Keywords

Objectives

  • Discuss ACGME Requirements for point of care ultrasound training.

  • Highlight ultrasound training recommendations by the American College of Emergency Physicians.

  • Discuss development of a residency ultrasound training program in emergency medicine.

  • Compare different specialty residency training guidelines.

Introduction

In the 1990s, ultrasound began to evolve as a key diagnostic tool for a number of clinical specialties. The disseminated use of this technology caused established organizations of medical imaging to discourage ultrasound training outside historical boundaries. However, it also stimulated the formation of groups composed of passionate clinical physicians dedicated to expand ultrasound utilization into nearly every clinical environment short of psychiatry. By the turn of the twenty-first century many US universities had taken notice and had begun to include ultrasound training as a fixed component of the education for all of their medical students.

This chapter reviews the requirements for point of care (POC) ultrasound education in residency training in the United States and includes recommendations to integrate ultrasound education into an existing residency program. The authors’ perspective is from residency training in emergency medicine, but many recommendations can be applied to residency training in other specialties.

ACGME Requirements for Clinical Ultrasound Training

Utilization of diagnostic ultrasound by clinical specialists began in the 1960s with cardiology and obstetrics-gynecology. However, it was not until the beginning of the twenty-first century that the Accreditation Council for Graduate Medical Education (ACGME) began to formulate training requirements for CUS. These new requirements were initially included in the ACGME Program Requirements for emergency medicine in 2001 [1].

Revised in 2013, the emergency medicine program requirements for ultrasound training is as follows:

“Residents must use ultrasound for the bedside diagnostic evaluation of emergency medical conditions and diagnoses, resuscitation of the acutely ill or injured patient, and procedural guidance [1].”

The use of the word “must” specifically requires programs to provide ultrasound training, but the statement is relatively general compared to other ultrasound policy statements for professional organizations (e.g., ACEP). There are no requirements for the competence of emergency medicine faculty in bedside ultrasound or the presence of an adequate number of ultrasound systems capable of providing quality imaging in the emergency departments that serve as teaching sites for emergency medicine residents.

In 2013, ACGME also rolled out “The Next Step in the Outcomes-Based Accreditation Project [2]” (often referred to as “Next Accreditation System” or “NAS”) as a joint effort by the ACGME and medical specialty boards. For emergency medicine this collaboration included the American Board of Emergency Medicine (ABEM). The goal of NAS was to overhaul the evaluation system for postgraduate medical education in the United States, clearly define observable skills expected at particular stages of training within a given specialty, and recommend competency assessment tools [2]. The cornerstone of this process was the development of “Milestones” for each specialty to act as a framework for the assessment of resident physician competencies [2].

For emergency medicine there are 23 milestones [2] (Table 8.1). Of these, five are clinical procedures:

  • Airway Management

  • Anesthesia and Acute Pain Management

  • Goal-Directed Focused Ultrasound

  • Vascular Access

  • Wound Management

Table 8.1 ACGME milestones for emergency medicine [2]
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The inclusion of POC US as a milestone firmly established the importance of this skill from the viewpoint of ABEM and the ACGME.

Emergency medicine programs are now required to assess and regularly report directly to ACGME a given resident’s progress at utilizing POC US over the course of their training (Table 8.2). This includes a requirement that each resident perform 150 “focused ultrasound examinations ,” and it is still used as the primary benchmark for the ACGME milestone for POC US in emergency medicine residency training.

Table 8.2 Other diagnostic and therapeutic procedures: goal-directed focused ultrasound (diagnostic/procedural) (PC12)
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Suggested assessment tools for the POC US milestone include:

  • Standardized Direct Observation Tool (SDOT)

  • Observation of Resuscitations

  • Simulation

  • Video Review

Ultrasound Training Recommendations by the American College of Emergency Physicians

There are many professional medical colleges, societies, and associations that have developed policies and position statements on POC US. Many of these have undergone revisions as POC US implementation has matured in various specialties, and negotiations between the leaders of organizations for different specialties have searched for common ground to safely increase POC US utilization.

The American College of Emergency Physicians (ACEP) is the largest organization of this type in emergency medicine. In the 1990s, ACEP convened a group of experts in POC US to produce a consensus document for emergency physicians interested in using POC US.

This document described two pathways for emergency physicians to competently use POC US (Table 8.3).

Table 8.3 ACEP pathways for emergency physicians to proficiency in ultrasound [4]
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This became the first document sanctioned by ACEP to include a specific number of examinations to acquire competence (150 studies) [5]. Although it has been criticized, it became the standard for most policies in emergency ultrasound as well as credentialing standards for hospital privileges. Even as ACEP broadened its recommendations to achieve competence in subsequent revisions of its policy, the required number of examinations has remained constant.

