Night Vision: A New Blueprint for Bedside Ultrasound Training in Medical Residency

Night Vision: A New Blueprint for Bedside Ultrasound Training in Medical Residency | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Night Vision: A New Blueprint for Bedside Ultrasound Training in Medical Residency Timothy Johnson, Leticia Flores, Alexander Pandelidis, Michael Broda, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5760020/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Medical Education → Version 1 posted 8 You are reading this latest preprint version Abstract Background Faculty expertise and support, resident scheduling, and cost of ultrasound machines are common barriers encountered when attempting to implement a new point-of-care ultrasound (POCUS) curriculum. Integration of a POCUS curriculum into existing night medicine rotations helps bypass these barriers by minimizing the amount of trained faculty required and harnessing clinical opportunities within a pre-existing curriculum. Methods 37 PGY-1 residents participated in this pilot study within the inpatient setting of VCU Health hospital, primarily during their night medicine rotations. Faculty included four full-time nocturnists. Residents received didactics on pulmonary and abdominal imaging and completed online modules. Practice opportunities occurred primarily during night medicine rotations under the supervision of the nocturnists. Results Residents underwent pre- and post-curriculum surveys and knowledge/skills assessments. Comfort, knowledge, and skills significantly increased pre- to post-curriculum. Mean skills assessment scores increased from 13.4 to 23.6 points out of 34 ( p < 0.001). Mean knowledge assessment scores increased from 54% to 61% ( p < 0.001). Conclusion Integration of a POCUS curriculum into the existing night medicine rotation bypassed common barriers and resulted in statistically significant increases in resident comfort, knowledge, and skills. Ultrasound POCUS medical education curriculum internal medicine Figures Figure 1 Background As of 2020, approximately 57% of medical schools reported having a formal ultrasound curriculum and 60% of internal medicine residency training programs have either a formal elective or required curriculum for diagnostic point-of-care ultrasound (POCUS). 1,2 The American College of Physicians formally acknowledged “the important role of point-of-care ultrasound (POCUS) in internal medicine.” The Alliance for Academic Internal Medicine “recognizes and supports the integration of POCUS across the longitudinal training environment of UME, GME, and CME.” 3 Beyond residency, POCUS has an important role among hospitalists, general internists, primary care, and within the subspecialties. 4,5 The integration of POCUS into clinical practice allows providers to spend more time at the bedside, conveying results in real time, and increases patients’ satisfaction and understanding of the diagnostic process. 6–9 Though POCUS is a beneficial component of graduate medical education (GME), there are common barriers to implementing a curriculum. On a recent national survey of internal medicine program directors, the difficulties include faculty expertise and support, resident scheduling, and cost of ultrasound machines. 2 In the 2022–2023 academic year, a pilot longitudinal curriculum in diagnostic POCUS was implemented for residents in the internal medicine residency program at Virginia Commonwealth University (VCU) in Richmond, Virginia. This curriculum was integrated into the existing night medicine rotations to provide opportunities for direct observation and one-on-one training by a cadre of four teaching nocturnists trained in POCUS. The integration helped bypass barriers by limiting the number of faculty to train and harnessing clinical opportunities available within a pre-existing curriculum. Training in this environment can also be carried out with limited equipment, with the trained nocturnist utilizing a handheld ultrasound device available to the housestaff working at night. Night rotations are a prime setting for learning opportunities, particularly when supervised by an on-site attending. Hanson et al describe nighttime clinical care as “typically devoid of administrative demands, which affords more opportunities for faculty to observe direct patient contact and provide guidance and specific feedback for advanced learners.” 10 Residents have noted that the advantages of experiential learning at night include “evaluating undifferentiated patients, having more time to think, fewer competing demands, and monitoring patients over time.” 11 “Twelve tips for teaching” recommends a return to the bedside, as bedside teaching and patient-centered teaching points are particularly memorable and engaging for learners. 12 Dedicated overnight supervision by attendings has been well received by residents and improves educational and clinical value. 12–14 In contrast, a less robust nighttime education model can be detrimental to resident training. 15 Incorporation of POCUS into a night medicine structure can not only bypass the common barriers but also enhance resident nighttime education by providing additional supervised learning opportunities at the bedside, with a focus on patient-centered learning. The creation of a POCUS curriculum within GME is not a novel idea, but there is no description of a POCUS curriculum integrated into night-based rotations in the literature. Based on these key points about the existing landscape for this type of training, and the advantages that the night medicine setting offers, we developed a single-center feasibility pilot study integrating POCUS into nighttime teaching. Methods Setting and Participants Participants of this pilot curriculum included 37 PGY-1 residents in the internal medicine residency program at VCU in Richmond, VA. This came from a combination of 33 categorical internal medicine interns and 4 combined medicine-pediatrics interns. The primary learning environment was the inpatient setting of VCU Health hospital during night medicine rotations. The primary faculty were four full-time teaching nocturnists who supervise the residents on night medicine rotations. Faculty included a hospitalist who created and directs the curriculum, and had completed the national Society of Hospital Medicine-Chest POCUS Certificate of Completion. Another faculty member received their training through an ACGME-accredited combined emergency medicine and internal medicine residency program, and is board certified in both fields. Two additional full-time nocturnists were pursuing ongoing training in point-of-care ultrasound at the time of the pilot year. The curriculum director was granted 0.10 full-time equivalent hours during the pilot year. The protected time allowed the director to coordinate and provide core conference lectures, perform quality assurance on resident submitted images, conduct the pre- and post-curriculum assessments, and to provide additional hands-on scanning opportunities. Program Description The purpose of the curriculum is to provide trainees with foundational skills