A point-of-care ultrasound (POCUS) revolution is unfolding before our eyes, forever changing the way we interact with patients. It started with a revolution in specialties such as emergency medicine and critical care, and now it has entered into my sphere with internal medicine and hospital medicine. I see this whenever I’m on clinical service. A 3rd year medical student talks about diffuse B-lines as we stop antibiotics and start diuretics on a patient with pulmonary edema; a 3rd year resident asks to look at a patient’s kidney with ultrasound as we manage undifferentiated acute kidney injury; nursing staff curiously looking on as a patient is shown their weak heart as goals of care are discussed.
At the same time, we in internal medicine and hospital medicine are living in a medical world filled with many challenges towards implementation of POCUS. Though there are many devices in the emergency rooms and some in the critical care wards, there are not many in the inpatient wards nor in the clinics. Though numerous workshops and courses abound in POCUS, many attendees do not continue to use this skillset after training. Those that received initial training find it too challenging to discipline themselves to continue to scan.
It is that latter sentiment that caught my attention this last year. The concept of discipline and viewing POCUS through its lens. A quote by Luciano Pavarotti comes to mind,
“People think I’m disciplined. It is not discipline. It is devotion. There is a great difference.”
I’ve often heard the sentiments:
“It is so hard to learn POCUS, how do you find the time for it on a busy clinical service to get images?”
“I find it hard to set aside time during my non-clinical work days as other work and life piles up.”
I’m not sure about you, but the word discipline does not often carry an inspirational tone to it. There is a sense of drudgery, lack of passion surrounding the word. As an ultrasound director, that is the farthest from what I want my learners to experience with POCUS.
When I looked up the word discipline in the Oxford Dictionary there it was as well:
the practice of training people to obey rules or a code of behavior, using punishment to correct disobedience.
“a lack of proper parental and school discipline”
a branch of knowledge, typically one studied in higher education.
“sociology is a fairly new discipline”
Is it #1 that we were aiming for? Or at the very least, is that what people are sensing? Hopefully, we’re not using punishment to correct disobedience. The Pavorotti quote struck a chord in me. As a contrast to discipline, we have devotion.
The word “devotion” is defined by Oxford Dictionary as follows:
1. love, loyalty, or enthusiasm for a person, activity, or cause.
“Eleanor’s devotion to her husband”
synonyms: loyalty, faithfulness, fidelity, constancy, commitment, adherence, allegiance, dedication; More
• religious worship or observance.
“the order’s aim was to live a life of devotion”
synonyms: devoutness, piety, religiousness, spirituality, godliness, holiness, sanctity
“a life of devotion”
• prayers or religious observances.
plural noun: devotions
synonyms: religious worship, worship, religious observance
Devotion does have some concepts borne from religion or worship but that doesn’t make it an irrelevant word for the POCUS learner or teacher. The first definition of love, loyalty, or enthusiasm captures the essence of what most of us are hoping POCUS to be for our learners. As my good friend and POCUS enthusiast, Dr. Gordy Johnson, from Portland, Oregon, says, we need to remember “our first kiss.” What was the moment that grasped us with POCUS?
Don’t get me wrong, I’m not completely opposed to the word discipline, but it moves beyond that if we’re going to develop fully devoted clinicians in the realm of bedside ultrasound. Those that are equipped with the cognitive elements know when POCUS should be used, why it should be used, how to acquire images, and then how to clinically integrate it.
This post was originally intended as a follow-up of the AIUM webinar on the Comprehensive Hospitalist Assessment & Mentorship with Portfolios (CHAMP) Ultrasound Program with hopes to continue the conversation surrounding what makes for an effective training program. The program involved online modules, an in-person course with assessments, portfolio development, refresher training, and final assessments. The key lesson we have learned is that longitudinal training with deliberate practice of POCUS skills with individualized performance feedback is critical for skill acquisition. However, the intangible pieces of how people continued to scan was developing an enthusiasm and love surrounding ultrasound by seeing its impact in the marketplace. As they were continuing to scan, their patients, their students, the many nursing staff were partnering in a stronger way with this diagnostic powerhouse in their hands.
With all this, I cannot help but be optimistic when I see the commitment of many in the POCUS movement already. I would urge all of us to evaluate how we develop devotion in ultrasound, how to tap into the dynamism of the POCUS movement coming up the pipeline with our medical students and residents. They have the potential to disrupt inertia and be an impactful force to integrate POCUS more into internal medicine and hospital medicine.
If you are an ultrasound educator, how do you inspire devotion? What are some of your best practices surrounding training in POCUS? Which do you think is most important: discipline or devotion? Comment below or let us know on Twitter: @AIUM_Ultrasound.
Benji K. Mathews, MD, FACP, SFHM, is the Ultrasound Director of the Department of Hospital Medicine at HealthPartners in St. Paul, Minnesota.