- Email: [email protected]
Graduating Surgical Residents Lack Competence in Critical Care Ultrasound
ORIGINAL REPORTS
Graduating Surgical Residents Lack Competence in Critical Care Ultrasound Renuka Tripu, BS,*,1 Margaret H. Lauerman, MD,*,1 Daniel Haase, MD,*,1 Syeda Fatima, RCS,*,1 Jacob Glaser, MD,†,1 Cassandra Cardarelli, MD,‡,1 Thomas M. Scalea, MD,*,1 and Sarah Murthi, MD*,1 *
Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland; †Naval Medical Research Unit, San Antonio, Texas; and ‡Departement of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
OBJECTIVE: Ultrasound provides accessible imaging for bedside diagnostics and procedural guidance, but may lead to misdiagnosis in untrained users. The main objective of this study was to determine observed and self-perceived competence with critical care ultrasound in graduated general surgery residents. DESIGN: The design of this study was a retrospective review. Ultrasound training program records were reviewed for number of prior ultrasound examinations performed, self-perceived competence, observed competence on faculty examinations, and intended future use of individual critical care ultrasound examinations. SETTING: This study was undertaken at the R Adams Cowley Shock Trauma Center, which is a tertiary care center in Baltimore, MD. PARTICIPANTS: Graduated general surgery residents were identified at the beginning of their surgical critical care fellowship at our institution, and were included if they participated in our critical care ultrasound education program. Fifteen graduated general surgery residents were included. RESULTS: Prior ultrasound experience ranged from 100%
for focused assessment of sonography for trauma (FAST) to 13.3% for advanced cardiac assessment. Self-perceived competence ranged from 46.7% with FAST to 0% for advanced cardiac assessment. Observed competence ranged Meetings: This work was presented as an oral presentation at the 2017 Academic Surgical Congress. Correspondence: Inquiries to Margaret H. Lauerman, MD, Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene, St Baltimore, MD 21201; fax: (410) 328-6382; e-mail: [email protected] 1
Originating Institution: R Adams Cowley Shock Trauma Center, University of Maryland.
from 20.0% for FAST examinations to 0% for basic cardiac assessment, advanced cardiac assessment, and inferior vena cava (IVC) assessment. All participants intended to use ultrasound in the future for FAST, pneumothorax detection and basic cardiac assessment, and 86.7% for IVC assessment and advanced cardiac assessment. Of participants with self-perceived competence, 28.6% had observed competence with FAST, 0% with IVC assessment, and 100% with pneumothorax detection. CONCLUSIONS: Graduated general surgery residents are
not competent in multiple critical care ultrasound examinations despite universally planning to use critical care ultrasound in future practice. Current exposure to ultrasound in residency may give a false sense of competency with ultrasound use. A standardized ultrasound curriculum is an urgent need for general surgery training. ( J Surg Ed ]:]]]-]]]. Published by Elsevier Inc on behalf of the Association of Program Directors in Surgery) KEY WORDS: surgical education, resident education, ultrasound education, point of care ultrasound, critical care ultrasound COMPETENCIES: Patient Care, Medical Knowledge
INTRODUCTION Point of care ultrasound (POCUS) encompasses ultrasound examinations that can be performed by nonradiology clinicians, and has become an increasingly prevalent tool for surgeons. Many individual ultrasound examinations encompass POCUS, including cardiac assessment with echocardiography, pulmonary assessment for pneumothorax or effusions, abdominal assessment with the focused assessment for sonography in trauma (FAST) examination,
Journal of Surgical Education Published by Elsevier Inc. on behalf of the Association of Program 1931-7204/$30.00 Directors in Surgery http://dx.doi.org/10.1016/j.jsurg.2017.09.022
1
self-perceived competence with critical care ultrasound upon completion of residency, and their observed competence with critical care ultrasound upon completion of residency through our faculty proctored examination. We hypothesized that recently graduated general surgery residents would have high self-perceived competence but low observed competence with critical care ultrasound.
vascular assessment for aortic dissection or aneurysm, renal assessment for hydronephrosis with renal stones, gynecologic assessment for pregnancy or other gynecologic pathology, fluid status assessment, and guidance of bedside procedures. This is by no means a comprehensive list of the broad applications of POCUS, and the commonly used POCUS examinations grow as clinician experience with POCUS increases. A key component of POCUS as a whole is critical care ultrasound. There are multiple important purposes for using critical care ultrasound. Foremost, ultrasound is an immediately available diagnostic imaging modality, and can drastically decrease time to diagnosis and allow rapid intervention on life-threatening pathology. Ultrasound is also portable, and can travel to critically ill patients who can be too unstable for transfer to the radiology suite. Ultrasound examinations can be performed in a serial fashion to evaluate for change over time, such as with repeated echocardiography or fluid status assessment. When ultrasound is used for procedural guidance, this should increase the safety of the procedure. However, if surgeons are not properly trained, patient safety may become compromised. There is no required training in POCUS for general surgery residents, and no minimum number of POCUS examinations required before residency completion. Standardized resources do exist for POCUS education for general surgery residents, such as the curriculum developed by the National Ultrasound Faculty (NUF) of the American College of Surgeons (ACS).1 However, without a required ultrasound curriculum or credentialing process, it is difficult to discern the level of POCUS competency among graduating general surgery residents. This study focused on a specific set of critical care ultrasound examinations within the broad spectrum of POCUS examinations, including: FAST examination, pulmonary ultrasound for pneumothorax detection, basic cardiac assessment, advanced cardiac assessment, and inferior vena cava (IVC) assessment. This specific set of critical care ultrasound examinations was chosen for multiple reasons. Foremost, these ultrasound examinations are commonly used in our own clinical practice and are a focus of our surgical critical care fellowship education program, enabling assessment of these examinations by reviewing our educational records. Additionally, these critical care ultrasound examinations encompass examinations in which a general surgery resident would be expected to have trained (FAST, pulmonary ultrasound for pneumothorax detection, and basic cardiac assessment) and examinations in which general surgery residents may have trained (advanced cardiac assessment and IVC assessment), allowing stratification of the breadth of critical care ultrasound skills gained in general surgery residency. In this review we aimed to describe the experience of graduated general surgery residents with critical care ultrasound through number of examinations performed, their
Approval was obtained from the Institutional Review Board (IRB) at the University of Maryland before beginning this study. A retrospective review was then performed of prospectively collected ultrasound education records of incoming surgical critical care fellows at the R Adams Cowley Shock Trauma Center from 2015 to 2016. This encompassed 2 years of our educational program and incoming fellows. The population of graduated general surgery residents included in this study were all pursuing a surgical critical care fellowship at our institution, and observed competency testing was performed before beginning fellowship but after completion of general surgery residency during a 1-day course provided to our incoming fellows. All participants included in this study had completed a general surgery residency before inclusion in this study. Overall, competence with critical care ultrasound includes the ability to perform specific scans and the ability to actually operate the ultrasound machine, both of which were assessed in this study. Specific critical care ultrasound examinations in this study included: FAST examination, pulmonary ultrasound for pneumothorax detection, basic cardiac assessment, advanced cardiac assessment, and IVC assessment. For the purposes of this study, FAST assessment was defined as obtaining 4 windows: pericardial, splenorenal space, hepatorenal space, and pouch of Douglas. Basic cardiac assessment was defined as ability to perform 4 common cardiac views: parasternal long, parasternal short, apical 4 chamber, and subxiphoid views. Advanced cardiac assessment was measured by ability to obtain velocity time integral and stroke volume variation as measured through the aortic valve. Pulmonary ultrasound for pneumothorax detection included evaluation for lung sliding. IVC assessment represented visualization of the suprarenal IVC and IVC diameter measurement. It should be noted that the subxiphoid view (a component of basic cardiac assessment) and IVC assessment were recorded as a single measure. Measurement of ability to operate an ultrasound machine included observation of machine set-up, selecting the proper patient, selecting proper machine settings, selecting the correct transducer, adjusting the depth of field, adjusting the gain, acquiring video, and saving and ending the examination.
