Internal Medicine and Bedside Ultrasound–A Match Made in Heaven

I am an internist who does bedside ultrasound. This has not always been true. From 1986, when I got my MD from Johns Hopkins School of Medicine, to November 2011, I was a traditional internist, taking care of a panel of patients in a small university town in Idaho. I saw my patients in the office when they could walk or wheel in with their problems and in the hospital when they were sicker. I took call for my partners on rotating weekends and holidays. I occasionally ordered ultrasounds and echocardiograms and thought of them as blurry representations of internal structures that could be magically interpreted by radiologists.

In 2011, events such as the growing up of our 2 children allowed me to reconsider my choices of what to do with my MD. I had always wanted to do medicine in resource-poor settings overseas. I had often been curious about locum tenens work in other states, which would involve adventure and exposure to new practice styles and surprisingly generous compensation compared to my predominantly outpatient practice. I also had an urge to binge on continuing medical education courses, which I had denied myself for years due to responsibilities at home.

Janice Boughton, MD

One of the CME courses I treated myself to was an introductory course in emergency ultrasound through Harvard/Massachusetts General Hospital. It was wonderfully taught and I was immediately hooked. Ultrasound at the bedside would transform my practice and had the potential to transform the whole practice of internal medicine! The Cupid of bedside ultrasound had sunk his arrow straight between my eyes.

I went on to take more courses in bedside ultrasound both in person and online and bought myself a small pocket ultrasound which rapidly developed my imaging skills. I began to use ultrasound clinically as a diagnostic tool within weeks of my first exposure. I discovered over-expanded bladders, failing hearts, pleural effusions, ascites, or lack thereof in my patients with big bellies. I became a better doctor, and enjoyed my job more. My patients were happy to have benefitted from what looked to them like Star Trek technology.

I expected at any point that someone in the diverse hospitals where I served as a locum tenens hospitalist would ask for my credentials or forbid me to use ultrasound. I expected skepticism by cardiologists with whom I worked. I expected radiologists to be upset at me. I even did a 1-month UC Irvine mini-fellowship and ARDMS certification as a sonographer. These experiences gave me a vast amount more expertise and confidence, but were mostly to ward off imagined disapproval. Yet nobody ever made me present my certification. Nobody disapproved to my face except one radiologist, who I’m still working on. Cardiology consultants were tickled to get imaging information in addition to history and vital signs. I may have benefitted from being in hospitals where people were too busy taking care of patients to fuss with me. It really seemed, though, that the vast majority of people with whom I worked realized that I was a better doctor with an ultrasound than without.

I have gone on to teach bedside ultrasound and participate in research on malaria and schistosomiasis with medical students in Tanzania. I have taught basic ultrasound to overburdened healthcare workers and physicians from Doctors Without Borders in South Sudan during its ongoing civil war. Knowing how to teach basic bedside ultrasound means I am valuable in resource poor settings even if I can only stay for a couple of weeks. I have been able to teach my internal medicine colleagues in the US along with residents and medical students, which has been a wonderful opportunity for a nonacademic rural physician.

So what’s my point here? As an “early adopter” of bedside ultrasound in internal medicine I have made myself a test case. So far these are the results:

  1. It wasn’t too hard to learn enough ultrasound to be a better doctor.
  2. There was never a time when I was too much of a novice to benefit from bedside imaging, yet every time I ultrasound a patient I learn something new. I can’t foresee a time when my learning will be complete.
  3. There has been surprisingly little push-back and a gratifying amount of appreciation.
  4. Bedside ultrasound is the perfect extension of the physical exam in internal medicine. It brought back my joy in physical diagnosis. We should all be doing it!

 

Have you used ultrasound in your internal medicine practice? Have you gone after ultrasound education after obtaining your degree? How can medical education be modified to encourage the widespread use of ultrasound by future internists? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Janice Boughton, MD, is an internist working as a staff Hospitalist at Gritman Medical center as well as is a locum tenens physician at other northwest hospitals. She also supervises and serves in rural health clinics, and blogs about bedside ultrasound and other issues at http://whyisamericanhealthcaresoexpensive.blogspot.com/?m=1.

Why SonoStuff.com?

Three reasons:

As a co-director of technology enabled active learning (TEAL) at the UC Davis school of medicine I incorporate important technologies into the medical curriculum, which has primarily been point of care ultrasound (POCUS). Ultrasound is an incredible medical education tool and curriculum integration tool. It can be used to teach, reinforce, and expand lessons in anatomy, physiology, pathology, physical exam, and the list goes on.

