Building Curricula from the Ground Up: Developing a List of Essential Competencies in Ultrasound in Family Medicine Training Matt Chan, MD, OHSU FM R4 Kim Insel, MD, MPH, OHSU FM Associate Professor Jason Yost, MD, OHSU Cascade Easts FM , Associate Professor

Disclosures I have no financial disclosures

Point of Care Ultrasound POCUS is fully immersed in Emergency Medicine as an augmentation and diagnostic tool, with established curriculums and fellowships It is slowly becoming integrated into Internal Medicine teaching as well Family Medicine has extensive US use. Currently residents are exposed to US use in the ED, on OB and through sports medicine. Some Family Medicine programs nationally have established US curriculum in residency. Family Medicine physicians will be expected in the future to have met certain base competencies in ultrasound.

Point of Care Ultrasound POCUS has wide applicability (clinic, hospital, procedures, rural and global health medicine) Improves patient care and access to care, is safe to perform, and is cost-effective, especially as technology becomes more available (Steinmetz et al, 2016). Many studies show applicability for AAA screening, lung ultrasound for PNA, OB ultrasound, cardiac ultrasound, MSK, etc. FM Residencies around the country are integrating POCUS curriculums Hall et al. (2014), CERA study presented at STFM, out of 224 surveyed program directors, 2.2% had established curriculum, 29% indicated they had started a program within the past year, and 11.2% reported starting the process of establishing such training

PDSA #1 – Evaluating the Work Environment P: Administer survey assessing baseline resident experience, interest, and comfort with ultrasound D: Administered survey to 23 residents at OHSU FM S: Broad range of interest, very little experience or comfort, and identified barriers most listed include time, lack of opportunities to learn, and concerns about lack of experienced faculty A: Establish buy in and support from program or faculty, create fishbone diagram outlining barriers, aggregate data

Identified Barriers Time Training Workflow Patient Supplies Cost Lack of time Repetitions How to fit it into a session? Lack of trained faculty Implementing POCUS Curriculum Overwhelmed Clinical benefits Machines Reimbursement Space Patient satisfaction Patient Supplies Cost

PDSA #2 – Develop Alliances and Relationships P: Reach out to contacts and colleagues engaged in point-of-care ultrasound at OHSU D: Create dialogues with faculty in IM, ED, and Klamath Falls FM, and attended Grand Rounds hosted by Drs Jason Yost and Brandon Chase, of Cascade East FM Residency (K Falls) S: OHSU ED and IM have established programs with POCUS, and K Falls has implemented a basic curriculum for their FM program with an IRB-approved study to track progress A: Adapt a standardized POCUS curriculum for OHSU FM in collaboration with Klamath Falls program

PDSA #3 – Standardization of Baseline Numbers P: Standardize what would be the necessary numbers to achieve competency D: Research gold standard for competencies S: There are not clear competency levels established in FM Curriculum. Family Medicine residency programs with well-established POCUS curriculums have used 150 - 300 total scans for general point-of-care ultrasound competency, 25-50 supervised exams for a specific diagnostic exam, and 5-10 supervised scans for ultrasound guided procedures. A working group through AAFP POCUS interest group is currently formulating proposal for submission of standards A: Repeat survey at end of year to see where OHSU residents are at in terms of unstructured learning, given no set curriculum in place

PDSA #4 – Investing more Resources into Improvement P: Reassess measures of naturally acquired experience over the last year, changes in interest, and comfort levels in performing and teaching ultrasound D: Re-administer survey after about 8 months post-baseline survey S: Preliminary survey of 17 residents (ongoing), however general trends remained the same. Scattered amount of hours obtained, similar low confidence scores. A: Ongoing structuring of formal curriculum, presenting to administrative body

Moving forward Unanimously, residents expressed interest in having an ultrasound curriculum on the surveys They also unanimously cited likelihood of using ultrasound in their future practices (although variation in what skills they would choose) Continue to partner with Klamath Falls, and other programs nationwide Adopt our own OHSU FM U/S curriculum based off of AAFP and Klamath Falls submitted documents

Round Table Discussion What aspects of POCUS do you find useful or relevant? Should we be training all FM residents with a fundamental, structured curriculum? What would you include as “basic” skills in this curriculum? How do we justify reimbursement and payment?

Thanks to Kim Insel and Jason Yost for their guidance! Thanks to STFM for taking interest in POCUS!

References Bornemann P. Assessment of a Novel Point-of-Care Ultrasound Curriculum’s Effect on Competency Measures in Family Medicine Graduate Medical Education. J Ultrasound Med 2017; 00:00–00. 0278-4297. Hall JW, Holman H, Bornemann P, Barreto T, Henderson D, Bennett K, Chamberlain J, Maurer DM. Point of Care Ultrasound in Family Medicine Residency Programs: A CERA Study. Fam Med 2015;47(9):706-711. International Federation for Emergency Medicine. POCUS Curriculum Guidelines. Mjolstad OC, Snare SR, Folkvord L, et al. Assessment of left ventricular function by GPs using pocket-sized ultrasound. Fam Pract. 2012;29:534-540. Steinmetz P, and Oleskevich S. “The benefits of doing ultrasound exams in your office.” The journal of family practice. August 2016, Vol 65, Number 8, p 517-523 Ye X, Xiao H, Chen B, Zhang S (2015). Accuracy of Lung Ultrasonography versus Chest Radiography for the Diagnosis of Adult Community-Acquired Pneumonia: Review of the Literature and Meta-Analysis. PLoS ONE 10(6): e0130066. doi:10.1371/journal.pone.0130066