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Point of care ultrasound training for internal medicine: a Canadian multi-centre learner needs assessment… Watson, Kathryn; Lam, Ada; Arishenkoff, Shane; Halman, Samantha; Gibson, Neil E; Yu, Jeffrey; Myers, Kathryn; Mintz, Marcy; Ma, Irene W Y Sep 20, 2018

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RESEARCH ARTICLE Open AccessPoint of care ultrasound training forinternal medicine: a Canadian multi-centrelearner needs assessment studyKathryn Watson1, Ada Lam2, Shane Arishenkoff3, Samantha Halman4, Neil E. Gibson2, Jeffrey Yu5, Kathryn Myers5,Marcy Mintz1 and Irene W. Y. Ma1,6*AbstractBackground: Significant gaps currently exist in the Canadian internal medicine point-of-care ultrasound (POCUS)curriculum. From a learner’s perspective, it remains unknown what key POCUS skills should be prioritized. Thisneeds assessment study seeks to establish educational priorities for POCUS for internal medicine residents at fiveCanadian residency training programs.Methods: All internal medicine trainees [postgraduate year (PGY) 1–5] from five internal medicine residencytraining programs in Canada (n = 598) were invited to complete an online survey on 15 diagnostic POCUSapplications, 9 bedside procedures, and 18 POCUS knowledge items. For POCUS applications and procedures,participants were asked how applicable they are to patient care in internal medicine and the participants’ reportedskills in those domains. Self-reported knowledge and skills were rated on a 5-point Likert scale, where 1 = very poorand 5 = very good. Applicability was rated, where 1 = not at all applicable and 5 = very applicable.Results: A total of 253 of 598 residents (42%) participated in our study. Data from one centre (n = 15) was removedbecause of low response rate (15%) and significant baseline differences between those trainees and the remainingparticipants. Of the remaining analyzable data from four training programs (n = 238), participants reported highestapplicability to internal medicine for the following applications and procedures: identifying ascites/free fluid [meanapplicability score of 4.9 ± standard deviation (SD) 0.4]; gross left ventricular function (mean 4.8 ± SD 0.5) andpericardial effusion (mean 4.7 ± SD 0.5); thoracentesis (mean score 4.9 ± SD 0.3), central line insertion (mean 4.9 ± SD 0.3), and paracentesis (mean 4.9 ± SD 0.3), respectively. Overall reported knowledge/skills was low, with skill gapsbeing the highest for identifying deep vein thrombosis (mean gap 2.7 ± SD 1.1), right ventricular strain (mean 2.7 ± SD1.1), and gross left ventricular function (mean 2.7 ± SD 1.0).Conclusions: Many POCUS applications and procedures were felt to be applicable to the practice of internalmedicine. Significant skill gaps exist in the four Canadian training programs included in the study. POCUScurriculum development efforts should target training based on these perceived skill gaps.Keywords: Point-of-care ultrasound, Education needs assessment, Curriculum development, Internal medicine* Correspondence: ima@ucalgary.ca1Department of Medicine, University of Calgary, Calgary, AB, Canada6W21C, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1,CanadaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Watson et al. BMC Medical Education  (2018) 18:217 https://doi.org/10.1186/s12909-018-1326-8BackgroundThere is an increasing recognition of the value ofpoint-of-care ultrasound (POCUS) in the practice of in-ternal medicine. Its use in the guidance of procedures,such as central venous catheterization and thoracentesis,has been shown to improve patient safety [1, 2] and isconsidered to be the standard of care [2–9]. Addition-ally, the use of ultrasound as an adjunct to the physicalexamination to clarify clinical findings [10–12] and itsability to identify important clinical conditions at thebedside in the acutely ill patient is also increasingly rec-ognized [13].Appropriate training is integral for incorporating POCUS into the practice of internal medicine. POCUS in-volves a complex set of skills, including image acquisition,image interpretation, and integration of findings that re-quire consideration of the patient’s clinical context andpre-test probability [14, 15]. To practice POCUS safely,the trainee must have sufficient medical and sonographicknowledge of possible differential diagnoses [16], as wellas an awareness and insight into the limitations of bothPOCUS use in general and one’s own skill limitations.Given this complexity, it is not surprising the performanceof POCUS is highly operator dependent and that thelearning curves differ significantly depending