The Current State of Ultrasound Training in ... - Wiley Online Library

EDUCATIONAL ADVANCE

The Current State of Ultrasound Training in Canadian Emergency Medicine Programs: Perspectives From Program Directors Daniel J. Kim, MD, Jonathan Theoret, MDCM, Michael M. Liao, MD, Emily Hopkins, MSPH, Karen Woolfrey, MD, and John L. Kendall, MD

Abstract Objectives: There is a paucity of data about emergency ultrasound (EUS) training in emergency medicine (EM) residency programs accredited by the Royal College of Physicians and Surgeons of Canada (Royal College) and the College of Family Physicians of Canada (CFPC). Historically the progress of EUS in Canada has been different from that in the United States. We describe the current state of EUS training in both Royal College and CFPC-EM programs. Methods: All Royal College EM program directors and all CFPC-EM program directors were invited to participate in a website-based survey. Main outcome measures were characteristics of currently offered EUS training. Results: The response rate of the survey was 100% (30 ⁄ 30). EUS is part of the formal residency curriculum in 100% (13 ⁄ 13) of Royal College EM programs and in 88% (15 ⁄ 17) of CFPC-EM programs. EM resident rotations in ultrasound (US) are provided by 77% (10 ⁄ 13) of Royal College programs but only 47% (8 ⁄ 17) of CFPC-EM programs. There are specific requirements for numbers of EUS exams to be completed by graduation in 77% (10 ⁄ 13) of Royal College programs and 47% (8 ⁄ 17) of CFPC-EM programs. EM faculty and residents make clinical decisions and patient dispositions based on their EUS interpretation without a consultative study by radiology in 100% (13 ⁄ 13) of Royal College programs and 88% (15 ⁄ 17) of CFPC-EM programs. However, 69% (9 ⁄ 13) of Royal College programs and 53% (9 ⁄ 17) of CFPC-EM programs have no formal quality assurance program in place. Conclusions: EUS training in Canadian EM programs is prevalent, but there are considerable discrepancies among residency programs in scope of training, curricula, determination of proficiency, and quality assurance. These findings suggest variability in both the level and the quality of EUS training in Canada. ACADEMIC EMERGENCY MEDICINE 2012; 19:1073–1078 ª 2012 by the Society for Academic Emergency Medicine

From the Division of Emergency Medicine, Department of Medicine, University of Toronto (DJK, KW), Toronto, Ontario, Canada; the Department of Emergency Medicine, University of British Columbia (JT), Vancouver, British Columbia, Canada; the Department of Emergency Medicine, Royal Columbian Hospital (JT), New Westminster, British Columbia, Canada; the Department of Emergency Medicine, Denver Health Medical Center (MML, EH, JLK), Denver, Colorado; and the Department of Emergency Medicine, University of Colorado School of Medicine (MML, JLK), Aurora, Colorado. Received January 16, 2012; revision received March 21, 2012; accepted April 11, 2012. Dr. Liao was supported by the Agency for Healthcare Research and Quality (F32 HS018123); Ms. Hopkins is supported in part by Colorado Department of Public Health and Environment for her position as a project manager; Dr. Theoret is a paid teacher for Rocky Mountain Ultrasound, a commercial ultrasound course provider; and the rest of the authors have no disclosures or conflicts of interest to report. Supervising Editor: Nicole M. DeIorio, MD. Address for correspondence and reprints: Daniel Kim, MD; e-mail: dkim000@gmail.com.

