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Dr. Irene Ma

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

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.

Comments

Name
Matti McFarlane

Mon, 11/21/2022 - 17:24

Hi Nicole!

You did a wonderful job reviewing Dr. Ma’s MGR talk and subsequent round-table discussion. It was interesting to learn about the clinical use of POCUS and the significant learning curve for clinicians to become confident in its utilization. It appears that education may be a significant barrier to wide-spread uptake of POCUS, especially seeing as Dr. Ma had to travel to the United States to pursue an ultrasound fellowship. Dr. Ma highlighted infrastructure challenges, especially in teaching institutions where attendings must review learners’ images before they can be used to make clinical decisions. She also commented that competence with POCUS requires years of practice. Have you come across in your reading, or do you have any thoughts yourself has to how these barriers can be overcome? Do you think that POCUS should be introduced into medical schools to decrease some of the learning challenges for residency programs?

I look forward to hearing your thoughts.

Best,

Matti

Name
Matti McFarlane

Hi Matti,

Thanks for your thoughtful comments. I did find one study that surveyed clinical ultrasound directors and curricular deans at medical schools across the United States to evaluate the current state of POCUS integration in undergraduate medical education (1). As it turns out, 57% of schools had an approved POCUS curriculum, and the majority required POCUS instruction during the first two years of study (1). To answer your question, I do think that the integration of POCUS curriculum into undergraduate medical education could help address some of the learning challenges trainees face in residency programs, however it comes with its own unique set of barriers that would still need to be overcome. For one, incorporating POCUS into curricula would probably require having to remove something else (time spent learning is not unlimited in medical school) – how would we decide what to change? The aforementioned study described other barriers not dissimilar to the ones Dr. Ma mentioned regarding residency programs at our round-table discussion. For example, medical schools in the study also reported a lack of trained faculty to pass on these skills to undergraduate medical students, and a lack of equipment (1). Perhaps one solution that could address barriers encountered at both the undergraduate and residency education levels would be to incentivize more senior physicians to pursue fellowships like the one Dr. Ma did. What do you think? Do you have any thoughts on who should be doing the incentivizing (e.g. institutions vs. governments)?

Best,
Nicole

References
1. Russell FM, Zakeri B, Herbert A, Ferre RM, Leiser A, Wallach PM. The State of Point-of-Care Ultrasound Training in Undergraduate Medical Education: Findings From a National Survey. Acad Med. 2022 Apr 27;97(5):723–7.

Name
Nicole Morris

Name
Maria Korovina

Tue, 11/22/2022 - 11:33

Hi Nicole,

Thank you for sharing your summary and thoughts on the MGR. It is clear that one of the biggest reasons for set back in utilizing POCUS as an efficient and cost-effective diagnostic tool is lack of training. Nonetheless, from Dr. Ma's presentation, it seems to me that there is a significant number of benefits that may arise if we implement POCUS within the hospital as a form of "safety check". Aside from resistance to change experienced during the implementation of POCUS, do you think there are other reasons for the hesitance in implementing POCUS or offering training on POCUS during medical school/residency? If it is clear that the biggest issue is the lack of training provided, why aren't medical schools implementing this into their curriculum in the first place? Do you think this is due to a lack of available specialized trainees, knowledge of the overall benefits POCUS may provide, or simply the cost & time for implementing these into the curriculum?

Cheers,

Maria

Name
Maria Korovina

Hi Maria,

In response to Matti’s comments I actually conducted some research and found that many medical schools have already integrated a POCUS curriculum into their undergraduate medical programs. I mentioned above that barriers to implementation in this environment include time constraints, a lack of resources, and a lack of trained faculty to pass down these skills (1).

I did some further research and another barrier I’ve identified is the fact that an undergraduate POCUS education during medical school would not benefit everyone. POCUS has little utility for future dermatologists or ophthalmologists, for example. Some do argue that a POCUS education can improve students’ understanding of anatomy and aid the teaching of how to perform a physical exam, however I found a systematic review that came to the opposite conclusions (2).

It is clearly a multifaceted issue and there are a number of stakeholder perspectives to consider. I think it would be interesting to conduct a cost-benefit analysis to determine whether standardizing POCUS education policies will provide great enough benefits to patients at the bed-side. Is it really worth the investment of time, money and resources at the institutional level? What do you think?

