Do Emergency Ultrasound Fellowship Programs Impact Emergency Medicine Residents' Ultrasound Education?

Do Emergency Ultrasound FellowshipPrograms Impact Emergency MedicineResidents’ Ultrasound Education?

ver the past 2 decades, emergency ultrasound (EUS) hasundergone a substantial evolution, and point-of-care ultra-sound (US) is being used increasingly by emergency

physicians.1 Emergency medicine (EM) residents are currentlyrequired to learn bedside US. In 1997, EUS was included in the corecontent for EM.2,3 The Accreditation Council for Graduate MedicalEducation and Emergency Medicine Residency Review Committeedesignated EUS as 1 of 3 core procedures assessed during accredi-tation visits, and all EM residency programs were required to showevidence of training and competency assessment in bedside US for

Srikar Adhikari, MD, MS, Christopher Raio, MD, Daniel Morrison, MD, James Tsung, MD, MPH,Stephen Leech, MD, Jehangir Meer, MD, Matthew Lyon, MD, Fernando Lopez, MD, Saadia Akhtar, MD

Received July 26, 2013, from the Department ofEmergency Medicine, University of ArizonaMedical Center, Tucson, Arizona USA (S.Ad.);Department of Emergency Medicine, North ShoreUniversity Hospital, Manhasset, New York USA(C.R.); Department of Emergency Medicine,University of Medicine and Dentistry of New Jersey –Robert Wood Johnson Medical School, NewBrunswick, New Jersey USA (D.M.); Departmentof Emergency Medicine, Mount Sinai School ofMedicine, New York, New York USA (J.T.);Department of Emergency Medicine, OrlandoRegional Medical Center, Orlando, Florida USA(S.L.); Department of Emergency Medicine,Emory University School of Medicine, Atlanta,Georgia USA (J.M.); Department of EmergencyMedicine, Georgia Regents University, Augusta,Georgia USA (M.L.); Division of EmergencyMedicine, Duke University, Durham, North Carolina (F.L.); and Department of EmergencyMedicine, Albert Einstein Beth Israel Medical Center, New York, New York USA (S.Ak.). Revision requested September 10, 2013. Revisedmanuscript accepted for publication October 1,2013.

We thank Valerie K. Shostrom for expertassistance with statistical analysis for this study.

Address correspondence to Srikar Adhikari,MD, MS, Department of Emergency Medicine,University of Arizona Medical Center, PO Box245057, Tucson, AZ 85724 USA.

E-mail: [email protected]

AbbreviationsACEP, American College of EmergencyPhysicians; CI, confidence interval; ED, emergency department; EM, emergency medicine; EUS, emergency ultrasound; US,ultrasound

O

©2014 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2014; 33:999–1004 | 0278-4297 | www.aium.org

ORIGINAL RESEARCH

Objectives—Recent years have seen a rapid proliferation of emergency ultrasound (EUS)programs in the United States. To date, there is no evidence supporting that EUSfellowships enhance residents’ ultrasound (US) educational experiences. The purposeof this study was to determine the impact of EUS fellowships on emergency medicine(EM) residents’ US education.

Methods—We conducted a cross-sectional study at 9 academic medical centers. A ques-tionnaire on US education and bedside US use was pilot tested and given to EM residents.The primary outcomes included the number of US examinations performed, scope ofbedside US applications, barriers to residents’ US education, and US use in the emer-gency department. The secondary outcomes were factors that would impact residents’US education. The outcomes were compared between residency programs with andwithout EUS fellowships.

Results—A total of 244 EM residents participated in this study. Thirty percent (95%confidence interval, 24%–35%) reported they had performed more than 150 scans.Residents in programs with EUS fellowships reported performing more scans thanthose in programs without fellowships (P = .04). Significant differences were noted inmost applications of bedside US between residency programs with and without fellow-ships (P < .05). There were also significant differences in the barriers to US educationbetween residency programs with and without fellowships (P < .05).

Conclusions—Emergency US fellowship programs had a positive impact on residents’ USeducational experiences. Emergency medicine residents performed more scans overall andalso used bedside US for more advanced applications in programs with EUS fellowships.

