Free Ultrasound Training for Faculty

[FiNorman]

I'm trying to gauge interest among PA program faculty members who wish to learn primary care clinical ultrasound on the need for a "train the trainer" program.

 

We 3 faculty members already enrolled, we are looking for 2-3 more.

 

Many PA programs have already begun the process of ultrasound integration into their curriculum.  Many more PA programs have reached out to SPACUS with inquiries on how they can take the next step into POCUS integration.  However, I the have sense some trepidation on taking the first step among the faculty members since many do not have POCUS training of their own.  

The question I am posing to you, would faculty be better prepared to integrate Ultrasound into their programs if they were more personally skilled in performing POCUS, and could we increase the skill and confidence in our educators through program specifically designed to help our educators learn?  Is there an appetite among our PA faculty to have such a program. Is there interest in using this experience to publish?

If there is interest, from the technical stand point this program would be very easy to create as self paced, and tailored the interest of the individual faculty participants. The didactic education would be digested through Internet content pushed to the faculty.  1 hour video conferencing sessions could be scheduled at the group's convenience to answer questions and improve technique (2-4 conferences/month).  The length of the program entirely depends on how many applications the participants are interested in learning, but this could be anywhere from 6 wks to 6 months.

If the participants don't have access to an ultrasound machine SPACUS will assist with the lease of a machine. 

Other options to consider:

Participation in a sonographic anatomy class for educators at the World Congress of Ultrasound in Education. 

A "field trip" to the University of South Carolina Medical School's Ultrasound Institute to see first hand how ultrasound has been fully integrated into the medical school's curriculum for the past 9 years.

Specific teaching dedicated to ultrasound leadership to include credentialing, starting a POCUS program, machine purchase, competency of providers, QA, machine maintenance.

The didactic educational content, mentorship and video conferencing would be free to the participants through scholarship provided by the Society of Physician Assistants in Clinical Ultrasound.  

http://spacus.org

[weezianna]

Just an observation - I have been a registered diagnostic medical sonographer for over 35 years, and worked full-time in that field for over 20 years before I became a PA.  I completed a formal program, and had to pass several certification exams, including the core requirement of ultrasound physics as well as areas of concentration - abdomen, Ob/Gyn and Adult Echocardiography.  Sonography was always truly an art, and of all imaging modalities the one most dependent on the skill of the examiner.  You can create pathology if you're not careful, and you can miss pathology if you don't know the tricks of the trade.  I just wanted to say that you can't become a sonographer overnight.  Quickie courses can show you some basics, and of course the equipment has come such a long way that it makes it much easier to scan.  Take an ultrasound course if you want, but it won't make you a ultrasonographer.  I say this out of extreme pride for the skills of good sonographers, and not to discourage those who want to learn the basics to assist their practice.

[FiNorman]

I have a great amount of respect for sonographers, and no one is saying that a "quickie coarse can make you a sonographer".  The intent of the teaching course isn't to make sonographers, it's to teach the faculty enough about sonography so help them decide how to best incorporate sonography into the curriculum of their programs.

 

What I am discussing is clinical sonography. 

 

With that being said we can examine the facts behind sonographers and clinical ultrasound. 

1.  With the exception of 4 states, sonographers are not required to be licensed or certified to perform ultrasound.  While you may have taken a course many sonographers use "OJT" to learn and many never become certified.

 

2.  Medical schools like Stanford, Ohio State, University of South Carolina, RVU, McGill and UC Irvine have been incorporating ultrasound into their curriculum, from day 1 for a number of years.  These medical students finish their undergraduate medical education already skilled in how to do 15 different types of scans.

 

3.   There are only two societies who have developed clinical ultrasound guidelines in the US, only one is currently published.  Both of those guidelines explicitly state a didactic course, 16-24 hrs of CME, followed by performing 25-50 proctored exams or exams compared to gold standard exams.  Those exams should total 150-250 total exams is sufficient to gain proficiency.  Some applications will take more, some will take less.

 

4.  These guidelines have been in place for 15 years, and have data tracking them back 20 years.  It's how we teach medical students and it's how we teach EM residents how to perform US. 

 

5.  POCUS is extremely safe- Two recent studies have shown that since these guidelines have been in place there have be exactly 6 law suits in the last 20 years as it relates to clinical ultrasound.  4 of those cases resulted in the death of the patient.  In all six cases the basis of the litigation was a breach of duty because the ultrasound was not performed, and should have been performed.

