Skip to main content

Critical care ultrasound training: a survey exploring the “education gap” between potential and reality in Canada

Abstract

Background

Critical care ultrasound (CCUS) is now a core competency for Canadian critical care medicine (CCM) physicians, but little is known about what education is delivered, how competence is assessed, and what challenges exist. We evaluated the Canadian CCUS education landscape and compared it against published recommendations.

Methods

A 23-item survey was developed and incorporated a literature review, national recommendations, and expert input. It was sent in the spring of 2019 to all 13 Canadian Adult CCM training programs via their respective program directors. Three months were allowed for data collection and descriptive statistics were compiled.

Results

Eleven of 13 (85%) programs responded, of which only 7/11 (64%) followed national recommendations. Curricula differed, as did how education was delivered: 8/11 (72%) used hands-on training; 7/11 (64%) used educational rounds; 5/11 (45%) used image interpretation sessions, and 5/11 (45%) used scan-based feedback. All 11 employed academic half-days, but only 7/11 (64%) used experience gained during clinical service. Only 2/11 (18%) delivered multiday courses, and 2/11 (18%) had mandatory ultrasound rotations. Most programs had only 1 or 2 local CCUS expert-champions, and only 4/11 (36%) assessed learner competency. Common barriers included educators receiving insufficient time and/or support.

Conclusions

Our national survey is the first in Canada to explore CCUS education in critical care. It suggests that while CCUS education is rapidly developing, gaps persist. These include variation in curriculum and delivery, insufficient access to experts, and support for educators.

Background

Critical care ultrasound (CCUS) allows physicians to rapidly diagnose and treat patients with a myriad life-threatening conditions [1,2,3,4]. It also facilitates real-time monitoring and greater procedural safety [1, 5,6,7,8,9,10,11,12,13]. Accordingly, it is an increasingly useful skill that needs to be taught, assessed and maintained: a job that typically falls on educators and ultrasound champions [14].

Experts have published recommendations [15, 16] in an effort to standardize the curriculum, its delivery, and how we assess competence in critical care ultrasound. While there are still unanswered questions about the best methods to implement and evaluate CCUS curriculum, the recommendations do provide a clear starting point and an instructive guide for those educators looking to formalize CCUS education. Unfortunately, little is known about the state of CCUS education in Canadian critical care residency training programs. There is reason to underscore this point; European and American surveys suggest a lack of trained faculty, and/or formal curriculum, and/or time to supervise trainees [2, 17]. This is the first nationwide Canadian survey examining whether national recommendations have been adopted, how CCUS education is delivered, how competence is assessed, and the challenges faced by educators and learners.

Methods

We developed a 23-item survey and contacted all 13 Canadian centers with residency training programs in Adult Critical Care Medicine. Only one survey was collected per program, and we did not incentivize participation.

The survey was refined over several iterations. We started with a MEDLINE literature search using the MeSH terms "critical care", "ultrasound", "curriculum", "fellowship” and "medical education", and incorporated any manuscript that included curriculum content, design of objectives, educational strategies, methods of assessment and/or feedback, and perceived barriers [2, 16, 18]. These findings were merged with the Canadian CCUS recommendations16 to identify/describe major domains. Two national CCUS experts provided additional data, wording, clarity and content validity. The revised survey was reviewed by two additional physician-experts in CCUS (who did not participate in the study). Suggestions from the pilot were incorporated into the final survey, which is available in the Additional file 1: appendix online.

Surveys were integrated into an online platform (SurveyMonkey Inc. San Mateo, California, USA; www.surveymonkey.com) and disseminated via email with four reminders, 2 weeks apart, between January and March 2019. Survey results were compiled, and descriptive statistics presented.

Ethics approval was obtained from the University of Alberta Research Ethics Board (ref # Pro000086823). All participants consented.

Results

Of 13 Canadian critical care training programs, 11 responded (85%). 6/11 (55%) respondents were program directors, and 5/11 (45%) were delegated local CCUS or curriculum champions. 10/11 respondents reported awareness of the Canadian CCUS training recommendations; 7/11 programs reported following them “closely” (64%), and 3/11 reported following them “somewhat”.

Table 1 summarizes CCUS curricular content and delivery. Critical care echocardiography was taught in 10/11 (91%) programs; lung and pleural space ultrasound was taught in 9/11 (82%) programs, but only 3/11 (27%, or less than one-third) taught how to assess for deep venous thrombosis (DVT). Only 4/11 programs (36%; approximately one-third) reported formal competency-based objectives, with entrustable professional activities and milestones.