ª 2012 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2012.01430.x

ISSN 1069-6563 PII ISSN 1069-6563583

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ULTRASOUND TRAINING IN CANADIAN EM PROGRAMS

La Situación Actual de la Formación en Ecografía en los Programas de Medicina de Urgencias y Emergencias de Canadá: Perspectivas de los Directores del Programa Resumen Objetivos: Existe escasa información sobre la formación en ecografía urgente (EU) en los programas de residencia de Medicina de Urgencias y Emergencias (MUE) acreditados por el Royal College of Physicians and Surgeons de Canadá (RCPS) y por el College of Family Physicians de Canadá (CFPC). Históricamente, el progreso de la EU en Canadá ha sido diferente al de Estados Unidos. Se describe la situación actual de la formación en EU tanto en los programas de MUE del RCPS como del CFPC. Método: Se invitó a todos los directores del programa de MUE del RCPS y del CFPC a participar en una encuesta electrónica. Los principales resultados recogidos fueron los tipos de formación en EU actualmente ofertados. Resultados: El porcentaje de respuesta de la encuesta fue del 100% (30 ⁄ 30). La EU es parte del plan oficial de formación de la residencia en el 100% (13 ⁄ 13) de los programas de MUE del RCPS y en el 88% (15 ⁄ 17) del CFPC. El 77% (10 ⁄ 13) de los programas del RCPS incluye rotaciones en EU para los residentes de MUE, pero sólo el 47% de los del CFPC. Se requiere realizar un número de exámenes específicos de EU para graduarse en el 77% (10 ⁄ 13) de los programas del RCPS y en el 47% (8 ⁄ 17) de los del CFPC. Los residentes y profesores de MUE toman decisiones clínicas y de ubicación del paciente basándose en sus interpretaciones de la EU sin consultar con radiología en el 100% (13 ⁄ 13) de los programas del RCPS y el 88% (15 ⁄ 17) de los del CFPC. Sin embargo, el 69% (9 ⁄ 13) de los programas del RCPS y el 53% (9 ⁄ 17) de los del CFPC no tienen un programa oficial que garantice in situ la calidad. Conclusiones: La formación en EU en los programas de MUE en Canadá es prevalente, pero existen discrepancias considerables entre los programas de residencia en el ámbito de la formación, el plan de estudios, la determinación de la competencia y la garantía de la calidad. Estos hallazgos sugieren variabilidad tanto en el nivel como en la calidad de la formación en EU en Canadá.

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mergency ultrasound (EUS) development in Canada has followed a very different trajectory from that in the United States. The Canadian Association of Emergency Physicians (CAEP) initially issued a position statement in 1999 supporting the availability of ultrasound (US) 24 hours per day. It used tempered language, stating that emergency physicians (EPs) could be among the providers, including radiologists, to perform focused US in the emergency department (ED).1 It was not until 2006 that CAEP issued an updated position statement with a much stronger endorsement for both the training and the use of EUS by EPs. This position statement supported the incorporation of EUS training into emergency medicine (EM) residency programs accredited by the Royal College of Physicians and Surgeons of Canada (Royal College), as well as the College of Family Physicians of Canada (CFPC).2 From 2008, EUS was officially introduced as a core competency to the Royal College EM training standards.3 The CFPC also introduced EUS as one of its terminal training objectives in the 2010 national guidelines for CFPC-EM programs.4 The timeline of EUS development in the United States started much earlier, when the American College of Emergency Physicians (ACEP) first published a position statement supporting the use of US by appropriately trained physicians, including EPs, in 1990.5

Starting in 1996, the Accreditation Council for Graduate Medical Education (ACGME) EM core curriculum required EUS competence for residency graduation.6 Additionally, many prominent EM and non-EM organizations have issued position statements supporting the use of EUS, including ACEP,7 the Society for Academic Emergency Medicine (SAEM),8 the Council of Emergency Medicine Residency Directors (CORD),9 and the American Institute of Ultrasound in Medicine (AIUM).10 Although EUS training has been well described in the United States,11 this is not the case for Canada. There are currently no data about the state of EUS training in Royal College EM residency programs and only a paucity of data about US training in CFPC-EM programs.12 This is likely due to the very recent implementation of EUS as a training objective in Canadian EM residency programs. The objective of this study was to describe the current state of EUS training in Royal College and CFPC-EM programs according to Canadian EM program directors. METHODS Study Design This was an online survey study approved by the Sunnybrook Health Sciences Research Ethics Board.