 

6.  The literature simply doesn't support your claim that clinical sonography is difficult to learn.  In fact there are a number of studies where residents who were US naive were given 10 minutes of training in a particular application, (DVT-2 point compression) and compared their findings to the gold standard, duplex sonography done by a sonography tech and read by a radiologist.  The residents with 10 min of training found all 46 dvt in the 199 patients.  The only disparity was a dvt called positive by the resident and negative by the sonography tech and radiologist.  Strangely enough, when the same patient returned for their one week follow up the duplex was repeated and found to have a dvt.  The point of the study was not to advocate for 10 minutes of education, but dispel the myth of how hard the modality was to learn.

 

7.  A similar study compared first year medical students with less than 20 hrs of POCUS training VS. Board Certified Cardiologists and a stethoscope.  46 patients with cardiac pathology were examined by both groups and the Medical students found 50% more pathology than the cardiologists.

 

I hear many detractors make statements like "ultrasound is operator dependent".... life is operator dependent, so is the physical exam, reading ekgs, driving a car.  There is no doubt that POCUS provides better outcomes for our patients.  We are professionals, we are clinicians who have a responsibility to our patients- we don't just surrender and walk away from a portion of our practice that gives our patients the best chance at having a good out come because it will take time to master.  

None of us were a master at performing the physical exam or reading an ekg, or performing a procedure when we first started the practice.  We practiced and got better.  I am thankful that when ever I tried to learn something new I always had positive encouragement around me that pushed me to learn.

[weezianna]

Gee, FiNorman, thanks for all the bullet points.  All I said was that I had a great career as a sonographer, and I get a big speech from you about how "the literature simply doesn't support your claim that clinical sonography is dfficult to learn".   You know, I spent decades, and so have others, trying to be the best at a profession that, contrary to your comments, IS dependent on the operator.   Incorporating a brief course in ultrasound may certainly be very useful as an introduction.  Let me know how you're doing in about 20 years when you master the skill via OJT.   

[LT_Oneal_PAC]

Gee, FiNorman, thanks for all the bullet points. All I said was that I had a great career as a sonographer, and I get a big speech from you about how "the literature simply doesn't support your claim that clinical sonography is dfficult to learn". You know, I spent decades, and so have others, trying to be the best at a profession that, contrary to your comments, IS dependent on the operator. Incorporating a brief course in ultrasound may certainly be very useful as an introduction. Let me know how you're doing in about 20 years when you master the skill via OJT.

Wow. I thought he gave the a respectful, evidence based, and thoughtful response. Never degraded the profession. Simply evidence to show why clinical ultrasound should be incorporated.

[FiNorman]

My intention wasn't to make you feel bad degrade your previous profession.  My point wasn't that it takes 20 years doing OJT to improve patient care and patient outcomes.  It's a skill you can learn today and apply tomorrow. 

 

In fact it is very easy to learn.  The "OJT" method you believe will take 20 yr to learn is being taught every day to every physician that hopes to complete an Emergency Medicine residency.  Once they have the minimum number of proctored scans, 150-250, they are competent to apply for credentialing.  I believe any skill that can be learned by a resident can be learned by a PA.

 

The Society of Physician Assistants in Clinical Ultrasound has a program where we teach PA students these basic scans.  This program is called a SUIS, or Student Ultrasound Interest Section.  We do it free of charge by having them form an extracurricular group that with the blessing of their school provides, through SPACUS,  a mentor, free text book, and help obtaining the US gear, free of charge.  These kids aren't experts when they complete the course, they are just better than they were before they started and completed the necessary didactic education to get proctored exams.

 

The mentors for these kids, arranged through SPACUS are very similar to myself as they are typically fellowship trained clinical POCUS PAs, some with RDMS.  Some have chosen not certify, as it is contrary to ACEP guideline.

 

SPACUS actively is seeking partners, like you that can help these students.  We have a group of kids in Ohio that out of a class of 50 students, 40 would like to form a SUIS.  Let's think about this... you can't get 80% of a PA class to come to a free extra curricular pizza and beer party, and these kids want to form a club to learn more.  I was very inspired by their effort. 

 

If you are interested in helping these kids I would beg for you to step forward and help them.   They could use someone exactly like you, who is experienced and knows his/her way around a machine.  I will personally cover the cost of your SPACUS membership.

 

Again I humbly apologize if you mistook my post as insulting or demeaning, it was not intended in that manner.  Please accept this IOU for a couple beers on me.