In 2008, ACEP significantly expanded its policy to include recommendations that physicians should perform 25–50 reviewed examinations for all common applications of POC US in the emergency department [6]. In addition, the document provided guidelines for ultrasound education in residency training that are discussed below.

Development of a Residency Ultrasound Training Program

The development and implementation of an ultrasound training program for a residency is a complicated and time-consuming process. It requires dedicated and skilled faculty members and has significant expenses. It takes several years to reach maturity at which point residents can utilize the technology to simultaneously evaluate and manage patients in the emergency department.

There are four assets required for the successful deployment of such a program:

  • Curriculum

  • Faculty

  • Equipment

  • Competency Assessment

Curriculum

Residents should be exposed to an introductory course at the beginning of their training. All residents attend a variety of courses during the first weeks of their PGY 1 year (e.g., Advanced Trauma Life Support and Advanced Cardiac Life Support). POC US training courses should also be included at this time. The course should provide residents with important basic information:

  • Machine operation and maintenance

  • Exam setup

  • Screen orientation

  • Logging exams for technical and interpretive review by faculty

  • How to access additional educational resources

A dedicated rotation to POC US should be a component of the first year of residency training as well. In general, the length of the rotation should not be less than 2 weeks in duration and should be composed of dedicated shifts to perform POC US without the burden of patient management. Shifts dedicated to ultrasound scanning should be designed to spend some time examining patients directly with faculty that possess expertise in POC US.

In addition, ACEP recommends that the rotation include:

  • Didactic sessions covering basic and advanced POC US applications

  • Scheduled reading assignments in texts and journals

  • Access to other digital educational resources including question banks on POC US applications

Beyond the PGY 1 ultrasound rotation the program should have longitudinal educational tools aimed specifically at teaching residents to integrate ultrasound into their daily practice. Examples include case presentation series during conference, continued online training modules, and simulation medicine training emphasizing the use of ultrasound in resuscitation and procedural guidance.

Faculty

ACEP recommends that all emergency residency programs should identify a full-time faculty member as its emergency ultrasound director. It is not required that the ultrasound director be fellowship trained. However, it is paramount for programs to recognize the substantial time commitment to developing and managing a successful program. In the past this position has often been relegated to junior faculty with little compensation in terms of protected time to accomplish a colossal task. Since there may be no older faculty mentors within the program to advise them, it is imperative that new directors are supported to attend outside conferences to encourage networking with directors at other institutions.

Per ACEP guidelines, a minimum of 50% of the “Core Faculty” members of a program should also be designated as core ultrasound faculty and credentialed by the host institution in the use of ultrasound. The ultrasound faculty should be responsible for direct and indirect review of the majority of the resident examinations and be able to provide feedback on scanning technique and interpretation. Ultrasound fellows may be delegated ultrasound faculty responsibilities.

Equipment

There are an increasing number of choices for ultrasound equipment for CUS. System capabilities continue to expand while cost has remained constant and in some cases decreased. Computer miniaturization has allowed for the production of small systems that can even fit into the lab coat of a physician.

The choice of equipment depends on many factors:

  • Number of residents

  • Patient census

  • Physical size of the emergency department

  • Budgetary issues

The number and type of ultrasound probes should be chosen based on the applications performed in each program’s clinical environment, but generally includes linear, curved linear, phased array, and endocavitary transducers.

Other important factors to consider include the mundane issues of durability, product warrantees, and regular maintenance. Product information should not only be obtained through sales representatives, but also through consultation with ultrasound program directors at other institutions.

Both new and experienced ultrasound program directors will benefit from routinely sampling a large number of systems to keep abreast of technology advances and to determine the best fit for their current and future needs.

Competency Assessment

The goal of competency assessment is to assure that each resident can integrate ultrasound into daily clinical practice. Two parameters are used to make this assessment:

  • Number of exams performed

  • Evaluation of technique and interpretation

Many organizations including the ACGME recognize that at least 150 ultrasound examinations in “critical” or “life-saving” scenarios promote a minimum acceptable level of exposure. However, completion of these exams does not establish competency, and the residency program must also qualitatively assess each resident’s ability to perform studies routinely conducted in an emergency department setting. This process should include assessment of the following parameters:

  • Proper machine settings

  • Probe positions

  • Image acquisition and documentation

  • Image quality

  • Identification of landmarks

  • Completeness of imaging protocol

  • Interpretation of findings

The majority of these experiences should be conducted while working with patients in an emergency department setting, but can also be performed in simulated settings using standardized patients or ultrasound simulators. Assessment methods include:

  • Standard Direct Observations Tool (SDOT)

  • Objective Structured Clinical Examination

The program should provide a system for residents to log their ultrasound exam experiences during training. This system should include a method to store images for each exam that can be reviewed by faculty with POC US expertise. Commercial systems are also available with annual fee structures based on the number of residents and the number of submitted exams (e.g., Q-path at http://www.telexy.com).