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Study Setting and Population All Royal College EM program directors (13 total) and all CFPC-EM program directors (17 total) across Canada were invited to participate in this study. Program director names and contact information were acquired from the Canadian Resident Matching Service (CaRMS) website.13 Study Protocol A survey instrument (Data Supplement S1, available as supporting information in the online version of this paper) was designed by the study investigators based on previously published survey studies focusing on EUS training and performance.11,14 Five academic EPs reviewed the survey for language and ease of use. Their comments were incorporated into the revision of this instrument. Potential program director participants were e-mailed a link to the website-based survey on Zoomerang (MarketTools Co., San Francisco, CA) in January 2011. The survey consisted of 26 mandatory close-ended questions, assessing US infrastructure, training, and perceptions. Nonrespondents were sent reminder e-mails at 2, 4, 6, and 8 weeks after the initial e-mail. All respondents were deidentified from their responses after completion of the survey. Data Analysis Data were analyzed with Microsoft Excel (Microsoft Corp., Redmond, WA), and descriptive statistics are reported using medians, interquartile ranges (IQRs), and ranges or number and proportion where appropriate.

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Table 1 Breakdown of Ultrasound Training Provided to EM Residents in Canada for Royal College and Family Physician EM Programs

Diagnostic Training Provided None FAST Intrauterine pregnancy Abdominal aortic aneurysm Cardiac Biliary ⁄ right upper quadrant Renal ⁄ urinary tract Deep vein thrombosis Soft-tissue ⁄ musculoskeletal Thoracic (pleural effusion, pneumothorax) Ocular Procedural guidance

Royal College Programs (n = 13), n (%) 0 13 11 13 13 3 3 5 5 6

(0) (100) (85) (100) (100) (23) (23) (38) (38) (46)

1 (8) 12 (92)

CFPC-EM Programs (n = 17), n (%) 0 17 15 17 17 1 1 1 2 3

(0) (100) (88) (100) (100) (6) (6) (6) (12) (18)

1 (6) 11 (65)

The Royal College of Physicians and Surgeons of Canada EM program is a 5-year post-graduate residency program specializing in EM. The CFPC-EM program is a 1-year fellowship program specializing in EM that can only be pursued after successful completion of a 2-year postgraduate family medicine residency program. CFPC-EM = College of Family Physicians of Canada-Emergency Medicine; FAST = focused assessment with sonography for trauma.

Table 2 Breakdown of Ultrasound Guided Procedural Training Provided to EM Residents in Canada for Royal College and Family Physician EM Programs

RESULTS All 30 potential program director participants completed the survey for a response rate of 100%. EUS is part of the formal residency curriculum in 100% (13 ⁄ 13) of Royal College EM programs and in 88% (15 ⁄ 17) of CFPC-EM programs. EUS has been part of the curriculum for a median of 4 years (IQR = 1.5 to 5 years, range = 1 to 10 years) in Royal College programs and a median of 3 years (IQR = 2 to 6 years, range = 2 to 7 years) in CFPC-EM programs. All programs have their own dedicated US equipment in the ED. There is a faculty member with the role of EUS director ⁄ coordinator in 11 of 13 (85%) Royal College programs, but only two (15%) have an affiliated EUS fellowship. Similarly, 15 of 17 (88%) CFPC-EM programs have an EUS director ⁄ coordinator, but only three (18%) have an affiliated EUS fellowship. Of programs without EUS fellowships, the majority (8 of 11 [73%] Royal College programs and 10 of 14 [71%] CFPC-EM programs) have no plans to introduce this type of program in the future. Table 1 outlines EUS applications for which programs provide training to their residents. Table 2 summarizes training in EUS-guided procedures. EM resident rotations in US are provided by 10 of 13 (77%) Royal College programs and eight of 17 (47%) CFPC-EM programs, but this is a mandatory rotation for only two (15%) Royal College programs and five (29%) CFPC-EM programs. Furthermore, three of 13 (23%) Royal College programs and nine of 17 (53%) CFPC-EM programs have no US rotation at all. The majority (10 of 13 [77%])

Procedural Training None Arterial line placement Arthrocentesis Central line placement Foreign body removal Incision and drainage Lumbar puncture Paracentesis Pericardiocentesis Peripheral venous cannulation Peritonsillar abscess incision and drainage Thoracentesis Transvenous pacemaker insertion