on the appli-cation and the learner in question [17–19]. In the handsof untrained or inadequately trained POCUS operators,medical errors may pose significant safety concerns forthe patient [20]. A growing body of evidence indicates thatdedicated training is indeed necessary to attain proficiencyin POCUS [5, 18, 21] and that training may mitigateagainst potential harm from common POCUS pitfalls [22,23]. Targeting skills and knowledge gaps is therefore crit-ical to POCUS education.For curriculum development, performing a needs as-sessment is one of the key recommended first steps [24].From a curriculum development standpoint, consensuswas recently established regarding what POCUS ele-ments should be included in a Canadian internal medi-cine training curriculum [25, 26]. However, this workstemmed from the viewpoint of the educator. Little isknown from the trainees’ perspective, both in terms ofwhat they feel are needed skills for internal medicineand what skill gaps exist. For adult learners, recognitionof their perspectives and needs is critical for curriculumsuccess [24, 27].Literature to date suggests gaps exist in POCUS train-ing. One study involving learners at the University ofIllinois at Chicago and Northwestern University showsthat learners felt generally incompetent in the use ofultrasound [28].These results are not surprising, consid-ering that, based on results from a survey administeredto internal medicine Program Directors in 2012, only25% reported having a formal POCUS curriculum [29].Significant training gaps are similarly present in Canada[30]. Specifically, while 100% of the internal medicineCanadian residency and fellowship program directors be-lieved that POCUS should be taught and used, only 53%had actually integrated it into their residency-training pro-grams [30].The aim of this study is to establish the current re-ported skill levels and perceived POCUS needs of in-ternal medicine trainees at five Canadian teaching siteswith regard to POCUS. The results from this study willhelp prioritize training needs for educators tasked withPOCUS curriculum development and implementation.MethodsStudy designThis multi-center cross-sectional survey study was under-taken at five Canadian universities: the Universities of Cal-gary, Alberta, British Columbia, Ottawa and WesternUniversity. The respective Ethics Board at each of the fiveuniversities approved this study.ParticipantsAll Internal Medicine residents (postgraduate year[PGY] 1–4), as well as General Internal Medicine sub-specialty trainees (PGY 4–5) during the year 2015–2016from the five institutions were invited to participate inthis study (n = 598). Only those who consented to thesurvey were included in the study.Survey developmentTo support the content development of our survey, keytexts and articles on POCUS were reviewed [31–35]. Aninitial survey was drafted with input from two researchers(KW and IM) in July 2015, containing a list of 15 diagnos-tic applications, 10 procedures, and 80 basic knowledgeitems. For each survey item on diagnostic applications andprocedures, two questions were asked: 1) How applicableis the application/procedure to patient care in internalmedicine? 2) What is the participant’s skill in that area?For knowledge items, only self-reported level of know-ledge was asked.This survey was then piloted with 8 non-internal medi-cine residents in order to obtain input on survey length,content, and clarity. Based on feedback from the pilotdata, in particular with respect to the length of the initialsurvey, we substantially revised the survey. For diagnosticapplications, items on A-lines and Z-lines were removed,as they were felt to be too specific. The addition of twodiagnostic applications was suggested: deep vein throm-bosis and hydronephrosis. For procedures, incision anddrainage was removed as the skills involved were felt to beredundant with the skills involved in abscess aspiration.Lastly, many of the 80 items on POCUS knowledge [26]were felt to be too specific, resulting in a survey that wasWatson et al. BMC Medical Education  (2018) 18:217 Page 2 of 8unacceptably long. Ultimately, knowledge items weregrouped into broader categories. The final survey included15 diagnostic applications, 9 procedures, and 18 know-ledge items, in addition to questions on baseline demo-graphic data (see Additional file 1).Using an online survey tool (SurveyMonkey Inc. SanMateo, California, USA; www.surveymonkey.com), thefinal survey was distributed to the trainees betweenApril and June 2016. Up to two reminder emails weresent between two and 8 weeks to maximize participantresponse rate. As this study was unfunded, no