Heart and Lung Point-of-Care Ultrasonography Tutoring in Internal Medicine: a Randomized Controlled Trial

Heart and Lung Point-of-Care Ultrasonography Tutoring in Internal Medicine: a Randomized Controlled Trial | 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 Heart and Lung Point-of-Care Ultrasonography Tutoring in Internal Medicine: a Randomized Controlled Trial Antonio Leidi, Juliette Krauer, Guillaume Soret, Thibault Parent, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4616323/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: In recent years, point-of-care ultrasonography (POCUS) has been integrated into internal medicine practice with most curricula composed of a single course. Despite competency acquisition during the course, a significant decline in proficiency occurs in the subsequent weeks due to a lack of regular practice and training. This study aims to evaluate the impact of a structured POCUS tutoring, on POCUS use and skills retention at 6 months. Methods: In this randomized controlled trial, internal medicine residents were enrolled after completing a practical course focused on heart and lung ultrasonography. Residents assigned to the intervention group were paired with a tutor, and time slots were scheduled for bedside direct supervision over the following 6 months. The primary outcome was the proportion of residents who successfully completed at least 25 POCUS examinations six months after inclusion. Secondary outcomes included self- and blinded-expert-assessed POCUS competency skills. Results: Between January and May 2022, 23 residents were included in the study. The intervention significantly increased the proportion of participants reaching the primary outcome (70% versus 0%; p <0.001) with a median of 27 (interquartile range, IQR, 6 to 44) supervised examinations performed versus 0 (IQR 0 to 0) in intervention and control arm respectively; p <0.001. After 6 months, proficiency was higher for most heart imaging but not for lung imaging, as assessed through self-assessment by participants or independently by blinded experts. Conclusions: Structured POCUS supervision significantly enhances the number of POCUS examinations and proficiency at 6-months, particularly in applications requiring greater visuospatial skills. POCUS ultrasound internal medicine tutoring skill retention proficiency Figures Figure 1 Figure 2 Figure 3 Introduction In recent years, point-of-care ultrasonography (POCUS) has emerged as a useful tool in clinical practice, enabling clinicians to address basic diagnostic questions, guide procedures, and make decisions regarding immediate therapies ( 1 , 2 ). The value of POCUS fundamentally relies on the skills of the operator as unthoughtful use may lead to unfounded reassurance, increased numbers of additional testing, incorrect diagnosis, and treatment ( 3 ). For this reason, minimal requirements for POCUS use in internal medicine have been established worldwide ( 4 , 5 ). In Switzerland, certification exists for 15 POCUS modules, three of which are particularly relevant in internal medicine: emergency ultrasonography (E-FAST, gallbladder, kidneys and bladder, aorta and venous compression ultrasound), focused echocardiography, and thoracic ultrasonography (US). The modules are comprised of theoretical and practical coursework, followed by practical training through a total of 200 POCUS examinations. Half of these must be supervised by a certified POCUS instructor. In some instances, combining two modules reduces the total amount of required examinations to 100 per module. Postgraduate curricula have been developed to familiarize young doctors with basic US investigations; most of them are exclusively composed of a theoretical and practical one-day course. While trainees significantly increase their competencies during the course ( 6 ), most of them experience a net loss of proficiency after 1–2 years because of lack of practical training ( 7 ). A decline in skills is observed within the first weeks following the course ( 8 ) and low engagement in practice is common as only 6% of participants perform at least 30 examinations six months after the course ( 9 ). Lack of training, absence of direct supervision, and insufficient time were the main perceived barriers to learning and using POCUS in previous surveys among North American and European internists ( 10 – 12 ). The aim of the present study was to investigate whether a structured longitudinal POCUS tutoring, including scheduled time slots for bedside direct supervision, could enhance POCUS use and skills retention among internal medicine residents 6 months after a theoretical