlap and converge; the core discursive effect makes the further elevation of POCUS in medical education, and the resulting attenuation of other curricular priorities, appear inevitable.

CONCLUSIONS

The three dominant discourses identified in this paper engender ideal conditions for the proliferation of POCUS in medical education through curricular guidelines, surveys of adherence to these guidelines and authoritative position statements. By identifying and analysing these dominant discourses, we can ask questions that do not take for granted the assumed truths underpinning the discourses, highlight potential pitfalls of proposed curricular changes and ensure these changes truly improve medical education.

The case for an ultrasound mandate

Emergency Medicine pioneered the use of ultrasound at the bedside. All of the Colleges of Emergency Medicine in the Anglo-American system have incorporated Emergency Ultrasound into their training curriculum, and all but ACEM have made training and proficiency mandatory. Emergency Ultrasound has not taken hold in Australasia the way it has in other parts of the world. It is a unique procedure that requires a College mandate to overcome the political and financial arguments that have kept it from flourishing in our hospitals. ACEM needs to instate such a mandate.

Ultrasonographic diagnosis of abdominal free fluid: accuracy comparison of emergency physicians and radiologists

OBJECTIVE

Blunt abdominal trauma is a diagnostic challenge for emergency physicians and ultrasonography is one of the diagnostic tools used in this type of injuries. The aim of this study was to evaluate the diagnostic value of ultrasonographies performed by emergency physicians and radiologists.

METHODS

This prospective diagnostic study was performed in the emergency departments of two trauma centers in Iran during a period of 12 months. The subjects were all patients with blunt abdominal trauma that were candidated for abdominopelvic computed tomography (CT) scanning in our emergency departments. The results of focused assessment with sonography for trauma (FAST) performed by emergency physicians and radiologists were compared blindly with the results of CT scans performed by radiologists. The sensitivity, specificity, and predictive values of diagnosis for different abdominal anatomic areas were calculated.

RESULTS

In total, 450 patients undergoing FAST and CT scanning were studied. The sensitivity of radiologists' diagnoses for Morison's, splenorenal, perivesical, and pleural effusion areas were, respectively, 88.0, 70.0, 38.0, and 30.0 %. The corresponding values for emergency physicians' diagnoses were, respectively, 82.0, 60.0, 28.0, and 30.0 %. The specificity of radiologists' diagnoses in the mentioned areas were, respectively, 98.9, 100, 93.1, and 100 %, and for emergency physicians, they were, respectively, 98.9, 100, 96.0, and 100 %.

CONCLUSION

Emergency physicians showed a promising performance in applying FAST in blunt abdominal trauma. The specificity of ultrasonographic diagnosis in the emergency physicians group and the radiologists group were comparable, while radiologists showed a higher performance regarding the sensitivity of the ultrasonographic diagnosis.

Evaluating emergency ultrasound training in India

Background:

In countries with fully developed emergency medicine systems, emergency ultrasound (EUS) plays an important role in the assessment and treatment of critically ill patients.

Methods:

The authors sought to introduce EUS to a group of doctors working in the emergency departments (EDs) in India through an intensive 4-day adult and pediatric ultrasound course held at the Apex Trauma Center and EM division of the All India Institute of Medical Sciences in New Delhi. The workshop was evaluated with a survey questionnaire and a hands-on practical test. The questionnaire was designed to assess the current state of EUS in India's EDs, and to identify potential barriers to the incorporation of EUS into current EM practice. The EUS course consisted of a general introductory didactic session followed by pediatric, abdominal and trauma, cardiothoracic, obstetrical and gynecologic, and vascular modules. Each module had a didactic session followed by handson applications with live models and/or simulators. A post-course survey questionnaire was given to the participants, and there was a practical test on the final day of the course. The ultrasound images taken by the participants were digitally recorded, and were subsequently graded for their accuracy by independent observers, residency, and/or fellowship trained in EUS.

Results:

There were a total of 42 participants who completed the workshop and took the practical examination; 32 participants filled in the course evaluation survey. Twenty-four (75%) participants had no prior experience with EUS, 5 (16%) had some experience, and 3 (9%) had significant experience. During the practical examination, 38 of 42 participants (90%) were able to identify Morison's pouch on the focused abdominal sonography for trauma (FAST) examination, and 32 (76%) were able to obtain a parasternal long axis cardiac view and identify the left ventricle. The inferior vena cava was identified as it crosses the diaphragm into the right atrium by 20 (48%) participants. All participants felt they would be able to incorporate what they had learned into their practice, and indicated that they were advocates for further training of non-radiologist clinicians in the use of ED ultrasound.

