Dear Editor,

I am writing in response to the October 5, 2022, article by Dana S. Miles, MS, PA-C, CAQ-EM, Is Point-of-Care Ultrasound Training Feasible During PA Programs?1 In many cases, it is prudent to question the necessity and feasibility of adding any additional curriculum to already arduous PA education programs. Although it may be easy to argue for the addition of training in new technologies, this change must always be weighed in terms of time and cost of training. There is likely little to no room in the packed curriculum to include the number of hours sufficient even to introduce common point-of-care-ultrasound (POCUS) examinations not to mention train PA students to be proficient.

Furthermore, without a supporting standard or mandate by Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), there is little incentive for PA programs to spend the time and money to build an ultrasound curriculum outside of student preferences or a desire to be an early adopter of ultrasound training.

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No money, no incentive, and no time make the recommendation to defer POCUS training to post-graduation a reasonable response. This does not mean, however, that PA education should remain stagnant and never change to reflect the real-world practices of PA generalists and specialists. While PA education is not to be a mirror or mini-medical school, institutions should be aware of the current climate and trends in medical education as a whole.

Bedside ultrasound is already on a trajectory to be included in more medical school and PA programs in the coming years. More than 80% of medical schools report mandatory ultrasound training, according to survey findings.2 Adopting POCUS training in PA education is not biting the bullet and adopting the shiny new toy that all the kids are using. It is integrating a superior way to detect and diagnose pathology and a safer way to perform bedside procedures. Studies have shown that bedside ultrasound is superior to lung auscultation,3,4,5-7 evaluation of endotracheal intubation,8 and detection of pneumothorax.9 Additionally, cardiac auscultation10-12 and carotid auscultation13 were both superior to using a stethoscope.

Although I will not go so far as to say that ultrasound should replace the stethoscope, nor do I suggest that we abandon teaching percussion and auscultation, I strongly advise teaching bedside ultrasound to augment the physical examination just like bronchophony or egophony or shifting dullness on percussion. (By the way, if you don’t remember these techniques from your clinical education, it makes me wonder about the utility of including them in the curriculum).

What is percussion, if not a poor man’s ultrasound? When percussing, a clinician sends sound waves into the body and feels how they bounce back. If the cavity is filled with air, the sound scatters and is resonant. If fluid or a solid mass is present under the skin, the percussion feels dull or the vibrations bounce back quickly. I have found percussion more helpful in finding studs under drywall than in clinical practice. Similarly, bronchophony and egophony are taught to PA students to help find lung consolidations or effusions while bedside ultrasound has proven to be superior at detecting lung pathology including pulmonary edema as well as effusions and consolidations.4,6,7,14 (And in case you forgot bronchophony and egophony, they describe changes in sound transmission through lung tissue when the patient says “E” or “99” and the sound is felt or heard differently through consolidation or effusion than through normal aerated lung fields.)

Am I suggesting we abandon teaching percussion? No! How will future PAs ever be able to sink a nail into a stud to hang a picture? Plus, I said percussion was a poor man’s ultrasound. I tell my students that if they can understand percussion then they will be much better during bedside ultrasound in understanding how ultrasonic waves scatter and don’t return to the probe well when passing through the air, but can give great images when penetrating fluid or solid organs.

There are too many applications of POCUS to consider teaching this technology in a full PA curriculum; plus, the ways in which POCUS can be used in diagnosis and procedures is likely to expand. A thorough and well-understood physical examination should always be part of a PA education. I suggest starting with the bedside examination and using ultrasound as an adjunct to give additional information, much like the stethoscope, which has had its fair share of detractors in favor of ultrasound as of late.15-18

Rather than dramatically expanding the required PA curriculum, let us look at the skills that we are currently teaching and incorporate bedside ultrasound into the physical examination. In addition to percussing a liver, students can begin to see it on ultrasound. When teaching wheezing, rales, and rhonchi, ultrasound findings of pulmonary edema and consolidation can be introduced. New graduates will at least enter their field with a base knowledge of how many current clinicians are using POCUS.

Proficiency in POCUS takes training and hundreds of hours of practice that cannot fit into a PA curriculum, just like many other skills that are honed post-graduation. POCUS is clearly in the future of many graduating PAs in many specialties. Let’s introduce the skill in PA training so that it can blossom over the career of many PAs.

