Insights on Residency Training

Welcome, everyone! I am thrilled at the prospect of sharing with you my thoughts on issues that pertain to residency training during the current academic year.

I recently attended the Fundamentals of Critical Care Ultrasound course hosted by the Society for Critical Care Medicine (SCCM). It was well attended by a mix of intensivits, anesthesiologists, and emergency medicine physicians all looking to further their practices with ultrasound skills that can be utilized on a daily basis. In two days, we gained a working ability to evaluate basic cardiac function, identify significant pericardial and pleural effusions, recognize ultrasound signs associated with a pneumothorax, perform a DVT screening exam, assess volume status, and obtain vascular access.  

Informally, I polled a handful of the faculty on whether they teach their residents these skill sets. While the emergency medicine and anesthesiology faculty generally incorporated routine use of ultrasound in their teaching, few internal medicine faculty said that they do. Increasingly, internal medicine programs integrate technology in the form of iPads and smart phones into their curriculums, yet few programs teach ultrasound.

During the evenings/nights when attendings and fellows are typically away from the hospital, resident interpretations of chest radiographs, CT scans, and EKGs have are routine elements used to aid clinical decision-making. Similarly, ultrasound can and should be used in a variety of settings as an extension of the physical exam.

A needs assessment¹ of medical students and internal medicine residents conducted in 2010 showed a clear desire to integrate ultrasound training into established curriculums. The natural question asked: is it feasible to teach internal medicine residents basic ultrasound skills that are readily applied to clinical care? Without hesitation, I would answer yes!

While a growing body of evidence in the emergency medicine and even medical school curriculum literature highlight successful implementation of an ultrasound curriculum, less has been published with respect to internal medicine residency programs. Several small studies have shown the effectiveness of ultrasound simulation modules², resident-driven assessment of cardiovascular function using ultrasound³, and heightened procedural confidence with ultrasound⁴.

While our residents at the University of Chicago have been using ultrasound for years to aid in procedures, we have not utilized a consistent curriculum. The brainchild of a former Chief Resident, Dr. James Town, we are in the midst of creating a standardized ultrasound curriculum for the internal medicine residency program. The curriculum provides formalized instruction on easy-to-acquire skills: using ultrasound for central venous access, measurement of IVC and IJ diameters for volume assessment, and DVT screening. Planned elements for the next phase of education will include ultrasound use for thoracentesis/paracentesis, evaluation of cardiac function, and identification of a pneumothorax.

Starting this year, we conducted formal ultrasound training sessions for nearly all of our housestaff. Following a pre-test and introductory lecture, interns and residents practiced ultrasound skills in groups of three or four on live models with the aid of a faculty member.

We also plan to host weekly “office hours” whereby trained faculty members in pulmonary/critical care and cardiology will be available on the wards to review images/clips that residents save onto USB drives. In addition, we are developing an ultrasound library of collected images/clips that can be used for future teaching and training.

Ultimately our goal is to create a proficiency list of ultrasound skills each resident must accomplish by the time he or she graduates. While it might take years before the American Board of Internal Medicine mandates residents have competency in ultrasound use, there is no question that ultrasound will increasingly find its way into internal medicine graduate medical education. Better to start sooner rather than later!

1. J Clin Ultrasound 2010 Oct; 38:401.
2. BMC Med Educ 2011 Sep 28; 11:75.
3. J Hosp Med 2012 Sep; 7:537.
4. J Grad Med Educ 2012 Jun; 4:170.