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ORIGINAL RESEARCH
Do Emergency Ultrasound Fellowship Programs Impact Emergency Medicine Residents’ Ultrasound Education? 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 of Emergency Medicine, University of Arizona Medical Center, Tucson, Arizona USA (S.Ad.); Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York USA (C.R.); Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey– Robert Wood Johnson Medical School, New Brunswick, New Jersey USA (D.M.); Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York USA (J.T.); Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida USA (S.L.); Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia USA (J.M.); Department of Emergency Medicine, Georgia Regents University, Augusta, Georgia USA (M.L.); Division of Emergency Medicine, Duke University, Durham, North Carolina (F.L.); and Department of Emergency Medicine, Albert Einstein Beth Israel Medical Center, New York, New York USA (S.Ak.). Revision requested September 10, 2013. Revised manuscript accepted for publication October 1, 2013. We thank Valerie K. Shostrom for expert assistance with statistical analysis for this study. Address correspondence to Srikar Adhikari, MD, MS, Department of Emergency Medicine, University of Arizona Medical Center, PO Box 245057, Tucson, AZ 85724 USA. E-mail: [email protected] Abbreviations
ACEP, American College of Emergency Physicians; CI, confidence interval; ED, emergency department; EM, emergency medicine; EUS, emergency ultrasound; US, ultrasound doi:10.7863/ultra.33.6.999
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 EUS fellowships enhance residents’ ultrasound (US) educational experiences. The purpose of 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 questionnaire 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 of bedside US applications, barriers to residents’ US education, and US use in the emergency department. The secondary outcomes were factors that would impact residents’ US education. The outcomes were compared between residency programs with and without 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 than those in programs without fellowships (P = .04). Significant differences were noted in most applications of bedside US between residency programs with and without fellowships (P < .05). There were also significant differences in the barriers to US education between residency programs with and without fellowships (P < .05). Conclusions—Emergency US fellowship programs had a positive impact on residents’ US educational experiences. Emergency medicine residents performed more scans overall and also used bedside US for more advanced applications in programs with EUS fellowships. Key Words—bedside ultrasound; emergency medicine residents; emergency ultrasound; emergency ultrasound fellowship
O
ver the past 2 decades, emergency ultrasound (EUS) has undergone a substantial evolution, and point-of-care ultrasound (US) is being used increasingly by emergency physicians.1 Emergency medicine (EM) residents are currently required to learn bedside US. In 1997, EUS was included in the core content for EM.2,3 The Accreditation Council for Graduate Medical Education and Emergency Medicine Residency Review Committee designated EUS as 1 of 3 core procedures assessed during accreditation visits, and all EM residency programs were required to show evidence of training and competency assessment in bedside US for
©2014 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2014; 33:999–1004 | 0278-4297 | www.aium.org
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Adhikari et al—Emergency Ultrasound Fellowship Programs for Emergency Medicine Residents
its graduates.1 In the 2011 “Model of the Clinical Practice of Emergency Medicine,”4 bedside US was listed as one of the procedures and skills integral to the practice of EM. The EM milestones released by the American Board of Emergency Medicine requires EM residents to demonstrate procedural competency in bedside US.5 The most recent American College of Emergency Physicians (ACEP) EUS guidelines published in 2008 recommended that US education be incorporated into the core educational program for all EM residency programs.1 Several formats have been proposed for developing a bedside US curriculum for EM residency training programs.6 The document developed from the EUS consensus conference held at the 2008 Council of Emergency Medicine Residency Directors Conference provided a framework for US curriculum development and competency assessment for EM residents.7 In the last few years, most EM residency programs have increased resources and instructional time to teach bedside US.8 However, variability still exists in bedside US education among residency programs despite educational recommendations proposed by national organizations.8,9 The reasons for interprogram variability and the difficulty in implementing the proposed curricula are multifactorial. Emergency US is a rapidly growing subspecialty in EM. Over the past decade, EUS fellowships have rapidly proliferated, and currently 92 such fellowships are offered in the United States (http://www.eusfellowships.com/ programs.php). The fellowship training is typically 1 year in length. The role of an EUS fellowship program is to train and foster the development of future leaders in the field of EUS. During fellowship training, fellows gain expertise in image acquisition and interpretation in advanced point-ofcare EUS applications. Fellows are required to complete one EUS research project and are responsible for teaching the faculty, residents, and medical students. Fellows also become proficient in the critical components required to run an EUS program, such as image archiving, digital image management, quality assurance, billing, and reimbursement. Generally, subspecialty fellowship programs enhance residency education. Fellows play an important role in resident training through their research and teaching efforts. They represent a vehicle for dissemination of subspecialty educational expertise and contribute to a richer educational environment. To our knowledge, no prior studies have examined the effects of EUS fellowships on residency education. Currently, there is no evidence supporting the idea that EUS fellowships improve residents’ US educational experiences. The objective of this study was to determine the impact of EUS fellowships on EM residents’ US education.