I knew there was a better way to teach medical students thaschick_photo_1n standing in front of the classroom and giving a lecture. Student’s need to learn hands-on, spatial reasoning, and critical thinking skills to become excellent physicians. Teaching clinically relevant topics with ultrasound in small groups with individualized instruction
is the best strategy. I needed to flip the classroom.

I started by creating online lectures for an introduction to ultrasound lecture, thoracic anatomy, and abdominal anatomy:

Introduction to Ultrasound, POCUS

FAST Focused Assessment of Sonography in Trauma Part 1

FAST Focused Assessment of Sonography in Trauma Part 2

Aorta Exam AAA POCUS

Introduction in Cardiac Ultrasound POCUS

Topics quickly grew in scope and depth. I initially housed my lectures on YouTube and emailed them out to students before the ultrasound laboratory sessions. However, I wanted a platform that allowed for improved organization and showcasing. I needed a single oschick_photo_2nline resource they could go to to find those materials I was making specific to their medical curriculum.

https://www.youtube.com/channel/UCOhSjAZJnKpo8pP7ypvKDsw

Around the same time, during a weekly ultrasound quality assurance session in my emergency department I realized we were reviewing hundreds of scans each month and the reviewers were the only ones benefiting educationally from the process. Many cases were unique and important for education and patient care.

We began providing more feedback to our emergency sonographers and I decided I could use the same software I was using to develop material for the school of schick_photo_3medicine to highlight the most significant contributions to POCUS in our department every week. I quickly realized I needed a resource to house all these videos, one that anyone in my department could refer to when needed. The most efficient and creative method was to start a blog. I was discussing the project and possible names for the blog with colleagues and Dr. Sarah Medeiros said, “sounds like it’s a bunch of ultrasound stuff”. https://sonostuff.com was born.

I owe a great deal to free and open access to medical education or FOAMed. I was hungry for more POCUS education in residency and the ultrasoundpodcast.com came to the rescue. I became a local expert as a resident and even traveled to Tanzania to teach POCUS.

schick_photo_4I primarily began www.SonoStuff.com to organize and share with my department of emergency medicine and school of medicine, but it grew into a contribution to the growing body of amazing education resources that is FOAMed. I now use it as a resource in my global development work along with the many other FOAMed resources.

The work we all do in FOAMed, including AIUM’s the Scan, are an incredible and necessary resource. I have read the textbooks and attended the lectures, but I would not be where I am without FOAMed. I know all or most of those contributing to FOAMed do it out of love for education and patient care, without reimbursement or time off. Thank you to the many high-quality contributors and I am proud to play a small part in the FOAMed movement.schick_photo_5

Michael Schick, DO, MA, is Assistant Professor of Emergency Medicine at UC Davis Medical Center and Co-Director of Technology Enabled Active Learning, UC Davis School of Medicine. He is creator of www.sonostuff.com and can be reached on Twitter: ultrasoundstuff.

Why I Love Credentials

My name is Mike. I am many things, including a veteran, a business man, a coach, and a sonographer. And while the “things” I am change over time, one thing has remained the same: I am a student! This is thompsonmost evidenced by the 8 professional credentials I currently hold.

I have found that after being in the field of ultrasound for more than 2 decades, credentialing and continuing education can distinguish the enthusiastic sonographer from the merely competent one. With the introduction of more focused credentials such as musculoskeletal, breast, pediatric, phlebology, and advanced cardiac subspecialties, sonographers can now stand out from the crowd in terms of awareness and competency while at the same time being on the cutting-edge of the latest techniques and literature.

Acquiring a new credential, or even just studying for the registry examination, requires you to learn valuable new knowledge that may impact the way you treat and diagnose patients. For example, while I was preparing for the RPhS registry, multiple sources recommended a pneumatic compression device to augment venous flow while a patient is standing as an alternative to the patient performing the Valsalva maneuver in order to induce and record venous reflux. For me, this method has helped me better evaluate for this condition with less strain on the patient while eliminating communication barriers that may exist. If I hadn’t been preparing for that exam, I probably would never have learned this technique.

