A road map for point-of-care ultrasound training in internal medicine residency.

BACKGROUND: Ever-expanding uses have been developed for ultrasound, including its focused use at the bedside, often referred to as point-of-care ultrasound (POCUS). POCUS has been well developed and integrated into training in numerous fields, but remains relatively undefined in internal medicine training. This training has been shown to be desirable to both educators and trainees, but has proven difficult to implement. We sought to create a road map for internal medicine residency programs looking to create a POCUS program. RESULTS: Four internal medicine residency programs that have successfully integrated POCUS training describe their programs, as well as the principles and concepts underlying program development and execution. Review of educational teaching and assessment methods is outlined, as well as suggestions for integration into an already busy residency curriculum. Commonly reported barriers to POCUS implementation such as faculty development, equipment purchasing, resident supervision and quality assurance are addressed. Specific POCUS applications to target are touched upon, and a comparison of applications taught within these four programs suggest that there may be enough similarities to suggest a common curriculum. Finally, future needs are discussed. CONCLUSIONS: POCUS can be successfully taught to internal medicine residents as a part of internal medicine training. Many common elements and principles are evident on review of these four described successful programs. Future support, in the form of endorsed medical society guidelines, will be needed before POCUS is universally incorporated across internal medicine residency training programs.

Point-of-Care Ultrasound in the Inpatient Setting: A Tale of Four Patients.

Point of-care ultrasound (POCUS) has become a mainstream bedside tool for clinicians in several specialties and is gaining recognition in hospital medicine. There are many clinical applications in which the inpatient practitioner can use POCUS to improve his or her diagnosis, monitoring, and treatment of patients. POCUS is valuable in many clinical scenarios, including acute renal failure, increasing lower extremity edema, change in inpatient clinical status, and acute dyspnea. The medical literature has demonstrated the ability of nonradiologists to accurately detect conditions, including hydronephrosis; extremes of central venous pressure; deep venous thrombosis; pericardial effusion with tamponade; and several pulmonary pathologic states, including pulmonary edema, pleural effusion, consolidation, and pneumothorax. Further development of POCUS in hospital medicine is highly likely given increased awareness and exposure among medical trainees, a developing literature base, and growing engagement from specialty societies.

Entrusting internal medicine residents to use point of care ultrasound: Towards improved assessment and supervision.

Background: Internal medicine physicians and trainees are increasingly using, and seeking training in, diagnostic point of care ultrasound (POCUS). Numerous internal medicine training programs have described their curricula, but little has been written about how learners should be assessed, supervised, and allowed to progress toward independent practice, yet these practices are imperative for safe and effective use. Entrustable professional activities (EPAs) offer a practical method to assess observable units of professional work and make supervision decisions. Methods: An EPA for POCUS is used as a framework to assess and determine appropriate levels of supervision in an internal medicine residency program. Results: All learners have been able to advance to level 2 with a mandatory introductory boot camp course. Learners have been able to advance to higher levels of independence, often after taking formal elective programmatic coursework. However, not all learners taking the same coursework have been granted the same level of independence. Conclusions: It is feasible to assess and supervise internal medicine residents' ability to use diagnostic point of care ultrasound using an EPA.

Feasibility and acceptability of a structured curriculum in teaching procedural and basic diagnostic ultrasound skills to internal medicine residents.

BACKGROUND: Point-of-care ultrasound has emerged as a powerful diagnostic tool and is also being increasingly used by clinicians to guide procedures. Many current and future internists desire training, yet no formal, multiple-application, program-wide teaching interventions have been described. INTERVENTION: We describe a structured 30-hour ultrasound training course in diagnostic and procedural ultrasound implemented during intern orientation. Internal medicine interns learned basic ultrasound physics and machine skills; focused cardiac, great vessel, pulmonary, and abdominal ultrasound diagnostic examinations; and procedural applications. RESULTS: In postcourse testing, learners demonstrated the ability to acquire images, had significantly increased knowledge scores (P < .001), and demonstrated good performance on practical scenarios designed to test abilities in image acquisition, interpretation, and incorporation into medical decision making. In the postcourse survey, learners strongly agreed (4.6 of 5.0) that ultrasound skills would be valuable during residency and in their careers. CONCLUSIONS: A structured ultrasound course can increase knowledge and can result in learners who have skills in image acquisition, interpretation, and integration in management. Future work will focus on refining and improving these skills to allow these learners to be entrusted with the use of ultrasound independently for patient care decisions.

Point-of-Care Ultrasound in Internal Medicine: A National Survey of Educational Leadership.

BACKGROUND: Ultrasound is a valuable tool in the safe performance of an increasing number of procedures. It has additionally emerged as a powerful instrument for point-of-care assessment by offering internists an opportunity to extend their traditional physical examination. OBJECTIVE: This study explored how internal medicine (IM) educators perceive the use of ultrasound for procedures and point-of-care assessments, the extent to which curricula for teaching IM residents ultrasound skills exist, and perceived barriers to teaching its use. METHODS: In February 2012, we administered a 27-question survey to all members of the Association of Program Directors in Internal Medicine, eliciting their opinions about the use of point-of-care ultrasound. RESULTS: Of 2200 surveys distributed electronically, 234 were returned (a 11% response rate), including 167 by program directors or assistant program directors. Respondents highly rated the usefulness of ultrasound for central-line placement, thoracentesis, paracentesis, and diagnosis of pleural effusions. Evaluation of vena cava and heart, and placement of radial artery catheters received somewhat lower usefulness scores. Forty-five respondents (25%) reported having formal curricula to teach point-of-care ultrasound, and 46 respondents without current ultrasound programs were planning to initiate them in the next 12 months. Potential barriers to teaching and use of ultrasound included the time and cost to train faculty, the cost of ultrasound machines, and the time required to train residents. CONCLUSIONS: Educational leaders in IM view point-of-care ultrasound as a valuable tool in diagnosis and procedures, and many residency programs are teaching these skills to their learners.

The DnaK chaperone system facilitates 30S ribosomal subunit assembly.

Functional Escherichia coli 30S ribosomal subunits can be reconstituted in vitro. However, slow kinetics and sharp temperature dependence suggest additional assembly factors are present in vivo. Extract activation of in vitro assembly results in association of DnaK/hsp70 chaperone components with pre-30S particles. Purified DnaK, its cochaperones DnaJ and GrpE, and ATP can facilitate reconstitution of functional 30S subunits under otherwise nonpermissive conditions. A link has been observed between DnaK, 30S subunit components, and ribosome biogenesis in vivo as well as in vitro. These studies reveal a novel role for the DnaK/hsp70 chaperone system, in addition to its well-documented role in protein folding, and suggest that 30S subunit assembly can be facilitated.