A pilot survey on an understanding of point of care bedside ultrasound (POCUS) among medical doctors in internal medicine: Exposure,perceptions,interest and barriers to training

Abstract

Introduction:

Clinical bedside point-of-care ultrasonography (POCUS) is an important adjunct to history and physical examination. The objective of this pilot survey is to assess the level of exposure, perceptions, interest levels and possible barriers toward training of POCUS in internal medicine.

Methods:

In October 2015, all medical doctors who were working in the Singapore General Hospital Internal Medicine Department were invited to complete a hard-copy printed 27-question Likert-scale survey.

Results:

A total of 124 medical doctors participated in the survey (response rate 82.1%). The proportions of participants who have heard, witnessed, and performed POCUS were 65.6% (N = 82), 71.2% (N = 89) and 41.6% (N = 52), respectively. POCUS was rated highly on usefulness in the practice of internal medicine (M = 8.74; SD = 1.34). The top three POCUS skills that doctors would like to acquire would be (1) procedural guidance POCUS (70.8%); (2) point-of-care cardiac ultrasound (69%) and (3) lung ultrasound 58.4% (based on percentage ranked first through third). The sample mean of interest in undergoing further training in POCUS is 8.91 (SD = 1.27) (0 = not interested, 10 = very interested). The top three barriers identified were (1) lack of an ultrasound machine (M = 7.98 SD = 2.28); (2) cost of an ultrasound machine (M = 7.79 SD = 2.19) and (3) lack of a formal training curriculum (M = 7.25 SD = 2.08) (0 = not a barrier at all, 10 = severe barrier).

Conclusions:

There is a high level of exposure and interest in POCUS. Doctors perceived bedside POCUS as very useful in the practice of internal medicine. A lack of machine and formal curriculum impedes development of a training program. This pilot survey may serve as a basic needs assessment to an implementation of an internal medicine POCUS training curriculum.

Keywords

Ultrasound point-of-care internal medicine general medicine medical education training

Introduction

Clinical bedside point-of-care ultrasonography (POCUS) is increasingly being recognized as an important adjunct to traditional history and physical examination. Bedside US has the potential to improve clinical diagnostic capability, improve patient safety and achieve the goals of cost effectiveness in clinical medicine. Accepted clinical uses of POCUS include evaluation of central venous pressure,^1–4 cardiac function,^5,6 pericardial effusions,⁷ pleural effusions,^8,9 pulmonary edema,¹⁰ pneumothoraces¹¹ and ascites.¹²

POCUS can improve patient safety by being used as image guidance for procedures. US use improves the safety and success of many other bedside procedures. These include placement of central venous catheters (CVCs),¹³ insertion of arterial lines,¹⁴ paracentesis,^15,16 thoracentesis,^17,18 arthrocentesis,¹⁹ and the incision and drainage of superficial abscesses.²⁰ The Agency for Healthcare Research and Quality lists the “use of real-time ultrasound to place central venous lines” as one of its core safety measures, given adequate training on the part of the operator. Acute Medicine training in the United Kingdom (UK) lists bedside US as a core competency. The adaptation of POCUS has extended to medical undergraduate education. Medical schools have started to introduce US into their curricula.^21,22

Multiple internal medicine (IM) residencies programs in the United States have their own bedside US training curricula. The Accreditation Council for Graduate Medical Education requires that IM residencies have facilities available for sonography but no mention is made of formal training requirements. Despite this, previous studies have shown that doctors of IM desire this training.²³ Although IM has been slow to integrate this technology into clinical practice, internists are starting to acknowledge the usefulness of bedside US in the practice of general medicine.

At this moment in time, relatively little is known about which US applications internists believe are the most useful, what US skills IM will need or barriers that exist to the teaching or use of US within IM. Prior experiences in other specialties have shown that conflicts with traditional imagers,²⁴ liability,²⁴ time constraints,^25–27 and credentialing requirements^24,27 may be barriers to the teaching and use of POCUS.

In Singapore, there is no formal standardized training in bedside diagnostic and procedural US for the internist. There is no available literature assessing the current exposure, competency and interest of IM residents and internists with regards to bedside US for diagnostics and image-guided bedside procedures in Singapore. The primary objective of this pilot survey is to assess the level of exposure, perceptions and interest levels toward bedside US in IM.

A secondary objective of the survey is to assess perceived possible barriers to a training program.

Methods

Between October 2, 2015 and November 1, 2015, all medical doctors working in the Singapore General Hospital (SGH) Department of Internal Medicine were invited to complete a hard-copy printed 27-question Likert-scale survey to assess the level of exposure, perceptions, and interest levels to point-of-care bedside US. In addition, questions were asked about perceived possible barriers to a bedside US training program. Investigators derived questions via discussion after an extensive literature search on the topic with reference to surveys conducted in other similar needs analyses. An initial draft of the survey was created. The initial draft was circulated among a sample group of medical officers (two), senior residents (two) and consultants (two) for feedback via email. The draft underwent three revisions. Redundant and irrelevant questions were removed. Ambiguous phrasing was clarified. The draft survey was also sent to the program director (PD) of the Advanced IM program and underwent subsequent endorsement before being finalized.

The 27-question survey (see Appendix) included questions about participants’ understanding of POCUS. Participants were asked if they had performed bedside US before and if they had obtained any form of formal or informal training. Participants were also asked how often they used POCUS currently. Participants indicated which aspects of POCUS they used in the course of clinical work and were asked to self-rate their competency. They also rated how useful bedside US was for diagnostic purposes and procedural guidance in IM on a Likert scale of 0–10 (0 = not useful, 10 = very useful). Participants were asked to rank which skills in bedside US they would like to learn first and also the amount of interest they had in bedside US using a Likert-scale survey (0 = not interest, 10 = interest). The survey also asked respondents to rate potential barriers to the implementation of point-of-care US curricula using a 10-point Likert scale (0 = no barrier, 10 = very large barrier) among a collection of barriers. For each barrier, an average score for all respondents was calculated and ranked.