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Journal of Surgical Education Volume ]/Number ] ] 2017
MATERIAL AND METHODS
performed and observed competence with Fisher's exact testing. Statistics were performed with SPSS version 23 statistical software (Armonk, NY).
Self-Perceived Competence 1
Incompetent
2
Minimally competent
3
Neutral
4
Competent
5
Very competent
Intended Future Use 1
No
2
Maybe but probably not
3
Unsure
4
Probably
5
Of course, it is a must
RESULTS
Observed Competence 1
Cannot perform even with help
2
Needs lots of help
3
Needs help/image acquisition inadequate
4
Needs minimal help/images not ideal
5
No help needed/images properly obtained
FIGURE 1. Definitions of self-perceived competence, observed competence and intention of future use.
Our ultrasound training course includes a participant preassessment in which participants rate their own selfperceived competence and intended future use on scales from 1 to 5 for FAST, pulmonary ultrasound for pneumothorax detection, basic cardiac assessment, advanced cardiac assessment, and IVC assessment individually. This preassessment did not specify the components of FAST, pulmonary ultrasound for pneumothorax detection, basic cardiac assessment, advanced cardiac assessment, and IVC assessment, but rather queried about them as a general category. Participants also reported prior experience with critical care ultrasound. Faculty observed practical assessment is undertaken before beginning any educational content in a 1-on-1 fashion on human models. The faculty similarly grade observed competence in real time for each fellow on a 1 to 5 scale (Fig. 1). Observed competence for FAST, pulmonary ultrasound for pneumothorax detection and IVC assessment were recorded as individual measures. Measures for observed competence for basic cardiac assessment and advanced cardiac assessment were created as composite variables from multiple individual measures. Scores of 4 or 5 were considered to represent selfperceived competence, intended future use, or observed competence. Univariate analysis was performed for frequencies. Limited bivariate analysis was performed to assess the association between number of prior ultrasound examinations
Overall, critical care ultrasound training records from 15 graduated general surgery residents were included in this study. Prior critical care ultrasound experience varied between participants and by the specific ultrasound examination being performed (Table 1). All participants reported prior experience performing FAST examinations. However, only 11/15 (73.3%) participants had any prior experience with pneumothorax detection, 9/15 (60.0%) any prior experience with basic cardiac assessment, 2/15 (13.3%) any prior experience with advanced cardiac assessment, and 9/15 (60.0%) any prior experience with IVC assessment. Prior experience of greater than 50 examinations occurred only for FAST and pneumothorax detection, with 5/15 (33.3%) and 1/15 (6.7%) participants meeting this volume of studies performed, respectively. No participants reported performing greater than 50 examinations for basic cardiac assessment, advanced cardiac assessment, and IVC assessment. All 15 study participants intended to perform FAST, basic cardiac assessment, and pneumothorax detection in future clinical practice. For both IVC assessment and advanced cardiac assessment 13/15 (86.7%) participants intended to perform these specific examinations in future clinical practice. Self-perceived competence and observed competence varied broadly by specific ultrasound examination. Self-perceived competence was noted in 7/15 (46.7%) participants for FAST examinations, 2/15 (13.3%) for pneumothorax detection, 1/15 (6.7%) for basic cardiac assessment, 0/15 (0%) for advanced cardiac assessment, and 2/15 (13.3%) for IVC assessment. Observed competence was seen in 3/15 (20%) participants for FAST examinations, 2/15 (13.3%) for pneumothorax detection, 0/14 (0%) for basic cardiac assessment, 0/15 (0%) for advanced cardiac assessment, and 0/14 (0%) for IVC assessment (Fig. 2). However, self-perceived competence and observed competence did not always occur in tandem. Of the 7/15 participants who expressed self-perceived FAST competence, only 2/7 (28.6%) demonstrated observed
TABLE 1. Number of Critical Care Ultrasounds Performed by Graduated General Surgery Residents No Ultrasounds FAST Pneumothorax Basic Cardiac Assessment Advanced Cardiac Assessment IVC Assessment
0/15 4/15 6/15 13/15 6/15
(0%) (26.7%) (40.0%) (86.7%) (40.0%)
Journal of Surgical Education Volume ]/Number ] ] 2017
Less Than 10 Ultrasounds
10-50 Ultrasounds
6/15 8/15 6/15 2/15 6/15
4/15 2/15 3/15 0/15 3/15
(40.0%) (53.3%) (40.0%) (13.3%) (40.0%)
(26.7%) (13.3%) (20.0%) (0%) (20.0%)
Greater Than 50 Ultrasounds 5/15 1/15 0/15 0/15 0/15
(33.3%) (6.7%) (0%) (0%) (0%) 3
100.0%
100.0%
100.0%
100.0% 86.7%
90.0%
86.7%
80.0% 70.0% 60.0% 50.0%
46.7%
40.0% 30.0% 20.0%
20.0% 13.3% 13.3%
13.3% 6.7%
10.0%
0.0%
0.0% FAST
Pneumothorax
Self-Perceived Competence
Basic Cardiac Assessment Observed Competence
0.0% 0.0%
0.0%
Advanced Cardiac IVC Assessment Assessment Intended Future Use
FIGURE 2. Rates of critical care ultrasound self-perceived competence, observed competence, and intention of future use in graduated general surgery residents.