and practical course. Methods This study was a single-center randomized open-label superiority trial. Recruitment of participants took place at the general internal medicine service of the Geneva University Hospitals. At our institution, internal medicine residency consists of three years of postgraduate medical practice including several 4-month clinical rotations in external services, such as emergency medicine, intensive care, medical specialties and/or rehabilitation medicine. Residents usually spent two years in secondary hospitals before being integrated in our residency. Since 2019 a POCUS training program has been offered to the residents and at the outset of the study consisted of a pre-course e-learning and a single one-day hands-on supervised practical course focused on heart and lung US. Following this training, and after having obtained written informed consent, residents with little or no experience in POCUS were randomized in two groups with a 1:1 ratio by an independent investigator with no stratification nor block permutation. Participants allocated to the intervention arm were assigned to a certified POCUS tutor and time slots were scheduled for direct bedside supervision. Timeslots were agreed upon between trainees and supervisors through an agenda crosscheck; there was no allocation of dedicated time specifically for the purpose of the study. Participants allocated to the control arm were encouraged to practice supervised POCUS on a voluntary basis (i.e. standard of practice at our institution). In addition, in both groups, web-based indirect asynchronous supervision was provided through an electronic logbook (LogIC®, Reallience, Switzerland): participants performed POCUS independently and then sent the recorded and interpreted images and/or videos to the supervisors for validation. The intervention period started immediately after the practical course and lasted for 6 months. The trial design is schematically represented in Supplementary Fig. 1. The local ethics committee confirmed that the present study was exempt from the requirement for formal approval. Primary Outcome The primary outcome was the proportion of residents who successfully completed at least 25 supervised POCUS examinations 6 months after inclusion. Results are presented for the total population and a pre-specified subgroup of clinical rotations. Because of their higher availability of POCUS machines, internal, emergency and intensive medicine rotations were considered as favourable rotations. All other clinical rotations (e.g. immunology, rehabilitation) were considered as unfavourable rotations for POCUS. Secondary outcomes The total number of POCUS examinations, self-assessed POCUS competencies, and expert-assessed proficiency were evaluated as secondary outcomes. Self-assessed competencies Immediately after the practical course and at the end of the 6-month intervention period, all participants were asked to answer a self-assessment survey (Supplementary Table 1). Global satisfaction, global competencies in POCUS use and specific self-assessed competencies in heart and lung US were evaluated with a 5-point Likert scale (1 = “Strongly disagree” to 3 = “Neutral” to 5 = “Strongly agree”). For the purpose of simplicity, answers were grouped in a dichotomic way, “Satisfied” or “Competent” (i.e. “Strongly agree” to “Agree”) or “Unsatisfied” or “Incompetent” (i.e. “Neutral” to “Strongly disagree”). Blinded expert assessment Three months after the 6-month intervention period, the performances of participants were evaluated by blinded external POCUS experts. Participants were asked to perform focused echocardiography (i.e. parasternal views, apical four- and five-chamber views, subcostal 4-chamber view with IVC) and lung US (i.e. parasternal sagittal view and costophrenic recess) on one healthy volunteer and one patient with left ventricular systolic dysfunction. Participants and experts were blinded to the clinical data, experts were masked to the participants’ allocation arm. POCUS competencies were evaluated by experts through an adapted version of previously published assessment tools( 13 , 14 ) Global POCUS competencies were evaluated using a 3-point Likert scale (1 = “Some criteria obtained” to 3 = “All criteria obtained”), answers were grouped in “Competent” (i.e. “Most or All criteria obtained”) and Incompetent (“Some criteria obtained”). General autonomy was evaluated by experts using a 5-point Likert scale (1 = “I had to perform the exam” to 5 = “My presence is unnecessary”), answers were grouped in “Autonomous” (i.e. 3 = “Verbal correction from time to time” to 5 = “My presence is