Teaching Point-of-Care Ultrasound in Medicine

Point-of-care ultrasound (POCUS) is an important tool for diagnosis and management across medical specialties. This scoping review consolidates POCUS education literature, examining how curricula are developed, implemented, and assessed. We identify literature gaps, explore directions for further research, and provide recommendations for curriculum development, implementation, and improvement. Methods We conducted a scoping review per the framework outlined by Arksey & O’Malley. A systematic search of the MEDLINE, EMBASE, Cochrane, ERIC, Web of Science, and Scopus databases was conducted to identify published, English language literature, on POCUS education in undergraduate or graduate medical training. Results Of 6,164 articles identified, 421 were analyzed in depth. Curricular content included diverse diagnostic and therapeutic applications, varying significantly by specialty. Teaching modalities included in-person didactics (74%), human models (58%), simulation (33%), and web-based didactics (18%). Several studies showed better outcomes for structured vs. apprenticeship curricula, hands-on teaching vs. didactic lectures, and human models vs. simulators. Web-based didactics were as effective as in-person didactics and conveyed benefits in reusability, cost, and instructor time. Dedicated electives and boot-camps were identified as effective. Few curricula assessed knowledge retention (5%), clinical decision making (3%), learner behavior (12%), or patient outcomes (6%). Conclusion Scholarly POCUS education literature is expanding. Curricular content varies and should be tailored to specialty needs. Structured curricula utilizing hands-on learning, electives, and bootcamps can enhance educational outcomes. Higher-level outcomes such as knowledge retention, C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e 12 V o l u m e 1 5 , I s s u e 2 , 2 0 2 0 S y s t e m a t i c R e v i e w CJGIM_V2_2020_174310.indd 12 21/04/20 11:34 PM Point-of-care ultrasound (POCUS) has become a valuable clinical tool for the delivery of patient care across medical specialties. It is inexpensive, non-invasive, portable, and studies support its ability to improve patient care by providing timely and accurate diagnoses,1,2 guiding clinical management,3–11 and increasing success rates of bedside procedures.12–17 Ultrasonography was first proposed as a clinical tool in the late 1950s.18 Over the subsequent decades, technological advances made ultrasound more portable and affordable, paving the way for its use at the bedside. Initial viability studies in trauma literature of the 1980s-1990s19–21 demonstrated POCUS’ clinical benefits and led to its expansion across medicine. While POCUS has become increasingly validated and widespread in clinical use, numerous studies detail that clinical training in POCUS is often lacking or highly variable.22–28 Additionally, our understanding of what constitutes educational best practice in POCUS is incomplete. clinical decision making, learner behavior, and patient outcomes, are lacking and should be a focus of further research Resume L’échographie au point de service (POCUS) est un outil important pour le diagnostic et la gestion dans toutes les spécialités médicales. Cette étude de portée consolide la littérature éducative POCUS, en examinant comment les programmes d’enseignement sont élaborés, mis en œuvre et évalués. Nous identifions les lacunes de la littérature, explorons les directions à prendre pour des recherches plus approfondies et fournissons des recommandations pour le développement, la mise en œuvre et l’amélioration des programmes d’enseignement. Méthodes Nous avons procédé à un examen de portée conformément au cadre défini par Arksey & O’Malley. Une recherche systématique dans les bases de données MEDLINE, EMBASE, Cochrane, ERIC, Web of Science et Scopus a été effectuée afin d’identifier les publications en langue anglaise sur l’enseignement POCUS dans le cadre de la formation médicale de premier ou de deuxième cycle. Résultats Sur les 6 164 articles identifiés, 421 ont fait l’objet d’une analyse approfondie. Le contenu des programmes d’études comprenait diverses applications diagnostiques et thérapeutiques, variant considérablement selon les spécialités. Les modalités d’enseignement comprenaient la didactique en personne (74 %), les modèles humains (58 %), la simulation (33 %) et la didactique basée sur le web (18 %). Plusieurs études ont montré de meilleurs résultats pour les programmes structurés par rapport aux programmes d’apprentissage, l’enseignement pratique par rapport aux cours magistraux didactiques, et les modèles humains par rapport aux simulateurs. La didactique basée sur le web était aussi efficace que la didactique en personne et présentait des avantages en termes de réutilisation, de coût et de temps de l’instructeur. Les cours optionnels et les camps d’entraînement ont été jugés efficaces. Peu de programmes ont