Figure 1Structured teaching of point-of-care ultrasound skills: Weekly hands-on learning sessions under the instruction of consultants and experienced internists.
DOI: https://doi.org/https://doi.org/10.57187/s.4484
Point-of-care ultrasound (POCUS) represents a valuable addition to the diagnostic armamentarium of internal medicine specialists, improving patient assessment and treatment guidance. The numerous benefits of POCUS, including its speed, widespread availability, low cost, diagnostic integrity and high precision, position it as a highly valuable tool in narrowing the differential diagnosis in time-sensitive emergencies such as hypotension, shock or acute dyspnoea [1, 2]. It also facilitates assessing important dynamic changes and responses to treatment over time. The use of POCUS does not entail concerns about potential harm from ionising radiation or transportation of critically ill patients to different clinical units. Several studies have shown that procedures such as thoracentesis, paracentesis, arthrocentesis and catheter placements can be performed with reduced complication rates under sonographic guidance [3, 4]. Lastly, ultrasound appears to be a cost-effective imaging modality [5, 6].
The ability to address specific clinical questions, often on a dichotomised yes-or-no basis, facilitates the acquisition of appropriate skills. However, sufficient training is needed to achieve high quality in POCUS examinations. In 2022, the Swiss Institute for Postgraduate & Continuing Medical Education (SIWF/IFSM) decided that the POCUS Component 1 (basics of emergency medicine ultrasound) of the Swiss Society of Ultrasound in Medicine (SGUM) postgraduate certification programme will be mandatory for board certification in General Internal Medicine after 2026.
While this decision emphasises the growing importance of ultrasound skills for internal medicine specialists, it presents several challenges for teaching hospitals. First, there is a shortage of qualified instructors to educate and supervise all junior doctors completing board certification in General Internal Medicine. Secondly, clinical institutions are confronted with discussions about the quality and safety of ultrasound examinations, as both the diagnostic and harm potentials are defined by the skills of the examiner and their supervisor. The creation of standard operating procedures and image quality control mechanisms is paramount to ensure the reliability of diagnostic results. These processes are time-consuming, necessitating additional staffing and resource allocation.
To coordinate the efforts and capacities of all internists throughout Switzerland, an interest group for ultrasound in internal medicine (USIM) was formed on behalf of the Swiss Society of General Internal Medicine (SSGIM) to promote ultrasound within the scope of the General Internal Medicine and coordinate their activities with the SGUM. The USIM convenes at least twice annually at the SSGIM meetings for professional exchange and to address emerging challenges with a bottom-up approach. The USIM is responsible for planning and coordinating ultrasound activities in General Internal Medicine, developing an educational online platform and organising scientific events and training sessions biannually.
Significant variation in physicians’ practical experience and sonographic competencies has been observed across individuals, specialities and regions in Switzerland [7, 8]. The lack of standardised educational programmes during the six-year undergraduate medical education period means that the current generation of internal medicine physicians in Switzerland must acquire ultrasound skills during their residency. Historically, this has been undertaken voluntarily and was contingent on the local practice of the individual clinical institution. As the field of General Internal Medicine has evolved and become increasingly complex, junior physicians depend on the mentoring and guidance of their senior colleagues in planning their postgraduate education. Consequently, senior physicians assume a pivotal role in fostering, advocating for and practising ultrasound examinations. Currently, there is a notable deficit in senior physicians’ training in POCUS. The implementation of a structured training programme has the potential to address this gap by providing a standardised, high-quality ultrasound training curriculum for residents and senior doctors in General Internal Medicine.
In Stadtspital Zürich Triemli, a hands-on, peer-led ultrasound educational programme was initiated in 2022, aiming to promote a positive ultrasound teaching culture and enable all internal medicine specialists in the local General Internal Medicine division to acquire the necessary skills and complete the supervised exams required for the POCUS certificate. The blueprint for this programme is shared in the appendix tables S1 and S2 for use by other institutions. The template proposed here is designed to serve as a basis for a standardised education plan that is easily accessible, constantly optimised and adapted. We understand it as a guide to complement the formal training obtained during SGUM courses.
