The Value of Sonography Education Faculty in an Academic Emergency Ultrasound Program

Abstract

Within the West Virginia University (WVU) Department of Emergency Medicine (DEM), education related to point-of-care ultrasound (POCUS) has been under the jurisdiction of the POCUS director in the emergency department. To facilitate sonography education and extend the capabilities of the POCUS director, a dedicated sonography education faculty member (SEFM) was hired. A SEFM is an experienced sonographer who brings technical knowledge, experience, and pedagogical skills. In addition, the SEFM is able to assist with administrative and operational aspects of a POCUS program, including image archival, disinfection protocols, and quality guidelines. From the sonographer’s prospective, the position has been challenging and fulfilling, and there remain countless opportunities for growth. From the POCUS director’s perspective, the SEFM has been instrumental in strengthening the residency program and other educational offerings.

The workload for an emergency point-of-care ultrasound (POCUS) director has a complex scope of administrative, operational, clinical, and educational duties. These duties are typically added to an academician’s other teaching responsibilities and are further complicated by their research and scholarly obligations. As most POCUS programs begin, there is little financial support to justify physician expert costs and time away from clinical duties.

One solution that has been successfully implemented is the addition of a dedicated sonography education faculty member (SEFM) to the POCUS division. A SEFM is a skilled sonography professional with extensive experience in clinical sonography and in adult clinical education. These professionals serve to augment educational offerings and extend the capabilities of the US director in addition to assisting with administrative and operational aspects of a POCUS program.

While informal conversations at scientific meetings suggest some academic emergency medicine programs have incorporated sonographers into their educational teams, there are few published descriptions or data regarding their roles. Cormack et al. ¹ reported a successful collaboration between a radiology and emergency department with appointment of a sonography educator who helped lead educational and quality aspects of the program with attending emergency physicians. A pilot study incorporating a sonography educator for medical students during internal medicine physician rounds has been reported with positive results. ²

This symposium highlights the experience incorporating a SEFM into the POCUS division at West Virginia University (WVU) within the Department of Emergency Medicine (DEM). It also describes the benefits for learners, faculty, and the institution. Also included are personal perspectives from both the SEFM and POCUS director regarding this unique professional path.

History and Implementation of a SEFM

As of 2006, the WVU DEM, a tertiary academic referral center in Appalachia, had no dedicated sonography faculty, no defined residency clinical US experience, and a single Sonosite 180 (Fujifilm Sonosite, Bothell, WA, USA) with no process for image capture or documentation of findings.

In 2007, a new graduate of the program was asked to become director of the POCUS division within the DEM. The work of a new POCUS director is complex. Working with hospital information technology (IT), biomedical engineering, compliance, billing, and electronic medical records were all essential to the development of the unit. In addition to these technical barriers, the POCUS director was still responsible for image review, quality assurance, developing and delivering didactic and practical sessions for residents and faculty, and developing assessment for residents. From 2007 until 2011, lacking additional faculty trained in POCUS, the director was solely responsible for all facets of development, implementation, and management of the POCUS program.

It was envisioned that some of the functions of a POCUS director could be performed and augmented by an experienced, professional sonographer. Sonographers generally have robust clinical experience with extensive knowledge of sonographic physics, instrumentation, relevant anatomy, and machine maintenance. In addition, sonographers bring administrative strength in archiving, documentation, and compliance. The WVU DEM hired the first SEFM in 2011. Initially, the position centered on educational initiatives for medical students and residents. Over time, the SEFM position grew, becoming very active in all aspects of the program: administrative, operational, technical, education, and even research and curricular development.

Responsibilities

Currently, the SEFM holds a myriad of responsibilities. Above all is the instructional responsibility to all levels of study, from medical students to faculty. This is achieved through hands-on bedside scanning of patients in the DEM and teaching sessions alongside POCUS faculty within the simulation center. In addition to the instructional shifts, there are also administrative tasks and research opportunities for the SEFM.

During a scanning shift in the DEM, the SEFM may have several designated learners, including medical students on a sonography elective, as well as residents and/or fellows from multiple disciplines. During these shifts, the SEFM assists with both diagnostic and educational POCUS scans. The SEFM helps identify patients who may benefit from bedside scans and joins the learner at the patient’s bedside, providing real-time guidance and hands-on teaching. They can then discuss findings and related relevant ultrasound education immediately following the examination. Additional clinical integration and further instruction are sought from the physician, who is present in the clinical environment.

Other educational responsibilities include routine image review sessions with learners to provide direct feedback on scans. The SEFM is actively involved with the clinical sonography fellowship, including interviewing and evaluating candidates, assisting with image review, and leading didactic sessions. The SEFM also participates in research projects, identifying topics of study, collecting and analyzing data, and writing manuscripts.