to eventually become competent and confident POCUS users by learning indications for use and skills for image acquisition and interpretation and having the opportunity to practice and integrate it into medical decision-making. The curriculum provides trainees with an understanding of ultrasound physics and probe and machine manipulation to facilitate optimal image acquisition. Didactic components include brief indication and integration components with focus on POCUS physics and image acquisition. Bedside teaching and quality reviews facilitate honing image acquisition skills. Residents accumulate an image portfolio throughout residency. Images for consideration toward the portfolio are submitted to the curriculum director for quality assurance review, with feedback provided in a timely manner upon submission. The PGY-1 curriculum focused on pulmonary and abdominal systems. Additional systems were excluded for the pilot year to maximize feasibility. Educational sessions were during required core conference didactics. Sessions included an introduction to POCUS basics and physics, and lectures on pulmonary and abdominal scanning techniques. Residents completed online learning modules and also received training in utilization of Qpath. Residents underwent pre- and post-curriculum surveys, knowledge assessments, and skills assessments. All residents participated in night medicine during their PGY-1 year, during which they obtained hands-on experience integrating POCUS into assessment and management of patients, as well as practice opportunities. Additional hands-on scanning opportunities were also provided by the curriculum director during daytime inpatient ward settings. Evaluation Surveys, structured through Redcap, were developed for this study and assigned to the residents at the beginning and end of the year. The survey (see Methods Supplement S1) assesses prior training, confidence in using POCUS, likelihood of utilizing POCUS, and perceptions regarding the importance of POCUS. The survey tests knowledge with questions regarding ultrasound principles, physics, and case-based applications. Confidence and likelihood of utilizing POCUS were assessed on a 5-point Likert scale. Knowledge was measured on a continuous scale from 0 to max attainable value of 13 based on the questions correctly answered. Residents also participated in an 8-minute observed skills assessment utilizing standardized patients at the beginning and end of the year. A standardized grading rubric (see Methods Supplement S2) was created and used in the assessment. This was also measured on a continuous scale from 0 to max attainable value of 34 based on the checklist of items performed correctly. The survey and skills assessment, with its corresponding grading rubric, were created without the use of a previously validated tool. To ensure content validity, the two POCUS-trained nocturnists created the instruments and they were reviewed by additional content area experts. The results of these assessments were then used to compare pre- and post-intervention outcomes for the dependent variables of knowledge, skills, and attitudes. The intervention is defined as one year of training in the formal POCUS curriculum. Data was collected from July through October for pre-intervention assessments. Data was then collected again at the end of the academic year, in May and June. This study was conducted in an educational setting and involved normal educational practices. It was approved as exempt by the Institutional Review Board of VCU School of Medicine and informed consent to participate was not required. Written consent was not obtained, though all participants were thoroughly informed of the curricular components and associated research during an orientation session. Outcomes Fifty-nine percent of categorical internal medicine and combined medicine-pediatrics interns ( n =22) completed both the pre- and post-curriculum skills tests, and one hundred percent ( n =37) completed the knowledge assessments and were included in the analysis. The figure shows scores on the skills assessment comparing the score pre-curriculum (blue) to post-curriculum (orange). The table shows confidence scores for knowledge and comfort/likelihood of use. Notably, skills, knowledge and confidence showed a statistically significant increase from pre- to post-curriculum. Mean score on the skills assessment increased from 13.4 points to 23.6 points ( p < 0.001). Mean score on the knowledge assessment increased from 54% to 61% ( p < 0.003). Interns performed a total of 88 imaging studies (64 supervised by curriculum director) and submitted 69 for quality assurance. Of those, there were 121 accepted portfolio images. Paired samples t-test was used to compare pre- and post-test scores. Data analysis was performed using R version 4.3.0 (R Core Team, 2023). Effect sizes were calculated using the Hedges Correction of Cohen's d as implemented in the "rstatix" package in R (Kassambra, 2023). Table 1: Pre- and Post-Curriculum Knowledge Assessment Scores ( n =37). Values presented here represent means and standard errors. Pre-curriculum Post-curriculum p value Knowledge Assessment Scale 0-13 7±.4 8±.3 < 0.003 Comfort Scale 1-5 2.5±.2 2.8±.1 < 0.003 Likelihood of use Scale 1-5 4.6±.1 4.4±.1 < 0.023 All residents in the program evaluated their general experience and perceptions of POCUS in the residency program annual survey in January 2023. The majority of respondents agreed that POCUS is important to their future career (61.4%, n =93) and more than half (55.9%) have participated in point of care ultrasound since beginning post-graduate training. Respondents reported night medicine (29.1%, n =55) and intensive care units (30.9%) most frequently as settings in which they participated in POCUS. The most commonly reported barriers were competing clinical work (32.7%, n =49), availability of trained attendings (28.6%), and lack of equipment (22.4%). Discussion After the pilot year of the longitudinal diagnostic POCUS curriculum, residents had a statistically significant increase in comfort with POCUS and objective knowledge and skills assessment scores. There was a statistically significant decrease in the perceived likelihood of use by the end of the year. This may be attributed to a differentiation towards different career interests throughout intern year. Responses in the residency program survey regarding whether or not POCUS is important preparation for their future career indicated that residents with certain career interests found POCUS less applicable but acknowledged its importance in other career paths. The educational outcomes of this curriculum are comparable to those of daytime-focused curricula that have utilized pre- and post-curriculum surveys and tests. Ferre et al 16 at the Indiana University School of medicine piloted a GME POCUS curriculum that utilized online modules and a hands-on simulation session each month for four months. Results showed an increase in knowledge, comfort, and utilization of POCUS. Brant et al 17 describe implementation of a longitudinal curriculum at University of