incentiveswere used in this study at any study site.Study outcomesPerceived applicability of diagnostic applications andprocedures to the practice of internal medicine wasassessed using a 5-point Likert scale, where 1 = not at allapplicable and 5 = very applicable. Self-reported skilllevel and knowledge was assessed using a 5-point Likertscale, where 1 = very poor and 5 = very good. We definedskill gap as the difference between perceived applicabilityand self-reported skill level.Statistical analysisData were analyzed using standard descriptive statisticaltechniques. Comparisons of continuous variables be-tween groups were performed using Student’s t-tests.Categorical variables were compared with the use ofFisher’s exact tests and chi-square tests. All analyseswere performed using SAS version 9.4 (SAS InstituteInc., Cary, NC, USA).ResultsA total of 253 of 598 residents participated in our studyfor a cumulative response rate across all centers of 42%.We excluded data from 15 participants in a single cen-ter, as this center (Center E) did not achieve a responserate of > 40% (achieved only 12%). Further, baselinedemographics of survey respondents from Center E dif-fered significantly from respondents from Centers A toD in terms of procedural experience and in reported ac-cess to ultrasound preceptors (Table 1). The 4 centersincluded in this study had a mean response rate of 51 ±10%, with a total of 238 participants included in our finalanalyses.Diagnostic applicationsParticipants felt the following three diagnostic uses ofultrasound were most applicable to patient care in in-ternal medicine: identifying ascites/free fluid [mean ap-plicability score of 4.9 ± standard deviation (SD) 0.4];gross left ventricular function (mean 4.8 ± SD 0.5) andpericardial effusion (mean 4.7 ± SD 0.5, Fig. 1). Partici-pants reported lowest skill levels in identifying deep veinthrombosis (mean skill level 1.7 ± SD 0.8), hydronephrosis(mean 1.7 ± SD 0.8), and pulmonary interstitial syn-drome (mean 1.8 ± SD 0.9). Skill gaps (difference be-tween perceived applicability and self-reported skilllevel) were highest for identifying deep vein thrombosis(mean gap 2.7 ± SD 1.1), right ventricular strain (mean2.7 ± SD 1.1), and gross left ventricular function (mean2.7 ± SD 1.0).ProceduresResidents identified the following ultrasound-guidedprocedures as most applicable to internal medicine: thor-acentesis (mean applicability score 4.9 ± SD 0.3), centralline insertion (mean 4.9 ± SD 0.3), and paracentesis(mean 4.9 ± SD 0.3, Fig. 2). Participants reported lowestskill levels in using ultrasound for: peripherally insertedcentral catheter (mean skill level 1.6 ± SD 0.8), lumbarpuncture (mean 1.8 ± 3.9), and superficial abscess aspir-ation (mean 2.1 ± 0.9). Skill gaps were highest for lum-bar puncture (mean gap 2.1 ± SD 1.4), joint aspiration(mean 2.0 ± 1.3), and peripherally inserted central cath-eter (mean 1.8 ± SD 1.3).KnowledgeParticipants reported highest knowledge levels in: steriletransducer techniques (mean skill level 3.6 ± SD 1.3),transducer selection (mean 3.3 ± SD 1.2), and ability tointerpret pulmonary findings (mean 2.5 ± SD 1.9, Fig. 3).Participants reported lowest knowledge levels in: powerDoppler imaging (mean 1.6 ± SD 0.7), continuous wavespectral Doppler imaging (mean 1.6 ± SD 0.7), andpulsed wave spectral Doppler imaging (mean 1.6 ± SD0.8).DiscussionThis study demonstrates the perceived applicability tothe practice of internal medicine, self-reported skill/knowledge level, and skill gap of 15 POCUS diagnosticapplications, 9 ultrasound-guided procedures, and 18POCUS knowledge items for Canadian internal medicineresidents at four training sites. Our results suggest thatlearners felt using ultrasound to identify ascites/abdom-inal free fluid, gross left ventricular function and pericar-dial effusion were most applicable to the practice ofinternal medicine while least skillful in assessing fordeep vein thrombosis and focused cardiac ultrasound as-sessments. POCUS was felt to be most applicable for theguidance for thoracentesis, central line insertion andparacentesis. Self-reported proficiency was lowest in per-ipherally inserted central catheter, lumbar puncture, andsuperficial abscess drainage. Lastly, learners reportedoverall low level of knowledge of POCUS, especially withrespect to Doppler imaging.Watson et al. BMC Medical Education  (2018) 18:217 Page 3 of 8Our results mirror those from the University of Illinoiswhere learners reported low overall competence inPOCUS [28] and the University of Toronto where only21% of learners reported comfort in using POCUS forprocedures [30]. Our present study adds to existing lit-erature