unnecessary”) and “Not Autonomous” (i.e. 1 = “I had to perform the exam” to 2 = “I have to talk them through and reposition the probe”). Quality of imaging was rated on a 6-point Likert scale ranging from (0 = “Not obtained” to 3 = “Suboptimal quality but interpretation possible” to 5 = “Good quality, meaningful interpretation easy”), answers were grouped in “Poor quality” (zero to two) and “Good quality” (three to five). Moreover, experts rated in a dichotomic way (yes/no) whether the quality of images allowed a meaningful interpretation of left ventricular systolic function (LVF), right ventricular dilatation (RVD), hypervolemia and pericardial effusion. Participants' conclusions regarding left ventricular systolic function (i.e., normal, mild to moderate dysfunction, severe dysfunction) were documented and compared to echocardiography results from a reference cardiologist, conducted within a maximum of one year prior to the evaluation. The collected data were subsequently included into the study database with double checking by an independent data service provider (Data Conversion Service SA, Geneva, Switzerland). Sample size Based on previous reports and local experience, we expected that the proportion of success in the control group would not exceed 20% ( 9 ) A sample size of 20 residents was calculated to detect a 60% difference in the primary outcome (alpha of 0.05; 0.90 of power). The sample size was increased to 22 participants to anticipate 10% of loss to follow-up. Statistical considerations Baseline participants’ characteristics and characteristics of POCUS examinations are presented with descriptive statistics. Results of the primary outcome are presented in proportions, risk difference (RD), and number needed to supervise (NNS = 1/RD). Differences in the primary outcome are compared with the Fischer exact test for non-parametric distribution. Number of supervised POCUS examinations are compared using the Wilcoxon Mann-Whitney test. Between-group differences in self- and expert-assessed competencies are compared with the Chi-squared or Fischer exact test, as appropriate. Data are visually presented in the form of bar graphs. The proportion of participants drawing the right conclusion on LVF are compared between study arms with the Fischer exact test. A two-sided p-value of 0.05 is used to infer statistical significance. All statistical analyses were performed using a standard software package (Stata, version. 16.1; StataCorp). Results Between January and May 2022, 27 general internal medicine residents were assessed for eligibility; due to extensive prior experience with POCUS, 4 of them were excluded and 23 residents were included in the study; 11 were allocated to the intervention group (55% of women, mean age of 29.6 ± 1.0 years) and 12 to the control group (75% of women, mean age of 29.9 ± 1.6 years). Follow-up ended on the 26th of January 2023. Baseline characteristics are shown in Table 1 . Participants had variable clinical experience in internal medicine (two to five years after medical graduation) and small or no previous experience in POCUS. All participants intended to specialize in internal medicine. Characteristics of POCUS tutors are available in Supplementary Table 3. Table 1 Baseline characteristics of participants by study group Intervention (n = 11) Control (n = 12) Sex Female Male 6 (55%) 5 (45%) 9 (75%) 3 (25%) Age in years, mean (SD) 29.6 (1.0) 29.9 (1.6) Years since medical degree, n (%) 2 years 3 years 4 years 5 years 3 (27%) 1 (10%) 3 (27%) 4 (36%) 1 (8%) 3 (25%) 3 (25%) 5 (42%) Years since first POCUS use, n (%) 0 years 1 year 2 years 4 (36%) 5 (46%) 2 (18%) 5 (42%) 7 (58%) 0 (0%) Planned specialisation a Internal medicine Emergency medicine Infectiology Gastro-enterology 11 (100%) 1 (9%) 0 (0%) 1 (9%) 12 (100%) 0 (0%) 1 (8%) 0 (0%) Main clinical rotation during study period Favourable b Unfavourable 4 (36%) 7 (64%) 7 (58%) 5 (42%) SD: standard deviation; POCUS: point of care ultrasonography; a Two participants intended to obtain a double specialisation b Internal, Emergency and Intensive care medicine rounds were considered favourable clinical rotations. One participant in each group dropped out because of maternity leave. Twenty-one participants were included in the final analysis set for the primary outcome. All but one participant completed the post-program competencies self-assessment, whereas 9 participants in the intervention group and 11 participants in the control group completed the blinded expert assessment. Figure 1 shows the study flow chart. Primary outcome The proportion of participants obtaining at least 25 supervised examinations at 