Royal College Programs (n = 13), n (%) 1 3 3 12 4 5 1 4 4 5

(8) (23) (23) (92) (31) (38) (8) (31) (31) (38)

CFPC-EM Programs (n = 17), n (%) 2 2 0 14 1 4 1 2 1 1

(12) (12) (0) (82) (6) (24) (6) (12) (6) (6)

0 (0)

0 (0)

3 (23) 2 (15)

2 (12) 0 (0)

CFPC-EM = College of Family Physicians of Canada-Emergency Medicine.

of Royal College programs have specific requirements for numbers of EUS examinations to be completed by graduation, but less than half (eight of 17 [47%]) of CFPC-EM programs have such requirements. The faculty that provide EUS training come almost exclusively from EM backgrounds: 100% (13 of 13) in Royal College programs and 94% (16 of 17) in CFPC-EM programs. The only program for which this is not the

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Table 3 EUS Instructional Material Provided to EM Residents in Canada for Royal College and Family Physician EM Programs

Instructional Material Provided None Animal model Computer simulation DVD ⁄ CD program Journal articles Mannequin or manufactured model Online education resource Textbook Ultrasound course

Royal College Programs (n = 13), n (%) 0 0 2 7 5 6

(0) (0) (15) (54) (38) (46)

3 (23) 7 (54) 12 (92)

CFPC-EM Programs (n = 17), n (%) 1 0 1 5 2 5

(6) (0) (6) (29) (12) (29)

1 (6) 3 (18) 16 (94)

CFPC-EM = College of Family Physicians of Canada-Emergency Medicine; EUS = emergency ultrasound.

Table 4 Methods of Determining Competency in EUS in Canada for Royal College and Family Physician EM Programs

Method of Determining Competency None Certification from an ultrasound course Direct observation of performance Number of studies Objective standardized clinical exam (OSCE) Still image review Video review Written test

Royal College Programs (n = 13), n (%)

CFPC-EM Programs (n = 17), n (%)

0 (0) 11 (85)

1 (6) 11 (65)

12 (92)

12 (71)

10 (77) 1 (8)

9 (53) 0 (0)

7 (54) 7 (54) 9 (69)

5 (29) 5 (29) 6 (35)

CFPC-EM = College of Family Physicians of Canada-Emergency Medicine; EUS = emergency ultrasound.

case uses critical care physicians, in addition to EM staff, to teach US. Table 3 breaks down the different types of EUS instructional material provided by residency programs to their residents. Table 4 reports how EM programs determine competency in EUS. In 100% (13 of 13) of Royal College programs and 88% (15 of 17) of CFPC-EM programs, EM faculty and residents make clinical decisions and patient dispositions based on their EUS interpretation without a consultative study by radiology. However, the majority of programs (nine of 13 [69%] Royal College programs and nine of 17 [53%] CFPC-EM programs) have no formal quality assurance program in place for the use of EUS by EM staff and residents. DISCUSSION Bedside US is a paradigm shift from traditional consultative imaging, to the concept of performing a focused study in real time to allow direct correlation with the patient’s signs and symptoms. It has been shown to