Table 1 Development of current curricular delivery mechanisms and CCUS content

Curriculum delivery also differed. For example, while 8/11 (73%) used hands-on training, and 7/11 (64%) used educational rounds, only 5/11 (45%; less than half) incorporated routine feedback and almost two-thirds (7/11; 64%) did not formally assess skills in imaging acquisition or interpretation. Table 2 demonstrates the array of training strategies used, with a majority using textbooks (9/11: 82%), simulators (8/11: 73%) and websites (8/11: 73%). All 11 used at least one academic half day per annum, and approximately two-thirds relied upon unsupervised clinical service (7/11: 64%). In contrast, it was rare for programs to mandate a dedicated ultrasound rotation (4/11; 36%) or ultrasound course (2/11; 18%).

Table 2 Educational methods and materials in use for curricular delivery

The amount of dedicated hands-on training with an instructor (outside of clinical care) also varied. For example, 1 program reported delivering 1 to 4 h, whereas 3 programs providing greater than 15 h. Regarding contributions from other specialties, cardiology (6/11; 55%) and anesthesia (6/11; 55%) taught disproportionately compared to emergency medicine, internal medicine and radiology.

Table 3 summarizes potential barriers. On the positive side, regarding access to US machines, 10/11 (91%) programs reported “no barrier” to machines, and an average of 2 machines per 20–30 beds. In contrast, regarding access to experts, only 4 programs (36%; approximately one-third) felt it was “easy” to get local training, with 5 reporting “mild difficulty”, and 2 reporting “marked difficulty”. Overall, the most common “critical” or “major” barrier was difficulty identifying a local expert (4/11: 36%), inadequate supervision (7/11: 64%), and inadequate academic support (4/11; 36%). 9/11 programs identified having only 1 or 2 local experts (range 0–6).

Table 3 Barriers identified to be hindering curricular development and implementation

The minimum training requirements and typical methods of assessment were also explored. Approximately one-third of programs (4/11: 33%) required fellows to perform and interpret a minimum number of CCUS exams. All 4 programs required a minimum number of echocardiograms. 75% required a minimum number of lung and pleural ultrasounds and 25% required a minimum number of thoracenteses, paracenteses, and abdominal free fluid and vascular access scans. Approximately half of the programs used portfolio review, one program used a written formal exam, and three programs implemented an objective structured clinical exam (OSCE). Feedback was most often delivered in real time from a local expert (7/11: 64%), but also remotely with the use of USB image storage and digital archiving software (4/11, 36% each). Quality assurance rounds were only performed in two programs. Additional competency assessment tools included entrustability assessment, in-training evaluation reports (ITERs), CAE-ICCU© modules, online modules, and reliance on the National Board of Echocardiography CCM exam. 7/11 programs assessed learner experiences using feedback surveys, exams, and/or local research, whereas 4/11 did not evaluate learners.

Discussion

This is the first national evaluation of the Canadian CCUS education in critical care and summarizes the “educational gap” between recommendations and local educational practices, as shown in Table 4 [16].

Table 4 Comparison of Canadian CCUS recommendations [16] to the current state

Our data highlight encouraging signs but important caveats. First, all responding sites teach basic critical care echocardiography, many teach pulmonary ultrasound, and access to machines does not appear to be a substantial issue. In contrast, few teach how to detect abdominal free fluid (64%), do DVT assessment (27%), or perform renal ultrasound (36%). Moreover, few mandate formal training; few formally assess image acquisition and interpretation skills, and educators still feel under-supported.

Canadian academic centers are well-resourced compared to most jurisdictions. Therefore, it is noteworthy that cultural barriers persist. Moreover, these concerns are not unique or new. In a 2014 survey of American CCM fellowship directors, many reported insufficient experts to teach and supervise, and not enough faculty who modeled the use of ultrasound themselves [2]. Similarly, a 2017 survey of intensive care societies in Western European countries reported insufficient time, trainers, and consensus regarding core competencies [17]. Our work further highlights the importance of in-house educators, champions, mentors, supervision, and regular program evaluation.

Our results highlight that it is still rare for trainees to undertake dedicated CCUS rotations or for educators to receive protected time. Moreover, less than half of our programs assessed CCUS competency. National CCUS recommendations [16], highlight the need for deliberate assessment, and include ideas such as a portfolio and hands-on exam. This need not be onerous. After all, images can now be easily logged on a USB drive, or on the ultrasound machine, or via digital archiving systems. Our results also highlight that programs do not routinely evaluate curricula. Creating national groups, such as the Canadian Internal Medicine Ultrasound Group, could help with standardization and resource sharing [19].

