Internal Medicine Point-of-Care Ultrasound Curriculum: Consensus Recommendations from the Canadian Internal Medicine Ultrasound (CIMUS) Group.

Bedside point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. At present, no consensus exists for what POCUS curriculum is appropriate for internal medicine residency training programs. This document details the consensus-based recommendations by the Canadian Internal Medicine Ultrasound (CIMUS) group, comprising 39 members, representing 14 institutions across Canada. Guiding principles for selecting curricular content were determined a priori. Consensus was defined as agreement by at least 80% of the members on POCUS applications deemed appropriate for teaching and assessment of trainees in the core (internal medicine postgraduate years [PGY] 1-3) and expanded (general internal medicine PGY 4-5) training programs. We recommend four POCUS applications for the core PGY 1-3 curriculum (inferior vena cava, lung B lines, pleural effusion, and abdominal free fluid) and three ultrasound-guided procedures (central venous catheterization, thoracentesis, and paracentesis). For the expanded PGY 4-5 curriculum, we recommend an additional seven applications (internal jugular vein, lung consolidation, pneumothorax, knee effusion, gross left ventricular systolic function, pericardial effusion, and right ventricular strain) and four ultrasound-guided procedures (knee arthrocentesis, arterial line insertion, arterial blood gas sampling, and peripheral venous catheterization). These recommendations will provide a framework for training programs at a national level.

Quality of Widely Available Video Instructional Materials for Point-of-Care Ultrasound-Guided Procedure Training in Internal Medicine.

OBJECTIVES: Many instructional materials for point-of-care ultrasound (US)-guided procedures exist; however, their quality is unknown. This study assessed widely available educational videos for point-of-care US-guided procedures relevant to internal medicine: central venous catheterization, thoracentesis, and paracentesis. METHODS: We searched Ovid MEDLINE, YouTube, and Google to identify videos for point-of-care US-guided paracentesis, thoracentesis, and central venous catheterization. Videos were evaluated with a 5-point scale assessing the global educational value and a checklist based on consensus guidelines for competencies in point-of-care US-guided procedures. RESULTS: For point-of-care US-guided central venous catheterization, 12 videos were found, with an average global educational value score ± SD of 4.5 ± 0.7. Indications to abort the procedure were discussed in only 3 videos. Five videos described the indications and contraindications for performing central venous catheterization. For point-of-care US-guided thoracentesis, 8 videos were identified, with an average global educational value score of 4.0 ± 0.9. Only one video discussed indications to abort the procedure, and 3 videos discussed sterile technique. For point-of-care US-guided paracentesis, 7 videos were included, with an average global educational value score of 4.1 ± 0.9. Only 1 video discussed indications to abort the procedure, and 2 described the location of the inferior epigastric artery. CONCLUSIONS: The 27 videos reviewed contained good-quality general instruction. However, we noted a lack of safety-related information in most of the available videos. Further development of resources is required to teach internal medicine trainees skills that focus on the safety of point-of-care US guidance.

Defining Competencies for Ultrasound-Guided Bedside Procedures: Consensus Opinions From Canadian Physicians.

OBJECTIVES: This study sought to define the competencies in ultrasound knowledge and skills that are essential for medical trainees to master to perform ultrasound-guided central venous catheterization, thoracentesis, and paracentesis. METHODS: Experts in the 3 procedures were identified by a snowball technique through 3 Canadian tertiary academic health centers. Experts completed 2 rounds of surveys, including an 88-item central venous catheterization survey, a 96-item thoracentesis survey, and an 89-item paracentesis survey. For each item, experts were asked to determine whether the knowledge/skill described was essential, important, or marginal. Consensus on an item was defined as agreement by at least 80% of the experts. For items on which consensus was not reached during the first round of surveys, a second survey was created in which the experts were asked to rate the item in a binary fashion (essential/important versus marginal/unimportant). RESULTS: Of the 27 experts invited to complete each survey, 25 (93%) completed the central venous catheterization survey; 22 (81%) completed the thoracentesis survey; and 23 (85%) completed the paracentesis survey. The experts represented 8 specialties from 8 cities within Canada. A total of 22, 32, and 28 items were determined to be essential competencies for central venous catheterization, thoracentesis, and paracentesis, respectively, whereas 47, 38, and 42 competencies were determined to be important, and 8, 13, and 10 were determined to be marginal. The ability to perform real-time direct ultrasound guidance was considered essential only for the performance of central venous catheterization insertion. CONCLUSIONS: Our study presents expert consensus-derived ultrasound competencies that should be considered during the design and implementation of procedural skills training for learners.

Delivering Point-of-Care ultrasound teaching using a video conferencing technique.

Point-of-care ultrasound (POCUS) has usually been taught using a hands-on, in-person approach. We present a novel approach to delivering POCUS virtually using a dual image videoconferencing technique. We outline an easily implementable approach and summarize medical students' experience and feedback. This form of delivery has potential to improve instructional delivery in resource restricted settings or during pandemic restrictions where a hands-on approach may not be possible.