competence. Of the 2/15 participants indicating self-perceived competence for IVC assessment, 0/2 (0%) had observed competence. Conversely, of the 2/15 participants reporting self-perceived competence for pneumothorax detection, 2/2 (100%) had observed competence. Self-perceived competence varied with number of prior ultrasound examinations performed (Table 2). Overall higher rates of self-perceived competence were seen with a higher number of prior ultrasounds performed. The comparison between self-perceived competence and prior experience was not undertaken for basic cardiac assessment or advanced cardiac assessment given the limited self-perceived competence with these scans. Observed competence for ability to operate the ultrasound machine was low across all measured skills (Table 3). Observed competence for ability to operate the ultrasound machine was best performed for selection of the correct probe with observed competence in 3/15 (20.0%) participants and ending and saving the examination with observed competence in 3/14 (21.4%) participants. No participants demonstrated observed competence for selecting the proper settings, adjusting the depth, or acquiring video. Observed competence increased sequentially as previous ultrasound experience increased, with observed competence
for FAST increasing from 0% with less than 10 ultrasound examinations to 40% with greater than 50 ultrasound examinations (p ¼ 0.25) and for pneumothorax detection increasing from 0% with less than 10 ultrasound examinations to 100% with greater than 50 ultrasound examinations (p ¼ 0.01) (Fig. 3). Comparisons between previous ultrasound experience and observed competence were not performed for basic cardiac assessment, advanced cardiac assessment, and IVC assessment given the absence of course participants graded to have observed competence for these specific scans.
DISCUSSION Graduated general surgery residents have low self-perceived competence with critical care ultrasound, minimal prior critical care ultrasound experience, and lack observed competence with critical care ultrasound when evaluated with a faculty proctored, hands-on examination. Despite the lack of self-perceived and observed competence with critical care ultrasound, graduated general surgery residents entering a surgical critical care fellowship have a high intention to use critical care ultrasound in future clinical practice. Although this is an evaluation of a specific subset of general surgery
TABLE 2. Self-Perceived Competence and Prior Critical Care Ultrasound Experience in Graduated General Surgery Residents No Ultrasounds FAST Self-perceived competence No self-perceived competence Pneumothorax Self-perceived competence No self-perceived competence IVC assessment Self-perceived competence No self-perceived competence
4
Less Than 10 Ultrasounds
10-50 Ultrasounds
0/7 (0%) 6/8 (75.0%)
2/7 (28.6%) 2/8 (25.0%)
5/7 (71.4%) 0/8 (0%)
0/2 (0%) 4/13 (30.8%)
0/2 (0%) 8/13 (61.5%)
1/2 (50.0%) 1/13 (7.7%)
1/2 (50.0%) 0/13 (0%)
0/2 (0%) 7/13 (53.8%)
0/2 (0%) 5/13 (38.5%)
2/2 (100%) 1/13 (7.7%)
0/2 (0%) 0/13 (0%)
0/7 (0%) 0/8 (0%)
Greater Than 50 Ultrasounds
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TABLE 3. Observed Competence With an Ultrasound Machine in Graduated General Surgery Residents Observed Competence Machine set-up Select a patient Select the proper settings Select correct probe Adjust gain Adjust depth Acquire video End and save examination
1/15 2/15 0/15 3/15 1/15 0/15 0/13 3/14
(6.7%) (13.3%) (0%) (20.0%) (6.7%) (0%) (0%) (21.4%)
residency graduates, this does unearth a concerning disconnect between general surgery training and clinical practice. Before this report, the competence of general surgery residents with critical care ultrasound was unknown. Access to ultrasound is now widespread with development of portable and more affordable technology. Of all emergency rooms, approximately half have POCUS availability, although access to ultrasound varies with geographic location and patient volume.2,3 Similarly most ICUs have access to POCUS.4,5 With this increased access to ultrasound machines has come an increased use of ultrasound in clinical practice; for example, each day in the ICU 36% of patients undergo an ultrasound examination.6 Many procedures have improved patient outcomes when ultrasound is used, including internal jugular central venous catheter placement, thoracentesis, and paracentesis, with practitioners now often preferentially using ultrasound to guide these interventions.7,8 Use of POCUS in clinical practice is no longer a luxury, but a daily reality. Emergency medicine (EM) is another field of medicine in which POCUS is commonly used.9 EM physicians have long ago realized and embraced the need for POCUS education, with standardized recommendations for POCUS training during residency existing since 2008.10 The
Accreditation Council for Graduate Medical Education (ACGME) agreed that POCUS is a key component of EM education, and designated POCUS as one of 24 total subcompetencies needed for accreditation for an EM residency.11 The number of POCUS examinations required per trainee in EM residency is substantial, with performance of at least 150 examinations to ensure an acceptable level of exposure recommended.12 General surgery residency training has not been updated to reflect growth in POCUS use, and lags behind EM in formalizing POCUS education. Currently, there is no required POCUS curriculum for general surgery residents nor minimum number of POCUS examinations required for graduation as exists for operative cases or trauma patients managed, leaving most surgeons without formal POCUS training even for examinations as common as FAST.13 However, POCUS education is available for residents through the curriculum developed by the National Ultrasound Faculty (NUF) of the American College of Surgeons (ACS).1 The ultrasound program available from the ACS is quite robust and targeted toward surgical residents. Through the 4 separate modules, the program covers basics of ultrasound technique and physics, FAST, echo/intensive care ultrasound, and neck ultrasound.14 It is notable that 2 of the 4 modules in the ACS curriculum cover critical care ultrasound. The ACS has also made practice recommendations for a voluntary ultrasound verification program, maintenance of ultrasound qualifications, and facility guidelines where ultrasound is performed.15 Despite the availability of these resources, graduated general surgery residents in this study had performed a relatively few number of critical care ultrasound examinations. With mostly minimal or no exposure to critical care ultrasound in residency, it is unsurprising that general surgery graduates largely do not feel competent with many specific critical care ultrasound examinations nor are observed to be competent with these specific examinations. 100.0%
100.0% 90.0%
Observed Competence
80.0% 70.0% 60.0% 50.0%
50.0% 40.0%
40.0% 30.0%
25.0%
20.0% 10.0% 0.0%
0.0%
0.0%
FAST
0.0%
Pneumothorax
Number of Prior Crical Care Ultrasound Performed No Ultrasounds
Less Than 10 Ultrasounds
10-50 Ultrasounds
Greater Than 50 Ultrasounds
FIGURE 3. Number of prior critical care ultrasounds performed and observed competence for FAST and pneumothorax detection. Journal of Surgical Education Volume ]/Number ] ] 2017
