The utility of point-of-care ultrasound (POCUS) is readily apparent in a busy Emergency Department (ED) or Intensive Care Unit. Now, as healthcare in the U.S. changes and decentralizes, widespread POCUS in primary care is poised to show its value to medical systems in a way that will eclipse its impressive origins in hospitals. However, there are many reasons primary care ultrasound hasn’t taken off…yet. Among them is that effectively incorporating POCUS into a clinic can be hard work with many upfront challenges. The following is some advice on overcoming these challenges, focusing on 3 areas.
- Determine your desired scope of practice and manage expectations
- Get really good at POCUS
- Optimize your clinic POCUS workflow
1. Determine your desired scope of practice and manage expectations
Learning to use ultrasound is very similar to learning a musical instrument—you don’t jump in with Chopin, you start off by playing Chopsticks or practicing chords. When determining their intended POCUS scope of practice, outpatient clinicians need to consider that the things they are most interested in doing right away might be some of the more technically demanding or challenging things to learn. Here are some good examples of common outpatient POCUS goals and more appropriate starting points for beginners:
|Body Region||Aspirational POCUS Application||Appropriate POCUS Starting Point|
|Abdominal||Gallstones, Cirrhosis, Appendicitis||Ascites|
|Cardiac||LVH, Pulmonary Hypertension||Pericardial Effusion|
|Pulmonary||Pneumonia||Pleural Effusions and Pulmonary Edema|
|Musculoskeletal||Rotator Cuff Tears||Knee Effusion|
Furthermore, even if you appropriately start small and easy, chances are you will at some point perceive that you are terrible. This is normal and experienced by many POCUS experts when they first started. Keep at it, and ensure you have a marathoner’s mindset; remember it’s no quick sprint and requires a stepwise approach. You can learn more about a specific approach to teaching and a framework for growing a POCUS skillset for generalists (PEARLS) by watching the AIUM webinar, “PEARLS: A Physical Exam with Pocket Sized Ultrasound for Routine Use,” here: https://youtu.be/ywuIeoEfG1I
2. Get really good at POCUS
Easy as that, right? Unfortunately, learning POCUS in the clinic is HARDER than learning POCUS in the hospital setting. The time constraints are just as bad as in the ED and, generally, the pathology is much less frequent and more subtle when present. Obtaining cardiac windows in the patient who can’t get out of their wheelchair or rollator let alone climb up to the exam table is not an uncommon circumstance. So how do you get really good under these circumstances? Three key interconnected principles dominate the philosophy we try to instill in our learners as part of our training:
- Scan Routinely
- Practice Deliberately
- Track Your Experience (Build Your Portfolio)
Scan Routinely is probably the most controversial of these, and for me, also the most important. The routine performance of “educational” scans during residency, fellowship, or other training period is the bedrock for successful training and is generally accepted in the POCUS community. This allows one to practice deliberately and pursue a path towards mastery.
The number 1 biggest mistake I see in the early plateaued POCUS learner is they are only performing scans if they feel it is clinically indicated or they have a specific clinical question they expect POCUS to help them answer. If you are not routinely using POCUS you will likely not achieve or maintain the experience where your POCUS skillset will be clinically useful to you.
My threshold for incorporating ultrasound into my evaluation of patients is probably much lower than other POCUS users, and my experience has been that this has helped me tremendously. This experience has supported the perspective that POCUS should be viewed as a vital clinical skill to be perpetually maintained and improved upon, not a separate and distinct diagnostic test to be brought out only when patients fit into narrow predefined boxes.
Finally, even if you do not incorporate images into the EMR or bill for your exams (and there are many reasons why you should not do this early on), you should routinely save your images and build a portfolio. Committing your interpretations to a log, on paper or electronically, allows you to attain vital feedback through your longitudinal experience and patient follow-up. It also allows you to more easily seek expert mentorship, teach others, and can serve as inspiration if your motivation or progress seems to drop off.
3. Optimize your clinic POCUS workflow
Like many aspects of clinic, part of optimizing your POCUS workflow involves training your staff. In many ways, it helps to treat the POCUS device like the clinic EKG machine. If you know you will likely include POCUS because of the chief complaint (eg, dyspnea, flank pain, or lower extremity swelling) have staff put the patient in the most suitable room and ensure they are properly undressed/draped in advance. Train staff to be comfortable handling the device, cleaning it, and setting it up in the room with patient information entered in (if applicable). If you unexpectedly determine POCUS is needed during an encounter but setup is suboptimal, see another patient while the patient and room are prepared. Also, consider restructuring how you examine patients. Often time constraints do not permit the traditional order of history -> traditional examination -> ultrasound examination, and you will be more efficient by incorporating ultrasound sooner and blending history and pertinent traditional exam maneuvers along the way.
Finally, when first starting off, when incorporating routine scanning into your workflow, keep a narrow focus and a set time limit (<5 minutes). Don’t be shy about using an alarm on your phone to keep yourself honest. You may need to focus on obtaining a single high-quality view, and then add additional views as you’re able while still staying under time. Taking 20 minutes to perform POCUS in the middle of a packed clinic is another common mistake that can torpedo a workday and create negative associations that increase reluctance to practice and utilize POCUS.
Once you obtain some basic skills at POCUS and have a good clinic workflow, you’ll quickly get a few early saves and successes that enhance your dedication and propel you forward. Before long, you will wonder how you ever did without it!
Mike Wagner, MD, FACP, FAIUM, is an Associate Professor of Medicine at the University of South Carolina School of Medicine in Greenville.
Want to learn more from Mike Wagner? Check out these resources from the American Institute of Ultrasound in Medicine:
- On-demand webinar on YouTube: COVID-19: Advanced Applications of Lung Ultrasound: Viral Pneumonia and Acute Respiratory Distress Syndrome (ARDS)
- Article in the Journal of Ultrasound in Medicine (JUM): A Primary Care Ultrasound Fellowship: Training for Clinical Practice and Future Educators
- Article in the JUM: Prevalence and Scope of Point-of-Care Ultrasound Education in Internal Medicine, Pediatric, and Medicine-Pediatric Residency Programs in the United States