6 months was significantly higher in the intervention group. Seven participants in the intervention group (70%) versus zero (0%) in control group reached the primary outcome, corresponding to a risk difference of 70% (95% CI, 42 to 98%) and a number needed to supervise of 1.4 (95% CI, 1.0 to 2.4), p < 0.001. The difference remained significant in a worst-case scenario analysis where the drop out was classified as ‘failure’ in intervention group and ‘success’ in control group (risk difference 55% (95% CI, 23–88%, p = 0.01). Success seemed to be higher in a pre-specified subgroup of participants working mainly in POCUS-favourable clinical rotations, as reported in Table 2 . Table 2 Primary outcome by study group Intervention (N = 10) Control (N = 11) Risk Difference, % (95% CI) NNS p-Value a Primary outcome, n (%) 7 (70) 0 (0) 70 (42 to 98) 1.4 0.001* WCS, n (%) 7 (64) 1 ( 11 ) 55 (23 to 88) 1.8 0.01* Clinical rotation Favourable b , n (%) Unfavourable, n (%) 3/4 (75) 4/6 (66) 0/7 (0) 0/4 (0) 75 (33 to 100) 66 (29 to 100) 1.3 1.5 0.02* 0.06 a Fischer exact test; CI: confidence interval; NNS: number needed to supervise. WCS: worst-case scenario (drop out considered as failure in intervention arm and success in control arm); b internal, emergency and intensive care medicine rotations POCUS examinations During the study period a total of 334 supervised POCUS examinations were performed by participants in the intervention group versus 6 examinations in the control group. The median number was significantly higher in the intervention group (27, interquartile range, IQR: 6 to 44) than in the control group (0, IQR 0 to 0; p < 0.001). About half of the total examinations in the intervention group focused on the lungs and were justified by diagnostic purposes, as reported in Table 3 . Table 3 Median number and characteristics of POCUS examinations by study group Intervention (N = 334) Control (N = 6) p-Value Number of POCUS examinations, median (IQR) Total Clinical rotation Favourable a Unfavourable Investigation Lung Heart 27 (6 to 44) 39 (16 to 73) 28 (24 to 30) 13 (3 to 16) 14 (3 to 28) 0 (0 to 0) 0 (0 to 0) 0 (0 to 0) 0 (0 to 0) 0 (0 to 0) < 0.001* < 0.001* < 0.001* < 0.001* < 0.001* Reason for POCUS, n (%) Diagnostic purpose Training 154 (46%) 180 (54%) 6 (100%) 0 (0%) IQR: interquartile range; POCUS: point of care ultrasonography; a Internal, Emergency and Intensive medicine rounds were considered as favourable clinical rotations. Self-assessment questionary At follow-up, a higher proportion of participants in the intervention arm considered themselves globally competent for heart (60% versus 0%, p = 0.003) and lung US (60% versus 25%, p = 0.19), although the difference was statistically significant only for heart US. Between-group differences were particularly marked for heart applications (e.g. 90% versus 25% of participants considered themselves competent in LVF evaluation, p = 0.004). Notably, compared to the pre-tutoring assessment, the intervention group showed an increased proportion of participants who perceived themselves as competent across all items, whereas the control group showed stability or even a decrease in the perceived competencies. Detailed results are reported in Fig. 2 and in Supplementary Table 4. Expert testing When evaluated by blinded external POCUS experts, a higher proportion of participants in the intervention group were considered autonomous (83% versus 33%, p = 0.002), competent for the acquisition of images (83% versus 50%, p = 0.034) and for the optimisation of images (83% versus 44% p = 0.034). The proportion of participants obtaining high quality images was higher in the intervention group for all focused echocardiographic views, with a difference reaching statistical significance for apical five-chamber (65% versus 11%, p = 0.001), subcostal four-chamber (78 versus 44%, p = 0.04) and subcostal inferior vena cava views (78% versus 26%, p = 0.001). Furthermore, a higher proportion of participants obtained images allowing a meaningful interpretation of RVD (83% versus 39%, p = 0.006), and volemia (72% versus 22%, p = 0.003). There was no significant difference observed when testing for lung US. Complete results are reported in Fig. 3 and supplementary Table 5. Discussion In this randomized controlled trial following a hands-on heart and lung POCUS course, we tested a 6-month structured POCUS tutoring program versus usual practice in internal medicine residents. In the intervention arm, there was a significant increase in the proportion of residents obtaining at least 25 supervised examinations and in the absolute number of supervised POCUS examinations. This