Design and comparison of a hybrid to a traditional in-person point-of-care ultrasound course
BACKGROUND:Traditional introductory point-of-care ultrasound (POCUS) courses are resource intensive, typically requiring 2-3Â days at a remote site, consisting of lectures and hands-on components. Social distancing requirements resulting from the COVID-19 pandemic led us to create a novel hybrid course curriculum consisting of virtual and in-person components. METHODS:Faculty, chief residents, fellows and advanced practice providers (APPs) in the Department of Medicine were invited to participate in the hybrid curriculum. The course structure included 4 modules of recorded lectures, quizzes, online image interpretation sessions, online case discussions, and hands-on sessions at the bedside of course participant's patients. The components of the course were delivered over approximately 8Â months. Those participants who completed a minimum of 3 modules over the year were invited for final assessments. Results from the hybrid curriculum cohort were compared to the year-end data from a prior traditional in-person cohort. RESULTS:Participant knowledge scores were not different between traditional (nâ€‰=â€‰19) and hybrid (nâ€‰=â€‰24) groups (81% and 84%, respectively, Pâ€‰=â€‰0.9). There was no change in POCUS skills as measured by the hands-on test from both groups at end-of-course (76% and 76%, respectively, Pâ€‰=â€‰0.93). Confidence ratings were similar across groups from 2.73 traditional to 3.0 hybrid (out of possible 4, Pâ€‰=â€‰0.46). Participants rated the course highly, with an average overall rating of 4.6 out 5. CONCLUSIONS:A hybrid virtual and in-person POCUS course was highly rated and as successful as a traditional course in improving learner knowledge, hands-on skill and confidence at 8Â months after course initiation. These results support expanding virtual elements of POCUS educational curricula.
Design and evaluation of the I-SCAN faculty POCUS program
BACKGROUND:Point-of-care ultrasound (POCUS) is becoming widely adopted with increasing accessibility of courses. Little is known about the optimal design of the introductory course or longitudinal training programs targeting hospitalists that are critical to success. METHODS:Hospitalists at four academic sites participated in a two-day introductory course and a longitudinal phase comprising clinical POCUS practice, clip uploading with online feedback, hands-on teaching, and monthly ultrasound conferences. Assessments were performed immediately before and after the two-day course and after 1 year. RESULTS:Knowledge increased from baseline to post two-day course (median score 58 and 85%, respectively, pâ€‰<â€‰0.001) and decreased slightly at 1 year (median score 81%, pâ€‰=â€‰0.012). After the two-day introductory course, the median score for hands-on image acquisition skills, the principal metric of participant success, was 75%. After 1 year, scores were similar (median score 74%). Confidence increased from baseline to post two-day course (1.5 to 3.1 on a 4 point Likert scale from Not at all confident (1) to Very confident (4), pâ€‰<â€‰0.001), and remained unchanged after 1 year (2.73). Course elements correlating with a passing score on the final hands-on test included number of clip uploads (râ€‰=â€‰0.85, p,0.001), attendance at hands-on sessions (râ€‰=â€‰0.7, pâ€‰=â€‰0.001), and attendance at monthly conferences (râ€‰=â€‰0.50, pâ€‰=â€‰0.03). CONCLUSIONS:The I-ScaN POCUS training program increased hospitalist knowledge, skill and confidence with maintained skill and confidence after 1 year. Uploading clips and attending hands-on teaching sessions were most correlative with participant success.