1000
Materials and Methods Study Design and Population We conducted a cross-sectional study at 9 academic medical centers with EM residency programs and an annual emergency department (ED) census of at least 45,000. Rather than a random sample, we purposefully identified EM residency programs by the absence or presence of an EUS fellowship to allow for valid comparisons between different programs. To make it a fair representation of all residency programs, we used the Society for Academic Emergency Medicine EM residency directory and invited several programs to participate in this study based on the presence or absence of a fellowship and geographic location. Only 9 programs agreed to participate in this study and administer the survey, resulting in a convenience sample. Four of these EM residency programs were located at centers that had an EUS fellowship in their ED for at least 2 years. All EDs had a bedside US education program and dedicated EUS director, including hospital-based credentialing in EUS. All EM residency programs were 3-year training programs. The EUS fellowship training programs were 1 year long and implemented in accordance with ACEP EUS fellowship guidelines. An Institutional Review Board approval or waiver was obtained at all institutions. Survey Content and Administration A questionnaire on US education and bedside US use was developed based on existing literature and knowledge of current 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 education, and barriers to residents’ US education. The questionnaire contained multiple-choice questions with space for free-text comments. A biostatistician experienced in survey design and 4 emergency physicians with expertise in EUS reviewed the questionnaire for the relevance and clarity of each survey question. The questionnaire was pilot tested on a small group of EM residents and was modified to address deficiencies suggested by the pilot group. Each site’s EUS director was responsible for distributing and collecting the surveys. All EM residents in each residency program were offered the survey. Participation in the survey was on a voluntarily basis. Verbal consent was obtained from the residents before administering the questionnaires. The surveys were administered and collected anonymously to protect the confidentiality of the residents who agreed to participate. The percentage of surveys returned was tracked. One research assistant entered all J Ultrasound Med 2014; 33:999–1004
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Adhikari et al—Emergency Ultrasound Fellowship Programs for Emergency Medicine Residents
survey data into a database. To assess the accuracy of data entry, a randomly sampled 30% of the questionnaires were reentered by a second research assistant. Measures The primary outcomes were the number of US examinations performed, scope of bedside US applications, barriers to residents’ US education, and US use in the ED. The secondary outcomes were factors that would impact residents’ US education. The outcomes were compared between residency programs with and without EUS fellowships. Data Analysis Descriptive analyses were performed with SAS software (SAS Institute Inc, Cary, NC). Questionnaire responses were reported in terms of the percentage of total respondents along with 95% confidence intervals (CIs). To allow for comparisons between EM residency programs with and without EUS fellowships, a χ2 or Fisher exact test was used as appropriate. P < .05 was considered statistically significant. Interobserver agreement of data entry was determined by κ analysis.