trial succeeds to prove the feasibility and superiority of a tutoring program for POCUS supervision in comparison to the standard of practice in our and many institutions. Whereas participants in control group were strongly encouraged to seek supervision, only a few of them did so. Indeed, low rate of practice is usually observed after practical POCUS courses, as reported in a previous study in which only 6% of participants performed 30 examinations six months after the course ( 9 ). Interestingly, the increased number of prompted examinations appears to enhance perceived and observed proficiency in heart but not lung US. In contrast to our observations concerning the skills in lung US, a previously published study including 28 internal medicine residents, randomized to a standard POCUS curriculum (i.e. a half-day theoretical and practical course followed by 5 one-hour lecture and hands-on sessions) versus 20 additional hours of bedside supervision focused on lung US has demonstrated a significant increase in proficiency in the intervention group after 6 months ( 15 ). Divergence in results may be related to the level of assessed competency complexity: participants were asked to demonstrate 23 different lung US competencies, whereas only three simple lung competencies were tested by our assessment tool and were reached by most participants in both groups. The benefit of a structured supervision may thus be particularly important for the acquisition of complex POCUS skills. Considering the maintenance of complex POCUS skills, our observation of the loss in the perceived global competencies regarding heart ultrasound in the control group (Supplementary table 4) was also observed in previous studies. In a prospective cohort study including 23 medical students trained in POCUS examination (didactic lectures and hands-on practice on healthy volunteers), the authors reported a decline in image acquisition skills for heart (i.e. parasternal short and long axis, IVC) but not lung US (i.e. lung sliding) ( 8 ) Another randomized controlled trial involving 21 critical care fellows failed to demonstrate a statistically significant rise in 6-month POCUS knowledge and skills following 8-hour of refresh training, incorporating 6 hours of scheduled bedside supervision (assessment tool ranging from 0 to 200 points, higher value indicating greater competence). It is worth noting that all participants were enrolled in a fellowship POCUS curriculum, which encompassed learning modules, in-class lectures, and hands-on training, resulting in an increase in competency scores for all participants. This increase was more pronounced in the intervention group but the between-group difference did not reach statistical significance, possibly due to insufficient statistical power (median increase of 18 (IQR, 3.8 to 38) versus 31 (IQR, 21 to 46) in control and intervention group respectively, p = 0.09).( 16 ) Critical care physicians were the pioneers in POCUS implementation and previous studies focused mostly on critical care fellows ( 16 , 17 ). Our study is notable for implementing POCUS tutoring during internal medicine residency, a setting with lower level of familiarity with POCUS. The availability of devices and the exposure to a favourable environment for ultrasound utilisation is important for supporting the acquisition of skills. In our subgroup analysis, we observed an incremental benefit when residents were in a clinical rotation with higher availability of US devices (i.e. emergency, critical care and internal medicine). Ultrasonography devices alone without supervision slots are however insufficient, as demonstrated by the extremely low rate of POCUS examinations in control group, despite a greater proportion of participants with favourable rotations. Two previous trials of internal medicine residents randomized to receive personal handheld US devices or not, observed no differences in skills acquisition( 18 , 19 ) Consequently, to facilitate skills acquisition in POCUS and to maintain proficiency, in addition to basic training, students should benefit from structured supervision in an environment conducive to the application of this knowledge and equipped with the necessary tools for this task. Our study has some limitations. First, the study was powered only for the primary outcome and secondary outcomes must be considered as exploratory, due to the small sample size. Second, supervision time slots were scheduled in addition to clinical activity; unavailability of tutors or trainees may have influenced the success rate, even if this is expected to lower the magnitude of the observed effect. Clinical