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        Dedicated time for deliberate practice: one emergency medicine program’s approach to point-of-care ultrasound (PoCUS) training
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        Dedicated time for deliberate practice: one emergency medicine program’s approach to point-of-care ultrasound (PoCUS) training
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        Dedicated time for deliberate practice: one emergency medicine program’s approach to point-of-care ultrasound (PoCUS) training
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Abstract

Point-of-care ultrasound (PoCUS) has become an essential skill in the practice of emergency medicine (EM). Various EM residency programs now require competency in basic PoCUS applications. The education literature suggests that deliberate practice is necessary for skill acquisition and mastery. We used an educational theory, Ericsson’s model of deliberate practice, to create a PoCUS curriculum for our Royal College of Physicians and Surgeons of Canada EM residency.

Although international recommendations around curriculum requirements exist, this will be one of the first papers to describe the implementation of a specific PoCUS training program. This paper details the features of the program and lessons learned during its initial 3 years. Sharing this experience may serve as a nidus for scholarly discussion around how to best approach medical education in this area.

BACKGROUND

Recent surveys of Canadian emergency medicine (EM) residency programs have demonstrated heterogeneity amongst point-of-care ultrasound (PoCUS) curricula. 1 2 The Royal College of Physicians and Surgeons of Canada (RCPSC) EM objectives of training include competency in the following PoCUS applications:

  • Facilitation of vascular access

  • Presence of intraperitoneal free fluid

  • Measurement of abdominal aorta diameter

  • Presence of pericardial fluid

  • Presence of cardiac motion

  • Confirmation of intrauterine gestation 3

The Canadian Association of Emergency Physicians (CAEP) 4 and The College of Family Physicians of Canada (CFPC) 5 also recognize PoCUS as a core EM skill. To date, few papers have reported implementation-level descriptions of PoCUS curricula.

RATIONALE

Deliberate practice is a dominant educational framework for procedural learning. 6 K. Anders Ericsson proposed a model that explains the evolution of procedural learning and performance over time. 6 Using Ericsson’s model, we implemented a competency-based, residency-level, PoCUS curriculum grounded in his education theories. Our program facilitates the completion of the RCPSC PoCUS objectives 3 as a minimum competency, with optional extension to include more advanced applications as per national and international guidelines. 4 , 7 - 9

DESCRIPTION OF THE INNOVATION

We developed a unique curriculum for PoCUS education in the RCPSC EM residency program at McMaster University, based on Ericsson’s model. The stages of this model and how they map to our curriculum are summarized in Table 1.

Table 1 Mapping Ericsson’s model to our PoCUS curriculum

* This phase is available only to selected residents who apply and are accepted into the subspecialty experience.

Acronyms: PGY=postgraduate year; PoCUS=point-of-care ultrasound

In PGY-1 or early PGY-2, residents are introduced to PoCUS through a 1-day basic course with pre-readings, interactive lectures, and supervised hands-on practice. Within several weeks of the introductory course, the residents are provided with more deliberate practice during a 9-hour scanning day. They scan more than 50 volunteers under the direct observation of PoCUS-credentialed faculty. We provide an instructor-to-participant ratio of 1:2, permitting frequent feedback with immediate integration through subsequent practice. A pelvic mannequin is provided to facilitate practice of transvaginal exams. The residents also participate in a 1-hour interactive case review to encourage their understanding of PoCUS within a clinical context.

Next, residents complete a mandatory PGY-2 core rotation lasting 4 weeks (see Figure 1). Residents are provided with CanMEDS-based rotation objectives, competency assessment tools (e.g., observed structured assessment of technical skills, or OSATs), recommended resources, including selected text and journal readings, and case-based presentations.

Figure 1 PGY-2 mandatory core rotation phases

During the first 2 weeks of the rotation (Phase 1), the resident performs PoCUS examinations on patients in the emergency department with the sole objective of gaining experience in image generation and interpretation, and one-on-one mentorship using direct observation or near-real-time remote scan review. We use an online archiving system (Q-Path Ultrasound Data and Process Management Tool, Telexy Networks Inc., Richmond, BC) to facilitate this process. Prompt review allows continuous feedback that helps flag potential areas of difficulty early on. Alternatively, we can also identify the exceptional resident for whom advanced learning objectives can be offered. In this way, we can create individualized learning plans for each resident.

In the latter 2 weeks of the rotation (Phase 2), the resident performs clinical shifts alongside PoCUS-credentialed staff physicians. During this phase, the resident gains experience integrating PoCUS applications into their patient-care workflow.