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Unfortunately the small amount of critical care ultrasound training occurring currently may induce a false sense of ability without providing actual proficiency. Graduated residents with self-perceived competence in critical care ultrasound examinations generally had performed more critical care ultrasound examinations than graduated residents who did not express self-perceived competence. However, graduated residents with self-perceived competence did not always possess observed competence, despite the higher number of prior exams often performed. Use of critical care ultrasound by under-trained surgeons could result in harm rather than benefit to patients, and the current minimal, informal training in critical care ultrasound may be worse that no exposure at all. It was notable that graduated general surgery residents did not always have insight into their lack of competence with critical care ultrasound. However, in this study a higher number of prior critical care ultrasound examinations performed was associated with higher rates of observed competence. A greater number of examinations than are currently performed by most general surgery residents is likely required to achieve competency, as many general surgery residents in this study did not achieve the number of ultrasound examinations performed associated with the higher percentages of observed competence. Yet even in general surgery residents having performed a higher number of critical care ultrasound examinations, observed competence was not universal. Exposure to critical care ultrasound without formalized training may not be enough to assure competency in all graduating residents. In addition to establishing a minimum number of examinations, the addition of a didactic curriculum would likely improve competency, as previous research has shown competency with trauma ultrasound in surgical residents after dedicated training.16 Ultrasound examinations will need to be reviewed for quality and a standardized examination for competency developed. This is a substantial, but necessary undertaking. Limitations to this study include a small number of participants overall, which limits statistical analysis; however, a sample size of 15 faculty observed practical assessments represents a sizable undertaking for this specific topic. Multiple faculty evaluators participated in the observed assessments, and the results have not been evaluated for interobserver variation given the small number of participants. The R Adams Cowley Shock Trauma faculty expectations for ultrasound competency have also not been compared with faculty at other institutions or ultrasound training programs, and may be higher than average leading to lower observed rates of competence. This human model assessment tool has not undergone formal validation, and was developed at our institution to evaluate internal technical ability for ongoing quality improvement with our educational curriculum. Additionally, we did not record demographic information on our study participants, and it is possible that competency varies with such factors as size of
training programs or geographic location of training programs. Further work will be required to see if these results are generalizable to general surgery residents of all demographics and future career plans. Finally, POCUS is used in many fields of surgery, including endocrine surgery, breast surgery, and surgical oncology, with future research required to assess ultrasound competency in these specific subsets of POCUS as well. Another limitation includes the study population. This study was performed on a cohort of education records of graduated general surgery residents pursuing a surgical critical care fellowship. This selection of participants may bias measurement of number of prior critical care ultrasound examinations performed, as study participants may have sought out more experience in residency to prepare for fellowship given the common use of ultrasound in the ICU. This cohort may further bias towards overestimating future ultrasound use given their likely future work in an ICU. Despite these biases, basic critical care ultrasound (such as with FAST, pneumothorax detection, and basic cardiac assessment) is an expected component of current trauma, general surgery, and critical care practice, and should be a required skill of all graduating general surgery residents. Also not investigated in this study is the acumen of the surgical faculty in teaching ultrasound to residents. Acquisition of ultrasound skills requires both an investment from the surgical resident and from the attending staff, many of whom have likely not received formalized training in ultrasound use. Ongoing reinforcement of ultrasound concepts (beyond a formalized education program) from the surgical faculty will be needed to prevent loss of ultrasound knowledge and skill. Concerning imparity exists between competence with critical care ultrasound and intended future use in graduated general surgery residents, highlighting a previously undescribed disconnect between general surgery training and actual needs of modern practicing surgeons. General surgery residency training has not embraced the need for ultrasound education and has not expanded education to prepare graduates for this aspect of clinical practice. Current unstandardized training may provide graduating general surgery residents with a false belief in their own competency, and may be unsafe. Although a finite time exists in general surgery residency for training in open surgery, laparoscopy, endoscopy, and critical care, education in critical care ultrasound must be included in a similarly dogmatic manner.
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Journal of Surgical Education Volume ]/Number ] ] 2017
REFERENCES 1. American College of Surgeons. Ultrasound for Residents:
The Complete Course [Internet]. Chicago (IL): American College of Surgeons. Available at: https://www.facs.org/ education/accreditation/verification/ultrasound/residents Cited 2017 February 13, 2017.
2. Sanders JL, Noble VE, Raja AS, Sullivan AF,
10. Akhtar S, Theodoro D, Gaspari R, et al. Resident
Camargo CA. Access to and use of point-of care ultrasound in the emergency department. West J Emerg Med. 2015;16(5):747-752.
training in emergency ultrasound: consensus recommendations from the 2008 council of emergency medicine residency directors conference. Acad Emerg Med. 2009;16(suppl 2):S32-S36.
3. Talley BE, Ginde AA, Raja AS, Sullivan AF, Espinola JA,
Camargo CA. Variable access to immediate bedside ultrasound in the emergency department. West J Emerge Med. 2010;12(1):96-99. 4. Mosier JM, Malo J, Stolz LA, et al. Critical care
ultrasound training: a survey of US fellowship directors. J Crit Care. 2014;29(4):645-649.
11. ACGME. ACGME Program Requirements for Grad-
uate Medication Education in Emergency Medicine [Internet]. ACGME. Available at: https://www.acgme.org/ Portals/0/PFAssets/ProgramRequirements/110_emergency_ medicine_2016.pdf; 2016 Cited February 13, 2017. 12. Amini R, Adhikari S, Fiorello A. Ultrasound compe-
current use of ultrasound in the critical care unit: ECHOREA. Ann Fr Anesth Réanim. 2011;30(11): e69-e73.
tency assessment in emergency medicine residency programs; evaluación de la competencia en ecografía en los programas de residencia de medicina de urgencias y emergencias. Acad Emerg Med. 2014;21(7):799-801.