Results A total of 244 EM residents participated in this study. The residents were from regionally diverse EM residency programs: 9 EM residency programs located in 7 different states. The questionnaires received represented a 90% response rate. Of the responses, 48% were from the Northeast, 31% from the Midwest, and 21% from the Southeast. Data reentry by the second investigator showed high agreement (κ = 0.95). Seventy-one percent (95% CI, 65%–76%) of respondents reported that they had performed more 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 performing 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 per week. Only 4% (95% CI, 1.5%–6%) reported that they had performed more than 15 scans per week. The most commonly performed applications included focused assessment 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%), and gastrointestinal (18%). Table 1 summarizes the differences
J Ultrasound Med 2014; 33:999–1004
in the use of bedside US for different applications between EM residency programs with and without EUS fellowships. Statistically significant differences were noted for most of the applications of bedside US between residency programs with and without fellowships. Table 2 summarizes the barriers to US education identified by EM residents in EM residency programs with and without EUS fellowships. There were statistically significant differences in the barriers to US education between residency programs with and without fellowships. More residents in programs without fellowships thought that there were not enough faculty using US, and there was a lack of teaching and supervision while scanning in the ED. The need to obtain a radiology department US examination after a bedside US examination was more often a barrier in residency programs without EUS fellowships. The factors reported to make an impact on residents’ US education are listed in Table 3. Approximately threefourths (73%; 95% CI, 67%–78%) of the respondents cited proctored supervision while scanning in the ED as the best way to receive feedback about their scanning skills compared 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 US in future practice after residency training. Sixty-four percent (95% CI, 58%–70%) reported a concern about medicolegal liability with bedside US use in future practice.
Discussion Our study indicates that the presence of an EUS fellowship program results in a positive US educational experience for EM residents. There are several potential explanations for these findings. One of the major barriers for US education to clinicians is lack of enough faculty proficient in the use of bedside US.10 Emergency US fellowship would enhance residents’ US education by increasing the number of teaching faculty, specifically with fellows who are not distracted by heavy clinical and administrative responsibilities and more available to residents. Fellows spend additional time in the ED scanning patients, which leads to increased opportunities to interact and teach residents. Fellows also provide supplemental US lectures, grand round presentations, and hands-on training in both clinical and simulated settings. They participate in US quality assurance activities and provide feedback to residents on scanning techniques, image quality, and interpretation. They also actively engage in research, which further translates to improved resident education.
1001
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American College of Emergency Physicians EUS guidelines recommend a minimum of 150 total US examinations for general EUS competency.1 Not all EM residency programs meet ACEP guidelines at this time. In 2004, Moore et al8 reported that residents in 39% of EM residency programs were completing at least 150 US examinations. These findings are consistent with our study results. Our findings suggest that residents in training programs with EUS fellowships perform more scans overall and also use bedside US for more advanced applications.
Discrepancies exist in the US rotation formats offered by different EM residency programs.8 Some programs offer a dedicated US rotation, and others combine US with other subspecialty rotations such as anesthesia and radiology. There is also variability in the lengths of the rotations offered by different EM residency programs, ranging between 2 and 4 weeks. In our study, an overwhelming number of EM residents acknowledged the need for increases in didactic hours, conference time, and hands-on workshops. Residents indicated that recurring training
Table 1. Bedside US Applications
US Application No. of scans 150 Musculoskeletal Thoracic Renal Gastrointestinal Ocular Vascular (DVT) Superficial Vascular access Gallbladder Scrotal Aortic Procedural guidance Nonpregnant pelvic First-trimester pelvic Cardiac FAST
EM Residency Programs With EUS Fellowships (n = 116), % (95% CI)
EM Residency Programs Without EUS Fellowships (n =128), % (95% CI)
20 (13–27) 45 (36–54) 35 (26–43) 34 (25–42) 65 (56–73) 75 (67–82) 26 (18–33) 43 (34–52) 58 (49–66) 86 (80–92) 98 (95–100) 97 (94–100) 36 (27–44) 93 (88–97) 90 (84–95) 38 (29–46) 89 (83–94) 89 (83–94) 99 (97–100)
37 (28–45) 38 (29–46) 24 (16–31) 14 (8–20) 36 (28–44) 55 (46–63) 10 (5–15) 8 (3–12) 26 (18–33) 61 (52–69) 84 (77–90) 88 (82–93) 20 (13–27) 85 (79–91) 81 (74–87) 33 (25–41) 86 (80–92) 89 (84–94) 99 (97–100)
P
.04
ORIGINAL RESEARCH