Between October 2, 2015 and November 1, 2015, hard copies of the survey were administered to doctors during weekly department teaching. Participation in the survey was on a volunteer basis and all replies were anonymous. No identifiers were present on the survey document. Participants were encouraged to fully complete all questions in the survey. Department administrators and the investigating team were present to collect the survey forms after handing them out. Senior residents from each IM team also assisted in collecting the survey forms from junior doctors who needed more time to complete the survey later on. These forms were returned to the investigating team. Senior doctors who were not present at teaching were administered the survey by the department secretary. Secretaries of senior doctors handed the survey forms back to the investigating team when they were completed. All survey replies that fulfilled the responder criteria were analyzed. Non-responders were either doctors who completed less than 75% of the questions, decided not to participate in the survey or doctors who did not return the survey forms. There were no survey replies that had less than 75% of the questions completed.

Investigators analyzed the data with the Singhealth Biostatistics team. Data were analyzed using SPSS version 23. Descriptives and frequencies were used to describe the distribution (count, mean (M) and standard deviation (SD)) of the data collected. Chi-square tests were conducted to test for the significance in differences between groups. This study was exempted from review by the Singhealth Centralized Institutional Review Board (CIRB).

Results

A total of 125 medical doctors from Singapore General Hospital Department of Internal Medicine participated in the pilot survey. There were 152 IM doctors in the department (junior doctors N = 121, senior doctors N = 31) during the study period (October 2, 2015 and November 1, 2015). The net response rate was 82.1%. The mean average age of the participants was 28.2 years. The majority of responders (77.6% N = 97) were junior doctors (junior residents, medical officers and house officers), which reflected the demographic makeup of the department. A total of 19.8% (24/121) and 9.6% (3/31) of junior doctors and senior doctors respectively were non-responders.

Exposure

The proportions of participants who have heard, witnessed, and performed point-of-care bedside US were 65.6% (N = 82), 71.2% (N = 89) and 41.6% (N = 52), respectively (see Table 1 Sample Characteristics). A total of 43.1% (N = 53) of participants use POCUS in their clinical work, yet only 39.2% (N = 48) of participants had undergone some form of training/education in performing POCUS. About half of the participants (N = 65; 52.0%) had postings to critical care (CC)/emergency medicine before. A total of 39.2% of participants had undergone some form of training/education in performing POCUS. The top three most quoted forms of training were (1) bedside tutorials (N = 28), (2) practical course with demonstrations (N = 9) and (3) didactic lectures (N = 4). The rest of the responders had other forms of training via books and online resources.

Table 1.

Sample Characteristics.

	Total (N = 125)	No EM/CC posting (N = 60)	EM/CC posting (N = 65)	p
Mean age in years (SD)	28.22 (5.48)	26.08 (2.32)	30.22 (6.72)
POCUS awareness N (%)	82 (65.6%)	27 (45.0%)	55 (84.6%)	<0.001
POCUS during residency training N (%)	17 (13.6%)	5 (8.3%)	12 (18.5%)	0.81
POCUS training N (%)	49 (39.2%)	9 (15.0%)	40 (61.5%)	<0.001
POCUS observation N (%)	89 (71.2%)	32 (53.3%)	57 (87.7%)	<0.001
Performed POCUS N (%)	52 (41.6%)	8 (13.3%)	44 (67.7%)	<0.001
POCUS usage N (%)	53 (43.1%)	12 (20.0%)	41 (65.1%)	<0.001

EM/CC: emergency medicine/critical care; POCUS: point of care ultrasonography.

A significantly higher proportion of doctors who had undergone a CC and/or emergency medicine posting knew what POCUS was compared to those who had not undergone those postings (84.6% vs 45.0% p ≤ 0.01). CC and emergency medicine posting as well as seniority were associated with increased rates of exposure and performance of point-of-care bedside US, and this was statistically significant (see Table 1 Sample Characteristics). A majority of participants, 57.6% (N = 72), thought they were incompetent in POCUS and only 10.4% (N = 13) of participants thought they were quite/very competent in POCUS.

Perceptions

POCUS was rated highly on usefulness in the practice of IM (M = 8.74, SD = 1.34). POCUS usefulness increased with doctors’ rank, with senior doctors rating POCUS’s usefulness (M = 9.23, SD = 0.86) significantly higher than junior doctors’ (M = 8.60, SD = 1.43) ratings (M = 0.63, p = 0.006).

Participants were asked to rate the usefulness of the bedside US skills. The bedside US skills’ usefulness was subsequently ranked. The top five bedside POCUS skills that were rated by participants as most useful (via Likert scale 0 = not useful, 10 = most useful) were US-guided CVC insertion (M = 8.69, SD = 1.52), abdominal focused assessment with sonography in trauma (FAST) POCUS (M = 8.37, SD = 1.66), bedside POCUS cardiac US (M =8.27, SD = 1.91), bedside bladder volume assessment (M = 8.23, SD = 1.68) and US-guided thoracentesis (M =8.17, SD = 1.62) (see Table 2 Usefulness of POCUS evaluation).

Table 2.

Usefulness of POCUS evaluation.