While some credentials are necessary for certain jobs, multiple credentials prove to existing and future employers that you take your profession seriously and you don’t settle for the minimum standard. I am not saying you need to get multiple credentials. If your professional interest does not reach beyond one credential, that is fine, but few ultrasound labs today only perform only one specialty. Echocardiography labs and vascular labs are growing together as cardiovascular labs, and many departments are requiring a more comprehensive knowledge in ultrasound. Credentialing yourself to the highest degree may get you the new job you pursue or secure the one you have. While increased pay is always a motive, sometimes the satisfaction of being able to set yourself apart from others in the field can be just as rewarding.

Some sonographers have the position that if the credential doesn’t come with a pay raise, it’s not worth it. With reimbursement cuts and higher credentialing standards being proposed by private and government payors, my opinion is that keeping your job is a pay raise.

Why do you hold the credentials you have? What are your go-to resources? What book would you like to see written? Share your thoughts and ideas here and on Twitter: @AIUM_Ultrasound.

Mike Thompson, MPH, RDMS, RDCS, RVT, RPhS, RVS, RCS, RCCS, is Owner of Diagnostic Resources in Perry, Georgia.

 

I’m Tired of Falling Asleep During Lectures

I remember the first test I failed. It was an immunology exam that I took about halfway through my first year of medical school. Seeking some solace, I asked a classmate for advice. His snarky response was, “Why don’t you try NOT sleeping through the class?”

sleeping in classHe did have a point, but I couldn’t help it. The professor was so incredibly boring. I couldn’t understand why he would spend so long talking about a study performed decades ago involving injecting mice with bacteria. How would this make me a good doctor?

I quickly found the solution to my problem: I had to stop going to class. Imagine that? The best way for me to get a medical education was NOT attending the courses–at least this particular course. It turns out I learned a lot better reading by the pool in sunny Southern California than in that big lecture hall. I soon discovered that many of my classmates were doing the same thing. Some read the textbooks at home or at a coffee shop. Some bought entirely different textbooks on the same subject. Some bought audio tapes for a particular subject. Of course some did prefer the classroom. In the end, we all passed.

Spending 4 years in college and 4 more in medical school makes you extremely sensitive to the lecturer’s delivery of the material. We spend years sitting in large groups in dark rooms quietly listening to someone on some stage talking at us. These days, most lecturers are reading off slides and within the first minute, you know what you’ve got yourself into.

Why do we subject our learners to someone standing behind a podium reading slides for an hour? Why do we think this works? Most likely it’s because very few people know there is a better way of doing things.

Our ultrasound instructor in medical school, Dr Chris Fox, likes to talk about “flipping the classroom.” Prior to our ultrasound didactics, he would give us access to an online podcast for the scanning technique of the day. We could watch it in pieces or all at once and we could watch it at any time and however many times we wanted. Best of all, we could pause, rewind and fast forward. We would then show up for a brief lecture consisting of a 5- to 10-minute review of the podcast where we could ask questions. Then we split up into groups to practice scanning.

That’s what I call efficient. And fun.

I’m now in charge of teaching my co-residents the same ultrasound skills I learned in medical school. Problem is, I don’t have a podcast series of lectures. In fact, I started with no lectures at all. Truth is, I could have devoted hours creating engaging, interesting, and effective PowerPoint slides. But, why should I reinvent the wheel when colleagues of mine from around the world have already developed these presentations? If I could use those, then I could focus on what I do best, which is teach the hands-on components.

Thank goodness for FOAM (Free Online Access Meducation). The term was coined in 2012 in the emergency medicine community and Life in the Fastlane has a whole page dedicated to its history and explanation.

Essentially, FOAM is a growing movement to provide high-quality and FREE medical education materials online for anyone to use. It’s a dream come true for any educator. Time to give a lecture? You could spend hours throwing together 60 slides for a lecture, but somebody else has already done it, and they’re REALLY good at it. Let them teach the lecture so you can use your time to practice and reinforce. Whether it’s an ultrasound technique or reviewing how to work up and treat chest pain, the principle is the same.

For me, using FOAM to teach residents is a lifesaver. Walking a learner through the machine and the exam technique comes natural to those with experience. Putting together a presentation to introduce it all to a big group requires time that I don’t always have. Plus, my proficiency in PowerPoint is limited and producing high-quality videos and images with overlaid anatomy takes considerable time, assuming you know how to do it.