Colorado-affiliated hospitals, which involved three half-days of education over a three-month period. Results showed increased comfort and knowledge levels. Filler et all 18 analyzed the impact of a structured longitudinal curriculum for PGY-3 emergency medicine residents over 18 months that involved bi-monthly didactic sessions, a structured four-week rotation, and asynchronous online learning. Results showed an increase in trainee confidence, satisfaction, and perception of utilization of POCUS. They did not have a significant mean increase in quiz scores. While the educational outcomes of this curriculum are comparable to those previously described, it also benefited from harnessing clinical opportunities within a pre-existing curriculum, limiting the number of faculty to train, and minimizing required ultrasound equipment. The incorporation of POCUS into an existing night medicine rotation bypassed these common barriers encountered when attempting to implement a POCUS curriculum. The utilization of dedicated nocturnists addresses the limitation of trained faculty available. Only four instructors (two fully trained faculty, two undergoing training), working mostly during their clinical time, were needed. A majority of the images were obtained under the supervision of the curriculum director, signifying the impact that a single trained nocturnist can have on the curriculum. A single handheld ultrasound, obtained at a fraction of the cost of cart-based machines, was made accessible to residents through the nocturnist. The need for resident scheduling and potential interference is also negated, as the curriculum takes advantage of a pre-existing rotation which interns complete multiple times throughout the year. Due to the higher number of patients covered by a single intern and the emphasis of clinical work on assessment and management of acute situations overnight, there are increased opportunities for supervised image acquisition and integration into clinical care. In addition to bypassing common barriers with a night medicine-based POCUS curriculum, the resident nighttime educational experience can be enhanced, with additional opportunities for supervised observation at the bedside and increased patient-centered instruction. Reported barriers were not specific to POCUS on night medicine and were similar to those within daytime curricula. The lack of available trained faculty should improve with completion of faculty training following the pilot year. Access to ultrasounds was improved by focusing on acquisition of a less costly handheld device, primarily used at night, though the number of available ultrasounds overall remained limited. There are some limitations to this pilot study. The number of participants is small due to the constraints of it being limited to one year within one residency program and a significant percentage being unable to complete the pre and post skills assessments due to scheduling conflicts. The pilot year focused on PGY-1 residents, to increase the feasibility, with plans to integrate subsequent PGY-1 classes into the curriculum. Logistical issues resulted in a delay in obtaining the handheld ultrasound until approximately halfway through the academic year, which limited opportunities for image acquisition. Another limitation is the variability of education time amongst the residents. Even though all residents spent a similar amount of time on nights, there likely was a large amount of variability in scanning opportunities due to demands of the shift and intrinsic motivation of the residents to attempt scans. In addition, opportunities to acquire images outside of the night medicine curriculum were not consistently taken advantage of by all participants. Lastly, proximity of night medicine rotations to knowledge and skills assessment sessions likely led to a small amount of recall bias. In an effort to address these barriers and enhance the educational experience, steps are being taken for subsequent years of the curriculum. Additional resources, such as textbooks and ultrasound machines, are being acquired for resident use. Faculty training in point-of-care ultrasound is ongoing. A dedicated didactic and hands-on practice session is being built into intern orientation. Additional systems, including cardiac, are being incorporated in subsequent years. Efforts are underway to offer additional practice opportunities, including standardized simulation sessions during resident conference. A POCUS elective is also being created to offer residents a multidisciplinary experience and additional training opportunities. Conclusion With a majority of medical schools providing a formal POCUS curriculum 1 and the recognition of its importance in patient care in internal medicine 3,4,19 , it is imperative to continue the education and training during graduate medical education in internal medicine. This pilot curriculum study showed that a POCUS curriculum concentrated during night medicine rotations is feasible and can overcome common hurdles in implementing a residency POCUS curriculum, while also enhancing nighttime education and providing outcomes comparable to traditional daytime-based curricula. Declarations Contributors: None. Funding: None. Competing interests: The authors declare that they have no competing interests. Prior presentations: None. Ethics approval and consent to participate: The research was conducted in a commonly accepted educational setting and involved normal educational practices. This study was approved as exempt by the Institutional Review Board of VCU School of Medicine, being classified as category 1 exempt research under 45 CFR 46.104(d), so informed consent to participate was not required. Written informed consent was not obtained, but all participants were thoroughly verbally informed about the curricular components and associated research during an orientation session. This study adhered to the Declaration of Helsinki ethical principles. Consent for publication: Not applicable. Availability of data and materials: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Data is located in an institution-specific REDCap database. Supplementary information linked to the online version: Methods Supplement S1 Methods Supplement S2 References Russell FM, Zakeri B, Herbert A, Ferre RM, Leiser A, Wallach PM. The State of Point-of-Care Ultrasound Training in Undergraduate Medical Education: Findings From a National Survey. Acad Med. 2021 Nov 16. doi: 10.1097/ACM.0000000000004512. Epub ahead of print. doi: https://doi.org/10.1016/j.amjmed.2021.11.002. LoPresti CM, Schnobrich D, Novak W, et al. Current Point of Care Ultrasound Use and Training Among Internal Medicine Residency Programs from the 2020 APDIM Program Director's Survey. Am J Med. 2022 Mar;135(3):397-404. doi: 10.1016/j.amjmed.2021.11.002. Epub 2021 Dec 7. PMID: 34890562. LoPresti, C. M., Jensen, T. P., Dversdal, R. K., & Astiz, D. J. Point-of-care Ultrasound for Internal Medicine Residency Training: A position statement from the Alliance of Academic Internal Medicine. The American Journal of Medicine , 132 (11), 1356–1360. doi: 