Nicole

References
1. Russell FM, Zakeri B, Herbert A, Ferre RM, Leiser A, Wallach PM. The State of Point-of-Care Ultrasound Training in Undergraduate Medical Education: Findings From a National Survey. Acad Med. 2022 Apr 27;97(5):723–7.
2. Feilchenfeld Z, Dornan T, Whitehead C, Kuper A. Ultrasound in undergraduate medical education: a systematic and critical review. Med Educ. 2017;51(4):366–78.

Name
Nicole Morris

Name
Jana Livingston

Tue, 11/22/2022 - 17:59

Hi Nicole,

Great work summarizing the talk by Dr. Ma concerning the benefits and pitfalls of implementing point-of-care ultrasound (POCUS) in internal medicine. As you mentioned, the use of POCUS can assist patient diagnoses in low-income communities and the emergency care setting but should be used with caution. Additionally, POCUS images may improve physician confidence when diagnosing patients, subsequently leading to earlier detection and intervention. Considering the increasingly long wait times in emergency departments, how do you think POCUS can help reduce these wait times? Not only are long wait times bothersome, but they can also be detrimental to care by delaying immediate intervention. I’m excited to hear your thoughts.

Jana

Name
Jana Livingston

Hi Jana,

Thanks so much for your reply! This is a tough question to answer because in general, diagnostic imaging is associated with longer emergency department stays (1). I think that in cases where POCUS could replace the need for a patient to undergo a CT scan, this could definitely help reduce emergency department wait times. However, in cases where a CT scan is needed to confirm POCUS findings (as Dr. Ma mentioned in her practice as a general internist, she has used POCUS to make a stronger case for CT), it could potentially increase the length of emergency department stay.

On the other hand, in terms of patients deemed critically ill, POCUS is beneficial as it allows for extremely timely evaluation. I did find one study that asked emergency medicine residents to retrospectively review 75 emergency cases deemed high-risk (2). Interestingly, it was determined that in cases where POCUS was not used, for 45% of them, if it was used, it likely would have prevented morbidity and mortality (2). With this being said, in seven cases where POCUS was used, it was actually thought "to have possibly adversely affected the outcome of the morbidity and mortality” (2).

I imagine trying to determine who the best candidates are for POCUS in the emergency department is a difficult research question to tackle. Do you have any ideas on where we should start?

Looking forward to hearing your thoughts!

Nicole

1. Kanzaria HK, Probst MA, Ponce NA, Hsia RY. The association between advanced diagnostic imaging and ED length of stay. Am J Emerg Med. 2014 Oct;32(10):1253–8.
2. Goldsmith AJ, Shokoohi H, Loesche M, Patel RC, Kimberly H, Liteplo A. Point-of-care Ultrasound in Morbidity and Mortality Cases in Emergency Medicine: Who Benefits the Most? West J Emerg Med. 2020 Nov;21(6):172–8.

Name
Nicole Morris

Name
Tarrah

Thu, 11/24/2022 - 17:41

Hi Nicole,

You put together a great summary of Dr. Ma's lecture and TMED seminar, that really highlighted her key takeaway messages. She mentioned a case study which illustrated the importance of training with feedback, as one of her POCUS trainees mistakenly reported that there were no significant cardiac findings. This is an example of under-diagnosis. I was wondering about your thoughts on over-diagnosis using this technique. The New England Journal of Medicine published a perspective which stated that the use of POCUS resulted in a 10-fold increase in thyroid cancer diagnosis in South Korea and saw no concomitant increase in mortality. Obviously, there are many dangers associated with over-diagnosis and it should be something we aim to minimize. Do you think that the training strategies used to combat under-diagnosis, which Dr. Ma mentioned in her lecture, would also be effective with combating over-diagnosis?

I'm looking forward to your response!
Tarrah

Reference:

Vaccarella, S., Franceschi, S., Bray, F., Wild, C. P., Plummer, M., & Dal Maso, L. (2016). World-wide thyroid-cancer epidemic? The increasing impact of overdiagnosis. New England Journal of Medicine, 375, 614-617.

Name
Tarrah

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