Physical examination is the cornerstone of medical evaluation and the principles of this have remained the same for the last few centuries. The purpose of the physical examination is to evaluate patient complaints through observation, palpation, percussion, and auscultation. However, numerous studies have indicated poor diagnostic accuracy of conventional physical examination parameters, especially auscultation. Since many of the 'classic' signs and symptoms were described during an era when late-stage disease presentations were more prevalent, relying solely on them often results in overlooked abnormalities where timely intervention is possible. Adding to the problem, declining physical examination skills among doctors have been widely acknowledged. Therefore, it is unsurprising that requests for radiologic examinations such as ultrasound, CT scans, and echocardiograms have substantially increased over the past few decades.
Nevertheless, hospitalised patients continue to be assessed using the traditional four pillars of physical examination, supplemented by radiological examinations to aid in the diagnostic process. In the last couple of decades, however, there has been a rapid rise in radiological examination requests in healthcare. Data from NHS indicates 43.3 million imaging requests in one year and in the USA alone 70 million chest X-rays are performed each year. In addition, data from the USA indicated over seven million echocardiogram requests annually. Many of these scans turn out to be negative scans but this adds to the costs of healthcare and hospitalisation, which in capitated healthcare systems or countries with limited resources will be difficult to deliver.
Point-of-care ultrasonography (POCUS) is a clinician-performed limited ultrasound examination intended to answer focused clinical questions at the bedside. It is emerging as a valuable adjunct to physical examination. In fact, POCUS-enhanced physical examination was incorporated into emergency and critical care practices a couple of decades ago with the development of E-FAST and BLUE protocols to evaluate patients with undifferentiated shock or shortness of breath in patients where timeliness of care is very critical.
Advancements in ultrasound technology and miniaturisation of equipment have rendered POCUS an attractive bedside tool that enables prompt diagnosis and monitoring of the response to treatment, ultimately reducing the healthcare cost burden by avoiding unnecessary radiological examinations.
A report from the World Health Organization estimated there are 9.2 million doctors and 18.1 million nurses worldwide. In the UAE, there are over 26,000 doctors and 60,000 nurses. Many of them perform daily physical examinations, and these health professionals these folks need to be upskilled to make POCUS-assisted physical examination a standard of care in hospitalisation patients.
Dr. Siddiq Anwar is a Consultant Transplant and Interventional Nephrologist and is currently working at Sheikh Shakhbout Medical City. During his medical training, POCUS was mostly used for interventional procedures, like vascular access and kidney biopsies. But with the increased availability of ultrasound devices and the pioneering work led by critical care and emergency medicine colleagues, it was clear that the integration of POCUS assessment in clinical settings would be a game changer. When his project, in collaboration with colleagues from Khalifa University and Mohammed Bin Zayed University of Artificial Intelligence, won the hackathon organised by the UAE Ministry of Economy and Ericsson, it helped them secure research funding in terms of POCUS devices from Echonous. It presented a challenge to upskill current doctors in training and established clinicians to use POCUS in their clinical practice. There was no established playbook or curriculum that he could use to establish POCUS training for this demographic. He then reached out to leaders in POCUS education who had been successful in bringing a POCUS revolution not just in their institutions but in multiple centres across the world.
Dr. Siddiq Anwar
POCUS education in Europe
Dr. Hatem Soliman–Aboumarie is a Consultant Cardiothoracic Intensivist at Royal Brompton and Harefield hospitals in London and a leader in Critical Care Echocardiography and POCUS education. He has been instrumental in setting up Royal Brompton and Harefield Hospital POCUS Academy in the UK and helped set up the POCUS Academy at Sheikh Shakhbout Medical City with Dr. Anwar in the UAE.