10.1016/j.amjmed.2019.07.019 Soni NJ, Schnobrich D, Mathews BK, et al. Point-of-Care Ultrasound for Hospitalists: A Position Statement of the Society of Hospital medicine. J Hosp Med. 2019 Jan 2;14:E1-E6. doi: 10.12788/jhm.3079. Bhagra A, Tierney DM, Sekiguchi H, Soni NJ. Point-of-Care Ultrasonography for Primary Care Physicians and General Internists. Mayo Clin Proc. 2016 Dec;91(12):1811-1827. doi: 10.1016/j.mayocp.2016.08.023. Durston W, Carl ML, Guerra W. Patient satisfaction and diagnostic accuracy with ultrasound by emergency physicians. Am J Emerg Med. 1999 Nov;17(7):642-6. doi: 10.1016/s0735-6757(99)90150-x. Howard ZD, Noble VE, Marill KA, Sajed D, Rodrigues M, Bertuzzi B, Liteplo AS. Bedside ultrasound maximizes patient satisfaction. J Emerg Med. 2014 Jan;46(1):46-53. doi: 10.1016/j.jemermed.2013.05.044. Mathews BK, Miller PE, Olson APJ. Point-of-Care Ultrasound Improves Shared Diagnostic Understanding Between Patients and Providers. South Med J. 2018 Jul;111(7):395-400. doi: 10.14423/SMJ.0000000000000833. Andersen, C.A., Brodersen, J., Rudbæk, T.R. et al. Patients’ experiences of the use of point-of-care ultrasound in general practice – a cross-sectional study. BMC Fam Pract 22, 116 (2021). doi: 10.1186/s12875-021-01459-z. Hanson JT, Pierce RG, Dhaliwal G. The new education frontier: clinical teaching at night. Acad Med. 2014 Feb;89(2):215-8. doi: 10.1097/ACM.0000000000000096. PMID: 24362386. Torwekar BL, Robinson M, Durham M, Cooper D, Wurster W, Bowen JL. What Residents Want: Perceptions of Learning During a Pediatrics Night Float Rotation. Hosp Pediatr. 2023 May 1;13(5):401-408. doi: 10.1542/hpeds.2022-006954. PMID: 37070381. Richards JB, Wilcox SR, Roberts DH, Schwartzstein RM. Twelve tips for overnight teaching. Med Teach. 2014 Mar;36(3):196-200. doi: 10.3109/0142159X.2013.847911. Epub 2013 Oct 28. PMID: 24164552. Greene JG. Neurohospitalists enhance resident perception of the educational and clinical value of a night float rotation. Neurohospitalist. 2013 Oct;3(4):179-84. doi: 10.1177/1941874413495879. PMID: 24198898; PMCID: PMC3810834. Al-Khafaji J, Konjeti VR, Call S. Midnight Report: A Novel Faculty-Guided Night Curriculum to Enhance Resident Nighttime Education. Southern Medical Journal. 2020 May;113(5):201-204. DOI: 10.14423/smj.0000000000001090. PMID: 32358612. Bricker DA, Markert RJ. Night float teaching and learning: perceptions of residents and faculty. J Grad Med Educ. 2010 Jun;2(2):236-41. doi: 10.4300/JGME-D-10-00005.1. PMID: 21975627; PMCID: PMC2941384. Ferre RM, Russell FM, Peterson D, Zakeri B, Herbert A, Nti B, Goldman M, Wilcox JG, Wallach PM. Piloting a Graduate Medical Education Point-of-Care Ultrasound Curriculum. Cureus. 2022 Jul 23;14(7):e27173. doi: 10.7759/cureus.27173. PMID: 36017274. Brant JA, Orsborn J, Good R, Greenwald E, Mickley M, Toney AG. Evaluating a longitudinal point-of-care-ultrasound (POCUS) curriculum for pediatric residents. BMC Med Educ. 2021 Jan 19;21(1):64. doi: 10.1186/s12909-021-02488-z. PMID: 33468138. Filler L, Orosco D, Rigdon D, Mitchell C, Price J, Lotz S, Stowell JR. Evaluation of a novel curriculum on point-of-care ultrasound competency and confidence. Emerg Radiol. 2020 Feb;27(1):37-40. doi: 10.1007/s10140-019-01726-8. Epub 2019 Sep 4. PMID: 31485848. Qaseem A, Etxeandia-Ikobaltzeta I, Mustafa RA, et al. Appropriate Use of Point-of-Care Ultrasonography in Patients With Acute Dyspnea in Emergency Department or Inpatient Settings: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):985-993. doi: 10.7326/M20-7844. PMID: 33900792. Additional Declarations No competing interests reported. Supplementary Files MethodsSupplementS1.pdf MethodsSupplementS2.pdf Cite Share Download PDF Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 28 Apr, 2025 Editor assigned by journal 28 Apr, 2025 Reviews received at journal 22 Apr, 2025 Reviewers agreed at journal 22 Apr, 2025 Reviewers agreed at journal 20 Apr, 2025 Reviewers invited by journal 18 Apr, 2025 Submission checks completed at journal 18 Apr, 2025 First submitted to journal 17 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Values presented here represent means and standard errors. The blue plot indicates pre-curriculum scores, and the orange plot indicates post-curriculum scores.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5760020/v1/e2dd7ae5aa048fec5b67ff68.png"},{"id":86179826,"identity":"e0e40b4b-ab59-4b79-bbf9-6ee47feb0844","added_by":"auto","created_at":"2025-07-07 16:19:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":484122,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5760020/v1/e9c69400-b632-476c-aee9-c2f8adb8e435.pdf"},{"id":81032148,"identity":"e7c2cd58-0493-466b-b199-7874db5266e2","added_by":"auto","created_at":"2025-04-21 11:29:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":43593,"visible":true,"origin":"","legend":"","description":"","filename":"MethodsSupplementS1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5760020/v1/b758ed3e6aa559395ab8f001.pdf"},{"id":81033266,"identity":"94d3420c-20ea-44b1-9a90-037895152cdc","added_by":"auto","created_at":"2025-04-21 11:45:03","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":130572,"visible":true,"origin":"","legend":"","description":"","filename":"MethodsSupplementS2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5760020/v1/1daaeca7ded8e348a542cd9f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Night Vision: A New Blueprint for Bedside Ultrasound Training in Medical Residency","fulltext":[{"header":"Background","content":"\u003cp\u003eAs of 2020, approximately 57% of medical schools reported having a formal ultrasound curriculum and 60% of internal medicine residency training programs have either a formal elective or required curriculum for diagnostic point-of-care ultrasound (POCUS).\u003csup\u003e1,2\u003c/sup\u003e The American College of Physicians formally acknowledged \u0026ldquo;the important role of point-of-care ultrasound (POCUS) in internal medicine.\u0026rdquo; The Alliance for Academic Internal Medicine \u0026ldquo;recognizes and supports the integration of POCUS across the longitudinal training environment of UME, GME, and CME.\u0026rdquo;\u003csup\u003e3\u003c/sup\u003e Beyond residency, POCUS has an important role among hospitalists, general internists, primary care, and within the subspecialties.\u003csup\u003e4,5\u003c/sup\u003e The integration of POCUS into clinical practice allows providers to spend more time at the bedside, conveying results in real time, and increases patients\u0026rsquo; satisfaction and understanding of the diagnostic process.\u003csup\u003e6\u0026ndash;9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThough POCUS is a beneficial component of graduate medical education (GME), there are common barriers to implementing a curriculum. On a recent national survey of internal medicine program directors, the difficulties include faculty expertise and support, resident scheduling, and cost of ultrasound machines.