Society of Point of Care Ultrasound

SPOCUS members teach the AAA scan to 2nd year medical students.

Deans and Program Directors

SPOCUS can help program directors with budgeting, ultrasound machine selection, standards for competency, clerical tools, competency standards, text books, the selection of simulators, time management needed to devote to learning each application and contacts for ultrasound manufacturers.

Currently, ultrasound is fully integrated into the curriculum of more than 20 medical schools across the US and 3 PA Programs. These schools start by teaching ultrasound applications on day one of class and longitudinally incorporate the learning throughout the 4 years of medical school or PA school respectively.  These are links to curriculum of the integrated medical schools.

The American College of Emergency Physicians has submitted a resolution to the AMA to endorse longitudinal integration of ultrasound into UME throughout all four years of medical school.  Since ultrasound is relevant to every level of healthcare, ultrasound will eventually be integrated into every healthcare professional educational program to include medical, PA, residencies, fellowships, nursing and paramedic school. 

The Society of Ultrasound in Medical Education (SUSME) is dedicated to integrating ultrasound in undergraduate medical education, as well residencies and fellowships.  SUSME has created an International Consensus Conference on Ultrasound in Medical Education comprised of 150 individuals world wide that represent experts in medical education, clinical ultrasound, as well as representation for basic sciences and medical specialties.  The purpose of this body of experts, is to determine what are the core competencies medical students should achieve during their undergraduate medical education.

Defining Ultrasound Integration- Integration is not currently unequivocally defined; however, it implies that traditional classes like anatomy, physiology, pathology, differential diagnosis and the physical exam modules as well as the hospital practicum all have an ultrasound component which compliments the traditional learning.  In some medical schools integration translates to teaching students ultrasound applications and protocols.   Other medical schools use ultrasound as a teaching tool to enhance core competencies every medical student is already learning. 

These core competencies include learning points that ultrasound may reinforce as part of a strategy of spaced repetition of learned material.  For example, the heart may be dissected in the Gross Anatomy lab, it's normal function taught in physiology, the individual components of the auscultation taught in the Physical Examination class, while pathology, murmurs, and the physical exam reinforced with an ultrasound lab session.

SPOCUS is dedicated to helping PA programs integrate ultrasound into their curriculum, with a goal of 10% of programs integrating ultrasound by 2021, 50% integrating by 2026, and all programs integrating by 2031. However, as of 2017 there are 3 PA programs that have ultrasound integrated longitudinally in the curriculum, and several more that offer short blocks of instruction.  Five additional programs are scheduled to start their integration at the start of this incoming class.  If PA programs are to continue on the path of a medical model of education, then we must attempt to mirror the medical school example and provide our young graduates with the skills necessary to continue to easily collaborate with our physician colleagues.

To reach this goal, SPACUS has created tools to support educators, faculty, students and program directors learn from the didactic phase to clinical implementation.  This support is intended to provide mentorship, train faculty, integrate curriculum, advise on budgetary and capital expenditures and help PA programs find the funding to realize their individual ultrasound goal. 

In  2017 SPACUS Generalist Clinical Ultrasound Guidelines, which endorse PA program education as a pathway to initial training on the road to clinical ultrasound competency.

            "Full integration of clinical ultrasound training into PA program curricula will provide the richest longitudinal learning experience, therefore training in clinical ultrasound should begin at the earliest point of PA school to allow for the progression of skills throughout didactic and clinical training.

Instruction should begin with basic ultrasound physics and instrumentation, followed by a brief introduction to the clinical applications of bedside ultrasound. Ideally, this clinical training would begin during the anatomy and physiology courses.

Although ultrasound should be considered a separate entity from the clinical exam, it has the potential to complement the exam by offering otherwise unobtainable and clinically relevant anatomic and physiologic real time information to the scanning clinician.  Many UME programs have successfully incorporated clinical ultrasound into the physical exam training.41-44  PA programs should consider adding clinical ultrasound into the physical exam training as these two clinical skills greatly complement each other."

Program directors should understand that an ultrasound presence is not synonymous with adding time to a PA program's packed schedule or extending the length of the program.  The intention is not to "gut" the curriculum the program has worked hard to perfect, or stress the program's schedule.   It is intended to compliment the excellent work the faculty are already doing by enhancing the curriculum currently in place, and teaching clinically relevant topics that will help students become the best trained clinicians ready to accept the challenges of patient care.