Conclusion:

After this introductory workshop in EUS, the participants were comfortable in their ability to use the ultrasound machine. Participants deemed it particularly useful for certain ED applications, particularly the FAST examination, the lung examination, and vascular access.

Motivations, job procurement, and job satisfaction among current and former ultrasound fellows

OBJECTIVES

Over the past decade, emergency medicine ultrasound (US) fellowships have proliferated, yet there are no published data describing employment trends among fellowship graduates. This study sought to assess factors motivating emergency physicians to pursue an US fellowship and to characterize their employment and job satisfaction after graduation.

METHODS

An electronic survey was conducted of US fellows and graduates representing all 35 known fellowship programs. Non-responders were contacted at 2 weeks to encourage participation. Primary outcome measurements were the importance of factors motivating individuals to pursue an US fellowship (as rated on a numeric scale), job satisfaction among US fellowship graduates, the proportion of respondents practicing in academic versus community hospitals, clinical hours per week, and the rate of procurement of one's top choice of job after graduation. The chi-square test or Fisher's exact test was used for categorical variables, and the Mann-Whitney U-test was used to compare continuous variables between two groups.

RESULTS

Of 170 invitations sent, 10 were undeliverable. The response rate was 61%; 74 graduates and 23 fellows completed the survey. Enhancing job opportunities, enjoyment of US, long-term job satisfaction and gaining skills not learned in residency rated highest as reasons for pursuing an US fellowship. Among graduates, 20% are satisfied with their current job, while 78% are very satisfied or extremely satisfied. Nearly one-third of graduates (31%) work primarily in non-academic hospitals, while only 9% of current fellows aspire to work in non-academic settings in the future. There was no difference in job satisfaction between academic- and community-based graduates. In comparison to those graduating in previous years, fellows graduating in 2008 were less likely to get their top job (97% vs. 75.0%, p = 0.018).

CONCLUSIONS

Job satisfaction is high among US fellowship graduates and is unrelated to academic versus community affiliation. Three-fourths of recent graduates obtain their top choice of job upon completion of fellowship.

Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography

STUDY OBJECTIVE

Nearly all emergency medicine residency programs provide some training in emergency physician-performed ultrasonography, but the extent of emergency physician-performed ultrasonography in community emergency departments (EDs) is not known. We seek to determine the state of ultrasonography in community EDs in terms of access to ultrasonography by other specialists and performance of ultrasonography by emergency physicians.

METHODS

A 6-page survey that addressed access to ultrasonography performed by other specialists and emergency physician-performed ultrasonography was designed and pilot tested. A list of all US ED directors was obtained from the American College of Emergency Physicians. Twelve hundred of 5264 EDs were randomly selected to receive the anonymous survey, with responses tracked by separate postcard. There were 3 mailings from Fall 2003 to Spring 2004.

RESULTS

Overall response rate was 61% (684/1130). Respondents who self-reported as being academic with emergency medicine residents were excluded from further analysis (n=35). A sensitivity analysis (reported in parentheses) was performed on the key outcome question to adjust for response bias. As reported by ED directors, ultrasonography was available in the ED for use by emergency physicians at all times in 19% of EDs (12% to 28%), with an additional 15% (9% to 21%) reporting a machine available for use by emergency physicians in some capacity and 66% (51% to 80%) reporting that there was no access to a machine for emergency physician use. ED directors reported being requested or required to limit ultrasonography orders performed by radiology in 41% of EDs, with less timely access to radiology-performed ultrasonography in off hours. Of EDs with emergency physician-performed ultrasonography, the most common applications were Focused Assessment with Sonography for Trauma (FAST) examination (85%), code situation (72%), and check for pericardial effusion (67%). Of physicians performing ultrasonography, 16% stated they were currently requesting reimbursement (billing). The primary reason cited for not implementing emergency physician-performed ultrasonography was lack of emergency physician training. For the statement "emergency medicine residents now starting residency should be trained to perform and interpret focused bedside ultrasonography," 84% of ED directors agreed, 14% were neutral, and less than 2% disagreed.