Key Words—bedside ultrasound; emergency medicine residents; emergency ultrasound;emergency ultrasound fellowship

doi:10.7863/ultra.33.6.999

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its graduates.1 In the 2011 “Model of the Clinical Practiceof Emergency Medicine,”4 bedside US was listed as one ofthe procedures and skills integral to the practice of EM.The EM milestones released by the American Board ofEmergency Medicine requires EM residents to demon-strate procedural competency in bedside US.5 The mostrecent American College of Emergency Physicians (ACEP)EUS guidelines published in 2008 recommended that USeducation be incorporated into the core educational pro-gram for all EM residency programs.1 Several formats havebeen proposed for developing a bedside US curriculum forEM residency training programs.6 The document devel-oped from the EUS consensus conference held at the 2008Council of Emergency Medicine Residency DirectorsConference provided a framework for US curriculumdevelopment and competency assessment for EM resi-dents.7 In the last few years, most EM residency programshave increased resources and instructional time to teachbedside US.8 However, variability still exists in bedside USeducation among residency programs despite educationalrecommendations proposed by national organizations.8,9

The reasons for interprogram variability and the difficultyin implementing the proposed curricula are multifactorial.

Emergency US is a rapidly growing subspecialty in EM.Over the past decade, EUS fellowships have rapidly pro-liferated, and currently 92 such fellowships are offeredin the United States (http://www.eusfellowships.com/programs.php). The fellowship training is typically 1 yearin length. The role of an EUS fellowship program is to trainand foster the development of future leaders in the field ofEUS. During fellowship training, fellows gain expertise inimage acquisition and interpretation in advanced point-of-care EUS applications. Fellows are required to completeone EUS research project and are responsible for teachingthe faculty, residents, and medical students. Fellows alsobecome proficient in the critical components required to runan EUS program, such as image archiving, digital imagemanagement, quality assurance, billing, and reimbursement.Generally, subspecialty fellowship programs enhanceresidency education. Fellows play an important role in res-ident training through their research and teaching efforts.They represent a vehicle for dissemination of subspecialtyeducational expertise and contribute to a richer educa-tional environment. To our knowledge, no prior studieshave examined the effects of EUS fellowships on residencyeducation. Currently, there is no evidence supporting theidea that EUS fellowships improve residents’ US educa-tional experiences. The objective of this study was to deter-mine the impact of EUS fellowships on EM residents’ USeducation.

Materials and Methods

Study Design and PopulationWe conducted a cross-sectional study at 9 academic med-ical centers with EM residency programs and an annualemergency department (ED) census of at least 45,000.Rather than a random sample, we purposefully identifiedEM residency programs by the absence or presence of anEUS fellowship to allow for valid comparisons betweendifferent programs. To make it a fair representation of allresidency programs, we used the Society for AcademicEmergency Medicine EM residency directory and invitedseveral programs to participate in this study based on thepresence or absence of a fellowship and geographic location.Only 9 programs agreed to participate in this study andadminister the survey, resulting in a convenience sample.Four of these EM residency programs were located atcenters that had an EUS fellowship in their ED for at least2 years. All EDs had a bedside US education program anddedicated EUS director, including hospital-based creden-tialing in EUS. All EM residency programs were 3-yeartraining programs. The EUS fellowship training programswere 1 year long and implemented in accordance withACEP EUS fellowship guidelines. An Institutional ReviewBoard approval or waiver was obtained at all institutions.

Survey Content and Administration A questionnaire on US education and bedside US use wasdeveloped based on existing literature and knowledge ofcurrent EUS education derived from discussion and consensus with experts in the field. The questionnaire consisted of specific questions regarding demographics,current use, items that would impact residents’ US educa-tion, and barriers to residents’ US education. The ques-tionnaire contained multiple-choice questions with spacefor free-text comments. A biostatistician experienced insurvey design and 4 emergency physicians with expertise in EUS reviewed the questionnaire for the relevance and clarity of each survey question. The questionnaire was pilottested on a small group of EM residents and was modifiedto address deficiencies suggested by the pilot group.

Each site’s EUS director was responsible for distrib-uting and collecting the surveys. All EM residents in eachresidency program were offered the survey. Participation inthe survey was on a voluntarily basis. Verbal consent wasobtained from the residents before administering the ques-tionnaires. The surveys were administered and collectedanonymously to protect the confidentiality of the residentswho agreed to participate. The percentage of surveysreturned was tracked. One research assistant entered all

Adhikari et al—Emergency Ultrasound Fellowship Programs for Emergency Medicine Residents

J Ultrasound Med 2014; 33:999–10041000


survey data into a database. To assess the accuracy of dataentry, a randomly sampled 30% of the questionnaires werereentered by a second research assistant.

