In this multi-centre survey of six North American academic institutions’ practicing internists who look after hospitalized patients, several findings emerged. First, whilst POCUS is commonly used for procedural guidance, its frequency of use in the general clinical assessments was only done on a median of 5% of patients. Second, general attitudes towards POCUS were positive, including high interest in learning POCUS and an overall positive belief about the utility of POCUS. Third, practicing internists reported a number of barriers, including the lack of training, supervision, quality assurance processes (archiving and review of images), handheld devices, and time to perform POCUS during rounds. Whilst there was only moderate concern regarding the use of POCUS potentially resulting in patient harm, participants did not particularly feel that POCUS findings will compel them to act contrary to their clinical judgement, or that they may lose their physical examination skills if they used POCUS. Further, external factors such as career opportunities and billing opportunities were not considered significant enabling factors. Overall, our results suggest that the practicing internists at these six academic centres have limited personal, attitudinal, work environment, or externally related barriers to using POCUS but significant skill and knowledge-based barriers may be limiting POCUS use. Whilst access to machines did not seem to be a barrier at their institutions, participants did feel that provision of a handheld ultrasound would facilitate increased use.
Our results are consistent with prior survey studies on barriers in using POCUS in practicing physicians. For example, personal and general attitude to the use of POCUS has been favourable in prior studies [7, 11, 13, 14, 17, 25, 26]. However, unlike other studies where time, equipment, and funding were the primary barriers [7, 11, 16,17,18], our study participants were more concerned with their own lack of training, supervision, and the lack of quality assurance processes. This concern with lack of training and supervision has also been suggested in other studies [14, 15, 25, 26]. Last, in one study of neonatal and pediatric critical care specialists, over 40% of participants were concerned with both liability issues and resistance from imaging specialists [16]. These two issues were only of moderate importance to our survey participants.
Our study has several limitations. First is the issue of generalizability. The academic centres in our study all have a designated internal medicine POCUS champion, a marker of higher quality POCUS education [27], as well as availability of machines and supportive work environment and colleagues. As such, our results may not apply to practitioners in POCUS-naïve settings. Indeed, a prior study found that attitudes of critical care fellowship program directors differed between programs that had an ultrasound machine, compared with programs that did not [13]. Second, our overall response rate was only 49%. Whilst five of our six sites achieved our target of greater than 40% response rate, one site achieved only 33%. Nonetheless, our response rate is typical of studies of this kind; in a systematic review of 68 surveys, a mean response rate of 39.6% was reported [28]. Third, despite an attempt to more comprehensively explore barriers, a complete catalogue of all barriers is not possible. Fourth, whilst statistics convey central tendencies, for each barrier and enabler, the responses ranged from 1 to 5 (from strongly disagree to strongly agree), with the exception of 2 items: “I do not need to know POCUS because it is not a ABIM/FRCPC requirement” (range 1–4); “Other internists at my institution are supportive of the use of POCUS in clinical practice” (range 2–5). The implication of these observed ranges is that despite our reported results, in our study population are individuals whose attitude towards POCUS was very negative, who felt very strongly that POCUS is a fad that will pass with time, and who still would not use POCUS if they had more training and supervision. The usual interventions to effect behavioural change may be less effective on these individuals. Finally, our online survey was administered anonymously; despite the absence of identical responses in surveys, we cannot exclude the possibility that some individuals may have responded more than once.