Point-of-Care Ultrasound and Modernization of the Bedside Assessment

• DOI: 10.4300/jgme-d-20-00216.1
• Publication Date: 2020-12-19T06:15:46Z
• Authors: Anna M. Maw; Amy G. Huebschmann; Nee-Kofi Mould-Mi...; Amanda F. Dempsey; Nilam J. Soni
• Keywords: Point-of-Care Testing

We live in an era of rapid technological advancement, and as newer diagnostic modalities have emerged, the traditional physical examination has become less central to clinical assessment patients. Point-of-care ultrasound (POCUS), imaging acquired interpreted by a treating clinician at bedside, emerged tool that can augment accuracy bedside assessment.1–3 Emerging evidence shows certain POCUS applications rivals sometimes surpasses conventional tests.4–6 Growing literature supports notion expedite diagnosis well reduce number tests, patient exposure ionizing radiation, overall costs.7–10 Recently, several low-cost handheld devices generate high-resolution images entered market are being purchased directly clinicians. Given increasing availability POCUS, we discuss its utility from patient, clinician, societal perspectives key barriers successful incorporation into graduate medical education.Available suggested improve detection many common diagnoses compared maneuvers.3,11–13 Although exhaustive discussion all is beyond scope this article, highlight relevant across multiple specialties, including emergency, family, internal medicine (table). For patients presenting with dyspnea, examinations heart lungs been shown be more accurate than techniques detecting most etiologies concern.2,3 Further, prospective cohort studies found lung chest x-ray, currently first-line modality for work up dyspnea pleural effusion,14 pulmonary edema,15 pneumonia,4 pneumothorax5—some causes dyspnea.While evaluating designed evaluate relative reference standard,6,16 rigorously intended effect on outcomes now emerging. A recent randomized control trial demonstrated diagnose acute decompensated failure quicker accurately standard workup brain natriuretic peptide x-ray.17 Two additional trials ultrasound-guided diuresis ambulatory reduces urgent visits.18,19 In order further inform best practices training use, pragmatic needed assess cost associated implementation real world settings.Critics expressed concerns may result testing incidental findings. However, mounting potential decrease use tests lower radiation fewer follow-up no difference adverse events studies.8–10,20 If these results broadly reproducible, savings higher value care seen implemented health systems.From perspective, offers advantages include avoidance immediate results, important, greater time their bedside. The available experience enhanced POCUS.21,22 From clinician's some highest yield basic cardiac, pulmonary, vascular relatively easy learn quick perform.11,16,23,24For reasons, stands poised offer renaissance. Many lamented waning skills uniquely brings clinicians back allowing thorough combines both maneuvers.Given complexity integration diverse multi-level systems, extent adoption will likely vary based wide range contextual factors, other population, workflow. Below prominent within date.Until recently, one significant was access machine related portability.25 Less 10 years ago, portable cart-based adequate image quality between $40,000 $50,000 had wheeled room clinician. surge affordable devices, connect smartphones or tablets, greatly mitigated barrier. Currently, approximately $2,000 $5,000, purchase own personal access.To date, widely undergraduate education (GME),26,27 there not yet clear consensus regarding what curriculum should contain specialties. following lead emergency medicine, national professional societies represent specialties like family officially endorsed POCUS.28–30 formal support desire among trainees residency leadership,25 expect least required competencies Lack faculty experts recurrently cited important leadership.25,31,32 To address current gap society recommendations actual practice, launched courses meant provide pathway competency.Although novice operators attain competency acquisition interpretation brief training,11,33 expert any test requires complex skill set integrate decision-making. This includes ability combine pretest probability knowledge characteristics limitations performed arrive posttest appropriate management plan. Because decision-making, competency, skills, consistently achieved longitudinal mentoring settings. reason, expertise critical effective GME.25,34,35 Residency leadership interested developing competency-based curricula must consider investing development educators foundational strategy.Given growing utility, endorsement societies, availability, modernize Residencies play pivotal role widespread POCUS. Development first step creating allow attainment during residency.