Do Emergency Ultrasound Fellowship Programs Impact Emergency Medicine Residents’ Ultrasound Education? 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 of Emergency Medicine, University of Arizona Medical Center, Tucson, Arizona USA (S.Ad.); Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York USA (C.R.); Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey– Robert Wood Johnson Medical School, New Brunswick, New Jersey USA (D.M.); Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York USA (J.T.); Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida USA (S.L.); Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia USA (J.M.); Department of Emergency Medicine, Georgia Regents University, Augusta, Georgia USA (M.L.); Division of Emergency Medicine, Duke University, Durham, North Carolina (F.L.); and Department of Emergency Medicine, Albert Einstein Beth Israel Medical Center, New York, New York USA (S.Ak.). Revision requested September 10, 2013. Revised manuscript accepted for publication October 1, 2013. We thank Valerie K. Shostrom for expert assistance with statistical analysis for this study. Address correspondence to Srikar Adhikari, MD, MS, Department of Emergency Medicine, University of Arizona Medical Center, PO Box 245057, Tucson, AZ 85724 USA. E-mail: [email protected] Abbreviations
ACEP, American College of Emergency Physicians; CI, confidence interval; ED, emergency department; EM, emergency medicine; EUS, emergency ultrasound; US, ultrasound doi:10.7863/ultra.33.6.999
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 EUS fellowships enhance residents’ ultrasound (US) educational experiences. The purpose of 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 questionnaire 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 of bedside US applications, barriers to residents’ US education, and US use in the emergency department. The secondary outcomes were factors that would impact residents’ US education. The outcomes were compared between residency programs with and without 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 than those in programs without fellowships (P = .04). Significant differences were noted in most applications of bedside US between residency programs with and without fellowships (P < .05). There were also significant differences in the barriers to US education between residency programs with and without fellowships (P < .05). Conclusions—Emergency US fellowship programs had a positive impact on residents’ US educational experiences. Emergency medicine residents performed more scans overall and also used bedside US for more advanced applications in programs with EUS fellowships. Key Words—bedside ultrasound; emergency medicine residents; emergency ultrasound; emergency ultrasound fellowship
O
ver the past 2 decades, emergency ultrasound (EUS) has undergone a substantial evolution, and point-of-care ultrasound (US) is being used increasingly by emergency physicians.1 Emergency medicine (EM) residents are currently required to learn bedside US. In 1997, EUS was included in the core content for EM.2,3 The Accreditation Council for Graduate Medical Education and Emergency Medicine Residency Review Committee designated EUS as 1 of 3 core procedures assessed during accreditation visits, and all EM residency programs were required to show evidence of training and competency assessment in bedside US for
©2014 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2014; 33:999–1004 | 0278-4297 | www.aium.org
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Adhikari et al—Emergency Ultrasound Fellowship Programs for Emergency Medicine Residents
its graduates.1 In the 2011 “Model of the Clinical Practice of Emergency Medicine,”4 bedside US was listed as one of the procedures and skills integral to the practice of EM. The EM milestones released by the American Board of Emergency Medicine requires EM residents to demonstrate procedural competency in bedside US.5 The most recent American College of Emergency Physicians (ACEP) EUS guidelines published in 2008 recommended that US education be incorporated into the core educational program for all EM residency programs.1 Several formats have been proposed for developing a bedside US curriculum for EM residency training programs.6 The document developed from the EUS consensus conference held at the 2008 Council of Emergency Medicine Residency Directors Conference provided a framework for US curriculum development and competency assessment for EM residents.7 In the last few years, most EM residency programs have increased resources and instructional time to teach bedside US.8 However, variability still exists in bedside US education among residency programs despite educational recommendations proposed by national organizations.8,9 The reasons for interprogram variability and the difficulty in implementing the proposed curricula are multifactorial. Emergency US is a rapidly growing subspecialty in EM. Over the past decade, EUS fellowships have rapidly proliferated, and currently 92 such fellowships are offered in the United States (http://www.eusfellowships.com/ programs.php). The fellowship training is typically 1 year in length. The role of an EUS fellowship program is to train and foster the development of future leaders in the field of EUS. During fellowship training, fellows gain expertise in image acquisition and interpretation in advanced point-ofcare EUS applications. Fellows are required to complete one EUS research project and are responsible for teaching the faculty, residents, and medical students. Fellows also become proficient in the critical components required to run an EUS program, such as image archiving, digital image management, quality assurance, billing, and reimbursement. Generally, subspecialty fellowship programs enhance residency education. Fellows play an important role in resident training through their research and teaching efforts. They represent a vehicle for dissemination of subspecialty educational expertise and contribute to a richer educational environment. To our knowledge, no prior studies have examined the effects of EUS fellowships on residency education. Currently, there is no evidence supporting the idea that EUS fellowships improve residents’ US educational experiences. The objective of this study was to determine the impact of EUS fellowships on EM residents’ US education.