Procedures	Total (N = 125)
Central venous catheter insertion	8.69 (1.52)
Abdominal	8.37 (1.66)
Bedside cardiac ultrasound	8.27 (1.81)
Bladder volume assessment	8.23 (1.68)
Thoracocentesis	8.17 (1.62)
Femoral catheter insertion	8.08 (1.70)
Abdominal paracentesis	7.85 (1.71)
Bedside lung ultrasound	7.75 (1.90)
Pericardiocentesis	7.65 (2.21)
DVT evaluation	7.43 (2.07)
Peripheral inserted central catheter insertion	7.28 (2.08)
Inferior vena cava evaluation	7.26 (2.13)
Renal ultrasound	7.21 (1.94)
Arterial line insertion	7.19 (2.12)
Aorta ultrasound	7.12 (1.92)
Intravenous catheter insertion	7.06 (2.46)
Liver ultrasound	6.92 (1.86)
Gall bladder and bile duct evaluation	6.80 (1.87)
Thyroid evaluation	6.50 (2.13)
Skin, soft tissue and joint evaluation	6.35 (1.98)
Spleen ultrasound	6.18 (1.98)
Arthrocentesis and joint injections	6.12 (2.24)
Lumbar puncture	5.37 (2.34)
Assessment of intracranial pressure	5.17 (2.32)
Intubation	4.50 (2.59)

Usefulness score: 1=not useful; 10=most useful.

DVT: deep vein thrombosis.

The top five ranked bedside US skills that medical doctors in IM departments would like to acquire proficiency in (based on percentage ranked first through third) would be (1) procedural guidance on bedside US (70.8%); (2) focused bedside echocardiography (69%); (3) lung US (58.4%); (4) abdominal FAST, hepatobiliary system (35.4%) and (5) vascular/deep vein thrombosis (DVT)/inferior vena cava (IVC) point-of-care US (34.4%) (See Table 3 Ranked POCUS Skill most desired to learn). All respondents felt that POCUS allowed procedures to be carried out more safely. Majority of respondents felt that POCUS would allow more accurate diagnosis and also rationalized the ordering of detailed radiological investigations.(See Table 4 Reasons for POCUS Use in Internal Medicine).

Table 3.

Ranked POCUS Skills Most Desired to learn.

POCUS skill	Total (N = 125)
Procedural bedside ultrasound	70.8%
Bedside cardiac ultrasound (ECHO)	69.0%
Bedside lung ultrasound	58.4%
Abdominal/liver/gall bladder and biliary	35.4%
Vascular ultrasound/DVT/IVC ultrasound	34.4%
Renal ultrasound	14.1%
Skin, soft tissue and joint ultrasound	7.9%
Aorta ultrasound	5.4%
Thyroid evaluation	4.5%

ECHO: echocardiography; POCUS: point of care ultrasonography; IVC: inferior vena cava.

Table 4.

Reasons for POCUS Use in Internal Medicine.

Reason for POCUS use	Total N = 116
Allows for a procedure to be carried more safely	100%
Allows for more accurate diagnosis	97.5%
Rationalized ordering of detailed radiological investigations	88.7%
Allows for student teaching, e.g. anatomy	6.1%
It is a technologically advanced equipment	6.0%
Allows for career advancement	1.7%

POCUS: point of care ultrasonography.

Interest

The sample mean (SD) of interest in undergoing further education and training in POCUS is 8.91 (SD = 1.27) (0 = not interested, 10 = very interested) (See Table 5 Interest in POCUS training and Education) and this interest was not significantly different when interest was stratified between seniors and junior doctors and between participants who had undergone an emergency medicine or CC posting. Even when the participants were polled on their interest level if they were to pay for their own training, the sample mean for interest was 6.02 (SD = 2.71) (0 = not interested, 10 = very interested). A majority of the participants (66.9%; N = 83) were willing to devote a maximum of only three hours per week to POCUS training or to maintain competency and preferred small portable machines (75.8%; N = 94) compared to pocket handheld (21.8% N = 27) or parked machine in the room (2.4% N = 3) for best efficiency. With regards to the number of supervised scans before being considered competent in bedside US modality, 31.5% (N = 39), 35.5% (N = 44) and 21% (N = 26) mentioned 10, 20 and 50, respectively as the minimum supervised accurate scans required before being considered competent.

Table 5.

Interest in POCUS Training & Education.

Interest levels by training format	Total N = 125Mean (SD)
Overall interest to undergo further POCUS training and education	8.91 (1.27)
Training organized by medical school or residency	8.73 (1.46)
Signing up voluntarily using personal training fund	7.85 (2.04)
Signing up for overseas course using personal training fund	7.03 (2.60)
Signing for course paid by self	6.02 (2.71)

POCUS: point of care ultrasonography.

Interest level. 0=Not interested. 10=Very Interested.

Barriers

When participants were asked to evaluate the severity of barriers toward development of a point-of-care bedside US training program, the top five barriers identified by participants were (1) lack of a US machine (M = 7.98, SD = 2.28); (2) cost of a US machine (M = 7.79, SD = 2.19); (3) lack of formal training curriculum (M = 7.25, SD = 2.08); (4) time to train faculty member (M = 7.21, SD = 2.13) and (5) time to train learners (M = 6.99, SD = 1.92) (0 = not a barrier at all, 10 = severe barrier) (see Table 6 Barriers to POCUS teaching and learning).

Table 6.

Barriers to POCUS Learning & Teaching.

Reasons	Total (N = 125)
Lack of machine	7.98 (2.28)
High cost of machine	7.79 (2.19)
Lack of formal training curriculum	7.25 (2.08)
Lack of time to train faculty members	7.21 (2.13)
Lack of time to train learners	6.99 (1.92)
Lack of mentors	6.85 (2.09)
High cost of training faculty members	6.78 (2.00)
High cost of training learners	6.59 (1.96)
Lack of interest in learning POCUS	4.51 (2.73)
Lack of formal accreditation	6.56 (2.19)
Fear of litigation due to inaccurate results	6.28 (2.42)
Steep learning curve	5.79 (2.17)
Conflict with specialty	5.23 (2.34)
Lack of training space	4.86 (2.47)

POCUS: point of care ultrasonography.