\u003csup\u003e2\u003c/sup\u003e In the 2022\u0026ndash;2023 academic year, a pilot longitudinal curriculum in diagnostic POCUS was implemented for residents in the internal medicine residency program at Virginia Commonwealth University (VCU) in Richmond, Virginia. This curriculum was integrated into the existing night medicine rotations to provide opportunities for direct observation and one-on-one training by a cadre of four teaching nocturnists trained in POCUS. The integration helped bypass barriers by limiting the number of faculty to train and harnessing clinical opportunities available within a pre-existing curriculum. Training in this environment can also be carried out with limited equipment, with the trained nocturnist utilizing a handheld ultrasound device available to the housestaff working at night.\u003c/p\u003e \u003cp\u003eNight rotations are a prime setting for learning opportunities, particularly when supervised by an on-site attending. Hanson et al describe nighttime clinical care as \u0026ldquo;typically devoid of administrative demands, which affords more opportunities for faculty to observe direct patient contact and provide guidance and specific feedback for advanced learners.\u0026rdquo;\u003csup\u003e10\u003c/sup\u003e Residents have noted that the advantages of experiential learning at night include \u0026ldquo;evaluating undifferentiated patients, having more time to think, fewer competing demands, and monitoring patients over time.\u0026rdquo; \u003csup\u003e11\u003c/sup\u003e \u0026ldquo;Twelve tips for teaching\u0026rdquo; recommends a return to the bedside, as bedside teaching and patient-centered teaching points are particularly memorable and engaging for learners.\u003csup\u003e12\u003c/sup\u003e Dedicated overnight supervision by attendings has been well received by residents and improves educational and clinical value.\u003csup\u003e12\u0026ndash;14\u003c/sup\u003e In contrast, a less robust nighttime education model can be detrimental to resident training.\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIncorporation of POCUS into a night medicine structure can not only bypass the common barriers but also enhance resident nighttime education by providing additional supervised learning opportunities at the bedside, with a focus on patient-centered learning. The creation of a POCUS curriculum within GME is not a novel idea, but there is no description of a POCUS curriculum integrated into night-based rotations in the literature. Based on these key points about the existing landscape for this type of training, and the advantages that the night medicine setting offers, we developed a single-center feasibility pilot study integrating POCUS into nighttime teaching.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eSetting and Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants of this pilot curriculum included 37 PGY-1 residents in the internal medicine residency program at VCU in Richmond, VA. \u0026nbsp;This came from a combination of 33 categorical internal medicine interns and 4 combined medicine-pediatrics interns. The primary learning environment was the inpatient setting of VCU Health hospital during night medicine rotations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe primary faculty were four full-time teaching nocturnists who supervise the residents on night medicine rotations. \u0026nbsp;Faculty included a hospitalist who created and directs the curriculum, and had completed the national Society of Hospital Medicine-Chest POCUS Certificate of Completion. Another faculty member received their training through an ACGME-accredited combined emergency medicine and internal medicine residency program, and is board certified in both fields. Two additional full-time nocturnists were pursuing ongoing training in point-of-care ultrasound at the time of the pilot year.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe curriculum director was granted 0.10 full-time equivalent hours during the pilot year. The protected time allowed the director to coordinate and provide core conference lectures, perform quality assurance on resident submitted images, conduct the pre- and post-curriculum assessments, and to provide additional hands-on scanning opportunities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProgram Description\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe purpose of the curriculum is to provide trainees with foundational skills to eventually become competent and confident POCUS\u0026nbsp;users by learning indications for use and skills for image acquisition and interpretation and having the opportunity to practice and integrate it into medical decision-making. The curriculum provides trainees with an understanding of ultrasound physics and probe and machine manipulation to facilitate optimal image acquisition.\u0026nbsp;Didactic components include brief indication and integration components with focus on POCUS physics and image acquisition. Bedside teaching and quality reviews facilitate honing image acquisition skills. Residents accumulate an image portfolio throughout residency. Images for consideration toward the portfolio are submitted to the curriculum director for quality assurance review, with feedback provided in a timely manner upon submission.\u003c/p\u003e\n\u003cp\u003eThe PGY-1 curriculum focused on pulmonary and abdominal systems. Additional systems were excluded for the pilot year to maximize feasibility. Educational sessions were during required core conference didactics. Sessions included an introduction to POCUS basics and physics, and lectures on pulmonary and abdominal scanning techniques. Residents completed online learning modules and also received training in utilization of Qpath. Residents underwent pre- and post-curriculum surveys, knowledge assessments, and skills assessments. All residents participated in night medicine during their PGY-1 year, during which they obtained hands-on experience integrating POCUS into assessment and management of patients, as well as practice opportunities. Additional hands-on scanning opportunities were also provided by the curriculum director during daytime inpatient ward settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSurveys, structured through Redcap, were developed for this study and assigned to the residents at the beginning and end of the year. The survey (see Methods Supplement S1) assesses prior training, confidence in using POCUS, likelihood of utilizing POCUS, and perceptions regarding the importance of POCUS. The survey tests knowledge with questions regarding ultrasound principles, physics, and case-based applications. Confidence and likelihood of utilizing POCUS were assessed on a 5-point Likert scale. \u0026nbsp;Knowledge was measured on a continuous scale from 0 to max attainable value of 13 based on the questions correctly answered. Residents also participated in an 8-minute observed skills assessment utilizing standardized patients at the beginning and end of the year. A standardized grading rubric (see Methods Supplement S2) was created and used in the assessment. This was also measured on a continuous scale from 0 to max attainable value of 34 based on the checklist of items performed correctly. The survey and