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Emergency Ultrasound

Ask The Expert: An interview with a family medicine trained EUS fellow

As a family medicine trained emergency ultrasound (EUS) fellow, what are the challenges and opportunities for family medicine and EUS?

Point-of-care ultrasound (POCUS) is becoming more widely used in all areas of medicine. Emergency medicine is the first specialty to incorporate bedside ultrasound well within its core curriculum for residency training. To enhance education in performing and interpreting POCUS, many emergency ultrasound (EUS) fellowships have been created. A listing of these fellowships could be found on www.eusfellowships.com.

Family medicine is similar to emergency medicine as one of the broadest clinical fields providing various opportunities to utilize bedside sonography to improve patient care and patient satisfaction. However, the specialty of family medicine has not yet formally introduced POCUS training to its resident physicians. While many medical schools now have longitudinal ultrasound curriculum for medical students, only a few family medicine residency programs have a POCUS curriculum. This may lead to lack of continuity in ultrasound education if residency programs are not structured to further the training of these medical students. Availability of well-designed POCUS training could be an important recruiting factor for family medicine residency programs.

One of the main factors hampering development of POCUS education in family medicine is lack of ultrasound-trained faculty physicians. POCUS workshops that are offered at national and regional conferences may provide interested physicians brief education of bedside sonography but may not be able to provide them required comfort level to use POCUS in daily practice, the ability to teach it, or the knowledge to run an ultrasound program. In order to solve this issue, family physicians need exposure to immersive POCUS education. Fellowship training dedicated to POCUS could bridge this gap in education and could rapidly generate well-trained faculty members who could propagate POCUS education in family medicine residencies. Since there are few primary care POCUS fellowships, utilizing EUS fellowships for training of family physicians could be effective and convenient.

There are several potential benefits of EUS fellowship training for family physicians. Utilizing POCUS in the emergency department exposes a family physician to the spectrum of urgency of various clinical conditions. Concepts learned from point-of-care emergency ultrasound could be applied to day-to-day cases in any area of family medicine.

Many family physicians work in outpatient traditional clinics and in urgent care centers where POCUS could have significant diagnostic and procedural value. Critical care and trauma sonography could instill an additional diagnostic skill-set in a family physician for hospitalist medicine. Obstetric ultrasound could be significantly useful for family physicians that practice obstetrics and gynecology. In a pediatric clinic, POCUS could be used for various applications to enhance patient care and to prevent excessive emergency room visits. In sports medicine, POCUS has a distinctive roll. MSK US education could expand a family physician’s clinical horizon in this area as well. Vascular ultrasound has potential place in preventive care when it comes to AAA scanning and carotid duplex imaging.

In a nutshell, POCUS may decrease delays in patient care, overall healthcare cost and family physician’s dependence on specialists by revealing objective evidence of suspected pathology in areas where POCUS is proven to be helpful.

The first challenge to POCUS fellowship level training is that many family medicine residency programs have no plans to incorporate POCUS education. This may have stemmed from lack of comfort in performing and interpreting ultrasonography independently. Ignoring POCUS training at residency level could lead to a snowball effect coming from top down where more and more trainees would start feeling uncomfortable using POCUS. This may indirectly lead to lack of interest in fellowship level training.

Moreover, credentialing for POCUS is not standardized for family physicians. Hence there is absence of clarity about a fellow’s ability to integrate POCUS into his/her desired area of clinical practice after completion of EUS fellowship.

The family medicine EUS fellow only gets exposed to emergency room cases, which may not reflect a practical scenario for a given family physician. Depending on the hospital, not being board certified in EM, a family medicine EUS fellow may not be able to work clinically in main ER, which could lead to lack of ownership of patient he/she is utilizing POCUS on. This could lead to delay in diagnosis and fragmentation of patient care.

As the family physician often will not be able to be credentialed to practice in the ED, alternate ways of financing the fellowship need to be considered. Multispecialty groups or agreements between emergency medicine and family medicine training programs in facilities to provide a training relationship for the fellow need to be developed.

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