Our study has limitations. For example, it is hard to objectively define what constitutes “good” instruction or supervision, just as it is difficult to state when a curriculum is “optimal” or “mature”; indeed, there are not clear published “best practice” standards for CCUS education. Further, Canadian recommendations [16] are expert panel-driven, and do not include a robust methodology. Nonetheless, in the absence of competing Canadian recommendations, we felt that this panel of experts from across Canada provided an informed and representative starting point and that mirrors those in the United States [2] and Europe [15]. We also relied upon assessments by program directors or champions rather than the opinion of the end-user, i.e., the trainee. Canada only has thirteen Adult Critical Care training programs, limiting our sample size. Lacking responses from only two programs may skew our results. We also focused on academic centers and were unable to capture the benefits gained through informal instruction or self-teaching. Despite these limitations, our acceptable response rate (85%), and a survey that covered multiple domains (e.g., content, delivery, infrastructure, and barriers) shows that CCUS is increasingly seen as an important in CCM training. Accordingly, we need to support both trainees and educators, and to close the gap between potential and reality.

Finally, one area in which this study did not explicitly examine is the evolving role of formal certification in CCUS in Canada. Over the last couple of years as critical care medicine has transitioned to competency-based medical education in Canada, key CCUS modalities (i.e., heart, lung, abdomen, vascular) have been selected as “required training experiences” for the sub-specialty of Critical Care Medicine by the Royal College Objective of Physicians and Surgeons of Canada [20]. Therefore, measures of assessment including Entrustable Professional Activities and licensing examinations do systematically assess these competencies in light of national standards for achievement. In contrast, the National Board of Echocardiography in the United States now provides a separate certification pathway through the “Examination of special competence in critical care echocardiography (CCEeXAM)” [21] for more advanced ultrasound examinations, which began in 2019. In our survey, only one training program highlighted that this was a part of their assessment strategy. While this exam may play a role in future certification in Canada, it has yet to be adopted by any national licensing body.

Conclusions

Critical care ultrasound is a useful adjunct in caring for the critically ill patient; ensuring that future critical care practitioners can perform this skill set is necessary. Our findings show that disparities in CCUS education persist and that more work needs to be done to achieve standardization of CCUS education across Canada. Expert recommendations have served as a practical benchmark in this study, but we acknowledge that there may be debate whether such recommendations constitute “best practice” evidence to inform curriculum design. Practical rotation-based exposure mandated by programs and formal assessment of technical skill and knowledge may be limited. Further, trained faculty, access to local champions, and dedicated time are scarce. Through program collaboration and prioritization of CCUS training for both faculty and trainees, closing the gap between recommendations to educational practice could easily be achieved.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

CCUS:

Critical care ultrasound

CCM:

Critical care medicine

ITERs:

In-training evaluation reports

References

  1. Schmidt GA (2009) ICU ultrasound: the coming boom. Chest 135(6):1407–1408. https://doi.org/10.1378/chest.09-0502

    Article  PubMed  Google Scholar 

  2. Mosier JM, Malo J, Stolz LA et al (2014) Critical care ultrasound training: a survey of US fellowship directors. J Crit Care 29(4):645–649. https://doi.org/10.1016/j.jcrc.2014.03.006

    Article  PubMed  Google Scholar 

  3. Neri L, Storti E, Lichtenstein D (2007) Toward an ultrasound curriculum for critical care medicine. Crit Care Med 35(5 Suppl):S290–S304. https://doi.org/10.1097/01.CCM.0000260680.16213.26

    Article  PubMed  Google Scholar 

  4. Morris AE (2015) Point-of-care ultrasound: seeing the future. Curr Probl Diagn Radiol 44(1):3–7. https://doi.org/10.1067/j.cpradiol.2014.05.012

    Article  PubMed  Google Scholar 

  5. Frankel HL, Kirkpatrick AW, Elbarbary M et al (2015) Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients-Part I: general ultrasonography. Crit Care Med 43(11):2479–2502. https://doi.org/10.1097/CCM.0000000000001216

    Article  PubMed  Google Scholar 

  6. Turner EE, Fox JC, Rosen M, Allen A, Rosen S, Anderson C (2015) Implementation and assessment of a curriculum for bedside ultrasound training. J Ultrasound Med 34(5):823–828. https://doi.org/10.7863/ultra.34.5.823

    Article  PubMed  Google Scholar 

  7. Marik PE, Mayo P, Marik PE, Mayo P (2008) Certification and training in critical care ultrasound. Intensive Care Med 34:215–217

    Article  Google Scholar 

  8. Hulett CS, Pathak V, Katz JN, Montgomery SP, Chang LH (2014) Development and preliminary assessment of a critical care ultrasound course in an adult pulmonary and critical care fellowship program. Ann Am Thorac Soc 11(5):784–788. https://doi.org/10.1513/AnnalsATS.201312-459BC

    Article  PubMed  Google Scholar 

  9. Kanji HD, McCallum J, Sirounis D, MacRedmond R, Moss R, Boyd JH (2014) Limited echocardiography-guided therapy in subacute shock is associated with change in management and improved outcomes. J Crit Care 29(5):700–705. https://doi.org/10.1016/j.jcrc.2014.04.008

