Point-of-care ultrasound (POCUS) has seen rapid expansion with increased use in general medicine, emergency medicine, and critical care settings.¹ Medical schools have integrated POCUS into their curriculum and residency program training for years¹; however, the majority of PA training programs have yet to integrate it into their curriculum. One reason: adding more skills into a PA program risks lengthening the training period and increasing cost, thereby negating the advantages of a 2-year PA curriculum.²

While some PA training programs have added some form of POCUS instruction to their curriculum, it is debatable whether POCUS should be added at the training level, as a postgraduate fellowship, or as continuing medical education (CME). Not every PA will have access to POCUS in their chosen work setting or specialty. Therefore, is it necessary to train all PAs on POCUS or should PA students be offered entry-level instruction and those wanting more in-depth training do so via elective rotation or independent of their PA program? Most medical students’ and residents’ POCUS training requires hundreds of live ultrasounds, both diagnostic and procedural, to be considered minimally proficient; therefore, PA students would likely have to add on several hours of didactic preparation and then complete approximately 150 to 300 scans to become minimally proficient.³

POCUS Equipment

Point-of-care ultrasound is a limited ultrasound examination at the bedside that is used as a diagnostic tool, for procedural guidance, and to support the clinician’s treatment decisions.⁴ This tool has become a workhorse in medicine where it can be used to perform cardiac, obstetric, abdominal, vascular, and integumentary examinations as well as focused assessment with sonography for trauma (FAST) examinations among other tests.³ Each specialty has its own set of POCUS examinations and techniques.

Since the 1970s with the implementation of FAST exams, bedside ultrasound has steadily progressed to be an invaluable tool. As technology has advanced with the advent of more portable options with the invention of semiconductors and smartphones, so has POCUS.^1,3 Breunig et al discussed several portable ultrasound device options including Butterfly iQ, Lumify, and SonoSite iViz.³

Point-of-Care Ultrasound Training

Training on POCUS in medical schools has steadily increased and over 60% of medical schools have incorporated it into their curriculum. Conversely, only approximately 29% of PA programs have incorporated POCUS into their curriculum.^1,4 Russell et al discussed the curriculum development and implementation within the Indiana University School of Medicine system, which has more than 360 students per year.⁴ The university incorporated POCUS training throughout the requisite 4 years with students weaving their POCUS modules between each year. Dinh et al surveyed 175 medical schools in the US and found that most schools implemented ultrasound training in years 1 and 2 with the average being across 3 years.⁵ Because of the shorter length of PA programs, the number of POCUS training hours would need to be reduced to be integrated into current curricula or PA programs would need to be lengthened. Breunig et al proposed a curriculum based on standards from various societies, medical schools, and residency programs and suggested a specific foundational list of POCUS skills³:

• FoCUS: qualitative left ventricular systolic function, qualitative right ventricular size and systolic function, presence of pericardial effusions, size and respiratory variation of the inferior vena cava
• Lung POCUS: lung sliding, absent lung sliding, A lines, B lines, consolidation, pleural effusion
• Abdominal POCUS (kidneys, aorta, bladder, free fluid): nephrolithiasis, hydronephrosis, abdominal aortic aneurysm, bladder volume, presence of peritoneal free fluid
• Soft tissue POCUS: cellulitis, abscess, hematoma
• Obstetric POCUS: confirmation of intrauterine pregnancy
• Vascular POCUS: lower-extremity deep vein thrombosis examination
• Musculoskeletal POCUS: long-bone fracture, joint effusion

By reducing the scope and number of skills to be taught, PA students have a better chance of learning a focused list of POCUS skills that can be incorporated through the didactic year and then a focused list of required scans in the clinical year. This reduction allows PA students to have at least a familiarity with POCUS but does not generate mastery. Breunig et al also outlined an advanced POCUS skills list that includes³:

• Vascular access: ultrasound-guided peripheral and central vascular access
• Critical illness: eFAST, rapid ultrasound in shock and hypotension (RUSH) examination, and basic lung ultrasound in emergency (BLUE) protocol
• Procedural guidance: lumbar puncture, paracentesis, and thoracentesis

These skills are technically complex, include multiple organ systems, and patients are often clinically unstable; therefore, this requires additional classroom and hands-on time for PAs to become competent.⁴ Breunig et al also suggested that training include approximately 25 to 50 scans for each body system to be proficient.³

What about PA students who aren’t going into a specialty that uses POCUS? Not many family practice clinicians need advanced clinical applications of ultrasound; therefore, proposing any sort of extension to PA training time is not reasonable for all students.

