Background: Point-of-care ultrasound training programs (POCUS) have proliferated, but the best method of skills assessment remains unclear. Most published testing protocols assess only image acquisition and interpretation. In a clinical scenario, recognizing an indication for POCUS, selecting the appropriate exam, integrating findings with the other data from the case, and formulating a differential diagnosis and management plan are critical skills that need to be taught and tested.
Purpose: Over the past four years, the NYU internal medicine (IM) residency program taught PGY-2 residents point-of-care ultrasound skills with instruction in image acquisition and image interpretation skills for four organ systems: lung, cardiac, abdominal, and lower extremity vasculature. It is unclear to what extent residents have integrated these skills into their practice. We developed an objective structured clinical examination (OSCE) to assess three questions:1) Does the resident know what ultrasound view to perform in a given scenario?2) Can the resident acquire adequate images on a standardized patient (SP)?3) Can the resident integrate supplied abnormal ultrasound clips in their approach to a case?
Description: Thirty-seven PGY-2 IM residents took this OSCE 9-12 months following their initial course. The OSCE comprised three cases: identification of B-lines in a dyspneic patient, identification of tamponade in a patient with shock, and identification of hydronephrosis in a patient with acute kidney injury. In each case, the resident was asked to select an organ system to scan, obtain images from an SP, and then view abnormal images via slideshow. They were asked to identify the abnormal image, to propose a differential diagnosis, and propose a management plan.The OSCE was scored via 45-question rubric by POCUS-trained faculty. Questions pertaining to study selection, machine usage, and clinical correlation were scored on a binary scale (yes/no). Questions pertaining to quality of images acquired were scored with a three-point scale (not done, partially done, well done). The correct view was correctly selected by the majority of residents in all cases (pulmonary edema – 92% [34/37], tamponade – 100% [37/37], hydronephrosis – 97% [36/37]).In regards to image acquisition, in the pulmonary edema case, 65% (24/37) residents examined bilateral lungs. For the tamponade case, 86% (32/37) acquired a ‘Well-’ or ‘Partly done’ subcostal view. In the hydronephrosis case, all residents obtained a ‘Well-’ or ‘Partly done’ view of the right kidney and 95% (35/37) did the same on the left.All residents identified an abnormal B-line pattern, however only 51% (19/37) generated a complete differential diagnosis for the finding. All residents were able to identify a pericardial effusion and make a diagnosis of cardiac tamponade. All residents were able to identify hydronephrosis with a distended bladder, then choose urethral catheter insertion as their management step.
Conclusions: The majority of PGY-2 IM residents identified the appropriate view to perform for three cases. They achieved adequate images on an SP for the abdomen views but performed less well with cardiac and lung views. Only 65% of the learners scanned both lungs in the pulmonary edema case, and only half were able to generate a broad differential for the abnormal finding. The results of this OSCE provide evidence that POCUS can be effectively learned by PGY-2 IM residents but that explicit curriculum aimed at clinical integration is needed for improved competency in POCUS.