L'échographie au chevet fait généralement l'objet d'un enseignement pratique, en personne. Nous présentons une nouvelle approche, virtuelle, pour son enseignement, par visioconférence à double flux vidéo. L'approche que nous décrivons est facile à mettre en œuvre. Nous résumons l'expérience et les commentaires des étudiants en médecine sur cette modalité qui est susceptible d'améliorer l'enseignement dans des contextes où les ressources sont limitées ou en cas de pandémie, lorsque l'approche pratique n'est pas possible.

Use of wearable point-of-view live streaming technology for virtual physical exam skills training.

We piloted a virtual teaching tool comprised of a chest-mounted smartphone streaming point-of-view footage over videoconferencing software to deliver a physical exam skills session. Compared to medical students taught via third person view through pre-recorded video followed by preceptor-led discussion, a higher proportion of students taught via point-of-view wearable technology reported improved knowledge of demonstrated skills and feeling engaged, comfortable interacting with their tutor, and better able to visualize demonstrated exam maneuvers. This accessible, affordable, and easily replicable innovation can potentially enhance virtual clinical skills teaching and enable novel distant clinical learning opportunities for healthcare professions students and educators.

Nous avons mis à l'essai un outil d'enseignement virtuel, notamment pour les cours de techniques d'examen physique, qui consiste dans le fait de porter un téléphone intelligent fixé sur la poitrine pour diffuser en direct, par le biais d'un logiciel de vidéoconférence, pour réaliser un examen physique plutôt que subjectif. Comparativement aux étudiants en médecine qui pour le cours ont visionné une vidéo préenregistrée prise par caméra objective, suivie d'une discussion dirigée par un précepteur, un plus grand nombre d'étudiants ayant suivi le cours par le biais d'une technologie portable avec par le biais d'un dispositif technologique portable déclarent avoir amélioré leurs connaissances sur les techniques présentées, se sentir engagés et à l'aise pour interagir avec l'enseignant, et avoir été en mesure de bien voir les gestes d'examen montrés. Cette innovation accessible, abordable et facilement reproductible pourrait permettre d'améliorer l'enseignement virtuel des habiletés cliniques et d'offrir de nouvelles possibilités d'enseignement.

Cost-Efficient Medical Education: An Innovative Approach to Creating Educational Products.

BACKGROUND: Cost is a barrier to creating educational resources, and new educational initiatives are often limited in distribution. Medical training programs must develop strategies to create and implement cost-effective educational programming. OBJECTIVE: We developed high-quality medical programming in procedural instruction with efficient economics, reaching the most trainees at the lowest cost. METHODS: The Just-In-Time online procedural program was developed at the University of Toronto in Canada, aiming to teach thoracentesis, paracentesis, and lumbar puncture skills to internal medicine trainees. Commercial vendors quoted between CAD $50,000 and $100,000 to create 3 comprehensive e-learning procedural modules-a cost that was prohibitive. Modules were therefore developed internally, utilizing 4 principles aimed at decreasing costs while creating efficiencies: targeting talent, finding value abroad, open source expansion, and extrapolating efficiency. RESULTS: Procedural modules for thoracentesis, paracentesis, and lumbar puncture were created for a total cost of CAD $1,200, less than 3% of the anticipated cost in utilizing traditional commercial vendors. From November 2016 until October 2018, 1800 online instructional sessions have occurred, with over 3600 pageviews of content utilized. While half of the instructional sessions occurred within the city of Toronto, utilization was documented in 10 other cities across Canada. CONCLUSIONS: The Just-in-Time online instructional program successfully created 3 procedural modules at a fraction of the anticipated cost and appeared acceptable to residents based on website utilization.

Familial pheochromocytoma and renal cell carcinoma syndrome: TMEM127 as a novel candidate gene for the association.

Germline mutations in Von Hippel-Lindau (VHL), succinate dehydrogenase subunit B (SDHB), SDHC, and SDHD have been detected in individuals with synchronous or metachronous pheochromocytoma/paraganglioma (PHEO/PGL) and renal cell carcinoma (RCC). Most recently, FH and TMEM127 germline mutations, which are known to cause familial PHEO/PGL, have also been identified in familial RCC. We report the first case of an individual with both a PHEO and a multilocular clear cell RCC driven by a novel germline mutation in the TMEM127 gene. Morphologically, both the PHEOs and multilocular RCC were indistinguishable from those associated with VHL disease. However, at the biochemical level, the predominant adrenergic catecholamine profile distinguishes this presentation from SDH- and VHL-related PHEOs. This case justifies the prioritization of genetic testing for germline TMEM127 in individuals with RCC and PHEO with a predominantly adrenergic phenotype.