skills assessment, with its corresponding grading rubric, were created without the use of a previously validated tool. To ensure content validity, the two POCUS-trained nocturnists created the instruments and they were reviewed by additional content area experts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results of these assessments were then used to compare pre- and post-intervention outcomes for the dependent variables of knowledge, skills, and attitudes. The intervention is defined as one year of training in the formal POCUS curriculum. Data was collected from July through October for pre-intervention assessments. Data was then collected again at the end of the academic year, in May and June. This study was conducted in an educational setting and involved normal educational practices. \u0026nbsp;It was approved as exempt by the Institutional Review Board of VCU School of Medicine and informed consent to participate was not required. Written consent was not obtained, though all participants were thoroughly informed of the curricular components and associated research during an orientation session.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFifty-nine percent of categorical internal medicine and combined medicine-pediatrics interns (\u003cem\u003en\u003c/em\u003e=22) completed both the pre- and post-curriculum skills tests, and one hundred percent (\u003cem\u003en\u003c/em\u003e=37) completed the knowledge assessments and were included in the analysis. The figure shows scores on the skills assessment comparing the score pre-curriculum (blue) to post-curriculum (orange). The table shows confidence scores for knowledge and comfort/likelihood of use. Notably, skills, knowledge and confidence showed a statistically significant increase from pre- to post-curriculum. Mean score on the skills assessment increased from 13.4 points to 23.6 points (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). Mean score on the knowledge assessment increased from 54% to 61% (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.003). \u0026nbsp;Interns performed a total of 88 imaging studies (64 supervised by curriculum director) and submitted 69 for quality assurance. Of those, there were 121 accepted portfolio images.\u003c/p\u003e\n\u003cp\u003ePaired samples t-test was used to compare pre- and post-test scores. Data analysis was performed using R version 4.3.0 (R Core Team, 2023). Effect sizes were calculated using the Hedges Correction of Cohen\u0026apos;s \u003cem\u003ed\u003c/em\u003e as implemented in the \u0026quot;rstatix\u0026quot; package in R (Kassambra, 2023).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003ePre- and Post-Curriculum Knowledge Assessment Scores (\u003cem\u003en\u003c/em\u003e=37). Values presented here represent means and standard errors.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"92%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-curriculum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-curriculum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eKnowledge Assessment \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eScale 0-13\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e7\u0026plusmn;.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e8\u0026plusmn;.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026lt; 0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eComfort\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eScale 1-5\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e2.5\u0026plusmn;.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e2.8\u0026plusmn;.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026lt; 0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eLikelihood of use\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eScale 1-5\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e4.6\u0026plusmn;.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e4.4\u0026plusmn;.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026lt; 0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAll residents in the program evaluated their general experience and perceptions of POCUS in the residency program annual survey in January 2023. The majority of respondents agreed that POCUS is important to their future career (61.4%, \u003cem\u003en\u003c/em\u003e=93) and more than half (55.9%) have participated in point of care ultrasound since beginning post-graduate training. Respondents reported night medicine (29.1%, \u003cem\u003en\u003c/em\u003e=55) and intensive care units (30.9%) most frequently as settings in which they participated in POCUS. The most commonly reported barriers were competing clinical work (32.7%, \u003cem\u003en\u003c/em\u003e=49), availability of trained attendings (28.6%), and lack of equipment (22.4%).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAfter the pilot year of the longitudinal diagnostic POCUS curriculum, residents had a statistically significant increase in comfort with POCUS and objective knowledge and skills assessment scores. There was a statistically significant decrease in the perceived likelihood of use by the end of the year. This may be attributed to a differentiation towards different career interests throughout intern year. Responses in the residency program survey regarding whether or not POCUS is important preparation for their future career indicated that residents with certain career interests found POCUS less applicable but acknowledged its importance in other career paths.\u003c/p\u003e \u003cp\u003eThe educational outcomes of this curriculum are comparable to those of daytime-focused curricula that have utilized pre- and post-curriculum surveys and tests. Ferre et al\u003csup\u003e16\u003c/sup\u003e at the Indiana University School of medicine piloted a GME POCUS curriculum that utilized online modules and a hands-on simulation session each month for four months. Results showed an increase in knowledge, comfort, and utilization of POCUS. Brant et al\u003csup\u003e17\u003c/sup\u003e describe implementation of a longitudinal curriculum at University of Colorado-affiliated hospitals, which involved three half-days of education over a three-month period. Results showed increased comfort and knowledge levels. Filler et all\u003csup\u003e18\u003c/sup\u003e analyzed the impact of a structured longitudinal curriculum for PGY-3 emergency medicine residents over 18 months that involved bi-monthly didactic sessions, a structured four-week rotation, and asynchronous online learning. Results showed an increase in trainee confidence, satisfaction, and perception of utilization of POCUS. They did not have a significant mean increase in quiz scores.