Many of us know about FOAM resources already, probably just not the name. The Ultrasound Podcast is a fantastic resource with educational videos and challenges. There is also a smartphone app called One Minute Ultrasound for Apple and Android phones, which is a great on-the-go resource. The American Academy of Emergency Medicine (ACEP) runs Sonoguide.com with a whole host of resources. Another great resource is Sonomojo.org, which is a collection of FOAM resources for ultrasound. AIUM offers free resources and practice guidelines as well as teaching tools for members.

So let’s stop putting our students to sleep and start engaging them on their own terms. Give them the resources then use your time more effectively to get practical and work on procedural skills or problem solving. FOAM is there to guide the way.

How do you make your presentations engaging? Do you use any FOAM resources with teaching? If so, have you found it useful? Have questions about the future of FOAM? Comment below or let us know on Twitter: @AIUM_Ultrasound.

David Flick is a 3rd year family medicine resident at Tripler Army Medical Center. He received 4 years of ultrasound training at the University of California, Irvine School of Medicine. He currently runs the resident ultrasound curriculum and is an outspoken proponent for ultrasound training in the primary care specialties.

 

It’s All About The Students

A relatively new AIUM award, the Peter H. Arger, MD, Excellence in Medical Student Education Award honors an AIUM member whose outstanding contributions to the development of medical ultrasound education warrant special merit. At the 2015 AIUM Annual Convention, David Bahner, MD, RDMS, was presented with this award. Here’s what he had to say about this honor and the future of medical ultrasound education.David Bahner

What does it mean to you to be named only the second recipient of the Peter H. Arger Excellence in Medical Student Education Award winner?
I am very honored to be recognized by the AIUM and feel it is an honor to receive this award named after a pioneer in imaging, Dr Peter H. Arger.  Dr Arger’s passion for medical education and his commitment to ultrasound is well known.  It is my hope to continue those activities in medical education that Dr Arger pioneered in his work with the AIUM. Watching the first award winner, Dr Richard Hoppmann, receive this award last year was a thrill because it meant that the AIUM was recognizing the importance of medical ultrasound education. I am grateful for this great honor and hope to live up to the substantial role model Dr Peter Arger has been for this important area in ultrasound.

Why is ultrasound in medical education so important?
In the past, the feeling that ultrasound is operator dependent has been a drag on its impact within medicine. However, since medical education has been changing at many institutions because of electronic medical records, changes in curricula, and changes in technology, opportunities for point-of-care ultrasound now abound. Add to that the fact that ultrasound has become portable and affordable, and we see more operators embracing this modality. Unfortunately, the training for this device many times doesn’t starts until residency or even after clinicians have completed their medical training. By that time, however, the technology has outpaced the education. If the future can be planned to prepare 21st century clinicians to use this ultrasound tool, implementing this within medical school allows “pluripotent” students the ability to learn the foundations of ultrasound before entering residency.

What do you see as the biggest barrier to having ultrasound integrated into the medical education curriculum?
The lack of trained faculty either funded or supported in this process of training medical students is the biggest barrier to implementing ultrasound training in medical school. This lack of faculty is coupled with a “crowded’ curriculum where medical educators don’t see the benefit of adding ultrasound at the expense of removing other parts of the curriculum. The true insight is that ultrasound can be integrated into many parts of the medical student curriculum when both teachers and students embrace learning how to use ultrasound.  For example, anatomists learning how to scan or family practitioners working with ultrasound to guide procedures are possible solutions to these barriers.

You are a born and bred Ohioan. Why are people from Ohio so proud of Ohio?
It probably has something to do with the history of the state and how that has played into innovation, politics and competitiveness. Ohio is best known for the Wright Brothers who hailed from Dayton and used their hard work and innovation to change the 20th century with the discovery of lift and flight. Politically it has been an influential state in most presidential elections. Plus, 6 presidents are from Ohio. Ohioans are fierce competitors and extremely proud of the 16 national football championships earned by The Ohio State University. Oh, and the Pro Football Hall of Fame and Rock and Roll Hall of Fame are located within Ohio. We have a lot to be proud of.

Personally, my family grew up in Ohio and I feel a bond with the change of seasons, the geography, the history, the people, and the culture of hard work and helping others. I am an American, an Ohioan, a doctor, an educator, an innovator, and a Buckeye.

What role does or should ultrasound play in medical education? What are you proud of? Where did you learn your ultrasound skills? Comment below or let us know on Twitter: @AIUM_Ultrasound.

David Bahner, MD, RDMS, is Professor and Director of Ultrasound in the Department of Emergency Medicine at The Ohio State University College of Medicine.