6. Zieleskiewicz L, Muller L, Lakhal K, et al. Point-of-
13. Kim DY, Yelle JD, Lee AC, Woo MY. National
care ultrasound in intensive care units: assessment of 1073 procedures in a multicentric, prospective, observational study. Intensive Care Med. 2015;41(9): 1638-1647.
14. American College of Surgeons. Exported Ultrasound
5. Quintard H, Philip I, Ichai C. French survey on
7. Karakitsos D, Labropoulos N, De Groot E, et al. Real-
time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care. 2006;10(6):R162. 8. Mercaldi CJ, Lanes SF. Ultrasound guidance decreases
complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest. 2013;143(2):532-538. 9. Dean AJ, Breyer MJ, Ku BS, Mills AM, Pines JM.
Survey of Canadian General Surgery Program Directors regarding focused assessment with sonography for trauma. J Surg Educ. 2009;66(4):193-195. Courses [Internet]. Chicago (IL): American College of Surgeons. Available at: https://www.facs.org/education/ accreditation/verification/ultrasound/exported Cited August 22, 2017. 15. American College of Surgeons Committee on Emerging
Surgical Technology and Education. Ultrasound examinations by surgeons [Internet]. Chicago (IL): American College of Surgeons. Available at: https://www.facs.org/ about-acs/statements/31-ultrasound-exam; 1998 Cited February 13, 2017.
Emergency ultrasound usage among recent emergency medicine residency graduates of a convenience sample of 14 residencies. J Emerg Med. 2010;38(2):214-221.
16. Smith R, Kern SJ, Fry WR, Helmer SD. Institutional
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learning curve of surgeon-performed trauma ultrasound. Arch Surg. 1998;133(5):530-536.
Graduating Surgical Residents Lack Competence in Critical Care Ultrasound Renuka Tripu, BS,*,1 Margaret H. Lauerman, MD,*,1 Daniel Haase, MD,*,1 Syeda Fatima, RCS,*,1 Jacob Glaser, MD,†,1 Cassandra Cardarelli, MD,‡,1 Thomas M. Scalea, MD,*,1 and Sarah Murthi, MD*,1 *
Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland; †Naval Medical Research Unit, San Antonio, Texas; and ‡Departement of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
OBJECTIVE: Ultrasound provides accessible imaging for bedside diagnostics and procedural guidance, but may lead to misdiagnosis in untrained users. The main objective of this study was to determine observed and self-perceived competence with critical care ultrasound in graduated general surgery residents. DESIGN: The design of this study was a retrospective review. Ultrasound training program records were reviewed for number of prior ultrasound examinations performed, self-perceived competence, observed competence on faculty examinations, and intended future use of individual critical care ultrasound examinations. SETTING: This study was undertaken at the R Adams Cowley Shock Trauma Center, which is a tertiary care center in Baltimore, MD. PARTICIPANTS: Graduated general surgery residents were identified at the beginning of their surgical critical care fellowship at our institution, and were included if they participated in our critical care ultrasound education program. Fifteen graduated general surgery residents were included. RESULTS: Prior ultrasound experience ranged from 100%
for focused assessment of sonography for trauma (FAST) to 13.3% for advanced cardiac assessment. Self-perceived competence ranged from 46.7% with FAST to 0% for advanced cardiac assessment. Observed competence ranged Meetings: This work was presented as an oral presentation at the 2017 Academic Surgical Congress. Correspondence: Inquiries to Margaret H. Lauerman, MD, Division of Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland, 22 South Greene, St Baltimore, MD 21201; fax: (410) 328-6382; e-mail: [email protected] 1
Originating Institution: R Adams Cowley Shock Trauma Center, University of Maryland.
from 20.0% for FAST examinations to 0% for basic cardiac assessment, advanced cardiac assessment, and inferior vena cava (IVC) assessment. All participants intended to use ultrasound in the future for FAST, pneumothorax detection and basic cardiac assessment, and 86.7% for IVC assessment and advanced cardiac assessment. Of participants with self-perceived competence, 28.6% had observed competence with FAST, 0% with IVC assessment, and 100% with pneumothorax detection. CONCLUSIONS: Graduated general surgery residents are
not competent in multiple critical care ultrasound examinations despite universally planning to use critical care ultrasound in future practice. Current exposure to ultrasound in residency may give a false sense of competency with ultrasound use. A standardized ultrasound curriculum is an urgent need for general surgery training. ( J Surg Ed ]:]]]-]]]. Published by Elsevier Inc on behalf of the Association of Program Directors in Surgery) KEY WORDS: surgical education, resident education, ultrasound education, point of care ultrasound, critical care ultrasound COMPETENCIES: Patient Care, Medical Knowledge
INTRODUCTION Point of care ultrasound (POCUS) encompasses ultrasound examinations that can be performed by nonradiology clinicians, and has become an increasingly prevalent tool for surgeons. Many individual ultrasound examinations encompass POCUS, including cardiac assessment with echocardiography, pulmonary assessment for pneumothorax or effusions, abdominal assessment with the focused assessment for sonography in trauma (FAST) examination,
Journal of Surgical Education Published by Elsevier Inc. on behalf of the Association of Program 1931-7204/$30.00 Directors in Surgery http://dx.doi.org/10.1016/j.jsurg.2017.09.022
1
self-perceived competence with critical care ultrasound upon completion of residency, and their observed competence with critical care ultrasound upon completion of residency through our faculty proctored examination. We hypothesized that recently graduated general surgery residents would have high self-perceived competence but low observed competence with critical care ultrasound.