Dr. Hatem Soliman–Aboumarie
Dr. Soliman-Aboumarie shared: “In the UK, point-of-care ultrasound has grown over the last years, and in several hospitals, it is now embedded in daily clinical practice. In our experience at a quaternary cardiothoracic specialist hospital, we started a training programme for our multidisciplinary team of physiotherapists, nurses, and medical professionals on lung ultrasound. Over the last three years, we had 15 practitioners accredited by the Intensive Care Society accreditation in focused lung ultrasound. We believe that one of the main barriers to using point-of-care ultrasound is the culture change within the healthcare system, therefore, training the multidisciplinary team is essential to leverage the skillset of the wider team as well as spread the practice of POCUS for the wider members of the healthcare team.
“Some data showed the value and safety of point-of-care lung ultrasounds performed by physiotherapists and nurses. We also established a new governance framework and a standard operating procedure for the safe use of this modality within critical care physiotherapy. Training and accreditation should go hand in hand with ongoing quality assurance and governance to ensure the best quality of care delivered whilst also ensuring the safe application of these new tools at the bedside by the wider members of the multidisciplinary team.”
POCUS education in the US
Dr. Abhilash Koratala is an innovative leader in medical education who has been at the forefront of bringing POCUS into Internal Medicine and Nephrology. His award-winning website nephropocus.com and Twitter account @NephroP is a free knowledge repository he has created to democratise POCUS education.
He shared: “The current challenges in bringing POCUS training to upskill the existing workforce include a limited number of trained faculty, access to standardised training programmes, and integrating POCUS into the workflow of existing healthcare systems. However, efforts have been made to overcome these challenges through various means such as social media, continuing medical education (CME) programmes, and advocacy.”
Dr. Abhilash Koratala
Social media platforms like Twitter, YouTube, and LinkedIn provide a space for clinicians, educators, and researchers to share POCUS-related content such as case vignettes, videos, research articles, and clinical insights. These platforms enable the rapid dissemination of information and foster learning among a global community of POCUS enthusiasts. However, not all information shared on these platforms may be accurate and requires considerable discretion on the part of the learner. Moreover, social media-based learning often lacks standardisation in terms of content, terminology, and teaching methods. This can lead to inconsistencies in the way POCUS concepts are presented and understood, resulting in substantial heterogeneity and knowledge gaps.
CME programmes have been organised to provide structured POCUS training to healthcare professionals. These include hands-on workshops, lectures, and online courses to enhance the skills of learners. Through these initiatives, clinicians have the opportunity to learn and practice POCUS techniques under the guidance of experienced instructors. One drawback of these programmes is the lack of ongoing longitudinal training. Similar to any other skill, proficiency in POCUS diminishes over time without consistent practice. Furthermore, unsupervised practice without a comprehensive understanding can foster overconfidence and potentially endanger patients.
Advocacy efforts have also been instrumental in promoting the importance of POCUS education. Key opinion leaders and various professional societies have advocated for the integration of POCUS into medical education curricula and clinical practice guidelines. Nevertheless, it remains a work in progress.
Ultimately, the responsibility of training the current workforce rests with individual institutions. While making use of available resources such as curated social media content, CME programmes facilitated by professional societies, and guidelines, institutions should design their training pathways. Such local or regional initiatives can be better tailored to the specific requirements of physicians and clinicians from different specialities, considering their prior experience with POCUS. These programmes should provide longitudinal training and progressive supervision until learners are competent in performing and interpreting the studies. With a growing pool of trained clinicians, there will be greater availability of experienced practitioners who can teach POCUS to others, resulting in a more sustainable and self-sufficient training ecosystem. Furthermore, it is crucial to establish comprehensive multidisciplinary quality assessment programmes to maintain the highest standards of study quality. While the expenses associated with training may seem significant, the long-term benefits in terms of improved patient care and overall healthcare efficiency make it a worthwhile investment.