Medical knowledge of POC US can be assessed using a standardized multiple-choice examination. Emsono (http://www.emsono.com/acep/exam.html) provides a free interactive modular exam covering all of the core applications of emergency ultrasound. This test includes video, still image, and case-based questions.

Other Residency Experiences

ACGME utilizes two documents to establish requirements for postgraduate medical training:

  • ACGME Program Requirements

  • The Milestones Project

The only specialty other than emergency medicine with written requirements for ultrasound education in both the ACGME Program Requirements and Milestones is anesthesiology (Table 8.4). Other clinical specialties that can utilize POC US have very limited written requirements that pertain specifically to ultrasound education. Cardiology is the only specialty other than emergency medicine to require the performance of a specific number of studies during postgraduate training (ironically also 150 examinations), but there are no milestones for ultrasound competence. Although obstetrics and gynecology (OB-GYN) is historically an early adopter of clinical ultrasound, OB-GYN does not have specific language in the ACGME program requirements for POC US education. However, there is a reference to ultrasound competence within one of the OB-GYN milestones. There are no ACGME specific requirements or milestones for POC US education in family medicine, internal medicine, pediatrics, or surgery.

Table 8.4 Comparison between specialties regarding ACGME program requirements and NAS milestones on ultrasound education [1,2,3, 7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24]
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Only a handful of the nation’s internal medicine programs incorporate bedside ultrasound training into their curriculum. A survey of internal medicine training programs found that while there is substantial interest in point of care ultrasound among internal medicine educators, only 25% indicated their program has a formal curriculum [25].

Although ACGME does not require POC US training in family medicine, the American Academy of Family Physicians (AAFP) Practice Profile Survey from 2008 reported that 18% of AAFP members offer obstetric ultrasound in their practices, 15% offer non-OB ultrasound, and 14% offer echocardiography [26]. The Society of Teachers of Family Medicine (STFM) and the American Academy of Family Physicians (AAFP) commission on education state that family medicine residents should learn basic and advanced obstetric ultrasound and be exposed to ultrasound-guided procedures including central vascular access, paracentesis, and thoracentesis [26].

ACGME program requirements for pulmonary critical care includes POC US training to “perform thoracentesis and place intravascular and intracavitary tubes and catheters,” but there are no milestones for ultrasound competence. The Surgical Critical Care Milestones document mentions ultrasound as an “advanced monitoring technique” for shock and resuscitation, but it is not discussed in the ACGME program requirements.

Pitfall for Ultrasound Training in Residency

  1. 1.

    Not introducing POC US early in residency training

    • Many programs fail to introduce residents to POC US until after their PGY 1 year of training.

    • By this point many residents become resistant to new techniques and skills.

    • Setting expectations on the first day of residency is critical to developing the habit of POC US utilization.

  2. 2.

    Depending on training venues or specialties outside your department to teach your residents

    • Depending on other specialties for POC US training often allows your program faculty to avoid learning how to utilize POC US.

    • This creates a clinical environment where residents are not actively encouraged to use POC US in their regular patient care.

  3. 3.

    Recreating the “educational wheel” of didactics, training, and testing rather than utilizing previously developed education resources

    • Curriculum development is a tremendous burden for a dynamic topic like POC US.

    • There is an enormous amount of previously developed educational content that can be used to assist in resident POC US education.

  4. 4.

    Not having faculty that are trained and supportive of POC US

    • Require minimum standards for your faculty regarding POC US competence.

    • Provide educational support through didactic training as well as hiring new faculty with POC US skills.

Key Recommendations

  • Development and implementation of a residency ultrasound training program requires significant planning and resources.

  • The ultrasound program director must be compensated to dedicate adequate time and effort to the process.

  • ACGME now requires the evaluation of clinical ultrasound skills for residents training in emergency medicine with evolving standards in other specialties.

  • There are four assets required for the successful deployment of a POC US program: curriculum, trained faculty, adequate equipment, and competency assessment tools.