vascular assessment for aortic dissection or aneurysm, renal assessment for hydronephrosis with renal stones, gynecologic assessment for pregnancy or other gynecologic pathology, fluid status assessment, and guidance of bedside procedures. This is by no means a comprehensive list of the broad applications of POCUS, and the commonly used POCUS examinations grow as clinician experience with POCUS increases. A key component of POCUS as a whole is critical care ultrasound. There are multiple important purposes for using critical care ultrasound. Foremost, ultrasound is an immediately available diagnostic imaging modality, and can drastically decrease time to diagnosis and allow rapid intervention on life-threatening pathology. Ultrasound is also portable, and can travel to critically ill patients who can be too unstable for transfer to the radiology suite. Ultrasound examinations can be performed in a serial fashion to evaluate for change over time, such as with repeated echocardiography or fluid status assessment. When ultrasound is used for procedural guidance, this should increase the safety of the procedure. However, if surgeons are not properly trained, patient safety may become compromised. There is no required training in POCUS for general surgery residents, and no minimum number of POCUS examinations required before residency completion. Standardized resources do exist for POCUS education for general surgery residents, such as the curriculum developed by the National Ultrasound Faculty (NUF) of the American College of Surgeons (ACS).1 However, without a required ultrasound curriculum or credentialing process, it is difficult to discern the level of POCUS competency among graduating general surgery residents. This study focused on a specific set of critical care ultrasound examinations within the broad spectrum of POCUS examinations, including: FAST examination, pulmonary ultrasound for pneumothorax detection, basic cardiac assessment, advanced cardiac assessment, and inferior vena cava (IVC) assessment. This specific set of critical care ultrasound examinations was chosen for multiple reasons. Foremost, these ultrasound examinations are commonly used in our own clinical practice and are a focus of our surgical critical care fellowship education program, enabling assessment of these examinations by reviewing our educational records. Additionally, these critical care ultrasound examinations encompass examinations in which a general surgery resident would be expected to have trained (FAST, pulmonary ultrasound for pneumothorax detection, and basic cardiac assessment) and examinations in which general surgery residents may have trained (advanced cardiac assessment and IVC assessment), allowing stratification of the breadth of critical care ultrasound skills gained in general surgery residency. In this review we aimed to describe the experience of graduated general surgery residents with critical care ultrasound through number of examinations performed, their
Approval was obtained from the Institutional Review Board (IRB) at the University of Maryland before beginning this study. A retrospective review was then performed of prospectively collected ultrasound education records of incoming surgical critical care fellows at the R Adams Cowley Shock Trauma Center from 2015 to 2016. This encompassed 2 years of our educational program and incoming fellows. The population of graduated general surgery residents included in this study were all pursuing a surgical critical care fellowship at our institution, and observed competency testing was performed before beginning fellowship but after completion of general surgery residency during a 1-day course provided to our incoming fellows. All participants included in this study had completed a general surgery residency before inclusion in this study. Overall, competence with critical care ultrasound includes the ability to perform specific scans and the ability to actually operate the ultrasound machine, both of which were assessed in this study. Specific critical care ultrasound examinations in this study included: FAST examination, pulmonary ultrasound for pneumothorax detection, basic cardiac assessment, advanced cardiac assessment, and IVC assessment. For the purposes of this study, FAST assessment was defined as obtaining 4 windows: pericardial, splenorenal space, hepatorenal space, and pouch of Douglas. Basic cardiac assessment was defined as ability to perform 4 common cardiac views: parasternal long, parasternal short, apical 4 chamber, and subxiphoid views. Advanced cardiac assessment was measured by ability to obtain velocity time integral and stroke volume variation as measured through the aortic valve. Pulmonary ultrasound for pneumothorax detection included evaluation for lung sliding. IVC assessment represented visualization of the suprarenal IVC and IVC diameter measurement. It should be noted that the subxiphoid view (a component of basic cardiac assessment) and IVC assessment were recorded as a single measure. Measurement of ability to operate an ultrasound machine included observation of machine set-up, selecting the proper patient, selecting proper machine settings, selecting the correct transducer, adjusting the depth of field, adjusting the gain, acquiring video, and saving and ending the examination.
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MATERIAL AND METHODS
performed and observed competence with Fisher's exact testing. Statistics were performed with SPSS version 23 statistical software (Armonk, NY).
Self-Perceived Competence 1
Incompetent
2
Minimally competent
3
Neutral
4
Competent
5
Very competent
Intended Future Use 1
No
2
Maybe but probably not
3
Unsure
4
Probably
5
Of course, it is a must
RESULTS
Observed Competence 1
Cannot perform even with help
2
Needs lots of help
3
Needs help/image acquisition inadequate
4
Needs minimal help/images not ideal
5
No help needed/images properly obtained
FIGURE 1. Definitions of self-perceived competence, observed competence and intention of future use.
Our ultrasound training course includes a participant preassessment in which participants rate their own selfperceived competence and intended future use on scales from 1 to 5 for FAST, pulmonary ultrasound for pneumothorax detection, basic cardiac assessment, advanced cardiac assessment, and IVC assessment individually. This preassessment did not specify the components of FAST, pulmonary ultrasound for pneumothorax detection, basic cardiac assessment, advanced cardiac assessment, and IVC assessment, but rather queried about them as a general category. Participants also reported prior experience with critical care ultrasound. Faculty observed practical assessment is undertaken before beginning any educational content in a 1-on-1 fashion on human models. The faculty similarly grade observed competence in real time for each fellow on a 1 to 5 scale (Fig. 1). Observed competence for FAST, pulmonary ultrasound for pneumothorax detection and IVC assessment were recorded as individual measures. Measures for observed competence for basic cardiac assessment and advanced cardiac assessment were created as composite variables from multiple individual measures. Scores of 4 or 5 were considered to represent selfperceived competence, intended future use, or observed competence. Univariate analysis was performed for frequencies. Limited bivariate analysis was performed to assess the association between number of prior ultrasound examinations
