Internal Medicine Ultrasound: How echogenic is the future? Presented by Dr. Irene Ma

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| 17 November 2022

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Internal Medicine Ultrasound: How echogenic is the future? Presented by Dr. Irene Ma

By Nicole Morris, MSc Candidate, TMED801 Student

The Department of Medicine welcomed guest speaker Dr. Irene Ma, MD, PhD, FRCPC, at last week’s medical grand rounds (MGR). Dr. Ma’s talk focused on the current challenges and benefits of, and future directions for, Point-of-Care Ultrasound use in internal medicine.

Point-of-Care Ultrasound (POCUS) refers to a diagnostic technology that allows clinicians to perform ultrasounds on patients at the bedside, using a portable, hand-held machine. Originally invented for military use in the late 90s, POCUS began to emerge as a “hot topic” in medical literature in the early 2000s (1). As Dr. Ma outlined in two case studies, in her practice as a general internist, POCUS has greatly aided her diagnostic and clinical decision-making, and helped to make the case for computed-tomography (CT) scans for her patients, when further investigation was warranted. Beyond the scope of internal medicine, use of POCUS is widely supported in emergency medicine (2) and has been embraced as a cost-effective diagnostic approach across low-resource settings globally (3).

While the advantages of POCUS are obvious, Dr. Ma cautioned on the potential for harm without the proper training. She reminded her fellow clinical educators of the importance of supervising trainees using a third case study. The resident on this case used POCUS and informed their senior attending that there were no significant cardiac findings. It was only later discovered by another senior attending on staff who was well-experienced with POCUS, that the initial interpretations made by the trainee were incorrect. At Dr. Ma’s home institution, the University of Calgary, there is a learner policy in place that requires the interpretations of any trainee’s POCUS scans to be reviewed by an experienced POCUS attending before they are integrated into clinical decision-making. However, the same is not true across the country. While Dr. Ma is currently working with the province of Alberta to implement a standardized POCUS learner policy, the pathway to policy change is not one without challenges.

In addition to enacting policy change, as Dr. Ma so eloquently emphasized, driving systemic change also requires developing strategies to address infrastructure and education. Unlike a “concept” that can be taught to trainees via lecture, POCUS education relies on the availability of ultrasound machinery and the ability of these machines to transmit information wirelessly and securely. Challenges related to infrastructure include overcoming the limited capacity for senior staff to review trainees’ POCUS interpretations in a timely fashion, and the potential for privacy issues.

As for the education piece, Dr. Ma clearly explained that POCUS is not necessarily about getting the best image (that’s what radiology and cardiology are for!). Rather, POCUS is all about what minimum criteria can be met. In her professional opinion, it is this “safety check” that is the single most important component of POCUS education. As an example, Dr. Ma highlighted the work of her colleagues at the University of Calgary, who recently published the minimal criteria they feel should be met for lung applications of POCUS in internal medicine (4). If these standards cannot be met (e.g. if certain lung features are missing or not appropriately shown on an image), then these POCUS interpretations should not be integrated into clinical decision-making.

Of course, a discussion on the hopes for driving systemic change would not be complete without touching on the inevitable: resistance to change. It was comforting to learn that the more time that passes, the more likely it is people will begin to recognize the presence of POCUS in internal medicine and accept the data that demonstrates its potential for positive impact (5,6). Finally, Dr. Ma did not shy away from stating that she felt like “a complete idiot” during the first few weeks of her ultrasound fellowship in Boston. As hard as stepping outside of our comfort zones can be, loss of status quo is necessary to adopt something new.

After the MGR, Dr. Ma met with the first-year TMED graduate students for a round table discussion about how POCUS is directly benefiting patients, its representation in the lay press, overcoming issues related to equitable access to POCUS machines, and Dr. Ma’s career as a clinician scientist. Notably, Dr. Ma spoke about innovative efforts to bring POCUS specialists to remote northern communities in Canada (thanks to drones and the use of zoom conferencing software!), as well as the benefits and pitfalls of circulating POCUS images on social media such as Twitter. For further reading on how social media is advancing medical education, check out this commentary: https://www.cmaj.ca/content/187/8/549

On behalf of our TMED 801 class, I would like to sincerely thank Dr. Ma for taking the time to speak with us. It was an honour and a privilege!

References

1. Lee L, DeCara JM. Point-of-Care Ultrasound. Curr Cardiol Rep. 2020;22(11):149.

2. Lewis D, Rang L, Kim D, Robichaud L, Kwan C, Pham C, et al. Recommendations for the use of point-of-care ultrasound (POCUS) by emergency physicians in Canada. CJEM. 2019 Nov;21(6):721–6.

3. Hashim A, Tahir MJ, Ullah I, Asghar MS, Siddiqi H, Yousaf Z. The utility of point of care ultrasonography (POCUS). Ann Med Surg. 2021 Nov 2;71:102982.

4. Desy J, Noble VE, Liteplo AS, Olszynski P, Buchanan B, Dversdal R, et al. Minimal Criteria for Lung Ultrasonography in Internal Medicine. Can J Gen Intern Med. 2021 Jun 21;16(2):6–13.

5. Dversdal RK, Piro KM, LoPresti CM, Northcutt NM, Schnobrich DJ. Point-of-Care Ultrasound in the Inpatient Setting: A Tale of Four Patients. South Med J. 2018 Jul 1;111(7):382–8.

6. Bhagra A, Tierney DM, Sekiguchi H, Soni NJ. Point-of-Care Ultrasonography for Primary Care Physicians and General Internists. Mayo Clin Proc. 2016 Dec 1;91(12):1811–27.

Internal Medicine Ultrasound: How echogenic is the future? Presented by Dr. Irene Ma

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Internal Medicine Ultrasound: How echogenic is the future? Presented by Dr. Irene Ma