Barrier level. 0=No barrier. 10=Severe Barrier.

While both senior and junior doctors regarded a lack of a US machine and cost of a US machine as the top two barriers to a POCUS training program, senior doctors were more concerned about lack of a formal training curriculum (junior doctors 7.00 vs senior doctors 8.03 p < 0.05), a lack of mentors (junior doctors 6.58 vs senior doctors 7.78 p < 0.01) and a lack of formal accreditation (junior doctors 6.28 vs senior doctors 7.52 p < 0.01) (0 = not a barrier, 10 = severe barrier).

Discussion

The results of this pilot survey provided valuable insights into the degree of exposure, perceptions, interest levels and potential barriers to clinical point-of-care US among IM medical doctors in the institution.

Exposure

First, point-of-care bedside US is not novel to doctors in IM in Singapore. More than two-thirds of doctors in the department have heard about and witnessed POCUS being performed but in contrast only slightly half had performed bedside US before. Even less had any form of formal training and most of the training was conducted in the form of bedside tutorials rather than as part of a formal training program. The rest had received training through a variety of courses, web resources and books via their own self-learning initiative. This is not surprising. Point-of-care bedside US is not part of the IM residency teaching syllabus nor is it part of departmental teaching. Point-of-care bedside US is a formal curriculum only in the emergency medicine residency. There are courses in Singapore organized by Alexander Academy of Clinical and Emergency Ultrasonography (AACES) but there is no accreditation process for IM doctors to perform this skill. The fact that a high proportion of doctors pursue self-directed learning for POCUS is highly encouraging and signals that there is a demand for such training.

Second, the proportion of IM doctors who know about POCUS is significantly higher among doctors who had experience in CC and emergency medicine as POCUS is utilized in intensive care units (ICUs) and emergency medicine departments (EDs) in Singapore. The intensivist and emergency medicine physicians, both advocates for bedside US, may play an important role as trainers and curriculum developers in a novel IM POCUS program.

Third, the majority of participants think they are incompetent in POCUS. This reflects a lack of formal training. Despite this fact, slightly half of the participants indicated on the survey they had performed POCUS before. This is of concern. There are no data collected as to whether POCUS was performed supervised or unsupervised. The fact that a high proportion of IM doctors are performing POCUS and yet a majority feel incompetent in POCUS suggests that development of formal training is necessary.

Perceptions

Most IM doctors viewed POCUS positively. US-guided CVC insertion, focused cardiac echocardiography, abdominal FAST and imaged-guided thoracocentesis were rated as the most useful applications of POCUS. Although not all doctors had exposure to POCUS, they were overall fairly accurate in evaluating the most useful aspects of bedside US. Procedural bedside US was rated as the US skill most IM doctors wanted to learn first followed by focused cardiac echocardiography. As mentioned previously US has been proven to improve the safety of many other bedside procedures such as the placement of CVCs,¹³ arterial lines,¹⁴ paracentesis,^15,16 thoracentesis,^17,18 arthrocentesis,¹⁹ and the incision and drainage of superficial abscesses.²³ The Agency for Healthcare Research and Quality lists the “use of real-time ultrasound to place central venous lines” as one of its core safety measures, given adequate training on the part of the operator. As part of the intervention to improve the safety and facilitate the training of bedside procedures, the University of California San Francisco²⁰ and the John Hopkins Medical Hospital have launched their own hospital procedural services. These procedural services make use of a team of doctors who are familiar with POCUS application. They standardized the supervision and training of IM resident doctors in bedside procedures that are conducted with US guidance. Hospitalist-supervised procedure service rotation substantially improved residents’ experience, confidence, and knowledge in performing bedside procedures early in their training. IM doctors do appear to be able to appreciate the improved safety and success of bedside procedures with US image guidance. One hundred percent of all IM doctors indicated that bedside US allows them to perform a procedure more safely as one of the top three reasons for the usage of POCUS in this pilot survey. A positive perception of POCUS in bedside procedures lays a good foundation for the development of a hospital procedures service.

Interest

The level of interest in undergoing further training in POCUS is very high. This is consistent with previous studies that concluded that interest in POCUS is very high among IM residents.²⁴ This interest extends even to medical students, although the response by medical students was not studied in our pilot survey.²⁵ The overall interest was still positive when asked if they were willing to fund their own training. Despite the high overall interest, it was difficult to agree what constitutes a fair amount of training and the number of scans to achieve competency. This is a relevant question as the quality of performance of bedside US varies by different training and achieving levels of competency requires repeated practice involving time and logistical cost. Training programs are divided on what constitutes sufficient training and differ in terms of their opinions on the proportion of time dedicated to knowledge acquisition, practical learning and supervised scanning. The American Medical Association states that each specialty should decide the needed training requirement to achieve competency.²⁶ The American Institute of Ultrasound in Medicine states that physicians performing diagnostic US should perform, evaluate, and interpret at least 300 sonograms.²⁷ The situation is made even more complex as this may differ by indication of sonography. For example, Brennan et al. found that four hours of didactics and 30 supervised sonograms were sufficient for residents to correctly assess inferior vena cava size.⁴ In contrast, Vignon et al.²⁸ included a shorter program that consists of a three-hour training course and five hours of hands-on training for focused echocardiography for non-cardiology residents in the ICU. Clay et al.²⁹ conducted a bedside US one-day training program with one day of lectures and two one-hour practical sessions. In Singapore, POCUS is performed by intensivists, emergency physicians and anesthetists. Formal accreditation for performance of point-of-care emergency US is available for residents via the emergency medicine residency pathway. Respiratory physicians utilized POCUS for thoracocentesis and chest drainage insertion. Gastroenterologists utilized POCUS for abdominal paracentesis. Cardiologists performed focus echocardiography in urgent settings. Each sub-specialty decides what is needed for practice and integrates it into practice. IM shares similarities with emergency medicine with regards to the aim of point-of-care US. First, US in both specialties is used in a limited way to answer a specific clinical question from the history and physical examination of which the answer is important for immediate progress to the next step of management. Second, POCUS is seen as an adjunct to rather than a replacement for the physical examination. Last, POCUS is used to make bedside procedures safer. The Singhealth Emergency Medicine Residency Program accredits residents via the residency pathway. Residents require at least 25 supervised scans of the extended FAST, renal, gall bladder, emergency IVC, and DVT examination. Musculoskeletal US is also part of the training. Residents are referred resources and attend bedside tutorials. At the end of the residency, residents are expected to take an examination to test their knowledge. As such, a discussion with the local emergency medicine residency committee may be the first step to development of a POCUS curriculum to fit with the demands of the IM practice that is consistent with the views of the American Medical Association.