We emphasize a self-directed approach where the residents are given competency-based objectives to complete within the 4-week period. Residents are required to complete 200 or more PoCUS scans to ensure an adequate level of exposure. When the residents feel confident in a particular modality, they can trigger a competency assessment using our locally derived OSATs.

During an OSAT, a PoCUS-credentialed assessor observes the resident as they perform a clinically relevant exam. A modality-specific checklist is completed to ensure that all major competencies are met (see example at http://teresachan.mededlife.org/wp-content/uploads/sites/6/2014/04/Aorta-OSAT-Creative-Commons.pdf, available for usage under creative commons license). Immediate feedback is provided. OSATs are used along with observations and feedback from supervising clinicians to inform the end-of-rotation report. If concerns about competency arise, the rotation supervisor mandates further practice of the relevant skills until competency is achieved.

Finally, selected residents who have demonstrated interest and skill are eligible for an intensive 6-month subspecialty period where they train in advanced ultrasound applications, as suggested by the literature. 8 , 9

OUTCOMES

Since implementing our new PoCUS curriculum in 2011, we have had 24 residents progress through the PGY-2 core rotation. Of these, 100% achieved competency in the basic PoCUS applications, as outlined in the RCPSC. All of these residents performed 200 or more reviewed scans during the 4 weeks and accumulated the requisite scans to qualify for the Canadian Emergency Ultrasound Society (CEUS) independent practitioner exam.

Our old curriculum offered the introductory scanning course only. There was no other formal structure in place to support subsequent progression to competency. In the 3 years prior to this program, the median year to qualify for the CEUS exam was PGY-5, with 33% of residents unable to accomplish this during their residency training. In contrast, after implementation, every resident (100%) who completed the dedicated ultrasound rotation was able to qualify for the CEUS exam in PGY-2.

DISCUSSION

PoCUS is a procedural skill that we are still learning how to incorporate into educational programming. 10 The “front-end” loading of deliberate practice early in EM residency is particularly advantageous and provides residents with more efficient routes to achieve PoCUS competency. Our curriculum for PoCUS education is a model that could be easily integrated into existing EM residency programs.

SUMMARY

Integration of modern educational frameworks (Ericsson’s Deliberate Practice, 6 Competency-Based Medical Education 8 ) can facilitate skill acquisition. After redesigning our PoCUS curriculum around the precepts of deliberate practice, our residents were able to achieve competency in all basic PoCUS applications during their junior years of training.

Acknowledgements

Thank you to the residents, directors, and administrators of the McMaster Emergency Medicine FRCP Residency Program, as well as St. Joseph’s Healthcare Hamilton Emergency Department staff, for supporting the development and implementation of our PoCUS curriculum.

Competing interests: None declared.

Potential conflicts of interest: All authors have received teaching stipends for their work at ultrasound learning days for the McMaster Emergency Medicine residents.

References

1. Kim, DJ, Theoret, J, Liao, MM, et al. The current state of ultrasound training in Canadian emergency medicine programs: perspectives from program directors. Acad Emerg Med 2012;19(9):E1073-E1078.
2. Fischer, LM, Woo, MY, Lee, AC, et al. Emergency medicine point-of-care ultrasonography: a national needs assessment of competencies for general and expert practice. CJEM 2015;17(1):74-88.
3. Royal College Objectives of Training for Emergency Medicine; 2011, p. 8. Available at: http://bit.ly/1kmtoIS (accessed 15 March 2014).
4. Hanson, A, Healey, A, Hebert, G, et al. Use of point of care sonography by emergency physicians. CJEM 2012;14(2):106-112.
5. Canadian College of Family Physicians. Emergency medicine residency objectives, p. 134. Available at: http://www.cfpc.ca/uploadedFiles/Education/FamilyMed-EMResidencyPrograms(1).pdf (accessed 15 March 2014).
6. Ericsson, KA, Krampe, RT, Tesch-Römer, C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev 1993;100(3):363.
7. Canadian Emergency Ultrasound Society. Recommended standards. Available at: http://ceus.ca/002-standards/002-00.standards.htm (accessed 13 July 2014).
8. Lewiss, RE, Pearl, M, Nomura, JT, et al. CORD-AEUS: consensus document for the Emergency Ultrasound Milestone Project. Acad Emerg Med 2013;20(7):740-745.
9. Atkinson, P, Bowra, J, Jarman, B, et al. International Federation for Emergency Medicine Point-of-care Ultrasound Curriculum Guidelines; 2014. Available at: http://www.ifem.cc/Resources/PoliciesandGuidelines.aspx (accessed 8 July 2014).
10. Solomon, SD, Salfana, F. Point-of-care ultrasound in medical education—stop listening and look. N Engl J Med 2014;370(12):1083-1085.