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improve outcomes, decrease costs, and decrease complications.15 Prior research has demonstrated that the primary barrier to the implementation of EUS into community EM practice is lack of education.16 The majority of EUS education in the United States occurs during EM residency training.11 Similar data for Canada have been described by Woo et al.,12 but that work dates to 2006 and focused exclusively on CFPC-EM programs. The progression of EUS in Canada has been characterized by a significant amount of resistance by radiology,17 and as recently as 2006, the Canadian Association of Radiologists published a position paper on portable US in the ED stating that there is a ‘‘growing body of evidence demonstrating the potential harm of misdiagnosis as a result of portable US exams performed by inexperienced operators who have a substandard level of training.’’18 This may partially explain the difference in EUS guideline development between Canada and the United States. Another contributing factor is the difference in EM training in Canada compared to the United States. While the United States has both 3- and 4-year ACGME-accredited EM programs, Canada has two EM training streams: a 5-year EM residency program administered by the Royal College and a 1-year EM fellowship program administered by the CFPC for individuals who have completed a 2-year family medicine residency. Our data demonstrate that all Royal College programs and the vast majority of CFPC-EM programs in Canada provide EUS training as part of their residency curriculum. However, this is a relatively new phenomenon, as EUS training has been part of residency curriculums for a median of only 3 to 4 years. There has been a modest increase in EUS training in CFPCEM programs compared to 2006, when Woo et al.12 reported that 71% of CFPC-EM programs offered US training. The majority of programs have a faculty member with the role of EUS director ⁄ coordinator, but only a few programs have an affiliated EUS fellowship program. One potential measure of a successful US training program is whether decisions related to patient care and disposition are made from the EUS exam interpretation. We found that the vast majority of programs make clinical decisions and patient dispositions based on their EUS interpretation without a consultative study by radiology. However, the majority of programs have no formal quality assurance process in place for the use of EUS by EM staff and residents. This is concerning, given that the goals of an EUS quality assurance process are to maximize patient safety and maintain a high quality of care. This is also concerning from the perspective that little has changed in CFPC-EM programs since 2006, as at that time, more than half (57%) of programs had no formal quality assurance processes for EUS.12 CAEP supports the principle of incorporating a strong quality improvement program for the use of EUS into the overall ED quality improvement program.2 ACEP states that quality assurance systems are an integral part of any US program.7 This seems to be a deficiency in current Canadian EM residency programs. While EUS training is prevalent, the scope of training is limited to focused assessment with sonography for

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trauma (FAST), intrauterine pregnancy, abdominal aortic aneurysm, cardiac, and procedural guidance. This scope satisfies both the 2008 Royal College objectives of training in EM3 and the 2010 CFPC-EM educational objectives.4 However, this is a smaller scope of practice than is found in the 2008 ACEP EUS guidelines.7 These guidelines additionally list biliary, urinary tract, deep vein thrombosis, soft tissue ⁄ musculoskeletal, thoracic, and ocular as core EUS applications. The 2006 CAEP position statement provides no specific guidance about which EUS applications should be incorporated into EUS training.2 CAEP also provides no specific guidelines for how training should be delivered and how competency should be determined.2 This possibly explains why 77% of Royal College programs and only 47% of CFPC-EM programs have specific requirements for numbers of EUS scans by graduation. Furthermore, there is variability in the ways in which competency is determined. Alternatively, the ACEP guidelines outline specific requirements: a minimum of 150 total EUS examinations and at least 25 documented and reviewed cases in each of the core applications.7 Despite these requirements, a recent survey of ACGME EM residency programs reported that 35% of respondents did not meet these criteria.19 This may reflect the fact that current training recommendations by CAEP,2 ACEP,7 SAEM,8 CORD,9 and AIUM10 are largely based on expert opinion. There are additional differences between programs for US rotations. There is no US rotation in 23% of Royal College programs and 53% of CFPC-EM programs. Comparing this to the United States, 95% of respondents reported offering a formal US rotation.19 The difference between Royal College and CFPC-EM programs is not surprising, given the difference in duration between the two training streams. CFPC-EM program directors and curriculum developers may feel limited by having to structure their curriculum within a 1-year period. As a result, they may be less likely to incorporate EUS as a formal rotation in their programs. Despite this, the majority of programs do provide an US course as instructional material to their residents.

discrepancies among EM residency programs in scope of training, curricula, determination of proficiency, and quality assurance. These findings suggest variability in both the level and the quality of emergency ultrasound training and a potential role for national guidelines to standardize ultrasound training for all EM residency programs. Future research is needed to determine the best methods for delivering emergency ultrasound education, determining proficiency, and managing quality assurance.