POCUS education in Latin America
Dr. Eduardo R. Argaiz is a nephrologist based at the National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico, and a Board Member of the Mexican Society of Echocardiography — Academic Committee. He is one of the emerging leaders from the next generation of educators advocating using POCUS as a bedside clinical assessment tool. Sharing his thoughts on how POCUS education is growing in Latin America, he said: Even though point-of-care ultrasound (POCUS) is increasingly being adopted in many clinical settings in Latin America, it is still significantly underutilised. A recent survey revealed that even in a relatively more developed region such as Brazil, up to 60 per cent of Intensive Care Units do not have access to ultrasound equipment. This same survey also revealed that most clinical applications for ultrasound are still focused on guided procedures such as central venous catheter placement.
Today, however, things might be turning brighter. In the last couple of years, we have experienced a large increase in demand for POCUS training in the region, largely driven by our social media efforts to educate and promote its use. Evidence of the impact that social media has had on disseminating POCUS education in Latin America can be easily obtained using Altmetric, a tool that monitors the reach and impact of scientific publications involving online interactions. By using this tool, we can see that our POCUS-publications rank in the top one per cent of publications, with the majority of online interactions originating from Mexico.
Dr. Eduardo R. Argaiz
As a POCUS educator in the region, my experience resonates with the Altmetric data. The increase in demand for POCUS training has been palpable in Mexico. For example, our efforts to increase POCUS workshops at all national nephrology meetings in Mexico have been met with an impressive turnout. It is not uncommon for many workshop participants to be non-nephrologists who learned about the workshop through social media. This increasing demand for training has also been met by an increasing supply of portable ultrasound equipment as large corporations such as EchoNous and Butterfly Network have entered the region.
Currently, there are only a few structured POCUS training programmes that offer a post-graduate degree in Mexico. One of the largest programmes has been offered by the National Institute of Cardiology in Mexico City since 2017. Additionally, the Argentinian Society of Critical Care Ultrasonography (ASARUC) has experienced impressive growth throughout the whole region. ASARUC was started by Dr. Francisco Tamagnone and colleagues in Argentina to bring POCUS education to a wider audience. They have subsequently gone on to establish centres in various countries across South and Northern America and Europe. While acceptance of POCUS is growing, standardisation and quality control in training are lacking. The single most important effort right now is to develop and incorporate a structured POCUS curriculum into the residency training programmes for every physician in training, especially in the areas of emergency medicine, critical care, and internal medicine branches.
Dr. Francisco Tamagnone
POCUS education in Asia and the Middle East
There are many efforts underway across the region to train the current and future medical workforce to adopt POCUS education in clinical practice. There is the Fundamentals of Point-of-Care Ultrasound (POCUS) Certificate, a one-year programme offered by the Postgraduate Medical Education Deanship at Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU). In addition, the Avatar Foundation is leading an active educational programme to upskill folks in the Indian subcontinent.
Recently ASARUC has established itself in the Middle East, bringing high-quality POCUS education to the region. The highlights of their CME programmes are the high-quality instructors and the use of an on-demand platform, Sonoflix, to deliver their theoretical classes. In addition, their collaboration with the Inteleos Foundation allows the attendees to gain certification with POCUS Academy. They also have CME credits from the Department of Health, Abu Dhabi.
In time all practicing clinicians will be trained in POCUS-assisted physical examination. This will become a requirement for hospital-based doctors and medical professionals, like Basic Life Support Training, and most will require ACLS training to maintain professional credentials and licensure. There is a huge demand for POCUS training, and all courses are currently oversubscribed. This means training the current workforce would require a lot of financial and time commitment. Most medical schools have now integrated POCUS education into their curriculum and so have multiple internal medicine residency programmes across the world.
Making POCUS-assisted physical examination a standard of care for all hospitalised patients will require the collaboration of educators, regulators, and industry to retain the existing workforce. We look forward to collaborating with all like-minded educators, institutions, and industry partners to bring a POCUS revolution across the world.
Register for upcoming courses from the ASARUC POCUS Academy in Abu Dhabi via the following link: ASRAUC- Abu Dhabi 2023.
This article appears in the latest issue of the Omnia Health Magazine, read more here