Barriers

At this moment in time, point-of-care US is not widely practiced or available for IM in Singapore. Increasingly, internists are recognizing the relevance of point-of-care US for diagnostics and daily practice. While point-of-care US is not part of the IM curriculum, some emergency physicians in Singapore offer introductory courses coupled with practical sessions for physicians. One example is the Basic Sonographic Integrated Care Course (BASIC).³⁰ Overseas, the American College of Physicians (ACP) has teamed up with the American Institute of Ultrasound in Medicine (AIUM) and the Society for Ultrasound in Medical Education (SUSME) to develop US continuing medical education (CME) opportunities to promote increased usage of US and provide access to quality training. Perhaps the low level of practice may reflect the significant barriers in the practice of point-of-care bedside US in Singapore. In this study, the most important barrier identified by participants in the practice of bedside US is the cost and availability of US machines. Handheld US machines easily cost at least S$10,000 and portable cart-based US machines may cost a minimum of S$50,000 to S$100,000. Cost is more than the price of the machine and will require inclusion of cost involved in training operators of bedside US. It appears that there is good understanding of the high-capital initial startup course of a point-of-care bedside US training program by IM doctors. While cost will continue be a major concern, companies involved in portable US systems are making cost more acceptable. The cost of point-of-care US can be made more acceptable with the introduction of handheld portable systems such as Lumify (Philips Healthcare; Andover, MA, USA), iViz (Fujifilm Sonosite; Bothell, WA, USA) and Vscan (GE Healthcare; Chicago, IL, USA). These new systems integrate data storage solutions and other image acquisition systems. Costs are made more acceptable as these systems have functional limitability that may fit with the focused needs of POCUS for IM. These new systems with limited function will need to be evaluated and may be cost effective point-of-care US solutions for the future. Potentially, the high initial startup cost of a POCUS may be offset by future cost savings. Mitchell et al. concluded that patients in early shock evaluated with POCUS spent less time on inotropes, and showed trends toward fewer days on mechanical ventilation and time in the ICU.³¹ There were potential savings of $20,000 from decreased morbidity from these results. Barsuk et al. also reported savings of $500 per US-guided paracentesis performed at the bedside, the majority of savings from reduction in post-procedure blood product transfusion.³² While the initial startup cost in training and machine acquisition at this point in time is high, the development of more cost-effective systems and potential cost savings from POCUS may justify its implementation. Senior doctors were more concerned than junior doctors with regards to the availability of mentors, formal curriculum and credentialing. This reflects a need for formal training that leads to a credentialing process for the standardization of quality in POCUS. What is encouraging is that a lack of interest was not a significant barrier to training in point-of-care US, which is a consistent finding throughout the whole study.

Overall, while significant barriers are still present in the implementation of a POCUS training program, this should not dissuade the development and practice of point-of-care bedside US. Overcoming these barriers will require identification and buy-in of institutional stakeholders in patient safety and will require involvement of traditional practitioners of bedside POCUS such as respiratory physicians, emergency physicians, intensivists and cardiologists.

Strengths and limitations

One of the strengths of this study is that this is the first of its kind attempting to evaluate the exposure, perceptions and interest levels of IM medical doctors regarding point-of-care bedside US in Singapore. In addition, the study had a high response rate and evaluated both junior and senior doctors in IM. Despite its strengths, the study has some limitations. First, this is a cross-sectional survey that is limited to a single institution of IM physicians. Second, the training level of the participants was not fully evaluated and the results may be biased toward medical doctors who were more enthusiastic about the practice of point-of-care bedside US. In addition, there were no data on the reason doctors did not respond to the survey although they constitute a low percentage of 17.9%. This may have led to a higher than expected interest level that was observed. Third, the composite of medical doctors in different IM departments may vary; hence, the results may not easily be generalizable to different institutions. Last, this survey is only a primary survey to gauge interest level; it is still difficult to evaluate if there will be a high uptake of an IM bedside US program if implemented.

Conclusions

There is a high level of exposure to clinical bedside US within the department, especially so if doctors had undergone a CC or emergency medicine posting. Surprisingly, despite a lack of a formal curriculum or training program, a high percentage of doctors have obtained bedside US education informally and have started to incorporate this knowledge and skills into daily practice. Both senior and junior doctors perceive bedside clinical US as very useful in the practice of IM both in terms of improving accuracy of diagnosis and improving performance and safety of bedside procedures via image guidance. There is an extremely high level of interest in bedside US training. The high level of informal exposure, positive perception and high level of interest in pursuing training in bedside US training is an opportunity that may be harnessed to develop an IM training program with an anticipated high amount of participation. Significant barriers are present in the development of a bedside US training curriculum. What is also challenging is ensuring acceptable standards in the practice of point-of-care bedside US. This pilot survey may serve as a basic needs assessment to a future implementation of a formal bedside point-of-care US training curriculum in IM.