The impact of the coronavirus pandemic on learning and using point-of-care ultrasound by internal medicine residents [Meeting Abstract]
LEARNING OBJECTIVES 1: Describe a longitudinal curriculum to train internal medicine (IM) residents in point-of-care ultrasound (POCUS). LEARNING OBJECTIVES 2: Recognize the impact of decreased patient contact on residents' retention of POCUS skills. SETTINGAND PARTICIPANTS:Despite thewell-documented benefits of POCUS, internal medicine residents receive little formal training. We implemented a curriculumin the 2019 academic year to train 55 PGY-2 IMresidents in POCUS across four urban teaching hospitals and a method to evaluate its efficacy. As the COVID pandemic hit, we additionally sought to understand the impact of COVID on the efficacy of our curriculum and to ascertain from IM residents their barriers to using POCUS during the COVID pandemic. DESCRIPTION: The curriculum was composed of three workshops, consisting of lectures and hands-on practice covering lung, cardiac, abdominal, and lower extremity vascular views. Following the workshops, we sought to consolidate learners' knowledge with a subsequent year-long skill building phase. The skill-building phase was truncated due to the pandemic.A hands-on assessment was performed prior to the course and not repeated at course conclusion due to social distancing concerns. An online knowledge test was administered before the course, immediately following the course, and at one year. A survey assessing attitudes and barriers to POCUS was administered before the course and at one year. EVALUATION: No resident passed the pre-course hands-on assessment. Prior to the course, the average resident score was 54% on the online knowledge quiz; directly after the workshop series, the average rose to 78%. At one year, the average score on the online knowledge quiz was 74%, a statistically significant decrease (p=0.04). Ninety-one percent of residents reported performing POCUS at least once/month prior to the pandemic. During the pandemic, scanning activity decreased; 67% residents reported they scanned rarely or never. DISCUSSION/ REFLECTION / LESSONS LEARNED: Our course led to significant improvement of knowledge regarding ultrasound technology and image interpretation, however this decayed at one year, likely due to lack of skill reinforcement. Though POCUS was widely used prior to the pandemic, usage dropped at the pandemic's peak, despite its utility as both a diagnostic and therapeutic tool. The most commonly cited reason for lack of use was concern regarding contamination and infectious exposure. While the COVID pandemic disrupted our curriculum, it also highlighted opportunities to incorporate POCUS into clinical practice and reinforced the importance of continued longitudinal practice to retain learned skills
Assessing Clinician Educator Professional Identity at an Academic Medical Center [Meeting Abstract]
DEVELOPMENT OF A STRUCTURED POINT-OF-CARE ULTRASOUND CURRICULUM FOR INTERNAL MEDICINE RESIDENTS [Meeting Abstract]
POCUS FACULTY I-SCAN PROGRAM DESCRIPTION AND ONE-YEAR EVALUATION [Meeting Abstract]
Theory-guided teaching: Implementation of a clinical reasoning curriculum in residents
Introduction: Educators have theorized that interventions grounded in dual process theory (DPT) and script theory (ST) may improve the diagnostic reasoning process of physicians but little empirical evidence exists. Methods: In this quasi-experimental study, we assessed the impact of a clinical reasoning (CR) curriculum grounded in DPT and ST on medicine residents participating in one of three groups during a 6-month period: no, partial, or full intervention. Residents completed the diagnostic thinking inventory (DTI) at baseline and 6 months. At 6 months, participants also completed a post-survey assessing application of concepts to cases. Results: There was a significant difference between groups in application of concepts (no intervention 1.6 (0.65) compared to partial 2.3 (0.81) and full 2.2 (0.91), pâ€‰=â€‰0.05), as well as describing cases in problem representation format (no intervention 1.2 (0.38) and partial 1.5 (0.55) compared to full 2.1 (0.93), pâ€‰=â€‰0.004). There was no significant difference in change in DTI scores (no intervention 7.0 (16.3), partial 8.8 (9.8), full 7.8 (12.0)). Conclusions: Residents who participated in a CR curriculum grounded in DPT and ST were effective in applying principles of CR in cases from their practice. To our knowledge, this is the first workplace-based CR educational intervention study showing differences in the reasoning process residents apply to patients.
A workshop to train medicine faculty to teach clinical reasoning
Background Clinical reasoning (CR) is a core competency in medical education. Few studies have examined efforts to train faculty to teach CR and lead CR curricula in medical schools and residencies. In this report, we describe the development and preliminary evaluation of a faculty development workshop to teach CR grounded in CR theory. Methods Twenty-six medicine faculty (nine hospitalists and 17 subspecialists) participated in a workshop that introduced a framework to teach CR using an interactive, case-based didactic followed by role-play exercises. Faculty participated in pre- and post-Group Observed Structured Teaching Exercises (GOSTE), completed retrospective pre-post assessments (RPPs), and made commitment to change statements (CTCs). Results In the post-GOSTE, participants significantly improved in their use of problem representation and illness scripts to teach CR. RPPs revealed that faculty were more confident in their ability and more likely to teach CR using educational strategies grounded in CR educational theory. At 2-month follow-up, 81% of participants reported partially implementing these teaching techniques. Conclusions After participating in this 3-h workshop, faculty demonstrated increased ability to use these teaching techniques and expressed greater confidence and an increased likelihood to teach CR. The majority of faculty reported implementing these newly learned educational strategies into practice.