1000
Materials and Methods Study Design and Population We conducted a cross-sectional study at 9 academic medical centers with EM residency programs and an annual emergency department (ED) census of at least 45,000. Rather than a random sample, we purposefully identified EM residency programs by the absence or presence of an EUS fellowship to allow for valid comparisons between different programs. To make it a fair representation of all residency programs, we used the Society for Academic Emergency Medicine EM residency directory and invited several programs to participate in this study based on the presence or absence of a fellowship and geographic location. Only 9 programs agreed to participate in this study and administer the survey, resulting in a convenience sample. Four of these EM residency programs were located at centers that had an EUS fellowship in their ED for at least 2 years. All EDs had a bedside US education program and dedicated EUS director, including hospital-based credentialing in EUS. All EM residency programs were 3-year training programs. The EUS fellowship training programs were 1 year long and implemented in accordance with ACEP EUS fellowship guidelines. An Institutional Review Board approval or waiver was obtained at all institutions. Survey Content and Administration A questionnaire on US education and bedside US use was developed based on existing literature and knowledge of current 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 education, and barriers to residents’ US education. The questionnaire contained multiple-choice questions with space for free-text comments. A biostatistician experienced in survey design and 4 emergency physicians with expertise in EUS reviewed the questionnaire for the relevance and clarity of each survey question. The questionnaire was pilot tested on a small group of EM residents and was modified to address deficiencies suggested by the pilot group. Each site’s EUS director was responsible for distributing and collecting the surveys. All EM residents in each residency program were offered the survey. Participation in the survey was on a voluntarily basis. Verbal consent was obtained from the residents before administering the questionnaires. The surveys were administered and collected anonymously to protect the confidentiality of the residents who agreed to participate. The percentage of surveys returned was tracked. One research assistant entered all J Ultrasound Med 2014; 33:999–1004
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Adhikari et al—Emergency Ultrasound Fellowship Programs for Emergency Medicine Residents
survey data into a database. To assess the accuracy of data entry, a randomly sampled 30% of the questionnaires were reentered by a second research assistant. Measures The primary outcomes were the number of US examinations performed, scope of bedside US applications, barriers to residents’ US education, and US use in the ED. The secondary outcomes were factors that would impact residents’ US education. The outcomes were compared between residency programs with and without EUS fellowships. Data Analysis Descriptive analyses were performed with SAS software (SAS Institute Inc, Cary, NC). Questionnaire responses were reported in terms of the percentage of total respondents along with 95% confidence intervals (CIs). To allow for comparisons between EM residency programs with and without EUS fellowships, a χ2 or Fisher exact test was used as appropriate. P < .05 was considered statistically significant. Interobserver agreement of data entry was determined by κ analysis.