\u003c/p\u003e \u003cp\u003eWhile the educational outcomes of this curriculum are comparable to those previously described, it also benefited from harnessing clinical opportunities within a pre-existing curriculum, limiting the number of faculty to train, and minimizing required ultrasound equipment. The incorporation of POCUS into an existing night medicine rotation bypassed these common barriers encountered when attempting to implement a POCUS curriculum. The utilization of dedicated nocturnists addresses the limitation of trained faculty available. Only four instructors (two fully trained faculty, two undergoing training), working mostly during their clinical time, were needed. A majority of the images were obtained under the supervision of the curriculum director, signifying the impact that a single trained nocturnist can have on the curriculum. A single handheld ultrasound, obtained at a fraction of the cost of cart-based machines, was made accessible to residents through the nocturnist. The need for resident scheduling and potential interference is also negated, as the curriculum takes advantage of a pre-existing rotation which interns complete multiple times throughout the year. Due to the higher number of patients covered by a single intern and the emphasis of clinical work on assessment and management of acute situations overnight, there are increased opportunities for supervised image acquisition and integration into clinical care. In addition to bypassing common barriers with a night medicine-based POCUS curriculum, the resident nighttime educational experience can be enhanced, with additional opportunities for supervised observation at the bedside and increased patient-centered instruction.\u003c/p\u003e \u003cp\u003eReported barriers were not specific to POCUS on night medicine and were similar to those within daytime curricula. The lack of available trained faculty should improve with completion of faculty training following the pilot year. Access to ultrasounds was improved by focusing on acquisition of a less costly handheld device, primarily used at night, though the number of available ultrasounds overall remained limited.\u003c/p\u003e \u003cp\u003eThere are some limitations to this pilot study. The number of participants is small due to the constraints of it being limited to one year within one residency program and a significant percentage being unable to complete the pre and post skills assessments due to scheduling conflicts. The pilot year focused on PGY-1 residents, to increase the feasibility, with plans to integrate subsequent PGY-1 classes into the curriculum. Logistical issues resulted in a delay in obtaining the handheld ultrasound until approximately halfway through the academic year, which limited opportunities for image acquisition. Another limitation is the variability of education time amongst the residents. Even though all residents spent a similar amount of time on nights, there likely was a large amount of variability in scanning opportunities due to demands of the shift and intrinsic motivation of the residents to attempt scans. In addition, opportunities to acquire images outside of the night medicine curriculum were not consistently taken advantage of by all participants. Lastly, proximity of night medicine rotations to knowledge and skills assessment sessions likely led to a small amount of recall bias.\u003c/p\u003e \u003cp\u003eIn an effort to address these barriers and enhance the educational experience, steps are being taken for subsequent years of the curriculum. Additional resources, such as textbooks and ultrasound machines, are being acquired for resident use. Faculty training in point-of-care ultrasound is ongoing. A dedicated didactic and hands-on practice session is being built into intern orientation. Additional systems, including cardiac, are being incorporated in subsequent years. Efforts are underway to offer additional practice opportunities, including standardized simulation sessions during resident conference. A POCUS elective is also being created to offer residents a multidisciplinary experience and additional training opportunities.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWith a majority of medical schools providing a formal POCUS curriculum\u003csup\u003e1\u003c/sup\u003e and the recognition of its importance in patient care in internal medicine\u003csup\u003e3,4,19\u003c/sup\u003e, it is imperative to continue the education and training during graduate medical education in internal medicine. This pilot curriculum study showed that a POCUS curriculum concentrated during night medicine rotations is feasible and can overcome common hurdles in implementing a residency POCUS curriculum, while also enhancing nighttime education and providing outcomes comparable to traditional daytime-based curricula.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eContributors:\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrior presentations:\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe research was conducted in a commonly accepted educational setting and involved normal educational practices. This study was approved as exempt by the Institutional Review Board of VCU School of Medicine, being classified as category 1 exempt research under 45 CFR 46.104(d), so informed consent to participate was not required. Written informed consent was not obtained, but all participants were thoroughly verbally informed about the curricular components and associated research during an orientation session. This study adhered to the Declaration of Helsinki ethical principles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Data is located in an institution-specific REDCap database.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplementary information linked to the online version:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eMethods Supplement S1\u003c/li\u003e\n \u003cli\u003eMethods Supplement S2\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRussell FM, Zakeri B, Herbert A, Ferre RM, Leiser A, Wallach PM. The State of Point-of-Care Ultrasound Training in Undergraduate Medical Education: Findings From a National Survey. Acad Med. 2021 Nov 16. doi: 10.1097/ACM.0000000000004512. Epub ahead of print. doi: \u0026nbsp;https://doi.org/10.1016/j.amjmed.2021.11.002.\u003c/li\u003e\n \u003cli\u003eLoPresti CM, Schnobrich D, Novak W, et al. Current Point of Care Ultrasound Use and Training Among Internal Medicine Residency Programs from the 2020 APDIM Program Director\u0026apos;s Survey. Am J Med. 2022 Mar;135(3):397-404. doi: 10.1016/j.amjmed.2021.11.002. Epub 2021 Dec 7. PMID: 34890562.\u003c/li\u003e\n \u003cli\u003eLoPresti, C. M., Jensen, T. P., Dversdal, R. K., \u0026amp; Astiz, D. J. Point-of-care Ultrasound for Internal Medicine Residency Training: A position statement from the Alliance of Academic Internal Medicine. \u003cem\u003eThe American Journal of Medicine\u003c/em\u003e, \u003cem\u003e132\u003c/em\u003e(11), 1356\u0026ndash;1360. doi: \u0026nbsp;10.1016/j.amjmed.2019.07.019\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSoni NJ, Schnobrich D, Mathews BK, et al. Point-of-Care Ultrasound for Hospitalists: A Position Statement of the Society of Hospital medicine. J Hosp Med. 2019 Jan 2;14:E1-E6. doi: 10.12788/jhm.3079.\u003c/li\u003e\n \u003cli\u003eBhagra A, Tierney DM, Sekiguchi H, Soni NJ. Point-of-Care Ultrasonography for Primary Care Physicians and General Internists. Mayo Clin Proc. 2016 Dec;91(12):1811-1827. doi: 10.1016/j.mayocp.2016.08.023.