Administratively, the SEFM acts as the imaging expert, performing analysis and implementing image correction through quality assurance. In addition, the SEFM also maintains the DEM’s picture archiving and communication system (PACS) and image archives, preserving a clean database and ensuring highly functional equipment. They also act as a point of contact for equipment maintenance and engage in problem solving relative to equipment functionality. Finally, the SEFM remains up to date on sonography billing and documentation to serve as a resource for providers.

The POCUS Director’s Perspective

As a new POCUS director for an academic DEM and without having prior significant training in program management, developing a new POCUS program was a significant undertaking. From the early stages, it was felt that the skills of an experienced sonographer would benefit both the director and the program as a whole. The DEM began the process of writing a job description, gaining approval for the position, and then searching for the best candidate. The search focused on sonographers with experience teaching in a sonography education program. The first SEFM had approximately 20 years of sonography experience, including previous supervisory roles and over 10 years as a sonography education coordinator. The newly hired sonographer educator had an immediate impact as she served as a resource for the director, faculty, and learners at all levels. Her expertise in the implementation of a clinical POCUS accelerated the department’s capabilities clinically with improved documentation, quality review, disinfection, and general sonographic knowledge. She was able to significantly relieve the burden of the POCUS director’s quality review duties, while assisting in the development and delivery of POCUS didactic content to all levels of learners. Her comprehensive sonographic acumen became a foundation to the POCUS division’s research and scholarship, as well as coauthoring several manuscripts with faculty.

The Sonographer’s Perspective

Helping providers and future physicians learn a skill they will use throughout their careers can be both challenging and fulfilling. The duties of a SEFM can include teaching introductory concepts to first-year medical students, polishing the skills of a fourth-year student developed through the curriculum, assisting residents with technically difficult studies, and supporting staff physicians providing patient care. Each day working as a SEFM brings new opportunities for teaching. Working closely with POCUS faculty physicians allows the SEFM to expand their clinical education and skills in unexpected ways. Besides learning examinations not routinely performed in a radiology setting, a SEFM has abundant opportunities to observe practical teaching methods from POCUS faculty, as well as developing unique instructional strengths.

One challenge of the position is developing the confidence required to teach physicians. A full scope of practice and clinical standards protocol, established by the Society of Diagnostic Medical Sonography (SDMS), maintains that a diagnostic sonographer functions “as a delegated agent of the physician.” ³ This includes patient assessment, education and communication, analysis of protocol for the procedure, implementation of the procedure, and evaluation and documentation of the procedure for review by the supervising physician. So, while not ultimately responsible for examination interpretation, due to the nature of POCUS education for early career physicians, it is necessary to be confident in diagnostic findings that directly affect patient care. This requires extensive knowledge of current sonographic practices, in addition to continuing education on constantly evolving applications and techniques.

The SEFM role in quality assurance, through image review, requires an especially high level of concentration and attention to detail. Constructive feedback to POCUS learners is critical for sonography competency. Although challenging and somewhat repetitive, this responsibility is useful to learners and allows for ongoing expansion of didactical approaches. This difficulty is offset by the ability to perform this work remotely and flexibly, which is a rare job benefit in the field of health care.

The SEFM position creates another opportunity to explore US education apart from sonography education programs. It allows the SEFM to increase their knowledge and advance their education and career opportunities within the field. The DEM setting is unique and stimulating, and the education, experience, and knowledge of the SEFM are respected from a variety of physicians. The SEFM is viewed as a resource to encourage physicians to use sonography more confidently, accurately, and often.

Outcomes

Since adding a SEFM to the POCUS division, the program and educational offerings have grown exponentially. Some selected highlights include the following:

• Seven thousand POCUS studies per year archived, documented, and billed for a 50,000 annual emergency department patient volume

• A total of seven full-time faculty and a fellowship program in emergency POCUS

• Sonography now a noted strength in our DEM’s residency program

• Other departments continuing to seek expertise and educational opportunities from within the DEM

• Development of 4th year POCUS elective and a longitudinal sonography curriculum, within our medical school

None of these accomplishments would have been possible without the continued efforts and expertise of the SEFM.

Conclusions

The addition of a SEFM has been an overwhelmingly positive experience within the academic institution. It is anticipated that there will be continued expansion of educational offerings, as well as DEM hiring an additional SEFM. The division hopes to continue to partner with the wider sonography community to better incorporate POCUS, while leveraging the knowledge and technical skills of sonographers. It is hoped that this will allow for ongoing professional development for sonographers, including faculty appointments within the School of Medicine, increased research participation, and greater roles and responsibilities in the clinical environment.