Tag Archives: family medicine

End-of-Residency Perspective on Early Ultrasound Education

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I remember clearly the first day I ever held an ultrasound probe. It was my second week of medical school, I knew next to nothing about medicine, and my faculty member turns to me and enthusiastically says “oh look, you have a few thyroid cysts.” I, of course, immediately thought a few things. First, how many are there, how big are they, what do I need to do, could it be cancer, and why is the faculty member so nonchalant about this.

The next thing I thought was “what is a thyroid”.

After the initial and very clearly unnecessary panic was over, I thought to myself that it was very interesting we were scanning things before we were taught about them in class. Throughout my training, I have come to realize how lucky I was to get such early exposure to ultrasound training and teaching. At Eastern Virginia Medical School, ultrasound was integrated into all aspects of the curriculum. This started in anatomy lab, continued into our second-year courses in pathology, and was a crucial part of 3rd year rotations where each rotation had several portable ultrasounds for students to use to scan. In the Family Medicine clerkship, we were tasked with scanning multiple people for AAA, and on surgery, we had to get 5 images of cholelithiasis. By the 4th year, faculty were using ultrasound to do procedural training and students were in the trauma bay performing FAST exams for the team. Although I thought this was the norm, I quickly found out on the interview trail that this experience separated me from a lot of my peers.

A selfie of a very young David sent to his clerkship director as proof he did his scans for the rotation.

In residency, we had a point-of-care or POCUS-centered curriculum. Although we all got the same instruction, I felt like my previous experience, and most of all my comfort with the probe, made me into the “ultrasound guy” of my program. While the immense clinical utility is not lost on any of my peers, the amount of time it takes to become comfortable just did not fit into the time constraints of residency.

While I do not think ultrasound can be filed under “you can’t teach an old dog new tricks,” I do strongly believe that integrating it into medical education early on is crucial for the future of medicine. Based on my conversations with colleagues at different schools and institutions, often, ultrasound training is saved for residents and fellows, and it really shouldn’t be. Although, this surely is based on several factors including class size, cost, requirement for specialization (eg, prenatal ultrasound for OB/GYN, MSK ultrasound for Sports Medicine and Orthopedics), and availability of sufficient machines.

One of the most frustrating things for me is the train of thought that imaging is ruining the art of the physical exam. While yes, many people will get a CT of their abdomen and pelvis in the ED, the dynamic and live view that ultrasound provides is invaluable in learning about anatomy. Multiple studies, including one that I have worked on, have shown that a longitudinal and integrated ultrasound curriculum improves procedural and physical exam skills. Many of these studies show that the biggest effect is when it is started early in training.

After being the confused MS1 who was freaking out about his thyroid cysts (which since have gone away by the way), and being slightly frustrated at the time that more work and learning was on my plate, it’s abundantly clear to me now that this is the direction that medical education needs to go. Every first-year medical student at every institution should have their hands on probes throughout their first year, especially while learning anatomy. My challenge to medical school leadership is to find a way to incorporate or expand on ultrasound in their curriculum. At first, your students will not be confident, and they will feel like they don’t know what they are doing, but it CAN and it WILL help in the long run. It certainly did for me.

David Neuberger, MD, is currently a 3rd year Family Medicine Resident at Emory University in Atlanta, GA. He will be pursuing a Primary Care Sports Medicine fellowship at the University of Louisville this upcoming year and has a special interest in ultrasound and ultrasound education.

How I Brought Point-of-Care Ultrasound (POCUS) to My Family Medicine Department

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As I demonstrate a handheld ultrasound (US) machine to the eager medical students in our clinical simulation laboratory today, I am struck by a vivid recollection of my own first time seeing a handheld US machine. I was a 4th year medical student on an away rotation at a rural hospital in my home country of Peru. A visiting foreign obstetrician produced an amazing small machine, detecting fetal malposition when unsatisfied with palpation with Leopold’s maneuvers alone.

My fascination with the clinical utility of bedside US began that day and has continued through my move to US postgraduate training in family medicine, a geriatric medicine fellowship, academic faculty roles, the completion of an accredited POCUS fellowship, and right through to my current passion for growing POCUS use within family medicine practice.

I have learned so much along the way, have been helped by so many mentors and colleagues, that I write today to share my POCUS journey in the hopes that my story may be useful to others.

In 2018, I joined the department of Family Medicine at the University of Michigan in Ann Arbor (AAFP). The AAFP had recently released its novel POCUS curriculum guidelines for family medicine physicians, and the department was in search of a champion to lead the development of a POCUS program for our department. I was fortunate to be chosen for this role and over the intervening 3 years have had the privilege of working with several wonderful, enthusiastic colleagues across our department, our institution, and on a national scale through the AAFP’s POCUS interest group.

Early on in my role as POCUS champion, I realized that to be successful with this project, I was going to need a lot of help from a lot of people! My first stop (along a long journey) was to ask my department chair for time and resources. He readily obliged, providing me with the protected time to do an established accredited POCUS fellowship (which luckily was available through our emergency medicine department) and important administrative resources, which were also vital as we developed our program.

During my yearlong fellowship, I worked hard to become a clinical sonographer, educator, academic leader, and administrator in US. These newly acquired skills have been invaluable since assuming the role of Clinical US director for my department. There have been many challenges and administrative headaches—who knew that selecting and purchasing ultrasound machines could be so complicated?!?—but countless successes.

In terms of successes, we have defined minimum credentialing requirements for POCUS use, defined pathways for faculty interested in training in POCUS, and obtained hospital privileges for the same from our department. We have developed billing for our clinical POCUS use in ambulatory care as well as electronic health record order sets and templates for easy documentation. With regard to the POCUS curriculum that we initially set out to create, we now have a formal POCUS curriculum for family medicine residents as well as an intensive US track for residents interested in a more in-depth POCUS educational experience. Additionally, I am so excited that we will be welcoming our first Advanced Primary Care US fellow for a one-year fellowship this July.