Footnotes

Appendix

A pilot survey on an understanding of Point of Care Bedside Ultrasound (POCUS) among medical doctors in internal medicine: Exposure, Perceptions, Interest and Barriers to training.

1.	Date of assessment
2.	What is your age?
3.	What is your gender?☐ MALE ☐ FEMALE
4.	Which country did you graduate from?☐ Singapore ☐ Malaysia ☐ Indonesia ☐ Philippines☐ Australia ☐ United Kingdom ☐ United States ☐ Others(_____________)
5.	Are you in any residency training program?(answer only if still a trainee)☐ YES ☐ NoIf yes, which residency training program are you in?
6.	What is your current position?☐ House Officer☐ Medical Officer (PGY 2/3/4/5/6/7/>8)(circle 1)☐ Junior Resident Y1/Y2/Y3(circle 1) (PGY 1/2/3/4/5/6/7/>8)(circle 1)☐ Senior Resident Y1/Y2/Y3(circle 1) (PGY 1/2/3/4/5/6/7/>8)(circle 1)☐ Associate Consultant☐ Consultant☐ Senior Consultant
7.	Have you ever undergone a critical care medicine posting?☐ YES ☐ No
8.	Have you ever undergone an emergency medicine posting?☐ YES ☐ No
9.	Do you know what Point Of Care Bedside Ultrasound is?☐ YES ☐ No
10.	Is Point of Care bedside Ultrasound part of your training in your residency program?☐ YES ☐ No
11.	Have you witnessed Point of Care Bedside Ultrasound performed?☐ YES ☐ No
12.	Have you ever performed Point of Care Bedside Ultrasound?☐ YES ☐ No
13.	Have you ever undergone any form of training/education in performing Point of Care Bedside Ultrasound☐ YES ☐ NoIf Yes, what kind of education/training have you obtained ( can tick more then 1)☐ Undergraduate exposure☐ Practical Course with demonstrations☐ Web base Online Course☐ Bedside Tutorials☐ Didactic Lectures☐ Self-taught via books and online resources☐ Certified program to be a qualified medical ultra-sonographer☐ Others. Please elaborate______________
14.	Do you use Point of Care Bedside Ultrasound in your clinical work?☐ YES ☐ NoIf Yes, how often do you use it(circle 1)Daily/Weekly/Monthly/Rarely
15.	If you do use Point of Care Bedside Ultrasound in your clinical work, what do you use it for? (Can tick more then 1)
15.	☐ Cardiac Ultrasound(Pericardial effusion, Ejection Fraction, RV & LV dysfunction)☐ Bedside lung ultrasound(Pleural Effusion, Pulmonary oedema, Pneumothorax, Pneumonia)☐ Abdominal(FAST examination & Ascites)☐ Liver ultrasound( Hepatic lesion)☐ Gall Bladder and bile duct evaluation☐ Spleen Ultrasound(Splenic lesion)☐ Renal Ultrasound(Renal mass and Hydronephrosis)					☐ Thyroid Evaluation☐ Skin, Soft tissue and joint evaluation(Abscess, cellulitis, Foreign body, Joint Swelling)☐ Assessment of intracranial pressure☐ Central Venous Catheter Insertion☐ Intravenous catheter insertion☐ Peripheral inserted central catheter insertion(PICC)☐ Arterial Line insertion☐ Femoral catheter insertion
	☐ Bladder volume assessment☐ Aorta Ultrasound(Aortic aneurysm)☐ Deep Vein thrombosis Evaluation☐ Inferior Vena Cava evaluation					☐ Abdominal paracentesis☐ Thoracocentesis☐ Pericardiocentesis☐ Lumbar puncture☐ Arthrocentesis and Joint injections☐ Intubation
16.	How would you rate your competency in bedside ultrasound (tick one only)☐ Very incompetentNever witnessed or use an ultrasound machine☐ Quite incompetentWitnessed bedside ultrasound but has never used an ultrasound machine☐ Neither competent or incompetentWitnessed bedside ultrasound and has performed bedside ultrasound under senior supervision☐ Quite competentWitnessed multiple bedside ultrasound and has performed bedside ultrasound at least 5 times independently☐ Very competentWitnessed multiple bedside ultrasound and has performed bedside ultrasound more than 10 times independently
17.	On a scale of 1-10(1:not useful, 10:very useful),How useful do you think Point of Care bedside ultrasound is for the following evaluation/procedures
	Bedside Cardiac Ultrasound(Pericardial effusion,Ejection Fraction, RV & LV dysfunction)
	1	2	3	4	5	6	7	8	9	10
	Bedside lung ultrasound(Pleural Effusion, Pulmonary oedema, Pneumothorax, Pneumonia)
	1	2	3	4	5	6	7	8	9	10
	Abdominal(FAST examination & Ascites)
	1	2	3	4	5	6	7	8	9	10
	Liver ultrasound( Hepatic Mass)
	1	2	3	4	5	6	7	8	9	10
	Gall Bladder and bile duct evaluation
	1	2	3	4	5	6	7	8	9	10
	Spleen Ultrasound(Splenic lesion)
	1	2	3	4	5	6	7	8	9	10
	Renal Ultrasound(Renal mass and Hydronephrosis)
	1	2	3	4	5	6	7	8	9	10
	Bladder volume assessment
	1	2	3	4	5	6	7	8	9	10
	Aorta Ultrasound(Aortic aneurysm)
	1	2	3	4	5	6	7	8	9	10
	Deep Vein thrombosis Evaluation
	1	2	3	4	5	6	7	8	9	10
	Inferior Vena Cava evaluation
	1	2	3	4	5	6	7	8	9	10
	Thyroid Evaluation
	1	2	3	4	5	6	7	8	9	10
	Skin, Soft tissue and joint evaluation(Abscess, cellulitis, Foreign body, Joint Swelling)
	1	2	3	4	5	6	7	8	9	10
	Assessment of intracranial pressure
	1	2	3	4	5	6	7	8	9	10
	Central Venous Catheter Insertion
	1	2	3	4	5	6	7	8	9	10
	Intravenous catheter insertion
	1	2	3	4	5	6	7	8	9	10
	Peripheral inserted central catheter insertion(PICC)
	1	2	3	4	5	6	7	8	9	10
	Arterial Line insertion
	1	2	3	4	5	6	7	8	9	10
	Femoral catheter insertion
	1	2	3	4	5	6	7	8	9	10
	Abdominal paracentesis
	1	2	3	4	5	6	7	8	9	10

