Using Standardized Patients to Teach Point-of-Care Ultrasound-Guided Physical Examination Skills to Internal Medicine Residents

摘要

Introduction Point-of-care (POC) ultrasound is a limited ultrasound examination performed at the bedside to answer a focused clinical question,1 and has been demonstrated to improve procedural outcomes, decrease complications, and increase the accuracy of the physical examination.2–7 Training in POC ultrasound has been widely integrated into emergency medicine (EM) residency programs,8,9 but there are few reports on POC ultrasound training in other specialties. The use of POC ultrasound by clinicians across specialties has rapidly expanded, including increasing use among internists and primary care physicians.10 The rapid expansion of usage by nonradiologists has not been universally accompanied by adoption of standards for training, competency testing, and quality assurance.10,11 As the cost and size of ultrasound technology continue to decrease,12 it is conceivable that future physicians will have widespread access to it, regardless of whether they have been properly trained in its use and indications. In internal medicine, POC ultrasound is potentially useful to residents pursuing many career paths, including generalists and subspecialists and inpatient and outpatient practice.12,13 The optimal format for teaching and assessing internal medicine residents in POC ultrasound is not known. Studies have demonstrated that EM physicians can acquire skills to accurately answer a focused clinical question with ultrasound after brief training.14 We created a half-day ultrasound workshop to instruct internal medicine residents on POC ultrasound of the abdominal aorta and kidneys. The 2 organ systems were selected because of their utility in varied clinical settings and also for relative ease of image acquisition for teaching novices unfamiliar with ultrasound operation.;Methods A half-day simulation center workshop was created for postgraduate year (PGY)-2 and PGY-3 internal medicine residents. A total of 6 to 8 residents participated in each session. The objectives of the workshop were to review ultrasound operation and teach residents to independently obtain ultrasound images of the abdominal aorta and kidneys on standardized patients (SPs). The monthly workshop occurred during an ambulatory block. Residents were encouraged to attend, but attendance was not mandatory. After a preworkshop assessment, the workshop began with a 45-minute interactive lecture reviewing ultrasound principles, basic ultrasound settings, techniques for obtaining images of the aorta and kidney, and example images of abnormal findings. The lecture was delivered by an internal medicine consultant with an extensive background in ultrasound. The lecture included “knobology” instruction, which emphasized adjustment of the 3 basic settings used to optimize image quality: gain, depth, and frequency. Residents were given the opportunity for hands-on practice on the same ultrasound machine model used for the workshop and in our department (M-Turbo, SonoSite). Residents then divided between 2 SP rooms for practice obtaining ultrasound images of the aorta and kidneys. Both SPs had normal renal and aortic anatomy, were not obese, were similar in body morphology, and were prescanned by the instructor. This section of the workshop lasted for 90?minutes as each participant was allowed to practice until he or she felt proficient in image acquisition. The lecture instructor and chief medical residents circulated between the 2 rooms to provide individualized instruction and feedback. An identical preworkshop and postworkshop assessment was administered to evaluate the efficacy of the workshop. The written component included survey questions on residents' attitudes on POC ultrasound, confidence with ultrasound use, and basic knowledge questions about medical ultrasound (sample question: “What color is fluid on ultrasound?”). The hands-on portion was conducted in the SP rooms. Each resident was given a brief case vignette and asked to identify the SP's aorta and kidney using u