Teaching point-of-care ultrasound in a rural family medicine residency

Winchester POCUS program

Winchester District Memorial Hospital is a 49-bed community hospital in rural Ontario. A small group of family medicine residents complete almost all of their residency training at this hospital and 3 local primary care clinics. Three handheld portable ultrasound devices are used in the POCUS program. One device is assigned to each outpatient clinic, but residents are encouraged to bring the machines to different environments (eg, hospital ward, obstetric clinic) as desired. They are also encouraged to use the cart-based machines available in the hospital.

At the beginning of each academic year, residents attend 4 half-day workshops to receive hands-on training in POCUS delivered by a single faculty expert. These workshops are spread over a month to provide spaced repetition and allow residents time to prepare and practice between sessions. Prior to each session, residents review 1 to 2 recorded lectures selected by the instructor from free online resources (see Additional Resources sidebar). During each session, residents practice POCUS first by scanning each other, and later by scanning patients in the hospital’s emergency department or inpatient ward. Short-answer quizzes and clinical vignettes are used to encourage discussion, and postgraduate year 2 (PGY-2) residents who have completed the training are asked to help teach PGY-1 residents.

After the workshops, residents are encouraged to practice independently by scanning the patients they encounter in clinical practice. Images acquired using a Butterfly IQ+ are recorded using the image archiving software included with the device. Images acquired using a cart-based machine are saved to the machine’s hard drive. All recorded images are reviewed by a POCUS instructor and feedback is provided intermittently via email or the Butterfly application. A review workshop is offered about 6 months after initial training to remediate any deficits identified by a competency assessment.

Program evaluation

All residents (N=10) training in Winchester from 2022 to 2024 participated in the evaluation. The first year included 3 PGY-1 residents and 3 PGY-2 residents. The second year included 4 PGY-1 residents (new to the program) and 3 PGY-2 residents (promoted from the previous year). All residents provided informed consent. Ethics approval was obtained from the University of Ottawa and the Rural Research Network.

Residents recorded 2279 scans from July 2022 to January 2024. Of these, 2009 (88%) were considered determinate (ie, adequate image quality to answer a focused clinical question) by the reviewing POCUS instructor. Each resident recorded an average of 170 scans per year (range 85 to 353), including 151 determinate scans (range 78 to 324). A handheld device was used in 83% of cases. The most commonly performed scans were parasternal views of the heart (15%), subxiphoid views of the heart (14%), and abdominal views to assess for free fluid (13%). Less frequently performed scans included lung (11%), renal (8.8%), aorta (8.7%), gallbladder (7.3%), and obstetric (6.6%) views. One-third (32%) of all scans were completed in the first month of the POCUS training program while introductory workshops were ongoing.

Competency assessments were performed at 0, 6, 12, and 18 months. The 0- and 12-month assessments occurred immediately after the workshops. Assessments were completed in the workplace by faculty with experience using POCUS. An assessor directly observed a resident scanning a patient and scored the resident’s performance using the Ultrasound Competency Assessment Tool (UCAT). The UCAT is a validated instrument that considers 4 domains of skill: preparation, image generation, image optimization, and clinical integration.^6,7 It also includes a 5-point entrustment scale, which asks assessors to describe how much supervision and assistance the resident needed. Assessors were asked to watch a short video that explained the UCAT and its scoring procedure.⁸ Residents were asked to obtain multiple assessments from different assessors to increase the validity of the evaluation.

Residents obtained a total of 53 competency assessments, with each resident averaging 4 assessments per year (range 2 to 9). Assessments were completed by 16 different faculty members. Most assessors (88%) were family physicians, and most (88%) worked at least part-time in the hospital’s emergency department. Scores showed a trend towards improving competency using POCUS and increasing levels of entrustment. Mean UCAT scores were 76% at 0 months and 94% at 18 months. The proportion of assessors describing their entrustment as “I needed to be there just in case” or “I did not need to be there” was 42% at 0 months (30% and 12%, respectively) and 100% (20% and 80%, respectively) at 18 months (Figure 1).

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Figure 1.

Distribution of entrustment scores across 4 sequential assessments: Sample size (n) indicates the number of Ultrasound Competency Assessment Tool assessments completed at 0, 6, 12, and 18 months. Ten residents participated in assessments at 0 and 6 months, and 3 residents participated in assessments at 12 and 18 months. No residents received a rating of “I had to do it for them” at any assessment.

Teaching tips

Residents in the Winchester POCUS program develop competency with POCUS over time, despite receiving only a limited amount of didactic instruction at the beginning of the academic year. After 18 months of independent practice, residents scored over 90% on a workplace-based assessment of competency, and faculty endorsed the high levels of entrustment. Our program uses handheld devices, asynchronous feedback, and a longitudinal approach to overcome many of the barriers that limit POCUS training in a family medicine residency program. For educators seeking to build or strengthen their own POCUS curriculum, we offer the following practical recommendations:

Teach POCUS the same way you teach any other procedure. Provide hands-on training at an introductory workshop, then supervise residents when they use the tool to assess patients in clinical practice. This is how residents learn to repair a laceration, read chest imaging, or place an intrauterine device.

Use a flipped-classroom approach to maximize hands-on experience. There are many recorded POCUS lectures available online (see Additional Resources sidebar). In our program, residents review 1 to 2 recorded lectures before attending a workshop where most of the time is spent practising scanning and generating images.

Teach at the bedside with real patients. At our workshops, residents first practise by scanning each other, then by scanning patients in the hospital. We obtain permission from the attending physician before proceeding, and we discuss the training program with our patients to obtain their informed consent. We do not hire standardized patients.

Handheld devices are cost-effective and well-suited to family medicine. Handheld devices are less expensive than cart-based machines, and they allow residents to scan patients in clinics, long-term care facilities, or during home visits. Spaced repetition and clinical integration can occur naturally over the course of a residency program. Note that handheld devices must be approved for use by the participating hospital and supervising university.

Teach residents to record their images. When images are recorded, a single POCUS instructor can supervise and support a group of learners with asynchronous feedback. This approach reduces both the number of instructors required and the amount of curriculum time needed to teach POCUS.

Reach out to your colleagues in emergency medicine. Most family medicine programs struggle with a lack of POCUS-trained faculty.² However, many of the scans routinely performed by emergency physicians (eg, to identify an intrauterine pregnancy or screen for an aortic aneurysm) are directly relevant to family medicine.

Start small and scale up. POCUS has a range of applications (Tables 1 and 2), but residents do not need to learn all of them. Focus on the topics most relevant to your clinical setting and select 2 to 4 indications you can confidently teach and supervise. Start with a pilot program that you can offer to a small group of residents and scale up when resources are in place.

All users should build experience before using POCUS to inform patient care. Learners develop competency at different rates, and the minimum amount of experience will vary among users and indications.^9,10 We ask residents to review at least 20 to 30 scans with a preceptor before using POCUS in clinical practice, and we recommend programs evaluate competency directly with a validated assessment tool.^8-10

Conclusion

The Winchester POCUS program shows that a longitudinal approach using handheld devices, asynchronous feedback, and independent practice can effectively support the development of competency in family medicine residents. This approach may serve as a model for other family medicine residency programs seeking to implement a POCUS curriculum.