It has not always been easy, but I have been so fortunate with wonderful supportive departmental leadership and fantastic emergency medicine colleagues who are always eager to help with advice on regulatory or administrative requirements. Developing the POCUS program for our department has taken a lot more time than I initially anticipated, and at times, the process has proved tedious. There certainly have been times when I have doubted if it has been worth the time and effort and doubted that colleagues share my vision for the potential POCUS offers for improving our patient care in family medicine or whether they see it as a burden, yet another thing to learn. However, the excitement I felt the first time I saw the handheld US those (many!) years ago in Peru, is reflected in the excitement I see in the faces of the medical students here in the clinical simulation lab today. This shared enthusiasm and passion for POCUS tells me that in the end, it truly will have been worth it.

An US track resident in training.
An US track resident performing US as part of training.

Juana Nicoll Capizzano, MD, is a Clinical Assistant Professor and Clinical US Director of Family Medicine at Michigan University.

Interested in learning more about developing ultrasound education? Check out the following posts from the Scan:

Getting Sonography Students Hands-on Experience

Ultrasound Education in the Post-COVID Era

Sink or Swim? Modifying POCUS Medical Education Curriculum During Coronavirus Pandemic

Teaching Point-of-Care Ultrasound

I’m Tired of Falling Asleep During Lectures

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I remember the first test I failed. It was an immunology exam that I took about halfway through my first year of medical school. Seeking some solace, I asked a classmate for advice. His snarky response was, “Why don’t you try NOT sleeping through the class?”

sleeping in classHe did have a point, but I couldn’t help it. The professor was so incredibly boring. I couldn’t understand why he would spend so long talking about a study performed decades ago involving injecting mice with bacteria. How would this make me a good doctor?

I quickly found the solution to my problem: I had to stop going to class. Imagine that? The best way for me to get a medical education was NOT attending the courses–at least this particular course. It turns out I learned a lot better reading by the pool in sunny Southern California than in that big lecture hall. I soon discovered that many of my classmates were doing the same thing. Some read the textbooks at home or at a coffee shop. Some bought entirely different textbooks on the same subject. Some bought audio tapes for a particular subject. Of course some did prefer the classroom. In the end, we all passed.

Spending 4 years in college and 4 more in medical school makes you extremely sensitive to the lecturer’s delivery of the material. We spend years sitting in large groups in dark rooms quietly listening to someone on some stage talking at us. These days, most lecturers are reading off slides and within the first minute, you know what you’ve got yourself into.

Why do we subject our learners to someone standing behind a podium reading slides for an hour? Why do we think this works? Most likely it’s because very few people know there is a better way of doing things.

Our ultrasound instructor in medical school, Dr Chris Fox, likes to talk about “flipping the classroom.” Prior to our ultrasound didactics, he would give us access to an online podcast for the scanning technique of the day. We could watch it in pieces or all at once and we could watch it at any time and however many times we wanted. Best of all, we could pause, rewind and fast forward. We would then show up for a brief lecture consisting of a 5- to 10-minute review of the podcast where we could ask questions. Then we split up into groups to practice scanning.

That’s what I call efficient. And fun.

I’m now in charge of teaching my co-residents the same ultrasound skills I learned in medical school. Problem is, I don’t have a podcast series of lectures. In fact, I started with no lectures at all. Truth is, I could have devoted hours creating engaging, interesting, and effective PowerPoint slides. But, why should I reinvent the wheel when colleagues of mine from around the world have already developed these presentations? If I could use those, then I could focus on what I do best, which is teach the hands-on components.

Thank goodness for FOAM (Free Online Access Meducation). The term was coined in 2012 in the emergency medicine community and Life in the Fastlane has a whole page dedicated to its history and explanation.

Essentially, FOAM is a growing movement to provide high-quality and FREE medical education materials online for anyone to use. It’s a dream come true for any educator. Time to give a lecture? You could spend hours throwing together 60 slides for a lecture, but somebody else has already done it, and they’re REALLY good at it. Let them teach the lecture so you can use your time to practice and reinforce. Whether it’s an ultrasound technique or reviewing how to work up and treat chest pain, the principle is the same.

For me, using FOAM to teach residents is a lifesaver. Walking a learner through the machine and the exam technique comes natural to those with experience. Putting together a presentation to introduce it all to a big group requires time that I don’t always have. Plus, my proficiency in PowerPoint is limited and producing high-quality videos and images with overlaid anatomy takes considerable time, assuming you know how to do it.

Many of us know about FOAM resources already, probably just not the name. The Ultrasound Podcast is a fantastic resource with educational videos and challenges. There is also a smartphone app called One Minute Ultrasound for Apple and Android phones, which is a great on-the-go resource. The American Academy of Emergency Medicine (ACEP) runs Sonoguide.com with a whole host of resources. Another great resource is Sonomojo.org, which is a collection of FOAM resources for ultrasound. AIUM offers free resources and practice guidelines as well as teaching tools for members.

So let’s stop putting our students to sleep and start engaging them on their own terms. Give them the resources then use your time more effectively to get practical and work on procedural skills or problem solving. FOAM is there to guide the way.

How do you make your presentations engaging? Do you use any FOAM resources with teaching? If so, have you found it useful? Have questions about the future of FOAM? Comment below or let us know on Twitter: @AIUM_Ultrasound.

David Flick is a 3rd year family medicine resident at Tripler Army Medical Center. He received 4 years of ultrasound training at the University of California, Irvine School of Medicine. He currently runs the resident ultrasound curriculum and is an outspoken proponent for ultrasound training in the primary care specialties.