	Thoracocentesis
	1	2	3	4	5	6	7	8	9	10
	Pericardiocentesis
	1	2	3	4	5	6	7	8	9	10
	Lumbar puncture
	1	2	3	4	5	6	7	8	9	10
	Arthrocentesis and Joint injections
	1	2	3	4	5	6	7	8	9	10
	Intubation
	1	2	3	4	5	6	7	8	9	10
18.	On a scale of 1-10(1:not useful, 10:very useful),do you think Point of Care Bedside Ultrasound is helpful in the practice of internal medicine?
18.	1	2	3	4	5	6	7	8	9	10
19.	Rank the following bedside ultrasound skills from 1 to 9(1=Wants to learn first. 9=Want to learn last) by which skill you would find most relevant and want to learn first.☐ Bedside Cardiac Ultrasound(ECHO)☐ Bedside Lung ultrasound☐ Abdominal/Liver/Gall Bladder and biliary☐ Renal Ultrasound☐ Aorta Ultrasound☐ Vascular Ultrasound/DVT/IVC Ultrasound☐ Thyroid Evaluation☐ Skin, Soft tissue and joint ultrasound☐ Procedural Bedside Ultrasound
20.	Bedside ultrasound is helpful in the practice of internal medicine for the following reasons(Rank from 1(most important to 6(least important))☐ It allows me to make more accurate diagnosis by confirming and co-relating my physical findings on the spot when physical findings may be vague.☐ It allows me to rationalize ordering detailed radiological investigations and save my patients money and time☐ It allows me to do a procedure more safely☐ It is a technologically advance piece of equipment☐ It allows for career advancement☐ It allows me to teach students eg anatomy
21.	On a scale of 1-10(1:not interested, 10:very interested),will you be interested in undergoing further education and training in point of care bedside ultrasound?
21.	1	2	3	4	5	6	7	8	9	10
22.	How interested would you be to undergoing training for bedside ultrasound if it was organized by medical school/residency program?
	1	2	3	4	5	6	7	8	9	10
	How interested would you be to undergo training for bedside ultrasound if you would have to sign up voluntarily using own personal training fund
	1	2	3	4	5	6	7	8	9	10
	How interested would you be to undergoing training in bedside ultrasound if you would have to sign up for overseas course using PTF?
	1	2	3	4	5	6	7	8	9	10
	How interested would you be to undergo training in bedside ultrasound if you have to pay for training yourself?
	1	2	3	4	5	6	7	8	9	10
23.	How much more interested will you be in undergoing bedside ultrasound training if it was possible to generate a revenue stream from performing it?☐ Not any more interested☐ Mildly more interested☐ Moderately more interested☐ Very much more interested
24.	How many hours a week would you be willing to devote to training/maintaining competency in bedside ultrasound☐ At most1 hours ☐ At most 3 hours ☐ At most 6 hours ☐ At most 12 hours☐ At most 24 hours ☐ As much as needed, even staying after work.
25.	How many accurate results must a trainee produce before you would judge him/her as being competent?☐ At least 5 ☐ At least 10 ☐ At least 20 ☐ At least 50 ☐ At least 100 ☐ More than a 100
26.	What model do you think should bedside ultrasound take for best efficiency in diagnostics and image guided procedures for patients (tick only 1 only)☐ Pocket portable machine carried around and be used when needed by physician☐ Small portable machine shared by all and pushed to patient bedside on ad hoc basis☐ Bigger machine parked in procedure room and patient pushed for examination
27.	On a scale of 1-10(1:no barrier, 10:severe barrier)What do you think are the main barriers to learning and teaching of point of care bedside ultrasound?
	Cost of training faculty members
	1	2	3	4	5	6	7	8	9	10
	Time to train faculty members
	1	2	3	4	5	6	7	8	9	10
	Cost to train learners
	1	2	3	4	5	6	7	8	9	10
	Time to train learners
	1	2	3	4	5	6	7	8	9	10
	Cost of machine
	1	2	3	4	5	6	7	8	9	10
	Lack of machine
	1	2	3	4	5	6	7	8	9	10
	Lack of interest in point of care bedside ultrasound learning
	1	2	3	4	5	6	7	8	9	10
	Lack of training space
	1	2	3	4	5	6	7	8	9	10
	Conflict with speciality(e med, critical care, radiology)
	1	2	3	4	5	6	7	8	9	10
	Steep learning curve
	1	2	3	4	5	6	7	8	9	10
	Lack of formal accreditation
	1	2	3	4	5	6	7	8	9	10
	Lack of formal training curriculum
	1	2	3	4	5	6	7	8	9	10
	Lack of mentors
	1	2	3	4	5	6	7	8	9	10
	Fear of litigation for inaccurate results
	1	2	3	4	5	6	7	8	9	10

Declaration of Conflicting Interests

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

Simonson

Schiller

. Sono spirometry: A new method for noninvasive estimation of mean right atrial pressure based on two-dimensional echographic measurements of the inferior vena cava during measured inspiration. J Am Coll Cardiol 1988; 11: 557–564.