A strategically planned ultrasound presence can enhance your well-oiled educational machine.  Ultrasound can be used as an extension of the physical exam where things like liver and spleen size, diaphragmatic excursion, ventricular hypertrophy, cardiomyopathy, murmurs, tissue planes, scrotal masses, muscles and tendon identification, pulmonary effusions, consolidations, pneumothorax, tumors, lymph nodes and cysts can be seen and not just palpated through the skin.

Ultrasound can also compliment physiology lectures by allowing the student to witness "live physiology."  For example, the relationship between the IVC and the cardiac cycle, JVD, and Valsalva maneuvers. Advanced concepts like to differentiation of shock, are easily understood with the aid of the ultrasound and the reinforcement of clinical scenario. 

Digestion physiology can be witnessed by ultrasound using models while they are eating.  Observing peristalsis of the intestines provides a basis for understanding bowel obstruction and ileus, and how ultrasound can be useful to differentiate between these two processes which can present in a clinically similar way.

Gross anatomy can be combined with "Live and Clinical Anatomy."  Nerve distributions and the brachial plexus are no longer concepts which are memorized and regurgitated for tests, only to be later forgotten.  These clinically relevant teaching points are learned by tracing the individual nerves and teaching the student about regional anesthesia. 

The shoulder anatomy lesson can be augmented by an ultrasound module that emphasizes clinically significant concepts and less on memorizing abstract thoughts.  "Clinical Anatomy" can also lead to "Illustrative Anatomy" where clinical landmarks like bursas, the aorta, the gall bladder, kidneys, muscles, the cricoid cartilage, and vessels are found with the aid of an ultrasound machine and drawn with a sharpie pen on the model.

The Budget- SPACUS has no financial relationship with any ultrasound manufacturer or product.  However, an ultrasound presence does not require an $80,000 ultrasound machine. Today's newest generation of machines are smaller, more sophisticated, and highly capable, with picture quality comparable to yesterday's high end machines. 

SPACUS can help programs qualify for academic pricing on machines.  Academic pricing requires the end user only use the machine for learning purposes, and commits to not billing for the studies and images produced.

Ultrasound machines used for teaching are specific to point of care ultrasound and essentially come in three varieties.  Laptop ultrasounds, touch screen ultrasounds and personal ultrasounds.  Most of these models qualify for academic pricing and they share some common features.  First, they are made to be intuitive, easy to operate, fast to boot up and don't require the user to have years of experience.   They all have preset features, which breaks down the effort needed to perform an application "Barney Style."  For example, to perform a DVT study, press the "DVT" button and the computer will program the appropriate settings, light up the linear probe and provide prompts to the next step.

Most higher end machines will have three probes.

1.    A high frequency Linear probe for superficial structures, line placement, regional anesthesia, cellulitis.

2.    A low frequency Curvilinear probe to examine the gall bladder, aorta, bladder, transabdominal pregnancy studies, lung and other deeper structures.

3.    A low frequency Phased Array probe to examine the heart.

The probes are a very expensive component of the ultrasound system, and the most easily damaged part of the machine.  The probes are fragile and are easy to drop, and the connections can be damaged when the cart holding the machine runs over the cables.

These machines range from $55,000 to $25,000.  Leasing options are common, with a 5 year lease averaging about $400/month for every $20,000 spent.  In a budget set up, two probes are used instead of three, typically a linear probe and a low frequency phased array probe.  Because the phased array and the curvilinear probe are both low frequency, the phased array can still look at the structures in the abdomen (although not as optimally), while the curvilinear cannot look at the structures in the chest (heart) because it's footprint cannot escape the ribs.

   The final type is the personal ultrasound scanner.  The newest generation of scanners places the ultrasound hardware in the individual probe.  Each probe plugs into a Windows based tablet or wirelessly connects to an iPad.  These personal scanners are very capable and most have Doppler, and motion mode capability. 

Academic pricing, as of the time of the writing of this document is $125 per probe, over a year long contract.  So each probe will cost about $1500 per year, and a full machine can be configured for $3000, with two probes plus a one time purchase of a $200 tablet. 