CONCLUSION

Community ED directors continue to report barriers to obtaining ultrasonography from consultants, especially in off hours. Nineteen percent of community ED directors report having a machine available for emergency physician use at all times; however, two thirds of EDs report no access to ultrasonography for emergency physician use. A majority of community ED directors support residency training in emergency physician-performed ultrasonography.

Ultrasound guidance for vascular access

The evidence that supports the general application of US guidance for venous access in the ED has reached a critical mass. The increasing familiarity of emergency physicians with US and the recent focus on patient safety and clinical outcomes has intensified attention on the capacity for US to improve patient care in the ED. US guidance can increase the safety and efficiency of venous access procedures and offers improved outcomes. The potential for these improvements is compelling, especially among certain types of ED patients such as those with difficult or complicated access. Varying levels of evidence support the use of US guidance over the traditional landmark approach for venous access in adult and pediatric populations and for central and peripheral veins. Many different techniques may be applied, depending on the clinical situation and equipment available.

Ultrasound in pregnancy

Ultrasound represents the cornerstone of the emergent evaluation of pregnancy-related complaints. Knowledge of the potential and the limitations of this imaging modality, regardless of who performs it, is important for physicians who evaluate and manage these patients and their unborn children in the ED.

Performance, training, quality assurance, and reimbursement of emergency physician-performed ultrasonography at academic medical centers

OBJECTIVE

To determine the current state of bedside emergency physician-performed ultrasonography in terms of prevalence, training, quality assurance, and reimbursement at emergency medicine residency programs.

METHODS

The link to a 10-question Web-based survey was e-mailed to ultrasound/residency directors at 122 emergency medicine residency programs in the United States.

RESULTS

The overall response rate was 84%. Ninety-two percent of programs reported 24-hour emergency physician-performed ultrasonography availability. Fifty-one percent of programs reported that a credentialing/privileging plan was in place at their hospital, and 71% of programs had a quality assurance/image review procedure in place. Emergency medicine specialty-specific guidelines of 150 ultrasonographic examinations and 40 hours of didactic instruction were met by 39% and 22% of residencies, respectively, although only 13.7% of programs were completing the 300 examinations recommended by the American Institute of Ultrasound in Medicine. Sixteen programs (16%) reported that they were currently billing for emergency physician-performed ultrasonography; of those not billing, 10 (12%) planned to bill within 1 year, and 32 (37%) planned to bill at some point in the future.

CONCLUSIONS

Performance and training in emergency physician-performed ultrasonography at academic medical centers continues to increase. The number of emergency medicine residency programs meeting specialty-specific guidelines has more than doubled in the last 4 years, but only a small number are meeting American Institute of Ultrasound in Medicine guidelines. Although only 16% of programs reported that they were currently billing for emergency physician-performed ultrasonography, most had plans to bill in the future.

Alternatives for improving veterinary medical students' learning of clinical sonography

With the widespread clinical use of sonography there is a need to introduce the topic into the curriculum. A new problem-based course in clinical sonography without lectures was developed to emphasise experiential learning, and engage students actively in individual and collective acts of discovery. Four different approaches were used to deliver the new course to 141 veterinary medical students over four semesters. The physical principles of sonography were taught by computer-assisted instruction and a practical class, clinical examinations were introduced during a session with a tutor, and finally each student wrote an essay on a sonographic topic of their choice. To evaluate the new course, students' responses to a questionnaire were analyzed. Students gained reasonable understanding of the physical principles of sonography and had some confidence in conducting a sonographic examination of an animal. Of most use to student learning was discussion with the teachers. Surprisingly, half the students thought the topic should also be taught by lectures. The students learned the material and acquired the sonographic skills through processes which required more independence and self-responsibility than traditional teaching methods. The teachers' interaction with students on an individual basis, as they encountered individual problems, was the most important resource in learning about sonography. The continued request for lectures suggests an insecurity in some students caught between two different paradigms of teaching and learning (experiential, problem-based learning versus lectures).

Ultrasound training for emergency physicians--a prospective study

OBJECTIVES

Bedside ultrasound examination by emergency physicians (EPs) is being integrated into clinical emergency practice, yet minimum training requirements have not been well defined or evaluated. This study evaluated the accuracy of EP ultrasonography following a 16-hour introductory ultrasound course.