[SERENITY NOW]

I can understand the pride for the profession.  I got to spend a couple of weeks with certified ultrasonographers who were incredible at what they did, and I learned a ton from them.  However, I think its important to keep in mind that we aren't trying to compare certified ultrasonographers to bedside clinicians, which are two entirely different groups of people with two entirely different goals.  Whereas the first aims to get a comprehensive evaluation of the entire system being studied without missing any potentially important findings, bedside clinician use aims to answer a few key clinical questions with simplified (and evidence based) means of accomplishing that.  For example, ruling in IUP on bedside ultrasound is a simplified means to effectively answer the question "does this patient have an ecoptic", and is well within the capabilities of anyone after doing a training course and 25+ scans.  Absolutely details will be missed, but if those things aren't relevant to the clinical question, its not really important at the bedside in the ED.  This is why many ultrasound fellowship trained EM physicians make it a point to not sit for the certified ultrasonographer's board exams, even though they've shown they have the experience to be able to pass them - they are making a point that the two applications/goals of ultrasound are two entirely different things.  

[FiNorman]

Very well said Serenity, you are 100% correct.  25+ scans will not make you an expert, but it will give you enough experience to incorporate POCUS into your practice and answer very specific binary questions. 

 

The new ACEP guidelines are just waiting for the signature from the ACEP board.  They are even more lenient in the initial training requirements and ACEP acknowledges some indications may take even less. I would argue that with just a few soft tissue scans most PAs can improve their practice and outcomes to differentiate abscess vs. cellulitis vs. necrotizing fasciitis.  Peripheral IV placement only takes 10 proctored exams.

 

The new scanners are basically the ultrasound probe which is leased- academic pricing put it at about $125/month per probe.  The screen is a hand held tablet which can be purchased at any electronic store.  

 

If your practice requires you to put a needle into a particular place in a patient, or differentiate PNA vs. CHF vs. COPD vs. PE in a dysgenic patient, or wonder if your patient is dehydrated, or work through a pts abdominal pain or leg pain then I would urge anyone who isn't using POCUS to reach out to SPACUS to obtain some resources.  They will be provided for free.

 

If there is any faculty interested in learning the modules, please reach out to SPACUS.

 

I will second Serenity's comment on certification.  I am personally eligible for certification but will not pursue this pathway.  I don't discourage anyone from pursuing their happiness, but certification is not required for POCUS.  They are two different pathways.

[Lisa Dickerson]

Hi FiNorman,

I'm on faculty at a PA Program in Atlanta and found your post this afternoon while researching how to go about adding POCUS to our curriculum.  I went on the SPACUS website and was impressed.  Our program has unlimited interest but limited classroom time and a limited budget. As  you mention in your initial post, we also are lacking a regular faculty member with expertise in this topic, which definitely makes it hard to teach.  If you are still looking for faculty that  would be interested in US training,  I may be able offer one up from our program....Lisa

[primadonna22274]

Speaking from a trainee perspective: we have a longitudinal POC US curriculum built into our 3-yr family medicine residency modeled on the USC curriculum. It's been cool to learn it and those of us who use it more are obviously better at it. We have USC medical students all the time who are far better at it than we are because they have a very strong foundation in the modality. The downside is the faculty who haven't learned it and aren't interested in learning or just quite frankly have too many other competing demands to add that one new skill...so most of us don't use our skills frequently enough to get good at it. We also have just one really good machine for 25 residents and 8 of us might be in clinic at the same time. It would be great if we had more handheld devices but they're expensive (the med students have theirs on loan from the school).

My .02: the faculty needs to be on board, as well as the preceptors. USC SOM offered residents and preceptors an extra training weekend crash course free...it was 8 hr of my weekend but I got some extra skills and a nice certificate for CME.

I consider POC US an additional bedside skill, another physical exam skill to get good at, to help me hone my Ddx and fine-tune my treatment plan. It does not replace formal US testing by a sonographer and interpretation/reporting by a radiologist.

 

 

Sent from my iPhone using Tapatalk

[FiNorman]

Prima,

If you were referring to USC, University of South Carolina Dr. Paul Bornemann, and Dr. Hoppmann have done an amazing job of integrating POCUS into the undergraduate medical education and into the residency program. As of today the American Academy of family practice is preparing standards by which every resident will have to learn ultrasound in order to complete the FM residency programs. Emergency medicine has already identified ultrasound as a skill integral to the practice of emergency medicine and has mandated training since 2007.

I am pleased to hear that others are using ultrasound in their daily practice as well, and if you're interested in helping the cause please contact SPACUS.org and get involved.