Integrated sonographic competency at NYU (I-ScaN): Program Description and early evaluation [Meeting Abstract]
Needs and Objectives: Point-of-care ultrasound (POCUS), when integrated with a physical examination, increases accuracy of diagnosis and decreases procedural complications. However, most hospitalists have not been trained to use this new technology. We developed a year-long curriculum, the Integrated Sonographic Competency at NYU (I-ScaN), to train hospitalists in POCUS. Setting and Participants: Twenty-three hospitalists from across the 4 hospitals affiliated with NYU Langone Health participated. Sixteen of the participants (72%) reported prior ultrasound training, with a range of 2-80 hours (median = 4 hours); 3 reported more than 5 hours of prior training. Three reported active clinical use of POCUS though none of them had more than 5 hours of prior training. The group averaged 4.5 years of clinical practice (range = 1-13 years). Description: The program began with an intensive 2-day course consisting of lectures and hands-on training on human models covering views of the heart, lungs/pleura, abdomen, and leg vasculature. We developed the remainder of the year-long program with the goal of helping participants retain and improve upon the skills acquired during the initial course. Our program included hands-on teaching sessions held at each institution by local experts, presentations at monthly conferences with the course director (HS), and online feedback on uploaded ultrasound images. To facilitate this final item, each participant was given access to portable ultrasound devices with the ability to upload ultrasound clips to a HIPAA-compliant website. Participants provided a clinical interpretation and assessment of image quality for each of their clips. The clips were then reviewed by an expert who provided feedback on both of these domains. Participants could then use these clips to create personal portfolios in accordance with national standards set by the Society of Hospital Medicine. Evaluation: Participants rated the 2-day intensive program as very useful and satisfaction with the individual components of the program ranged from useful to very useful. Participants reported statistically significant increases in their confidence in acquiring images, interpreting images, and performing a clinical evaluation using POCUS for all domains except in performing paracentesis. Knowledge scores increased from a baseline of 58% to 83%; p< 0.001. At 6 months into the program, 2 hospitalists had uploaded > 400 clips each and 7 had uploaded fewer than 20 clips each. Discussion/Reflection/Lessons Learned: I-ScaN is a highly rated and effective program to train hospitalists in core POCUS competencies. The 2-day intensive program significantly improves confidence and knowledge. Monitoring of progress and scanning activity was difficult because few hospitalists uploaded clips regularly. Our focus now is on identifying barriers to using POCUS for new trainees. Future analysis will include frequency of scanning, retention of knowledge and skill, and generation of learning curves for each view
Fistulization of hemorrhagic pancreatic pseudocyst [Meeting Abstract]
Learning Objective #1: Recognize pancreatic-enteric fistulization as a rare complication of pancreatitis Learning Objective #2: Define the mechanisms for fistula formation in hemorrhagic pseudocysts CASE: The patient is a 31-year-old female with a past medical history of systemic lupus erythematosus complicated by end stage renal disease on dialysis, and pancreatitis complicated by pseudocyst formation, presenting with acute onset abdominal pain, nausea, and vomiting. On presentation, she was afebrile and hemodynamically stable with exam notable for diffuse abdominal tenderness and voluntary guarding without rebound. CT abdomen and pelvis showed hemorrhage into the known pancreatic tail pseudocyst with interval enlargement from 8 to 12 cm. CTAngiogram obtained four days after the onset of abdominal pain showed an open fistula between the pseudocyst and transverse colon, without evidence of active arterial bleeding. The patient then had two episodes of bright red blood per rectum. She became tachycardic and hypotensive with labs notable for a one-point hemoglobin drop from 9.7 to 8.5. She was triaged to the surgical ICU and underwent urgent exploratory laparotomy with transverse colectomy, partial pancreatectomy, and splenectomy, followed by staged colostomy creation. IMPACT/DISCUSSION: Fistulization of pancreatic pseudocysts is an extremely rare complication, occurring in less than 3% of cases, and can involve a variety of abdominal organs. Connections with sources other than the colon often cause spontaneous drainage and resolution of symptoms, and thus do not require surgery. However, communication with the colon can lead to other complications such as hemorrhage and sepsis, as seen in this case, which require definitive management. A proximal diverting colostomy is standard practice in order to prevent further backup of fecal matter into the pseudocyst and prevent rupture into the abdominal cavity. Multiple mechanisms have been proposed to explain the cause of hemorrhage and rupture of pancreatic pseudocysts. These mechanisms include the presence of severe inflammation due to activated lytic enzymes of the pancreas, as well as persistent compression of blood vessels due to mass effect. Colonopancreatic fistula formation in the case of our patient with lupus is likely secondary to the pro-inflammatory environment compounded by high wall pressures and suppressed healing mechanisms due to chronic steroid use.
Conclusion(s): Given the gravity of a missed diagnosis, hospitalists must keep complications of pancreatic pseudocysts on their differential for patients with known pathology and acute abdominal pain. Management strategies differ based on the type of complication, however, urgent operative management is key in certain cases of fistula formation, especially when it involves the colon as in our patient