Overall, critical care ultrasound training records from 15 graduated general surgery residents were included in this study. Prior critical care ultrasound experience varied between participants and by the specific ultrasound examination being performed (Table 1). All participants reported prior experience performing FAST examinations. However, only 11/15 (73.3%) participants had any prior experience with pneumothorax detection, 9/15 (60.0%) any prior experience with basic cardiac assessment, 2/15 (13.3%) any prior experience with advanced cardiac assessment, and 9/15 (60.0%) any prior experience with IVC assessment. Prior experience of greater than 50 examinations occurred only for FAST and pneumothorax detection, with 5/15 (33.3%) and 1/15 (6.7%) participants meeting this volume of studies performed, respectively. No participants reported performing greater than 50 examinations for basic cardiac assessment, advanced cardiac assessment, and IVC assessment. All 15 study participants intended to perform FAST, basic cardiac assessment, and pneumothorax detection in future clinical practice. For both IVC assessment and advanced cardiac assessment 13/15 (86.7%) participants intended to perform these specific examinations in future clinical practice. Self-perceived competence and observed competence varied broadly by specific ultrasound examination. Self-perceived competence was noted in 7/15 (46.7%) participants for FAST examinations, 2/15 (13.3%) for pneumothorax detection, 1/15 (6.7%) for basic cardiac assessment, 0/15 (0%) for advanced cardiac assessment, and 2/15 (13.3%) for IVC assessment. Observed competence was seen in 3/15 (20%) participants for FAST examinations, 2/15 (13.3%) for pneumothorax detection, 0/14 (0%) for basic cardiac assessment, 0/15 (0%) for advanced cardiac assessment, and 0/14 (0%) for IVC assessment (Fig. 2). However, self-perceived competence and observed competence did not always occur in tandem. Of the 7/15 participants who expressed self-perceived FAST competence, only 2/7 (28.6%) demonstrated observed
TABLE 1. Number of Critical Care Ultrasounds Performed by Graduated General Surgery Residents No Ultrasounds FAST Pneumothorax Basic Cardiac Assessment Advanced Cardiac Assessment IVC Assessment
0/15 4/15 6/15 13/15 6/15
(0%) (26.7%) (40.0%) (86.7%) (40.0%)
Journal of Surgical Education Volume ]/Number ] ] 2017
Less Than 10 Ultrasounds
10-50 Ultrasounds
6/15 8/15 6/15 2/15 6/15
4/15 2/15 3/15 0/15 3/15
(40.0%) (53.3%) (40.0%) (13.3%) (40.0%)
(26.7%) (13.3%) (20.0%) (0%) (20.0%)
Greater Than 50 Ultrasounds 5/15 1/15 0/15 0/15 0/15
(33.3%) (6.7%) (0%) (0%) (0%) 3
100.0%
100.0%
100.0%
100.0% 86.7%
90.0%
86.7%
80.0% 70.0% 60.0% 50.0%
46.7%
40.0% 30.0% 20.0%
20.0% 13.3% 13.3%
13.3% 6.7%
10.0%
0.0%
0.0% FAST
Pneumothorax
Self-Perceived Competence
Basic Cardiac Assessment Observed Competence
0.0% 0.0%
0.0%
Advanced Cardiac IVC Assessment Assessment Intended Future Use
FIGURE 2. Rates of critical care ultrasound self-perceived competence, observed competence, and intention of future use in graduated general surgery residents.
competence. Of the 2/15 participants indicating self-perceived competence for IVC assessment, 0/2 (0%) had observed competence. Conversely, of the 2/15 participants reporting self-perceived competence for pneumothorax detection, 2/2 (100%) had observed competence. Self-perceived competence varied with number of prior ultrasound examinations performed (Table 2). Overall higher rates of self-perceived competence were seen with a higher number of prior ultrasounds performed. The comparison between self-perceived competence and prior experience was not undertaken for basic cardiac assessment or advanced cardiac assessment given the limited self-perceived competence with these scans. Observed competence for ability to operate the ultrasound machine was low across all measured skills (Table 3). Observed competence for ability to operate the ultrasound machine was best performed for selection of the correct probe with observed competence in 3/15 (20.0%) participants and ending and saving the examination with observed competence in 3/14 (21.4%) participants. No participants demonstrated observed competence for selecting the proper settings, adjusting the depth, or acquiring video. Observed competence increased sequentially as previous ultrasound experience increased, with observed competence
for FAST increasing from 0% with less than 10 ultrasound examinations to 40% with greater than 50 ultrasound examinations (p ¼ 0.25) and for pneumothorax detection increasing from 0% with less than 10 ultrasound examinations to 100% with greater than 50 ultrasound examinations (p ¼ 0.01) (Fig. 3). Comparisons between previous ultrasound experience and observed competence were not performed for basic cardiac assessment, advanced cardiac assessment, and IVC assessment given the absence of course participants graded to have observed competence for these specific scans.
DISCUSSION Graduated general surgery residents have low self-perceived competence with critical care ultrasound, minimal prior critical care ultrasound experience, and lack observed competence with critical care ultrasound when evaluated with a faculty proctored, hands-on examination. Despite the lack of self-perceived and observed competence with critical care ultrasound, graduated general surgery residents entering a surgical critical care fellowship have a high intention to use critical care ultrasound in future clinical practice. Although this is an evaluation of a specific subset of general surgery
TABLE 2. Self-Perceived Competence and Prior Critical Care Ultrasound Experience in Graduated General Surgery Residents No Ultrasounds FAST Self-perceived competence No self-perceived competence Pneumothorax Self-perceived competence No self-perceived competence IVC assessment Self-perceived competence No self-perceived competence
4
Less Than 10 Ultrasounds
10-50 Ultrasounds
0/7 (0%) 6/8 (75.0%)
2/7 (28.6%) 2/8 (25.0%)
5/7 (71.4%) 0/8 (0%)
0/2 (0%) 4/13 (30.8%)
0/2 (0%) 8/13 (61.5%)
1/2 (50.0%) 1/13 (7.7%)
1/2 (50.0%) 0/13 (0%)
0/2 (0%) 7/13 (53.8%)
0/2 (0%) 5/13 (38.5%)
2/2 (100%) 1/13 (7.7%)
0/2 (0%) 0/13 (0%)
0/7 (0%) 0/8 (0%)
Greater Than 50 Ultrasounds
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TABLE 3. Observed Competence With an Ultrasound Machine in Graduated General Surgery Residents Observed Competence Machine set-up Select a patient Select the proper settings Select correct probe Adjust gain Adjust depth Acquire video End and save examination
1/15 2/15 0/15 3/15 1/15 0/15 0/13 3/14
(6.7%) (13.3%) (0%) (20.0%) (6.7%) (0%) (0%) (21.4%)
residency graduates, this does unearth a concerning disconnect between general surgery training and clinical practice. Before this report, the competence of general surgery residents with critical care ultrasound was unknown. Access to ultrasound is now widespread with development of portable and more affordable technology. Of all emergency rooms, approximately half have POCUS availability, although access to ultrasound varies with geographic location and patient volume.2,3 Similarly most ICUs have access to POCUS.4,5 With this increased access to ultrasound machines has come an increased use of ultrasound in clinical practice; for example, each day in the ICU 36% of patients undergo an ultrasound examination.6 Many procedures have improved patient outcomes when ultrasound is used, including internal jugular central venous catheter placement, thoracentesis, and paracentesis, with practitioners now often preferentially using ultrasound to guide these interventions.7,8 Use of POCUS in clinical practice is no longer a luxury, but a daily reality. Emergency medicine (EM) is another field of medicine in which POCUS is commonly used.9 EM physicians have long ago realized and embraced the need for POCUS education, with standardized recommendations for POCUS training during residency existing since 2008.10 The