MeasuresThe primary outcomes were the number of US examina-tions performed, scope of bedside US applications, barriersto residents’ US education, and US use in the ED. The sec-ondary outcomes were factors that would impact residents’US education. The outcomes were compared between res-idency programs with and without EUS fellowships.

Data AnalysisDescriptive analyses were performed with SAS software(SAS Institute Inc, Cary, NC). Questionnaire responseswere reported in terms of the percentage of total respon-dents along with 95% confidence intervals (CIs). To allowfor comparisons between EM residency programs withand without EUS fellowships, a χ2 or Fisher exact test wasused as appropriate. P < .05 was considered statistically sig-nificant. Interobserver agreement of data entry was deter-mined by κ analysis.

Results

A total of 244 EM residents participated in this study.The residents were from regionally diverse EM residencyprograms: 9 EM residency programs located in 7 differentstates. The questionnaires received represented a 90%response rate. Of the responses, 48% were from the North-east, 31% from the Midwest, and 21% from the Southeast.

Data reentry by the second investigator showed highagreement (κ = 0.95). Seventy-one percent (95% CI,65%–76%) of respondents reported that they had performedmore than 50 scans. Thirty percent (95% CI, 24%–35%)reported that they had performed more than 150 scans. Residents in programs with EUS fellowships reported per-forming more scans than those without EUS fellowships(P = .04; Table 1). Overall 56% (95% CI, 49%–62%)reported that they had performed more than 5 scans perweek. Only 4% (95% CI, 1.5%–6%) reported that they hadperformed more than 15 scans per week. The most com-monly performed applications included focused assess-ment with sonography for trauma (99%), aortic (85%),cardiac (89%), gallbladder (93%), first-trimester pelvic(87%), vascular access (91%), procedural guidance (85%),superficial (73%), renal (65%), thoracic (50%), vascular(deep venous thrombosis; 42%), nonpregnant pelvic (36%),scrotal (28%), ocular (25%), musculoskeletal (24%), andgastrointestinal (18%). Table 1 summarizes the differences

in the use of bedside US for different applicationsbetween EM residency programs with and without EUSfellowships. Statistically significant differences were notedfor most of the applications of bedside US between resi-dency programs with and without fellowships.

Table 2 summarizes the barriers to US educationidentified by EM residents in EM residency programs withand without EUS fellowships. There were statistically sig-nificant differences in the barriers to US education betweenresidency programs with and without fellowships. More res-idents in programs without fellowships thought that therewere not enough faculty using US, and there was a lackof teaching and supervision while scanning in the ED.The need to obtain a radiology department US examinationafter a bedside US examination was more often a barrier inresidency programs without EUS fellowships.

The factors reported to make an impact on residents’US education are listed in Table 3. Approximately three-fourths (73%; 95% CI, 67%–78%) of the respondents citedproctored supervision while scanning in the ED as the bestway to receive feedback about their scanning skills com-pared to DVD review sessions (15%; 95% CI, 10%–19%)and still-image review sessions (11%; 95% CI, 7%–14%). A large majority of the residents (93%; 95% CI,90%–96%) acknowledged that they were going to use USin future practice after residency training. Sixty-four percent(95% CI, 58%–70%) reported a concern about medicole-gal liability with bedside US use in future practice.

Discussion

Our study indicates that the presence of an EUS fellowshipprogram results in a positive US educational experience forEM residents. There are several potential explanations for these findings. One of the major barriers for US educa-tion to clinicians is lack of enough faculty proficient in theuse of bedside US.10 Emergency US fellowship wouldenhance residents’ US education by increasing the num-ber of teaching faculty, specifically with fellows who are notdistracted by heavy clinical and administrative responsi-bilities and more available to residents. Fellows spend addi-tional time in the ED scanning patients, which leads toincreased opportunities to interact and teach residents. Fel-lows also provide supplemental US lectures, grand roundpresentations, and hands-on training in both clinical andsimulated settings. They participate in US quality assur-ance activities and provide feedback to residents on scan-ning techniques, image quality, and interpretation. Theyalso actively engage in research, which further translates toimproved resident education.

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American College of Emergency Physicians EUSguidelines recommend a minimum of 150 total US exami-nations for general EUS competency.1 Not all EM residencyprograms meet ACEP guidelines at this time. In 2004,Moore et al8 reported that residents in 39% of EM residencyprograms were completing at least 150 US examinations.These findings are consistent with our study results. Ourfindings suggest that residents in training programs withEUS fellowships perform more scans overall and also usebedside US for more advanced applications.