Kircher

Himelman

Schiller

. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol 1990; 66: 493–496.

Randazzo

Snoey

Levitt

et al . Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography. Acad Emerg Med 2003; 10: 973–977.

Brennan

Blair

Goonewardena

et al . A comparison by medicine residents of physical examination versus hand-carried ultrasound for estimation of right atrial pressure. Am J Cardiol 2007; 99: 1614–1616.

Moore

Rose

Tayal

et al . Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med 2002; 9: 186–193.

Alexander

Peterson

Chen

et al . Feasibility of point-of-care echocardiography by internal medicine house staff. Am Heart J 2004; 147: 476–481.

Mandavia

Hoffner

Mahaney

et al . Bedside echocardiography by emergency physicians. Ann Emerg Med 2001; 38: 377–382.

Joyner

Jr Herman

Reid

. Reflected ultrasound in the detection and localization of pleural effusion. JAMA 1967; 200: 399–402.

Sisley

Rozycki

Ballard

et al . Rapid detection of traumatic effusion using surgeon-performed ultrasonography. J Trauma 1998; 44: 291–296; discussion 296–297.

10.

Lichtenstein

Mezière

. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: The comet-tail artifact. Intensive Care Med 1998; 24: 1331–1334.

11.

Lichtenstein

. A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest 1995; 108: 1345–1348.

12.

Goldberg

Goodman

Clearfield

. Evaluation of ascites by ultrasound. Radiology 1970; 96: 15–22.

13.

Shiloh

Savel

Paulin

et al . Ultrasound-guided catheterization of the radial artery: A systematic review and meta-analysis of randomized controlled trials. Chest 2011; 139: 524–529.

14.

Nazeer

Dewbre

Miller

. Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: A prospective, randomized study. Am J Emerg Med 2005; 23: 363–367.

15.

Patel

Ernst

Gunnarsson

. Evaluation of hospital complications and costs associated with using ultrasound guidance during abdominal paracentesis procedures. J Med Econ 2012; 15: 1–7.

16.

Jones

Moyers

Rogers

et al . Ultrasound-guided thoracentesis: Is it a safer method? Chest 2003; 123: 418–423.

17.

Feller-Kopman

. Therapeutic thoracentesis: The role of ultrasound and pleural manometry. Curr Opin Pulm Med 2007; 13: 312–318.

18.

Sibbitt

Jr Kettwich

Band

et al . Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee? Scand J Rheumatol 2012; 41: 66–72.

19.

Squire

Fox

Anderson

. ABSCESS: Applied bedside sonography for convenient evaluation of superficial soft tissue infections. Acad Emerg Med 2005; 12: 601–606.

20.

Mourad

Ranji

Sliwka

. A randomized controlled trial of the impact of a teaching procedure service on the training of internal medicine residents. J Grad Med Educ 2012; 4: 170–175.

21.

Hoppmann

Rao

Poston

et al . An integrated ultrasound curriculum (iUSC) for medical students: 4-year experience. Crit Ultrasound J 2011; 3: 1–12.

22.

Afonso

Amponsah

Yang

et al . Adding new tools to the black bag—introduction of ultrasound into the physical diagnosis course. J Gen Intern Med 2010; 25: 1248–1252.

23.

Kessler

Bhandarkar

. Ultrasound training for medical students and internal medicine residents—a needs assessment. J Clin Ultrasound 2010; 38: 401–408.

24.

Rao

van Holsbeeck

Musial

et al . A pilot study of comprehensive ultrasound education at the Wayne State University School of Medicine: A pioneer year review. J Ultrasound Med 2008; 27: 745–749.

25.

Wittich

Montgomery

Neben

et al . Teaching cardiovascular anatomy to medical students by using a handheld ultrasound device. JAMA 2002; 288: 1062–1063.

26.

American Medical Association. Policy H-230.960. Privileging for ultrasound imaging, http://www.ama-assn.org/ (accessed February 2009).

27.

American College of Emergency Physicians. ACEP emergency ultrasound guidelines—2001. Ann Emerg Med 2001; 38: 470–481.

28.

Vignon

Dugard

Abraham

. Focused training for goal-oriented hand-held echocardiography performed by non-cardiologist residents in the intensive care unit. Intensive Care Med 2007; 33: 1795–1799.

29.

Clay

. Teaching the internist to see: Effectiveness of a 1-day workshop in bedside ultrasound for internal medicine residents. Crit Ultrasound J 2016; 8: 11.

30.

Alexandra Academy for Clinical and Emergency Sonography. AACES Basic Sonographic Integrated Care (BASIC) Course, https://www.aaces.sg/basic-sonography-intergrated-care [sic] (2017, accessed 10 January 2016).

31.

Mitchell

Leng

Gardiner

et al . Using point-of-care bedside ultrasound for volume assessment in early shock: An outcome study. Chest 2016; 149 (Suppl): A148.

32.

Barsuk

Cohen

Feinglass

et al . Cost savings of performing paracentesis procedures at the bedside after simulation-based education. Simul Healthc 2014; 9: 312–318.