Point‐of‐care ultrasound: ready for prime time in internal medicine?

Point-of-care ultrasound (POCUS) is an emerging modality with the potential to enhance the care of internal medicine patients in both the inpatient and ambulatory settings. It has a well-established role in emergency departments, intensive care units and the perioperative space providing timely additional information to augment physical examination. POCUS provides real-time, bedside diagnostics to expedite clinical decision-making and can be applied to a range of organ systems to validate working diagnoses, refine differential diagnoses and monitor responses to therapy.1, 2 This is particularly useful when more formal diagnostics are not readily available. Beyond its clinical implications, POCUS has exhibited a positive impact on patient experience. Patients who receive POCUS often report increased satisfaction with their medical care and better understanding of their medical condition.3 With the advent of hand-held devices, the portability and accessibility of POCUS have improved, and this will promote its use. However, until now, adoption by general physicians in Australia and New Zealand has been limited in comparison to similar healthcare settings. While there are significant potential benefits to greater use of POCUS in internal medicine, there is a need for caution to ensure those that use POCUS are well trained, recognise its limitations and appreciate the role formal diagnostics still play in the diagnosis and management of patients. To ensure the safe, appropriate and effective use of POCUS, Australian and New Zealand general physicians require specific training and credentialling, and a specific scope of practice needs to be developed. Much can be learned from other craft groups such as the emergency and intensive care faculties in Australia and New Zealand, along with international internal medicine societies. General physicians are expert diagnosticians dealing with acute pathology across all organ systems and compounded by chronic multimorbidity. This complexity highlights not only the potential that additional diagnostics can offer but also the potentially wide scope of what may be imaged. A substantial body of evidence demonstrates the significantly greater diagnostic accuracy of POCUS when compared to physical examination alone,4 for example, for detection of pulmonary congestion. As a result, many consider POCUS to be an extension of physical examination, where the information gathered is integrated immediately into the clinical decision-making process. The decision on what to scan is ultimately tailored to clinical question(s). For example, combined cardiac, lung and deep vein POCUS in patients with respiratory symptoms significantly improves diagnostic accuracy when added to standard care2, 5 (Table 1). In addition, single-organ or localised scanning can answer a discrete diagnostic question (e.g. is there renal tract obstruction?) and safely guide procedures such as paracentesis. The evidence supports the significant utility of POCUS in internal medicine. Studies exclusively in internal medicine cohorts have demonstrated how POCUS influences clinical decision-making. Notably, primary diagnosis is modified in up to 25% of cases,5 and a consequential secondary diagnosis is made in 24% of cases.6 This valuable information triggers alterations in the management plan in up to 52% of cases.6, 7 POCUS can additionally play a crucial role in time-sensitive scenarios like medical emergency team calls and perioperative consultations within the inpatient setting, providing the generalist with a valuable tool for rapid decision-making.8, 9 In addition to enhanced clinical decision-making, POCUS has the potential to influence hospital length of stay and imaging-resource utilisation.10, 11 It not only reduces unnecessary investigations but can refine selection for further standard imaging.7 In many jurisdictions, heart failure (HF) patients (particularly those with comorbidities) are predominately cared for by general physicians and care across settings can be optimised by POCUS. Beyond the initial diagnostic role in patients presenting with dyspnoea,12-14 lung POCUS can guide diuretic therapy. This highlights its use as an easily repeatable test. By detecting residual pulmonary congestion not apparent by auscultation, lung POCUS predicts hospital readmission better than other clinical, radiographic or biochemical markers of congestion.15, 16 Indeed, outpatient HF care incorporating lung POCUS results in fewer urgent hospital visits,17 and hand-held devices allow in-home scanning, thus vastly expanding the reach of POCUS benefit in the early post-discharge phase, where readmission risk is high. In-home POCUS is in its infancy, but momentum is building owing to the move towards acute care delivery at home. In the United Kingdom, the Hospital at Home (HAH) Society makes explicit that HAH services must provide timely, hospital-level diagnostics that include POCUS. Furthermore, general physicians are well suited to deliver acute HAH programmes, but there is scope for improved POCUS expertise. This is a snapshot of the potential of POCUS in internal medicine. Only by systematically adopting this technology will its use be refined and impacts on patient care and health service delivery be known. Currently, in Australia and New Zealand, there is no dedicated POCUS training programme or credentialling pathway for general physicians. General physicians or trainees seeking to pursue POCUS training must navigate their own path. The Australian Society for Ultrasound Medicine (ASUM) offers a certificate in clinician-performed ultrasound (CCPU), providing a range