LIMITATIONS This study specifically surveyed program directors and reported their responses. As these responses are based on the perceptions of each program director, they may not reflect the positions of the actual programs. One of the authors (KW) is a program director who completed the survey. To accurately describe EUS training in all EM residency programs in the country (given the 100% response rate), her responses are included. This should be considered when interpreting the results. Finally, the survey instrument was designed by the study investigators and is not a formally validated survey tool. CONCLUSIONS Emergency ultrasound training in Canadian EM programs is prevalent, but there are considerable

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References 1. Canadian Association of Emergency Physicians. Ultrasonography in the Emergency Department, 1999 Position Statement. Available at: http://caep. ca/resources/position-statements-and-guidelines/ ultrasonography-ed-1999. Accessed Mar 12, 2012. 2. Emergency Department Targeted Ultrasound Interest Group, Canadian Association of Emergency Physicians. Emergency department targeted ultrasound: 2006 update. CJEM. 2006; 8:170–1. 3. Royal College of Physicians and Surgeons of Canada. Objectives of Training in Emergency Medicine. Available at: http://rcpsc.medical.org/residency/ certification/objectives/emergmed_e.pdf. Accessed Jun 21, 2012. 4. Mackey DS, Steiner IP (eds). National Guidelines: Family Medicine - Emergency Medicine Residency Programs. Available at: http://www.cfpc.ca/uploaded Files/Education/FamilyMed-EMResidencyPrograms(1). pdf. Accessed Jun 21, 2012. 5. American College of Emergency Physicians. Council resolution on ultrasound. ACEP News. 1990 Nov. 6. Accreditation Council for Graduate Medical Education. Emergency Medicine Guidelines. Available at: http://www.acgme.org/acWebsite/RRC_110/110_ guidelines.asp. Accessed Jun 21, 2012. 7. American College of Emergency Physicians. Emergency Ultrasound Guidelines. Available at: http:// www.acep.org/WorkArea/linkit.aspx?LinkIdentifier= id&ItemID=32878. Accessed Jun 21, 2012. 8. Society for Academic Emergency Medicine. Ultrasound Position Statement. SAEM Newsletter. 1991; 3:3. 9. Akhtar S, Theodoro D, Gaspari R, Tayal V, Sierzenski P, LaMantia J, et al. Resident training in emergency ultrasound: consensus recommendations from the 2008 Council of Emergency Medicine Residency Directors conference. Acad Emerg Med. 2009; 16(Suppl 2):S32–6. 10. American Institute of Ultrasound in Medicine. AIUM officially recognizes ACEP Emergency Ultrasound Guidelines. AIUM Sound Waves Newsletter. Available at: http://www.aium.org/soundWaves/ article.aspx?aId=442&iId=20111117. Accessed Jun 21, 2012. 11. Counselman FL, Sanders A, Slovis CM, Danzl D, Binder LS, Perina DG. The status of bedside ultrasonography training in emergency medicine residency programs. Acad Emerg Med. 2003; 10:37–42. 12. Woo MY, Nussbaum C, Lee AC. Emergency medicine ultrasonography: national survey of family

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medicine-emergency medicine program directors. Can Fam Physician. 2009; 55:1010–1. Canadian Resident Matching Service (CaRMS). About CaRMS. Available at: http://www.carms.ca/ eng/index.shtml. Accessed Jun 21, 2012. Moore CL, Gregg S, Lambert M. Performance, training, quality assurance, and reimbursement of emergency physician-performed ultrasonography at academic medical centers. J Ultrasound Med. 2004; 23:459–66. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011; 364:749–57. Moore CL, Molina AA, Lin H. Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography. Ann Emerg Med. 2006; 47:147–53. McPhee D. A radiologist’s perspective. CJEM. 1999; 1:123–4.

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18. Choi D. Emergency ultrasound: a stethoscope extension? CJEM. 2008; 10:579–80. 19. Ahern M, Mallin MP, Weitzel S, Madsen T, Hunt P. Variability in ultrasound education among emergency medicine residencies. W J Emerg Med. 2010; 11:314–8. Supporting Information The following supporting information is available in the online version of this paper: Data Supplement S1. Survey instrument for emergency medicine program directors. The document(s) is (are) in PDF format. Please note: Wiley Periodicals Inc. is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.