Adam Broughton, PA-C, is a graduate and faculty member at the Northeastern University PA Program where he serves as an assistant clinical professor. He has worked for 15 years in emergency medicine and continues to serve in his community hospital. Prior to PA school, he worked as an EMT and remains dedicated to advancing the profession.

References

  1. Miles DS. Is point-of-care ultrasound training feasible during PA programs? Clinical Advisor. October 5, 2022. Accessed April 24, 2023. https://www.clinicaladvisor.com/home/my-practice/physician-assistant-career-resources/point-of-care-ultrasound-training-for-pas
  2. Nicholas E, Ly AA, Prince AM, Klawitter PF, Gaskin K, Prince LA. The current status of ultrasound education in United States medical schools. J Ultrasound Med. 2021;40(11):2459-2465. doi:10.1002/jum.15633
  3. Aujayeb A. Could lung ultrasound be used instead of auscultation? Afr J Emerg Med. 2020;10(3):105-106. doi:10.1016/j.afjem.2020.04.007.
  4. Cox EGM, Koster G, Baron A, et al; SICS Study Group. Should the ultrasound probe replace your stethoscope? A SICS-I sub-study comparing lung ultrasound and pulmonary auscultation in the critically ill. Crit Care. 2020;24(1):14. doi:10.1186/s13054-019-2719-8
  5. Gargani L. Lung ultrasound: a new tool for the cardiologist. Cardiovasc Ultrasound. 2011;9:6. doi:10.1186/1476-7120-9-6
  6. Arbeid E, Forfori F, Bernardeschi G, Giunta F, Hemmerling TM. Utility of lung ultrasound. Br J Anaesth. 2012;108(6):1041-1042. doi:10.1093/bja/aes159
  7. Lichtenstein D. Lung ultrasound in the critically ill. Curr Opin Crit Care. 2014;20(3):315-322. doi:10.1097/MCC.0000000000000096
  8. Ramsingh D, Frank E, Haughton R, et al. Auscultation versus point-of-care ultrasound to determine endotracheal versus bronchial intubation: a diagnostic accuracy study. Anesthesiology. 2016;124(5):1012-20. doi:10.1097/ALN.0000000000001073
  9. Dahmarde H, Parooie F, Salarzaei M. Accuracy of ultrasound in diagnosis of pneumothorax: a comparison between neonates and adults-a systematic review and meta-analysis. Can Respir J. 2019;2019:5271982. doi:10.1155/2019/5271982
  10. Kobal SL, Trento L, Baharami S, et al. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol. 2005;96(7):1002-1006. doi:10.1016/j.amjcard.2005.05.060
  11. Gardezi SKM, Myerson SG, Chambers J, et al. Cardiac auscultation poorly predicts the presence of valvular heart disease in asymptomatic primary care patients. Heart. 2018;104(22):1832-1835. doi:10.1136/heartjnl-2018-313082
  12. Watsjold B, Ilgen J, Monteiro S, et al. Do you hear what you see? Utilizing phonocardiography to enhance proficiency in cardiac auscultation. Perspect Med Educ. 2021;10(3):148-154. doi:10.1007/s40037-020-00646-5
  13. Magyar MT, Nam EM, Csiba L, Ritter MA, Ringelstein EB, Droste DW. Carotid artery auscultation–anachronism or useful screening procedure? Neurol Res. 2002;24(7):705-708. doi:10.1179/016164102101200618
  14. Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology. 2004;100(1):9-15. doi:10.1097/00000542-200401000-00006.
  15. Silverman B, Balk M. Digital stethoscope-improved auscultation at the bedside. Am J Cardiol. 2019;123(6):984-985. doi:10.1016/j.amjcard.2018.12.022
  16. Gillman LM, Kirkpatrick AW. Portable bedside ultrasound: the visual stethoscope of the 21st century. Scand J Trauma Resusc Emerg Med. 2012;20:18. doi:10.1186/1757-7241-20-18
  17. Copetti R. Is lung ultrasound the stethoscope of the new millennium? Definitely yes! Acta Med Acad. 2016;45(1):80-1. doi:10.5644/ama2006-124.162
  18. Bledsoe A, Zimmerman J. Ultrasound: the new stethoscope (point-of-care ultrasound). Anesthesiol Clin. 2021;39(3):537-553. doi:10.1016/j.anclin.2021.03.011

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