\u003c/li\u003e\n \u003cli\u003eDurston W, Carl ML, Guerra W. Patient satisfaction and diagnostic accuracy with ultrasound by emergency physicians. Am J Emerg Med. 1999 Nov;17(7):642-6. doi: 10.1016/s0735-6757(99)90150-x.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHoward ZD, Noble VE, Marill KA, Sajed D, Rodrigues M, Bertuzzi B, Liteplo AS. Bedside ultrasound maximizes patient satisfaction. J Emerg Med. 2014 Jan;46(1):46-53. doi: 10.1016/j.jemermed.2013.05.044.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMathews BK, Miller PE, Olson APJ. Point-of-Care Ultrasound Improves Shared Diagnostic Understanding Between Patients and Providers. South Med J. 2018 Jul;111(7):395-400. doi: 10.14423/SMJ.0000000000000833.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAndersen, C.A., Brodersen, J., Rudb\u0026aelig;k, T.R. et al. Patients\u0026rsquo; experiences of the use of point-of-care ultrasound in general practice \u0026ndash; a cross-sectional study. BMC Fam Pract 22, 116 (2021). doi: \u0026nbsp; 10.1186/s12875-021-01459-z.\u003c/li\u003e\n \u003cli\u003eHanson JT, Pierce RG, Dhaliwal G. The new education frontier: clinical teaching at night. Acad Med. 2014 Feb;89(2):215-8. doi: 10.1097/ACM.0000000000000096. PMID: 24362386.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTorwekar BL, Robinson M, Durham M, Cooper D, Wurster W, Bowen JL. What Residents Want: Perceptions of Learning During a Pediatrics Night Float Rotation. Hosp Pediatr. 2023 May 1;13(5):401-408. doi: 10.1542/hpeds.2022-006954. PMID: 37070381.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRichards JB, Wilcox SR, Roberts DH, Schwartzstein RM. Twelve tips for overnight teaching. Med Teach. 2014 Mar;36(3):196-200. doi: 10.3109/0142159X.2013.847911. Epub 2013 Oct 28. PMID: 24164552.\u003c/li\u003e\n \u003cli\u003eGreene JG. Neurohospitalists enhance resident perception of the educational and clinical value of a night float rotation. Neurohospitalist. 2013 Oct;3(4):179-84. doi: 10.1177/1941874413495879. PMID: 24198898; PMCID: PMC3810834.\u003c/li\u003e\n \u003cli\u003eAl-Khafaji J, Konjeti VR, Call S. Midnight Report: A Novel Faculty-Guided Night Curriculum to Enhance Resident Nighttime Education. Southern Medical Journal. 2020 May;113(5):201-204. DOI: 10.14423/smj.0000000000001090. PMID: 32358612.\u003c/li\u003e\n \u003cli\u003eBricker DA, Markert RJ. Night float teaching and learning: perceptions of residents and faculty. J Grad Med Educ. 2010 Jun;2(2):236-41. doi: 10.4300/JGME-D-10-00005.1. PMID: 21975627; PMCID: PMC2941384.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFerre RM, Russell FM, Peterson D, Zakeri B, Herbert A, Nti B, Goldman M, Wilcox JG, Wallach PM. Piloting a Graduate Medical Education Point-of-Care Ultrasound Curriculum. Cureus. 2022 Jul 23;14(7):e27173. doi: 10.7759/cureus.27173. PMID: 36017274.\u003c/li\u003e\n \u003cli\u003eBrant JA, Orsborn J, Good R, Greenwald E, Mickley M, Toney AG. Evaluating a longitudinal point-of-care-ultrasound (POCUS) curriculum for pediatric residents. BMC Med Educ. 2021 Jan 19;21(1):64. doi: 10.1186/s12909-021-02488-z. PMID: 33468138.\u003c/li\u003e\n \u003cli\u003eFiller L, Orosco D, Rigdon D, Mitchell C, Price J, Lotz S, Stowell JR. Evaluation of a novel curriculum on point-of-care ultrasound competency and confidence. Emerg Radiol. 2020 Feb;27(1):37-40. doi: 10.1007/s10140-019-01726-8. Epub 2019 Sep 4. PMID: 31485848.\u003c/li\u003e\n \u003cli\u003eQaseem A, Etxeandia-Ikobaltzeta I, Mustafa RA, et al. Appropriate Use of Point-of-Care Ultrasonography in Patients With Acute Dyspnea in Emergency Department or Inpatient Settings: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):985-993. doi: 10.7326/M20-7844. PMID: 33900792.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ultrasound, POCUS, medical education, curriculum, internal medicine","lastPublishedDoi":"10.21203/rs.3.rs-5760020/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5760020/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFaculty expertise and support, resident scheduling, and cost of ultrasound machines are common barriers encountered when attempting to implement a new point-of-care ultrasound (POCUS) curriculum. Integration of a POCUS curriculum into existing night medicine rotations helps bypass these barriers by minimizing the amount of trained faculty required and harnessing clinical opportunities within a pre-existing curriculum.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e37 PGY-1 residents participated in this pilot study within the inpatient setting of VCU Health hospital, primarily during their night medicine rotations. Faculty included four full-time nocturnists.\u003cstrong\u003e \u003c/strong\u003eResidents received didactics on pulmonary and abdominal imaging and completed online modules. Practice opportunities occurred primarily during night medicine rotations under the supervision of the nocturnists.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResidents underwent pre- and post-curriculum surveys and knowledge/skills assessments. Comfort, knowledge, and skills significantly increased pre- to post-curriculum. Mean skills assessment scores increased from 13.4 to 23.6 points out of 34 (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). Mean knowledge assessment scores increased from 54% to 61% (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIntegration of a POCUS curriculum into the existing night medicine rotation bypassed common barriers and resulted in statistically significant increases in resident comfort, knowledge, and skills.\u003c/p\u003e","manuscriptTitle":"Night Vision: A New Blueprint for Bedside Ultrasound Training in Medical Residency","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-21 11:28:58","doi":"10.21203/rs.3.rs-5760020/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-28T04:49:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-28T04:48:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-22T14:50:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"169609060087671265222815738594361860463","date":"2025-04-22T14:28:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"148783163678050623175203683286451197479","date":"2025-04-21T00:07:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-18T10:32:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-18T09:15:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-04-17T14:02:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"748a26c1-90b2-477f-b812-da55127b48e6","owner":[],"postedDate":"April 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:11:46+00:00","versionOfRecord":{"articleIdentity":"rs-5760020","link":"https://doi.org/10.1186/s12909-025-07531-x","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-07-01 15:58:09","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2025-04-21 11:28:58","video":"","vorDoi":"10.1186/s12909-025-07531-x","vorDoiUrl":"https://doi.org/10.1186/s12909-025-07531-x","workflowStages":[]},"version":"v1","identity":"rs-5760020","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5760020","identity":"rs-5760020","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}