by providing additional granularity on gaps inspecific ultrasound diagnostic skills, procedural skillsand areas of knowledge. Time and costs of training arecited barriers to implementing a POCUS curriculum forinternal medicine [29, 30, 36]. These results can help in-ternal medicine educators who are tasked with imple-menting a POCUS curriculum focus their efforts onapplications, procedures, or knowledge that are per-ceived to be the most applicable, where the learnersTable 1 Baseline demographics and experience of survey participants, presented as number (%).aAll participants(N = 253)Centers A to D(N = 238)Center E(N = 15)p-valuePost-graduate year (PGY)PGY-1 74 (29) 71 (30) 3 (20) 0.49PGY-2 73 (29) 67 (28) 6 (40)PGY-3 65 (26) 62 (26) 3 (20)PGY-4 15 (6) 14 (6) 1 (7)PGY-5 16 (6) 14 (6) 2 (13)GenderMales 132 (52) 122 (51) 10 (67) 0.43Females 109 (43) 104 (44) 5 (33)Number of ultrasound-guided paracenteses performedNone 23 (9) 22 (9) 1 (7) 0.011–2 52 (21) 51 (21) 1 (7)3–5 73 (29) 72 (30) 1 (7)6–9 43 (17) 39 (16) 4 (27)10 or more 52 (21) 44 (18) 8 (53)Number of ultrasound-guided thoracenteses performedNone 41 (16) 41 (17) 0 0.011–2 74 (29) 71 (30) 3 (20)3–5 66 (26) 63 (26) 3 (20)6–9 36 (14) 29 (12) 7 (47)10 or more 25 (10) 23 (10) 2 (13)Number of ultrasound-guided central line insertions performedNone 35 (14) 34 (14) 1 (7) 0.171–2 27 (11) 26 (11) 1 (7)3–5 39 (15) 39 (16) 06–9 42 (17) 37 (16) 5 (33)10 or more 99 (39) 91 (38) 8 (53)Number of ultrasound-guided peripheral intravenous catheterizations performedNone 173 (68) 167 (70) 6 (40) 0.0041–2 26 (10) 20 (8) 6 (40)3–5 26 (10) 24 (10) 2 (13)6–9 5 (2) 4 (2) 1 (7)10 or more 11 (4) 11 (5) 0How often learners wanted to perform an US-guided procedure but was not able to do sodue to lack of supervisor/teacher (and not because of lack of equipment):b Mean ± standarddeviation2.1 ± 0.8 2.1 ± 0.8 1.7 ± 0.6 0.04aNot all participants responded to all questionsbResponses in Likert scale from 1 to 4, where 1 = never and 4 =most of the timeWatson et al. BMC Medical Education  (2018) 18:217 Page 4 of 8Fig. 1 Diagnostic applications and their perceived applicability to the practice of internal medicine (rated on a 5-point Likert scale, where 1 = verynot applicable and 5 = very applicable, black solid bars) and participants’ reported skill level (where 1 = very poor and 5 = very good, dashed bars)Fig. 2 Bedside ultrasound-guided procedures and the perceived applicability to the practice of internal medicine (rated on a 5-point Likert scale,where 1 = very not applicable and 5 = very applicable, black solid bars) and participants’ reported skill level (where 1 = very poor and 5 = verygood, dashed bars)Watson et al. BMC Medical Education  (2018) 18:217 Page 5 of 8report the least skills/knowledge, and/or where skill gapsare the highest, which takes into account both applic-ability and reported levels of skills and knowledge.Our study has a few limitations. First, our results arebased on learner self-report and the accuracy of self-assessed competence in skills and knowledge is questio-nable [37, 38]. Therefore, curriculum efforts should notnecessarily ignore applications, procedures, or know-ledge in which learners report high competence. Further,our definition of skill gap is only a surrogate measure,based on the difference between reported applicabilityand skills. Inaccurate assessment of either (or both) ofthese variables may render the interpretability of the skillgap measure questionable. Second, although this studyprovides the learner’s perspective on POCUS, curricu-lum implementation should take into account other fac-tors, such as which POCUS applications can bemastered within constraints of each local curriculum set-ting (e.g. time requirement for various skill acquisitionand availability of trained preceptors). Time require-ments and trained preceptors are important consider-ations in curriculum design. We recommend that ourresults be triangulated with educators’ perspectives,which were sought based on clinical and educationalneeds and evidence, education feasibility, as well as con-sideration of patient safety issues [25]. These principlesmay not have been considered by the learners duringsurvey response. Third, contrary to our expectations,our participants felt that the identification of interstitialsyndrome [39] has low applicability to internal medicine.Existing data suggest that lung ultrasound is in facthighly applicable to internal medicine as it improvesdiagnostic accuracies and narrowing of differential diag-noses [40, 41]. In retrospect, it is likely that the term“interstitial syndrome,” while concordant with inter-national recommendations [39], may be unfamiliar to oursurvey participants. The reported low skill level in identi-fying interstitial syndrome supports our hypothesis thatour survey participants may not be familiar with the con-cept. As such, we would not recommend deferring thetraining of lung ultrasound to internal medicine residentsbased on our survey results. Fourth, our surveys wereadministered to Canadian internal medicine trainees atfive training sites only and consequently, generalizabilitymay be limited. Lastly, despite our best efforts, our overallresponse rate was only 42%, while not entirely out ofkeeping with physician survey response rate in general[42, 43], is lower than we would like.Fig. 3 Self-report knowledge level in items related to point-of-care ultrasound knowledge (rated on a 5-point Likert scale, where 1 = very poorand 5 = very good)Watson et al. BMC Medical Education  (2018) 18:217 Page 6 of 8Despite these limitations, to our knowledge, this studyreports results from the largest multicenter internalmedicine learners. As such, their collective experienceand opinions regarding skill gaps are important to con-sider in our efforts to integrate POCUS safely into thepractice of internal medicine [40].ConclusionsOur multi-center survey results from Canadian internalmedicine residents suggest that learners found POCUShighly applicable to the practice of internal medicine, es-pecially for identifying ascites and cardiac findings andfor guiding central line insertion, paracentesis, and thor-acentesis. Significant gaps were reported in skills andknowledge. Development of POCUS education shouldtake these results into consideration when decidingwhere to focus curriculum efforts.Additional fileAdditional file 1: Point-of-care ultrasound needs assessment surveyadministered. (PDF 324 kb)AbbreviationsPGY: Postgraduate year; POCUS: Point-of-care ultrasound; SD: StandarddeviationAcknowledgementsThe authors wish to thank all trainees who completed the survey and Dr.Mireille Sayegh for her assistance with the drafting and distribution of thesurveys for the University of Ottawa.FundingThis study was unfunded.Availability of data and materialsThe datasets generated and/or analyzed during the current study are notpublicly available but are available from the corresponding author onreasonable request.Authors’ contributionsKW contributed to the study design, data acquisition, analysis andinterpretation, and writing and critical revision of the manuscript. AL, SA, SH,JY, KM contributed to the study design, data acquisition and interpretation,and critical revisions of the manuscript. NEG, MM contributed to the dataacquisition and interpretation, and critical revisions of the manuscript. IWYMcontributed to conception and design, data acquisition, analysis andinterpretation, and writing and critical revisions of the manuscript. All authorsread and approved the final manuscript and agree to be accountable for allaspects of the work in ensuring that questions related to the accuracy orintegrity of any part of the work are appropriately investigated and resolved.Ethics approval and consent to participateImplied consent was obtained for all participants included in this study. Thisstudy was approved by the University of Calgary Conjoint Health ResearchEthics Board (Ethics ID number: REB 15–2054), University of Alberta ResearchEthics Office (ID: Pro00058881), University of British Columbia BehaviouralResearch Ethics Board (H15–01955), Ottawa Health Science Network ResearchEthics Board (Protocol #20160025-O1H), and Western University Office ofResearch Ethics (HSREB 107616).Consent for publicationNot applicableCompeting interestsSA has received stock options for an advisory role in Clarius, outside thesubmitted work. The remaining authors declare that they have nocompeting interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Department of Medicine, University of Calgary, Calgary, AB, Canada.2Department of Medicine, University of Alberta, Edmonton, AB, Canada.3Department of Medicine, University of British Columbia, Vancouver, BC,Canada. 4Department of Medicine, University of Ottawa, Ottawa, ON, Canada.5Department of Medicine, Western University, London, ON, Canada. 6W21C,University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada.Received: 3 January 2018 Accepted: 11 September 2018References1. Arienti V, Camaggi V. Clinical applications of bedside ultrasonography ininternal and emergency medicine. Intern Emerg Med. 2010;6:195–201.2. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance forplacement of central venous catheters- A meta-analysis of the literature. 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