Accreditation Council for Graduate Medical Education (ACGME) agreed that POCUS is a key component of EM education, and designated POCUS as one of 24 total subcompetencies needed for accreditation for an EM residency.11 The number of POCUS examinations required per trainee in EM residency is substantial, with performance of at least 150 examinations to ensure an acceptable level of exposure recommended.12 General surgery residency training has not been updated to reflect growth in POCUS use, and lags behind EM in formalizing POCUS education. Currently, there is no required POCUS curriculum for general surgery residents nor minimum number of POCUS examinations required for graduation as exists for operative cases or trauma patients managed, leaving most surgeons without formal POCUS training even for examinations as common as FAST.13 However, POCUS education is available for residents through the curriculum developed by the National Ultrasound Faculty (NUF) of the American College of Surgeons (ACS).1 The ultrasound program available from the ACS is quite robust and targeted toward surgical residents. Through the 4 separate modules, the program covers basics of ultrasound technique and physics, FAST, echo/intensive care ultrasound, and neck ultrasound.14 It is notable that 2 of the 4 modules in the ACS curriculum cover critical care ultrasound. The ACS has also made practice recommendations for a voluntary ultrasound verification program, maintenance of ultrasound qualifications, and facility guidelines where ultrasound is performed.15 Despite the availability of these resources, graduated general surgery residents in this study had performed a relatively few number of critical care ultrasound examinations. With mostly minimal or no exposure to critical care ultrasound in residency, it is unsurprising that general surgery graduates largely do not feel competent with many specific critical care ultrasound examinations nor are observed to be competent with these specific examinations. 100.0%
100.0% 90.0%
Observed Competence
80.0% 70.0% 60.0% 50.0%
50.0% 40.0%
40.0% 30.0%
25.0%
20.0% 10.0% 0.0%
0.0%
0.0%
FAST
0.0%
Pneumothorax
Number of Prior Crical Care Ultrasound Performed No Ultrasounds
Less Than 10 Ultrasounds
10-50 Ultrasounds
Greater Than 50 Ultrasounds
FIGURE 3. Number of prior critical care ultrasounds performed and observed competence for FAST and pneumothorax detection. Journal of Surgical Education Volume ]/Number ] ] 2017
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Unfortunately the small amount of critical care ultrasound training occurring currently may induce a false sense of ability without providing actual proficiency. Graduated residents with self-perceived competence in critical care ultrasound examinations generally had performed more critical care ultrasound examinations than graduated residents who did not express self-perceived competence. However, graduated residents with self-perceived competence did not always possess observed competence, despite the higher number of prior exams often performed. Use of critical care ultrasound by under-trained surgeons could result in harm rather than benefit to patients, and the current minimal, informal training in critical care ultrasound may be worse that no exposure at all. It was notable that graduated general surgery residents did not always have insight into their lack of competence with critical care ultrasound. However, in this study a higher number of prior critical care ultrasound examinations performed was associated with higher rates of observed competence. A greater number of examinations than are currently performed by most general surgery residents is likely required to achieve competency, as many general surgery residents in this study did not achieve the number of ultrasound examinations performed associated with the higher percentages of observed competence. Yet even in general surgery residents having performed a higher number of critical care ultrasound examinations, observed competence was not universal. Exposure to critical care ultrasound without formalized training may not be enough to assure competency in all graduating residents. In addition to establishing a minimum number of examinations, the addition of a didactic curriculum would likely improve competency, as previous research has shown competency with trauma ultrasound in surgical residents after dedicated training.16 Ultrasound examinations will need to be reviewed for quality and a standardized examination for competency developed. This is a substantial, but necessary undertaking. Limitations to this study include a small number of participants overall, which limits statistical analysis; however, a sample size of 15 faculty observed practical assessments represents a sizable undertaking for this specific topic. Multiple faculty evaluators participated in the observed assessments, and the results have not been evaluated for interobserver variation given the small number of participants. The R Adams Cowley Shock Trauma faculty expectations for ultrasound competency have also not been compared with faculty at other institutions or ultrasound training programs, and may be higher than average leading to lower observed rates of competence. This human model assessment tool has not undergone formal validation, and was developed at our institution to evaluate internal technical ability for ongoing quality improvement with our educational curriculum. Additionally, we did not record demographic information on our study participants, and it is possible that competency varies with such factors as size of
training programs or geographic location of training programs. Further work will be required to see if these results are generalizable to general surgery residents of all demographics and future career plans. Finally, POCUS is used in many fields of surgery, including endocrine surgery, breast surgery, and surgical oncology, with future research required to assess ultrasound competency in these specific subsets of POCUS as well. Another limitation includes the study population. This study was performed on a cohort of education records of graduated general surgery residents pursuing a surgical critical care fellowship. This selection of participants may bias measurement of number of prior critical care ultrasound examinations performed, as study participants may have sought out more experience in residency to prepare for fellowship given the common use of ultrasound in the ICU. This cohort may further bias towards overestimating future ultrasound use given their likely future work in an ICU. Despite these biases, basic critical care ultrasound (such as with FAST, pneumothorax detection, and basic cardiac assessment) is an expected component of current trauma, general surgery, and critical care practice, and should be a required skill of all graduating general surgery residents. Also not investigated in this study is the acumen of the surgical faculty in teaching ultrasound to residents. Acquisition of ultrasound skills requires both an investment from the surgical resident and from the attending staff, many of whom have likely not received formalized training in ultrasound use. Ongoing reinforcement of ultrasound concepts (beyond a formalized education program) from the surgical faculty will be needed to prevent loss of ultrasound knowledge and skill. Concerning imparity exists between competence with critical care ultrasound and intended future use in graduated general surgery residents, highlighting a previously undescribed disconnect between general surgery training and actual needs of modern practicing surgeons. General surgery residency training has not embraced the need for ultrasound education and has not expanded education to prepare graduates for this aspect of clinical practice. Current unstandardized training may provide graduating general surgery residents with a false belief in their own competency, and may be unsafe. Although a finite time exists in general surgery residency for training in open surgery, laparoscopy, endoscopy, and critical care, education in critical care ultrasound must be included in a similarly dogmatic manner.
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