évalué la rétention des connaissances (5 %), la prise de décision clinique (3 %), le comportement des apprenants (12 %) ou les résultats pour les patients (6 %). Conclusion La littérature éducative POCUS est en pleine expansion. Le contenu des programmes d’études varie et doit être adapté aux besoins spécifiques. Des programmes structurés utilisant un apprentissage pratique, des cours optionnels et des camps d’entraînement peuvent améliorer les résultats scolaires. Des résultats de plus haut niveau, tels que la rétention des connaissances, la prise de décision clinique, le comportement de l’apprenant et les résultats pour le patient, font défaut et devraient faire l’objet de recherches plus approfondies. C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e V o l u m e 1 5 , I s s u e 2 , 2 0 2 0 13 M o s e s e t a l . CJGIM_V2_2020_174310.indd 13 21/04/20 11:34 PM POCUS is often taught through apprenticeship models whereby learners undergo “on-the-job” training in clinical settings by more experienced practitioners. This creates a dependency on educators’ abilities to convey skills and knowledge, identify weaknesses, and assess competency, making this model highly variable. Furthermore, little data is showing its efficacy. Recent literature has shown the benefits of structured teaching curricula over apprenticeship models in POCUS education.29–31 Educational bodies32–35 have established recommendations for content knowledge and competency in POCUS, but do not provide direction regarding other key aspects of POCUS education, such as optimal teaching modalities, and methods of learner assessment and training evaluation. The International Federation of Emergency Physicians (IFEM)36 provides some recommendations on curriculum delivery and learner assessment, but these are minimal compared to their guidelines on content. There is a robust body of primary literature on POCUS education, but it is diverse in scope and methodology. Various reviews have attempted to summarize this literature. Scoping reviews by Birrane et al.37 and Tarique et al.38 focus on undergraduate medical education literature and identify themes in curricular content and learner assessment. A scoping review by Meadley et al.39 focuses on POCUS education in paramedics to examine curricular structure. Our scoping review asks: what content is being taught in POCUS education curricula and how does this differ between specialties; what training methods are effective; how are learners evaluated; and what are the gaps in the POCUS education literature. Our review differs from those above in that we assess POCUS education literature in both undergraduate and graduate medical education. Additionally, our review takes a more specific look at the exact content that is being taught across specialties. Finally, we look specifically at and summarize comparative studies to better understand the relative merits of various teaching modalities. We excluded studies that solely focused on central line insertion, as this topic has been studied extensively and summarized in other reviews.40–42 This was done to ensure the number of included studies was kept at a manageable number and allowed us to focus more closely on other aspects of POCUS education. The goals of our study are threefold: (1) contribute to the understanding of current practices in POCUS curriculum development, implementation, and assessment, (2) provide specific recommendations to educators to aid in the design of POCUS curricula, and (3) discover gaps in the POCUS education literature and explore directions for further research. Methods Our decision to utilize a scoping review methodology was made after a first look at the literature revealed a study base that was too heterogeneous in methodology, study population, and objective to be adequately captured by a systematic review. We decided that a scoping review would better allow us to capture and understand the full depth and breadth of the primary POCUS education literature. We used the scoping review framework outlined in 2005 by Arksey & O’Malley43 and expanded on by Levac et al.44 Our strategy is summarized as (a) identifying the research question (described above); (b) identifying relevant studies; (c) study selection; (d) charting the data; (e) collating, summarizing, and reporting the results. This scoping review methodology was chosen to systematically capture the full depth and breadth of the existing literature. Identifying Relevant Studies A comprehensive search strategy was developed by a medical librarian (AOC) to identify published, English language literature on ultrasound education for medical trainees. The initial search strategy was developed for Ovid MEDLINE by using a combination of database-specific subject headings and text words; this was then customized for each subsequent database search. Searches were conducted between March 9 and 15, 2017 in the following databases: Ovid MEDLINE, Ovid MEDLINE Epub Ahead of Print and In-P