of different units and requiring attendance at an approved course and completion of a logbook under appropriate supervision. ASUM also oversees the Diploma of Diagnostic Ultrasound, which is a 2-year course providing a higher level of expertise. Additionally, universities offer online courses such as the graduate certificate, diploma and masters in clinical ultrasound by the University of Melbourne. Most online courses lack continuous supervision and mandatory logbooks. Even in instances where such provisions are included, as in the CCPU, identifying an adequate number of supervisors to meet demand presents a formidable, if not insurmountable, challenge. Overall, current courses are designed for intensivists, anaesthetists, emergency physicians and others. This presents an opportunity to design training targeted to the needs of general physicians. Despite these limitations, such courses are vital to the initial phases of adoption – this is how many generalists at present will have gained basic expertise. However, tailored courses that are linked with practical application will eventually provide the best foundational training, recognising that gaining true expertise involves cumulative experience and reflective practice. In the initial phase, the shortage of experienced mentors in internal medicine may require innovative approaches to deliver proper training, such as including ultrasound simulators, sonographer educators or colleagues from other specialities. Trainees in other medical specialities may gain recognition of competency in POCUS as part of their training curriculum. A ‘recognition of competency’ in thoracic ultrasound is overseen by the Thoracic Society of Australia and New Zealand for respiratory medicine trainees, for example. The indications for and appropriate use of POCUS in general medicine must be carefully considered, acknowledging variation depending on the geography of practice and resources available, prior to developing a scope of practice and tailored training pathway. The lack of a scope of practice and, therefore, training poses challenges for the governance of POCUS at the healthcare organisation level. General physicians who have undertaken a POCUS course or qualification may not be permitted to perform POCUS at their institution. Anecdotally, governance structures vary widely from no formal structure to internal accreditation and credentialling of POCUS operators. A lack of structured governance incorporating, among other things, image archiving and structured reporting prevents quality control and educational activities.18 This may compromise learning and, at worst, patient safety. When it comes to implementing POCUS, it falls upon each medical speciality to identify techniques useful to their practice. In Australia and New Zealand, the rural and remote practice settings, where conventional diagnostic resources are less accessible, will pose unique considerations for implementation. International guidelines for the use of POCUS in internal medicine already exist, and these could be adapted to suit the Australian and New Zealand landscape. In 2019, the European Federation of Internal Medicine published a position statement that addressed the two main issues – competencies (scope of practice) and training.19 Notably, POCUS was already featured in the European curriculum for internal medicine at the time of publication; however, adoption, and indeed how it was being used, was not uniform. The statement details a symptom-based approach to scanning and establishes core competencies. Training requirements are proposed, including minimum syllabus standards and number of scans to be performed under supervision. It advocates for a recognised body responsible for the evaluation of training at teaching centres. The Canadian Internal Medicine Ultrasound group has taken a pragmatic approach to designing their curriculum, producing a limited set of applications4 that expands as postgraduate training years progress.20 Its application is defined by target or pathological findings, for example, pleural effusion, rather than a symptom-based approach. This was shaped by considering the feasibility of providing training given resource limitations and departmental expertise. In response to the need for general physicians to adopt POCUS, the Internal Medicine Society of Australia and New Zealand has formed a POCUS special interest group (SIG). The SIG will be tasked with developing a position statement that will address the scope of practice by defining core competencies, while considering approaches to scanning depending on the clinical scenario (e.g. symptom-based in acute diagnostics or targeted for specific questions or monitoring), as well as settings of POCUS use. In the short term, those already with expertise and qualifications must be recognised, and we need to understand what expertise exists and where it is located. In the medium term, however, the SIG must consider how the training of advanced trainees is overseen, delivered and implemented to allow credentialling. Advice relevant to implementing local POCUS governance structures and infection control procedures should be given, acknowledging this is outside the jurisdiction of the group. Finally, there must be close engagement with the Royal Australasian College of Physicians advanced training committee for general and acute medicine to ensure feasibility within the curriculum and training settings. All these aspects are vital to widespread, successful implementation; the time is now. We would like to acknowledge Dr. Drew Comeau (Townsville University Hospital) for insights relating to POCUS training.

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