Results A total of 244 EM residents participated in this study. The residents were from regionally diverse EM residency programs: 9 EM residency programs located in 7 different states. The questionnaires received represented a 90% response rate. Of the responses, 48% were from the Northeast, 31% from the Midwest, and 21% from the Southeast. Data reentry by the second investigator showed high agreement (κ = 0.95). Seventy-one percent (95% CI, 65%–76%) of respondents reported that they had performed more 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 performing 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 per week. Only 4% (95% CI, 1.5%–6%) reported that they had performed more than 15 scans per week. The most commonly performed applications included focused assessment 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%), and gastrointestinal (18%). Table 1 summarizes the differences
J Ultrasound Med 2014; 33:999–1004
in the use of bedside US for different applications between EM residency programs with and without EUS fellowships. Statistically significant differences were noted for most of the applications of bedside US between residency programs with and without fellowships. Table 2 summarizes the barriers to US education identified by EM residents in EM residency programs with and without EUS fellowships. There were statistically significant differences in the barriers to US education between residency programs with and without fellowships. More residents in programs without fellowships thought that there were not enough faculty using US, and there was a lack of teaching and supervision while scanning in the ED. The need to obtain a radiology department US examination after a bedside US examination was more often a barrier in residency programs without EUS fellowships. The factors reported to make an impact on residents’ US education are listed in Table 3. Approximately threefourths (73%; 95% CI, 67%–78%) of the respondents cited proctored supervision while scanning in the ED as the best way to receive feedback about their scanning skills compared 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 US in future practice after residency training. Sixty-four percent (95% CI, 58%–70%) reported a concern about medicolegal liability with bedside US use in future practice.
Discussion Our study indicates that the presence of an EUS fellowship program results in a positive US educational experience for EM residents. There are several potential explanations for these findings. One of the major barriers for US education to clinicians is lack of enough faculty proficient in the use of bedside US.10 Emergency US fellowship would enhance residents’ US education by increasing the number of teaching faculty, specifically with fellows who are not distracted by heavy clinical and administrative responsibilities and more available to residents. Fellows spend additional time in the ED scanning patients, which leads to increased opportunities to interact and teach residents. Fellows also provide supplemental US lectures, grand round presentations, and hands-on training in both clinical and simulated settings. They participate in US quality assurance activities and provide feedback to residents on scanning techniques, image quality, and interpretation. They also actively engage in research, which further translates to improved resident education.
1001
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Adhikari et al—Emergency Ultrasound Fellowship Programs for Emergency Medicine Residents
American College of Emergency Physicians EUS guidelines recommend a minimum of 150 total US examinations for general EUS competency.1 Not all EM residency programs meet ACEP guidelines at this time. In 2004, Moore et al8 reported that residents in 39% of EM residency programs were completing at least 150 US examinations. These findings are consistent with our study results. Our findings suggest that residents in training programs with EUS fellowships perform more scans overall and also use bedside US for more advanced applications.
Discrepancies exist in the US rotation formats offered by different EM residency programs.8 Some programs offer a dedicated US rotation, and others combine US with other subspecialty rotations such as anesthesia and radiology. There is also variability in the lengths of the rotations offered by different EM residency programs, ranging between 2 and 4 weeks. In our study, an overwhelming number of EM residents acknowledged the need for increases in didactic hours, conference time, and hands-on workshops. Residents indicated that recurring training
Table 1. Bedside US Applications
US Application No. of scans 150 Musculoskeletal Thoracic Renal Gastrointestinal Ocular Vascular (DVT) Superficial Vascular access Gallbladder Scrotal Aortic Procedural guidance Nonpregnant pelvic First-trimester pelvic Cardiac FAST
EM Residency Programs With EUS Fellowships (n = 116), % (95% CI)
EM Residency Programs Without EUS Fellowships (n =128), % (95% CI)
20 (13–27) 45 (36–54) 35 (26–43) 34 (25–42) 65 (56–73) 75 (67–82) 26 (18–33) 43 (34–52) 58 (49–66) 86 (80–92) 98 (95–100) 97 (94–100) 36 (27–44) 93 (88–97) 90 (84–95) 38 (29–46) 89 (83–94) 89 (83–94) 99 (97–100)
37 (28–45) 38 (29–46) 24 (16–31) 14 (8–20) 36 (28–44) 55 (46–63) 10 (5–15) 8 (3–12) 26 (18–33) 61 (52–69) 84 (77–90) 88 (82–93) 20 (13–27) 85 (79–91) 81 (74–87) 33 (25–41) 86 (80–92) 89 (84–94) 99 (97–100)
P
.04
