A Decade of POCUS Training in Family Medicine: Curriculum and Outcomes

Primary care has for many years faced pressure to improve outcomes with fewer resources. Evidence from other specialties, such as emergency medicine, has shown that bedside imaging could reduce the need for costly diagnostic tests and improve procedural outcomes. When we initially considered implementing a curriculum in 2014, point-of-care ultrasound (POCUS) seemed well-suited to meet the challenge in primary care as well. Residents wanted training, but programs lacked experience in delivering POCUS training. These converging factors motivated us to develop a structured POCUS curriculum.

To meet these needs, we designed a 4-week ultrasound rotation for first-year residents that could run with limited faculty time and expertise. The curriculum blended asynchronous video modules, simulation, and supervised scanning with standardized patients, sonographers, and faculty preceptors, followed by structured image review. Residents completed a set number of examinations in high-yield applications, including cardiac, lung, aortic, venous thrombosis, soft tissue or musculoskeletal, and obstetric ultrasound. Tools were developed to assess knowledge, scanning skills, and attitudes, creating a model for family medicine residencies, with lessons learned over 10 years informing curriculum development and modification (Table 1).¹

Our inaugural POCUS faculty had significant ultrasound training and experience. When our health system established criteria for POCUS providers in 2019, these faculty were able to obtain privileges. Faculty without prior training were required to take POCUS continuous medical education and log 150 proctored exams for full POCUS privileges. Despite strong efforts and interest, this requirement proved too time-consuming for most faculty to achieve without dedicated, funded time. Most of our success in expanding POCUS-trained faculty has been in hiring our own graduates. Currently, we have 15 faculty privileged in some form of POCUS, eight trained via our curriculum, three as inaugural POCUS faculty, and four from outside institutions.

Aside from acquiring POCUS training faculty, faculty availability has been a challenge. Our initial POCUS curriculum included a 4-week PGY-1 rotation, which utilized a diverse array of ultrasound educators, including general sonographers, obstetric sonographers, and echocardiogram technicians.¹ In addition, our POCUS program’s initial launch was aided by the allotment of a half-day per week of dedicated faculty time, paid for by our School of Medicine’s Ultrasound Institute. This time was invaluable during the initial years of our POCUS program, but the funding was sunsetted in 2022. Since that time, our ultrasound faculty have managed to teach the most time-intensive components of this PGY-1 rotation (including the hands-on orientation, weekly supervised scanning sessions, and the end-of-rotation objective structured clinical examination) by double dipping—that is, utilizing administrative time and low-volume call days. Preserving the weekly supervised scanning sessions (gel rounds) has been particularly challenging, given time pressures and competing commitments for both faculty and the rotating PGY-1 residents. In the absence of protected faculty time, some curricular components have required adaptation, with image review sessions adopting a more flexible, resident-focused format. Image review is now commonly conducted during gel rounds or in smaller informal sessions with PGY-1 residents, allowing timely feedback while maintaining continuity of supervision. While the curriculum has been sustained through distributed faculty effort and workflow integration, renewed institutional investment in protected time would enhance opportunities for innovation and future program development.

One of the challenges throughout the continued development of our curriculum has been keeping continuity of ultrasound training throughout residency. Our PGY-1 residents complete a 4-week ultrasound rotation, but those without significant interest are often weak in ongoing self-directed learning and practice. Variable rotation training sites also has led to large gaps of time our learners had away from POCUS, leading to attrition. To further enhance the longitudinal experience, we added quarterly ultrasound didactic sessions with standardized patients in our clinic. These sessions have direct supervision by POCUS faculty and count toward total scan requirements. We also developed a 2 week ultrasound rotation completed in PGY-3 with dedicated time to complete required scans and the expectation to mentor the PGY-1 and PGY-2 rotators. This rotation has allowed faculty to reevaluate resident skills and ensure that residents have completed the required scans for graduation, evaluate competency for future practice, and increase bedside teaching in a way that off-loads teaching responsibilities of faculty.

Additional challenges have been the issues of equipment and billing.^2,3 Within the hospital setting, ultrasound machines are available in the emergency department, labor and delivery floor, medical-surgical floor, and intensive care unit. Obtaining machines for the ambulatory clinic has required concerted efforts because of the high dollar capital expense with an uncertain pathway for revenue generation. The first generation of machines came to our clinic through an educational grant, but scans using this device were not approved for medical decision-making or billing. As we worked with the medical system to use billing codes for these limited ultrasound scans, we had to have a way to upload images into an electronic record to justify the bills. Initially, this data storage was done through POCUS specialized software, which was later integrated into the electronic medical record. Fortunately, this process became more streamlined as our institution moved to a common interdepartmental workflow.

More cost-effective, handheld devices came later, allowing for easier acquisition. However, we have found that larger, laptop-style models still outperform handheld devices for educational purposes because of their larger screens and more nuanced capabilities.

In 2023, we surveyed alumni who graduated between 2015 and 2022 from the Prisma Health Midlands Family Medicine Residency (PHMFMR) to evaluate their POCUS use, barriers, and perceptions. This project was reviewed by the Prisma Health Institutional Review Board (IRB) and determined to be exempt from IRB review. Seventy-one alumni were surveyed, with 41 responses (Figure 1). Alumni from PHMFMR were more likely to bill for POCUS (19.5%) compared to the national average among primary care physicians (9.5%).⁴ Alumni who reported practicing in a rural area were significantly more likely to use POCUS (P = 0.046). Among alumni who did not continue to utilize POCUS, the most common barriers noted were the lack of equipment and time (P = 0.006). Of the respondents, 5.9% reported that they did not feel that they had received proper training, and 7.9% listed difficulty in financial reimbursement. POCUS was most utilized for skin and soft tissue, musculoskeletal, and procedural applications (Figure 2). The results of this survey, though not powered for statistical significance, suggest that the POCUS curriculum did influence POCUS use among graduates and underscore the fact that the variable practice environments, time, and available equipment have large impacts on regular use. This information could be used to direct training toward more commonly used exams in the ambulatory setting, as well as in coaching trainees toward implementation and compliant billing practices to increase confidence.

POCUS education in family medicine faces numerous challenges. Many of these—including the need for capable faculty, limited faculty availability, and barriers related to technology acquisition and integration—are not unique to family medicine. However, the breadth and variability inherent to family medicine training introduce distinct challenges. Residents frequently rotate through diverse clinical environments where POCUS may not be readily available, making regular longitudinal touchpoints essential to reinforce skills. Additionally, the wide range of practice models, settings, and clinical demands within family medicine suggests that a one-size-fits-all approach to POCUS education may be insufficient. Our data indicate that an emphasis on skin and soft tissue imaging, musculoskeletal applications, and procedural guidance may be particularly valuable for residents pursuing traditional ambulatory practice, whereas those planning to practice in rural settings may benefit from a broader POCUS skill set. Additional educational focus on best practices in billing, compliance, and workflow may also result in more confident and capable family medicine POCUS graduates.