    Article  PubMed  Google Scholar 

  10. Xirouchaki N, Magkanas E, Vaporidi K et al (2011) Lung ultrasound in critically ill patients: Comparison with bedside chest radiography. Intensive Care Med 37(9):1488–1493. https://doi.org/10.1007/s00134-011-2317-y

    Article  PubMed  Google Scholar 

  11. Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby J-J (2004) Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Clin Investig Anesthesiol 100(1):9–15. https://doi.org/10.1097/01.sa.0000140524.23073.da

    Article  Google Scholar 

  12. Vignon P, Chastagner C, Francois B et al (2003) Diagnostic ability of hand-held echocardiography in ventilated critically ill patients. Crit Care 7(5):R84-91

    Article  Google Scholar 

  13. Jones AE, Tayal VS, Sullivan DM, Kline JA (2004) Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients*. Crit Care Med 32(8):1703–1708. https://doi.org/10.1097/01.CCM.0000133017.34137.82

    Article  PubMed  Google Scholar 

  14. Cholley BP (2011) International expert statement on training standards for critical care ultrasonography. Intensive Care Med 37(7):1077–1083. https://doi.org/10.1007/s00134-011-2246-9

    Article  Google Scholar 

  15. Mayo PH, Beaulieu Y, Doelken P et al (2009) American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography. Chest 135(4):1050–1060. https://doi.org/10.1378/chest.08-2305

    Article  PubMed  Google Scholar 

  16. Arntfield RT, Millington SJ, Ainsworth CD et al (2014) Canadian recommendations for critical care ultrasound training and competency for the Canadian critical care society. Can Respir J 21(6):341–345

    Article  Google Scholar 

  17. Wong A, Barrachina L (2016) The state of critical care ultrasound training in Europe. Crit Care Med. https://doi.org/10.1097/01.ccm.0000509598.86109.65

    Article  PubMed  PubMed Central  Google Scholar 

  18. Jaidka A, Arntfield R. Developing a Longitudinal Post-Critical Care Ultrasound (CCUS) Course Curriculum: Identifying Barriers and Determining Interest. Crit Care Canada Forum. Published online 2017. https://cccf.multilearning.com/cccf/2017/eposter/198166/atul.jaidka.developing.a.longitudinal.post-critical.care.ultrasound.28ccus29.html?f=media=3*c_id=198166*listing=3*browseby=8

  19. Ambasta A, Balan M, Mayette M et al (2019) Education indicators for internal medicine point-of-care ultrasound: a consensus report from the Canadian Internal Medicine Ultrasound (CIMUS) Group. J Gen Intern Med 34(10):2123–2129. https://doi.org/10.1007/s11606-019-05124-1

    Article  PubMed  PubMed Central  Google Scholar 

  20. The Royal College of Physicians and Surgeons of Canada. Critical Care Medicine Training Experiences. 2021; version2:1–10. https://www.royalcollege.ca/rcsite/documents/ibd/critical-care-medicine-rte-training-experiences-e.pdf

  21. Panebianco NL, Mayo PH, Arntfield RT et al (2021) Assessing competence in critical care echocardiography: development and initial results of an examination and certification processes. Crit Care Med. https://doi.org/10.1097/CCM.0000000000004940

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Drs. Hailey Hobbs and Frank Myslik for their contributions.

Funding

Dr. Ma is funded as the chair holder of the John A. Buchanan Chair in General Internal Medicine at the University of Calgary. This funding source had no role in the design of this study, its execution, analyses, or interpretation of the data, or the decision to submit results. Dr. Daniels would like to acknowledge the Alberta Academic Medicine and Health Services Program for its financial support.

Author information

Authors and Affiliations

Authors

Contributions

JS and BB contributed equally to study and survey design, data collection and interpretation, and manuscript preparation. IM and VD assisted with survey design, data interpretation and manuscript preparation. SB contributed to study and survey design. PB contributed to data interpretation and manuscript preparation. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Jocelyn M. Slemko.

Ethics declarations

Ethics approval and consent to participate

Ethics approval was obtained from the University of Alberta Research Ethics Board (ref # Pro000086823). All participants consented.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1.

Survey—Residency program director or delegate.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Slemko, J.M., Daniels, V.J., Bagshaw, S.M. et al. Critical care ultrasound training: a survey exploring the “education gap” between potential and reality in Canada. Ultrasound J 13, 48 (2021). https://doi.org/10.1186/s13089-021-00249-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13089-021-00249-z

Keywords

  • Ultrasonography
  • Echocardiography
  • Critical care
  • Intensive care
  • Medical education