METHODS

In phase I of the study, a condensed 16-hour emergency ultrasound curriculum based on Society for Academic Emergency Medicine guidelines was administered to emergency medicine houseofficers, attending staff, medical students, and physician assistants over two days. Lectures with syllabus material were used to cover the following ultrasound topics in eight hours: basic physics, pelvis, right upper quadrant, renal, aorta, trauma, and echo-cardiography. In addition, each student received eight hours of hands-on ultrasound instruction over the two-day period. All participants in this curriculum received a standardized pretest and posttest that included 24 emergency ultrasound images for interpretation. These images included positive, negative, and nondiagnostic scans in each of the above clinical categories. In phase II of the study, ultrasound examinations performed by postgraduate-year-2 (PGY2) houseofficers over a ten-month period were examined and the standardized test was readministered.

RESULTS

In phase I, a total of 80 health professionals underwent standardized training and testing. The mean +/- SD pretest score was 15.6 +/- 4.2, 95% CI = 14. 7 to 16.5 (65% of a maximum score of 24), and the mean +/- SD posttest score was 20.2 +/- 1.6, 95% CI = 19.8 to 20.6 (84%) (p < 0. 05). In phase II, a total of 1,138 examinations were performed by 18 PGY2 houseofficers. Sensitivity was 92.4% (95% CI = 89% to 95%), specificity was 96.1% (95% CI = 94% to 98%), and overall accuracy was 94.6% (95% CI = 93% to 96%). The follow-up ultrasound written test showed continued good performance (20.7 +/- 1.2, 95% CI = 20.0 to 21.4).

CONCLUSIONS

Emergency physicians can be taught focused ultrasonography with a high degree of accuracy, and a 16-hour course serves as a good introductory foundation.

Role of emergency medicine physicians in US performed in patients in the emergency department: how substantial is their participation?

PURPOSE

To determine the extent to which emergency medicine physicians have assumed responsibility for performing and interpreting ultrasonographic (US) studies in emergency departments (EDs) in the United States.

MATERIALS AND METHODS

The national 1997 Medicare Part B database was searched by using standard US procedure codes, location codes, and physician specialty codes. The authors determined how many US studies were performed in EDs and what percentage of those studies were performed by emergency medicine physicians, radiologists, or other physicians.

RESULTS

During 1997, 234,820 ED US studies within nine major examination categories were performed in Medicare patients nationwide. Emergency medicine physicians performed 1,551 (0.7%) of these studies. When echocardiographic examinations were excluded, emergency medicine physicians performed 458 (0.2%) of the remaining total of 196,158 studies.

CONCLUSION

Although emergency medicine physicians have claimed to be actively involved in ED US on a broad scale, the data reveal that their involvement in 1997 was minimal. This raises doubt as to whether they can properly train their residents to perform US or maintain their own competence at acceptable levels.

A comparison of emergency medicine ultrasound training with guidelines of the Society for Academic Emergency Medicine

STUDY OBJECTIVES

To compare the current state of emergency medicine residency ultrasound training with guidelines for that training from the Society for Academic Emergency Medicine (SAEM).

METHODS

A brief questionnaire was sent to program directors from 119 emergency medicine residency programs in the United States. Responses were compared with the SAEM guidelines for clinical experience (150 total ultrasounds) and didactic experience (40 hours of didactic instruction).

RESULTS

The overall response rate was 92%. Seventy-six (69%) of the programs own an ultrasound machine (ownership defined as 24-hour availability and complete discretion over use). Of these, 12 (16%) indicated that their average 1998 graduate had done at least 150 total ultrasound scans during residency, although none of the programs had average numbers that exceeded the minimum guidelines for all 4 procedure categories. Information on didactic curriculum was available from 74 ultrasound-owning programs: the duration was 0 to 20 hours in 49 (66%), 20 to 40 hours in 19 (26%), and 40 to 100 hours in 6 (8%). Only 1 program's average graduate met or exceeded the SAEM guidelines for both didactic and clinical training.

CONCLUSION

Most emergency medicine residency programs own at least 1 ultrasound machine, with more than half of these obtaining their first machine within the past 3 years. Only 1 program currently meets SAEM training guidelines.