Another barrier to the incorporation of POCUS into entry-level PA training is the lack of faculty experience.¹ This is not exclusive to PA programs, Dinh et al noted that this is a barrier to medical schools as well. The authors wrote: “It can also be difficult to find sufficient faculty numbers to help teach, and a substantial amount of faculty development time may be needed.”⁵ They added that faculty need approximately 40 hours of training per year on average. Therefore, maintaining competence can also be a limitation, which is defined by the 4 core components “knowing when to use POCUS during a patient examination, knowing how to acquire good images, being able to interpret the images, and using the images in making clinical decisions.”¹

Additionally, what is the impetus for PA schools to add expense and time to their program? One of the most significant barriers to execution is cost. Between faculty participating in in-person training ($397-$1500; average, $949), travel costs for 2 faculty members ($1800), and ultrasound equipment ($2400-$35,000), Perdue et al stated the range of startup cost for POCUS training in a PA program could be between $4597 and $38,300, with the equipment being the largest percentage of the expense.6 However, this is a conservative estimate as most PA programs would likely require more than a single ultrasound machine per classroom/laboratory. According to Bruening et al, one way to defray the cost would be to require students to purchase handheld ultrasound equipment and applications that they can then use postgraduation in their practice settings.³

Is there any requirement or push from the National Commission on the Certification of Physician Assistants (NCCPA) or the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) on this training? According to the NCCPA,⁷ they do not require learning POCUS for initial PA certification or the Certificate of Added Qualification (CAQ) and, specifically with the CAQ, have no strict rule on making any specific skill a “must have.” For example, in the NCCPA CAQ-EM (Emergency Medicine) ultrasound is listed under procedures/patient care requirements, but it is clearly stated that: “The attestation of knowledge and skills must indicate that the PA has performed the procedures and patient management relevant to the practice setting and/or understands how and when the procedures should be performed.” The NCCPA added, “…the PA may not have experience with each procedure, but he or she must be knowledgeable of the basics of the procedures, in what situation the procedures should be done, and the associated management of patients.”

The ARC-PA standards are also vague on whether ultrasound should be included in entry-level PA education. According to section B2.09 of The Accreditation Standards for Physician Assistant Education, 5th edition, “the curriculum must include instruction in clinical and technical skills including procedures based on then-current professional practice.”⁸ Therefore, an argument could be made that it may not be an ARC-PA requirement, but will PA programs soon be obligated to include at least cursory knowledge on types of ultrasound scans and their place in diagnosis as this is becoming more prevalent in “current professional practice?”

Conclusion

While many PA programs have begun to incorporate POCUS training into their curriculum, many barriers to adding this training without significantly extending time in the program exist. Other barriers include the cost of equipment and acquiring trained faculty.¹ The cost of training faculty on POCUS to the level of competency required to then impart this to their students also needs to be factored in.

Although adding skills to the PA repertoire (especially new graduates) has added value and makes them more marketable to employers, the current barriers to POCUS training suggest that postgraduate CME or fellowship may be the best option for PAs entering a specialty that uses POCUS.

Dana S. Miles, DMSc (candidate), MS, PA-C, CAQ-EM, has been working in emergency medicine as a PA since 2005 and is currently in the Doctor of Medical Science (DMSc) program at A.T. Still University-Arizona School of Health Sciences.

References

1. Zak CL, Monti JD. PAs and point-of-care ultrasound: a scoping review. JAAPA. 2022;35(4):43-50. doi:10.1097/01.JAA.0000819568.41670.54

2. Williams, B. Eugene A. Stead, Jr. Oral history. Physician Assistant History Society. July 23, 1998. Accessed September 30, 2022. https://pahx.org/dr-eugene-stead-jr-oral-history/

3. Breunig M, Huckabee M, Rieck KM. An integrated point-of-care ultrasound curriculum: an evidence-based approach. J Physician Assist Educ. 2022;33(1):41-46. doi:10.1097/JPA.0000000000000402

4.Russell FM, Herbert A, Ferre RM, et al. Development and implementation of a point of care ultrasound curriculum at a multi-site institution. Ultrasound J. 2021;13(1):9. doi:10.1186/s13089-021-00214-w

5. Dinh VA, Fu JY, Lu S, Chiem A, Fox JC, Blaivas M. Integration of ultrasound in medical education at United States medical schools: a national survey of directors’ experiences. J Ultrasound Med. 2016;35(2):413-419. doi:10.7863/ultra.15.05073

6. Perdue M, Bosse B, Pasha J, Davison M. Implementation of point-of-care ultrasound in a physician assistant curriculum. J Physician Assist Educ. 2020;31(2):91-94. doi:10.1097/JPA.0000000000000301

7. National Commission on the Certification of Physician Assistants. Certificates of added qualifications: emergency medicine CAQ. Accessed September 30, 2022. https://www.nccpa.net/specialty-certificates/#emergency-medicine

8. Accreditation Review Commission on education for the physician assistant. The Accreditation Standards for Physician Assistant Education, 5th edition. Updated March 2022. Accessed September 30, 2022. http://www.arc-pa.org/accreditation/standards-of-accreditation/