Discrepancies exist in the US rotation formats offeredby different EM residency programs.8 Some programs offera dedicated US rotation, and others combine US with othersubspecialty rotations such as anesthesia and radiology.There is also variability in the lengths of the rotationsoffered by different EM residency programs, rangingbetween 2 and 4 weeks. In our study, an overwhelmingnumber of EM residents acknowledged the need forincreases in didactic hours, conference time, and hands-onworkshops. Residents indicated that recurring training


J Ultrasound Med 2014; 33:999–10041002

Table 2. Barriers to Residents’ US Education and US Use in the ED

EM Residency Programs EM Residency Programs

With EUS Fellowships Without EUS Fellowships

Barrier (n = 116), % (95% CI) (n =128), % (95% CI) P

Not enough faculty using US 49 (40–58) 76 (68–83) <.01

Not being able to review scans with faculty 32 (23–40) 65 (56–73) <.01

Not enough supervision while scanning 35 (26–43) 57 (48–65) <.01

Not enough US teaching during residency training 8 (3–13) 43 (34–51) <.01

Need to obtain radiology department US after a bedside scan 40 (31–48) 56 (47–64) .01

Not enough time during a busy shift 90 (84–95) 79 (72–86) .02

Not a user-friendly machine 17 (10–23) 26 (18–33) .09

Not being able to use US during off-service rotations 40 (31–48) 33 (25–41) .26

Availability of US services provided by radiology department 25 (17–32) 20 (13–26) .41

Not going to use US in future practice after residency training 5 (1–8) 6 (2–10) .7

Table 1. Bedside US Applications

EM Residency Programs EM Residency Programs

With EUS Fellowships Without EUS Fellowships

US Application (n = 116), % (95% CI) (n =128), % (95% CI) P

No. of scans

<50 20 (13–27) 37 (28–45)

51–150 45 (36–54) 38 (29–46) .04

>150 35 (26–43) 24 (16–31)

Musculoskeletal 34 (25–42) 14 (8–20) <.01

Thoracic 65 (56–73) 36 (28–44) <.01

Renal 75 (67–82) 55 (46–63) <.01

Gastrointestinal 26 (18–33) 10 (5–15) <.01

Ocular 43 (34–52) 8 (3–12) <.01

Vascular (DVT) 58 (49–66) 26 (18–33) <.01

Superficial 86 (80–92) 61 (52–69) <.01

Vascular access 98 (95–100) 84 (77–90) <.01

Gallbladder 97 (94–100) 88 (82–93) .01

Scrotal 36 (27–44) 20 (13–27) .01

Aortic 93 (88–97) 85 (79–91) .03

Procedural guidance 90 (84–95) 81 (74–87) .06

Nonpregnant pelvic 38 (29–46) 33 (25–41) .45

First-trimester pelvic 89 (83–94) 86 (80–92) .45

Cardiac 89 (83–94) 89 (84–94) .96

FAST 99 (97–100) 99 (97–100) .99

DVT indicates deep venous thrombosis; and FAST, focused assessment with sonography for trauma.


sessions throughout the residency would make a consider-able impact on residents’ US education in addition to dedi-cated rotations and an introductory course. More thanthree-fourths of EM residents also indicated that an EUS fellowship has a substantial impact on residents’ US education.

In our study, some of the common barriers indicatedby residents included a paucity of US expertise among EMfaculty, lack of bedside supervision, and lack of direct feed-back. These responses were consistent with findingsreported in the study by Moore et al,8 in which EM resi-dents performed US examinations without faculty super-vision in 44% of EM residency programs. Fellowshipprograms appear to have influences on faculty expertiseand credentialing in bedside US. In our study, nearly twiceas many EM residents in programs without EUS fellow-ships reported the above-mentioned barriers in compari-son to residents in programs with fellowships.

Bedside US is a mandatory skill set for all graduatingEM residents, and it is critical to address deficiencies andstandardize US training for all EM residency programs.In a study done by Moak et al,11 more than one-fourth offellows indicated that US education during their residencytraining was poor, and they pursued fellowship training toimprove their US skills. This finding highlights the needfor improvement in bedside US training in EM residencyprograms. Our study provides insights into the effectsof EUS fellowships on EM residency US education. Emergency US fellows can serve as valuable resources forresidents and augment residents’ US learning. The resultsof this study suggest that the presence of an EUS fellow-ship program improves US scanning experience for resi-dents and reduces barriers to residents’ US education andUS use in the ED. It is important for educators to be awareof the positive impact of EUS fellowship training programson EM residents’ US educational experiences.