This programme is based on the official SGUM syllabus for POCUS Component 1 with 10 teaching topics, including the 13 essential learning objectives (appendix table S1) and additional learning objectives (appendix table S2) for advanced sonographers. Each teaching topic is organised with two hands-on teaching sessions, spanning half a year (table S1) or one year (table S2). These sessions are led by consultants from various medical disciplines, including radiology, gastroenterology and hepatology, pneumology, cardiology, rheumatology and angiology, as well as already trained and experienced residents and senior internists (figure 1).
The additional objectives listed in table S2 are not mandatory for certification in POCUS Component 1. In addition to the learning objectives of other POCUS components – such as focused cardiac ultrasound (Component 13) and lung ultrasound (Component 11) – table S2 also includes objectives for the Certificate of Sonography (Module Abdomen). These objectives involve more descriptive or exploratory questions and examinations, which are beyond a binary answer and require instructors with advanced training and expertise. We consider a basic understanding of these objectives essential for advanced residents, as proficiency in ultrasound relies on recognising organs and structures, which is not fully addressed by POCUS Component 1. Additionally, focused cardiac and lung ultrasound are increasingly integrated in emergency care. Several senior General Internal Medicine physicians at Stadtspital Zürich Triemli are certified for Sonography (Abdomen). Moreover, expertise from other disciplines and supervision of Components 11 and 13 is available. As such, our programme also includes advanced topics (table S2). In a setting with limited skills and resources, the topics in table S1 are sufficient for Component 1 certification.
Figure 1Structured teaching of point-of-care ultrasound skills: Weekly hands-on learning sessions under the instruction of consultants and experienced internists.
Before each teaching session, all residents of General Internal Medicine receive an email containing the learning objectives and educational videos and images. This preparation ensures familiarity with the topic and reactivation of existing knowledge. Each teaching session begins with a short theoretical presentation, followed by a 30-minute hands-on guided training session in small groups. Scanning is performed on each other or selected patients with interesting pathological findings who consent to participate. For each training session, one supervised ultrasound is accredited. Supplementary learning materials, subject-specific presentations and e-learning courses on POCUS Component 1 and abdominal sonography, developed by the Institute of Primary Health Care Bern (BIHAM), are available on the intranet for residents and free to access at any time.
To obtain the certification for POCUS Component 1 of the SGUM program, trainees must complete a logbook with 200 patient examinations, of which 100 must be supervised. To address this challenge, optional short daily supervised ultrasound rounds have been implemented: residents inform the coordinator of these sessions via a designated ultrasound phone after daily ward rounds. Pathological sonographic findings are then reviewed together in the afternoon. Such an approach provides 2–3 supervised examinations for all participants, where findings can be discussed and interpreted in a clinical context.
The combination of weekly ultrasound training sessions and supervised ultrasound rounds has enhanced the performance of ultrasound within General Internal Medicine, fostering greater confidence and competence among both residents and senior physicians, ultimately improving patient care through timely and accurate diagnoses. The interdisciplinary nature of this programme has led to a widespread acceptance of our ultrasound curriculum across various divisions of our hospital, further promoting a familiar interdisciplinary collaboration and dynamic exchange during regular work hours.
POCUS is being increasingly recognised as an indispensable tool in internal medicine, and distinct clinical skills in POCUS will be required for board certification in General Internal Medicine. The future of POCUS lies in its continued integration into routine clinical practice. To facilitate this, there is a need for a robust framework and standardisation in the education and supervision of residents. Standardised training programmes, such as the one provided here, are essential to ensure the safe and effective use of POCUS, thereby consolidating its position as a cornerstone of modern internal medicine.
This project was supported by the Foundation Stiftung Stadtspital Zürich.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflict of interest related to the content of this manuscript was disclosed.
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The appendix is available in the pdf version of the article at https://doi.org/10.57187/s.4484.