A recent informal survey found that many programs offer their students the opportunity to purchase a "medical bundle," which includes items such as a stethoscope, BP cuff, otoscope/ophthalmoscope, and a reflex hammer.  The price of the package varies, but the most expensive is $1200, and the least expensive is $500.  The average price is over $600.

Another informal survey asked students if they would be willing to pay an additional $500 per year to learn clinical ultrasound.  Although not very scientific, every respondent gave an enthusiastic, "yes."

Now, let's imagine instead of buying the "medical bundle," each student devoted $500 to the ultrasound presence.  For a PA program with a class of 30 students, that's $15,000 per year.  Combining first and second year students, that's a budget of $30,0000 per year.

Each PA program will need to individually determine how many ultrasound machines are required, but we can use a medical school with a well-known and successful ultrasound presence as an example.  This medical school has 100 students per class, x 4 years of classes = 400 students in the school. 

They currently have 6 ultrasound machines in their simulation lab.  During each hour long lab, they have 6 groups (one group per machine) of 4 students.  Each hour-long session has 24 students, and there are 4 sessions per day, which completes an entire class. 

This medical school also has an additional ultrasound machine in the cadaver lab, and the OSCE (where one of the stations requires the students to perform an ultrasound.)  In addition they make some portable machines available to students during certain rotations.

A budget of $30,000 per year in a class of 30 students= 3 ultrasound machines in the ultrasound lab. (4 stations of 4 students each=16 students per lab, 2 lab sessions will finish the entire class.)  A machine in the cadaver lab, 4 machines for rotations.

That's a total of 9 machines@$3,000= $27,000 with $200 per tablet (a one-time expenditure) of $1,800 and there is still room in the budget for a simulator. 

Getting Started

Creating an ultrasound presence in a PA program is a process which is very personal to the program.  The path to integration of one program may not be possible or what is best in another program.  Factors such as faculty training, resource availability, institutional culture, role of a champion, and budgetary constraints all play variable roles as barriers to implementation. 

The time the PA program has been in existence should have little effect on the success of the ultrasound presence, and newer programs should not be discouraged from attempting to add this education to the curriculum.  In fact, older, more established PA programs may have more institutional barriers and roadblocks which allow newer, leaner programs to have an advantage.  Many of these barriers are cultural, which is often more difficult to overcome than economic barriers or having the barrier of having the faculty who providing the training POCUS competent.

The ultrasound presence may have it's greatest chance for success if the implementation is deliberate and thoughtful as opposed to sudden and completely integrated. 

The first step is to identify and name the Director of Clinical Ultrasound of Education.  The faculty member serving in this role should ideally be the faculty member with the most experience, however, experience is not absolutely required to fulfill this role.  The most important quality the DCUS must possess is enthusiasm for developing and implementing the program's ultrasound presence. 

Identifying and titling this position provides the PD the ability to have a point of contact for the implementation of the presence, and gives ownership and responsibility for the implementation to one individual. 

Innovative Ways for Program Directors to Create and Ultrasound PresenceD

1.    Ultrasound Honors Program-  This is a method where the PD choses 4 students from an incoming class to voluntarily take part in an Ultrasound Track.  The students undergo the same instruction as non-participating students, however everywhere in the curriculum where ultrasound interacts with the curriculum, these four students are exposed to additional instruction on the same material, with the involvement of ultrasound. 
This spaced repetition can come in the form of additional lectures, time in the ultrasound lab and free scanning sessions where the students simply gain the psycho-motor skills necessary to master the movement of the ultrasound. 
The estimated time investment for the students is about 2 hours a week.  The greatest time commitment is expected during the didactic year, although in the second year students will/can choose to take part in an elective ultrasound rotation.
This type of program is an excellent way for a PA program to "Beta Test" the education which the PD/DCUS feel may be helpful to students, but they unsure it the effort will be successful. 
2.    Ultrasound Elective Rotation- This is an excellent opportunity to allow students who are interested in clinical ultrasound the opportunity to sharpen their skills by learning more advanced applications and apply clinical context to their patient's ultrasound scans.  These rotations are mostly available in emergency departments with robust EUS programs, EDs with ultrasound fellowships and ICU settings.

┬ęSPOCUS is a 501(c)6 non-profit organization  •  P.O. Box 90434  •  San Antonio  •  TX • 78209

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