Our study had several methodological limitations,including a small sample size, which may have limited theconclusions that can be reached. We used a conveniencesample of residency programs, which raised the possibilityof a selection bias. Additionally, as with any survey study,results were dependent on the accuracy of the self-reporteddata and were vulnerable to error. Emergency medicineresidents might have overestimated or underestimated theiruse of bedside US. Most of the residents surveyed camefrom programs located in the Northeast, and none werefrom the West, which is not representative of EM residen-cies nationwide. Although the questionnaire was pilottested, most of the questions were closed ended, whichmight have introduced a potential for a response bias; how-ever, we did allow space for comments. The design of thestudy did not allow us to evaluate which factors related tothe EUS fellowships were causes of the improved residents’educational experiences and which were merely correlative.

In conclusion, the presence of EUS fellowship train-ing programs was associated with positive residents’ USeducational experiences. Emergency medicine residentsperformed more scans overall and also used bedside USfor more advanced applications in programs with EUSfellowships.

References

1. American College of Emergency Physicians. Emergency ultrasoundguidelines. Ann Emerg Med 2009; 53:550–570.

2. Allison EJ Jr, Aghababian RV, Barsan WG, et al. Core content for emer-gency medicine: Task Force on the Core Content for EmergencyMedicine Revision. Ann Emerg Med 1997; 29:792–811.

3. Costantino TG, Satz WA, Stahmer SA, Dean AJ. Predictors of success inemergency medicine ultrasound education. Acad Emerg Med 2003;10:180–183.

4. American College of Emergency Physicians. Model of the clinical practiceof emergency medicine. American College of Emergency Physicians web-site. http://www.acep.org/Content.aspx?id=29580. Accessed June 13,2013.

5. Council of Emergency Medicine Residency Directors. RRC-EM andABEM releases emergency medicine milestones. Council of EmergencyMedicine Residency Directors website. http://www.cordem.org/i4a/pages/ index.cfm?pageid=1. Accessed June 13, 2013.

6. Mateer JR, Plummer D, Heller M, et al. Model curriculum for physicianstraining in emergency ultrasonography. Ann Emerg Med 1994; 23:95–102.

7. Akhtar S, Theodoro D, Gaspari R, et al. Resident training in emergencyultrasound: consensus recommendations from the 2008 Council ofEmergency Medicine Residency Directors Conference. Acad Emerg Med2009;16(suppl 2):S32–S36.

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Table 3. Factors Reported to Make an Impact on US Education (n = 244)

Factor % (95% CI)

Regular image review sessions 96 (93–98)

Presence of a formal, structured US rotation 95 (92–98)

More faculty using US 95 (92–98)

Refresher workshops throughout the year 94 (91–97)

Dedicated conference time for US didactics,

cases, M&M 92 (89–95)

Having an EUS fellowship in the ED 77 (71–82)

Increase in didactic hours (>16 h) 75 (70–80)

Simulation technology to teach US 60 (54–66)

Cadaver laboratories to teach US 53 (47–59)

M&M indicates morbidity and mortality.


8. Moore CL, Gregg S, Lambert M. Performance, training, quality assur-ance, and reimbursement of emergency physician–performed ultra-sonography at academic medical centers. J Ultrasound Med 2004;23:459–466.

9. Counselman FL, Sanders A, Slovis CM, Danzl D, Binder L, Perina D. Thestatus of bedside ultrasound training in emergency medicine programs.Acad Emerg Med 2003; 10:37–42.

10. Eisen LA, Leung S, Gallagher AE, Kvetan V. Barriers to ultrasound train-ing in critical care medicine fellowships: a survey of program directors.Crit Care Med 2010; 38:1978–1983.

11. Moak JH, Gaspari RJ, Raio CC, Hart KW, Lindsell CJ. Motivations, jobprocurement, and job satisfaction among current and former ultrasoundfellows. Acad Emerg Med 2010; 17:644–648.


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Do Emergency Ultrasound Fellowship Programs Impact Emergency Medicine Residents' Ultrasound Education?