POCUS rotations with dedicated time has been suggested as a valuable solution and must be explored in further trials( 20 ). Third, both groups experienced drop-outs due to maternity leave, reflecting the pragmatic design of the trial. However, results maintained statistical significance in our worst-case scenario sensitivity analysis. Our study has several strengths. First, while the use of POCUS in internal medicine is experiencing exponential growth, there are few studies addressing the challenge of achieving and maintaining proficiency. This study contributes to the subject with high quality data. Second, participants underwent a rigorous and comprehensive learning process, overseen by a team of supervisors, all certified by the Swiss Society of Ultrasound in Medicine ( https://sgum-ssum.ch/ , Supplementary Table 3). Third, in contrast to prior studies, external POCUS experts were involved in the study to maintain assessor blinding and mitigate the risk of bias, thereby reinforcing the robustness of our assumptions. In conclusion, our findings highlight the feasibility and need for a structured supervision following a hands-on course to improve both the use and proficiency of POCUS, especially for complex tasks and POCUS applications requiring advanced visuospatial skills, such as focused echocardiography. The low level of supervised examinations and competency in the control group raises serious doubts regarding the relevance of POCUS single courses without further supervision. Structured POCUS tutoring can significantly enhance training and practice, providing a solid foundation for a practical and safe use of POCUS. Dedicated supervision time slots for trainees during acute medicine clinical rounds may further increase the success rate. Declarations Funding This study was founded by the Sennart fondation. The founder was not involved in the research project. Ethical approval and informed consent Exemption from ethical approval was confirmed by the local ethics committee. Informed consent was obtained prior study inclusion. Competing interests The authors declare they have no conflict of interest. References Leidi A, Rouyer F, Marti C, Reny JL, Grosgurin O. Point of care ultrasonography from the emergency department to the internal medicine ward: current trends and perspectives. Intern Emerg Med. 2020. Ultrasound Guidelines: Emergency, Point-of-Care and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med. 2017;69(5):e27-e54. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364(8):749-57. Ma IWY, Arishenkoff S, Wiseman J, Desy J, Ailon J, Martin L, et al. Internal Medicine Point-of-Care Ultrasound Curriculum: Consensus Recommendations from the Canadian Internal Medicine Ultrasound (CIMUS) Group. J Gen Intern Med. 2017;32(9):1052-7. Torres-Macho J, Aro T, Bruckner I, Cogliati C, Gilja OH, Gurghean A, et al. Point-of-care ultrasound in internal medicine: A position paper by the ultrasound working group of the European federation of internal medicine. Eur J Intern Med. 2019. Turner EE, Fox JC, Rosen M, Allen A, Rosen S, Anderson C. Implementation and assessment of a curriculum for bedside ultrasound training. J Ultrasound Med. 2015;34(5):823-8. Kimura BJ, Sliman SM, Waalen J, Amundson SA, Shaw DJ. Retention of Ultrasound Skills and Training in "Point-of-Care" Cardiac Ultrasound. J Am Soc Echocardiogr. 2016;29(10):992-7. Rappaport CA, McConomy BC, Arnold NR, Vose AT, Schmidt GA, Nassar B. A Prospective Analysis of Motor and Cognitive Skill Retention in Novice Learners of Point of Care Ultrasound. Crit Care Med. 2019;47(12):e948-e52. Rajamani A, Miu M, Huang S, Elbourne-Binns H, Pracher F, Gunawan S, et al. Impact of Critical Care Point-of-Care Ultrasound Short-Courses on Trainee Competence. Crit Care Med. 2019;47(9):e782-e4. Wong J, Montague S, Wallace P, Negishi K, Liteplo A, Ringrose J, et al. Barriers to learning and using point-of-care ultrasound: a survey of practicing internists in six North American institutions. Ultrasound J. 2020;12(1):19. Olgers TJ, Azizi N, Bouma HR, Ter Maaten JC. Life after a point-of-care ultrasound course: setting up the right conditions! Ultrasound J. 2020;12(1):43. Finn EM, Zwemer EK, Stephens JR, Dancel R. The State of Internal Medicine Point-of-Care Ultrasound (POCUS) Fellowships in the United States and Canada. Am J Med. 2023;136(8):830-6. Bell C, Wagner N, Hall A, Newbigging J, Rang L, McKaigney C. The ultrasound competency assessment tool for four-view cardiac POCUS. Ultrasound J. 2021;13(1):42. Millington SJ, Arntfield RT, Guo RJ, Koenig S, Kory P, Noble V, et al. The Assessment of Competency in Thoracic Sonography (ACTS) scale: validation of a tool for point-of-care ultrasound. Crit Ultrasound J. 2017;9(1):25. Matthews L, Contino K, Nussbaum C, Hunter K, Schorr C, Puri N. Skill retention with ultrasound curricula. PLoS One. 2020;15(12):e0243086. Suzuki R, Kanai M, Oya K, Harada Y, Horie R, Sekiguchi H. A prospective randomized study to compare standard versus intensive training strategies on long-term improvement in critical care ultrasonography proficiency. BMC Med Educ. 2022;22(1):732. Beraud AS, Rizk NW, Pearl RG, Liang DH, Patterson AJ. Focused transthoracic echocardiography during critical care medicine training: curriculum implementation and evaluation of proficiency*. Crit Care Med. 2013;41(8):e179-81. Buesing J, Weng Y, Kugler J, Wang L, Blaha O, Hom J, et al. Handheld Ultrasound Device Usage and Image Acquisition Ability Among Internal Medicine Trainees: A Randomized Trial. J Grad Med Educ. 2021;13(1):76-82. Kumar A, Weng Y, Wang L, Bentley J, Almli M, Hom J, et al. Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial. J Hosp Med. 2020;15(2):e1-e6. Hayward M, Chan T, Healey A. Dedicated time for deliberate practice: one emergency medicine program's approach to point-of-care ultrasound (PoCUS) training. CJEM. 2015;17(5):558-61. Supplementary Files USMITutoringSupplementarymaterialsIEM.docx Cite Share Download PDF Status: Posted Version 1 posted 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4616323","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":321850669,"identity":"30d38a2d-07df-46b4-b326-0bab2bd8a393","order_by":0,"name":"Antonio Leidi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYLCCBwwSjG3sPWA2Dx9h9cwMDAkgLTxnGBgOALWwEamFgbFBIgeshYGgFv7Z/QcfJFRYyPZJvj34+GOOnQwbA/PDRzfwaJG4c5jZIOGMhHGbdF6ywcFtyUCHsRkb5+Cz5kYym0RiGxBJ55hJHNzGDNTCwyaNT4s8WMs/oBbJMyAt9YS1GIC1NIAs4gFpOUxYi+GNZGODhGNAv/DkGBuc3Xach42ZgF/kbiQ+fPChpk52fvsZwweV26rt+dmbHz7G631MwEya8lEwCkbBKBgFWAAAMwRDutydbpcAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-3934-0104","institution":"Hopitaux Universitaires de Geneve","correspondingAuthor":true,"prefix":"","firstName":"Antonio","middleName":"","lastName":"Leidi","suffix":""},{"id":321850670,"identity":"85a81539-6563-416f-b826-82ecdf51209e","order_by":1,"name":"Juliette Krauer","email":"","orcid":"","institution":"Geneva University Hospitals: Hopitaux Universitaires Geneve","correspondingAuthor":false,"prefix":"","firstName":"Juliette","middleName":"","lastName":"Krauer","suffix":""},{"id":321850671,"identity":"c0109f84-f5cc-4837-b6ae-986cbae43d51","order_by":2,"name":"Guillaume Soret","email":"","orcid":"","institution":"Geneva University Hospitals: Hopitaux Universitaires Geneve","correspondingAuthor":false,"prefix":"","firstName":"Guillaume","middleName":"","lastName":"Soret","suffix":""},{"id":321850672,"identity":"73c90624-2067-4ca6-bdb0-aea2322bd431","order_by":3,"name":"Thibault Parent","email":"","orcid":"","institution":"Geneva University Hospitals: Hopitaux Universitaires Geneve","correspondingAuthor":false,"prefix":"","firstName":"Thibault","middleName":"","lastName":"Parent","suffix":""},{"id":321850673,"identity":"cf55ca06-75b1-4e38-800c-bbcdd828e5f9","order_by":4,"name":"Christophe Marti","email":"","orcid":"","institution":"Geneva University Hospitals: Hopitaux Universitaires Geneve","correspondingAuthor":false,"prefix":"","firstName":"Christophe","middleName":"","lastName":"Marti","suffix":""},{"id":321850674,"identity":"e61b6c18-c65b-4c9f-95ab-4fa0ffb47960","order_by":5,"name":"Philippe Meyer","email":"","orcid":"","institution":"Geneva University Hospitals: Hopitaux Universitaires Geneve","correspondingAuthor":false,"prefix":"","firstName":"Philippe","middleName":"","lastName":"Meyer","suffix":""},{"id":321850675,"identity":"d84a0cb2-951a-4331-b1c1-e31ca000b3e2","order_by":6,"name":"André Juillerat","email":"","orcid":"","institution":"Geneva University Hospitals: Hopitaux Universitaires Geneve","correspondingAuthor":false,"prefix":"","firstName":"André","middleName":"","lastName":"Juillerat","suffix":""},{"id":321850676,"identity":"db99c7f8-9639-4647-9135-bc6503420135","order_by":7,"name":"Stijn Bex","email":"","orcid":"","institution":"Geneva University Hospitals: Hopitaux Universitaires Geneve","correspondingAuthor":false,"prefix":"","firstName":"Stijn","middleName":"","lastName":"Bex","suffix":""},{"id":321850677,"identity":"1e3b9483-6be2-4e21-b309-f08bc256ef9b","order_by":8,"name":"Noémie Suh","email":"","orcid":"","institution":"Geneva University Hospitals: Hopitaux Universitaires Geneve","correspondingAuthor":false,"prefix":"","firstName":"Noémie","middleName":"","lastName":"Suh","suffix":""},{"id":321850678,"identity":"40a804da-ae33-40e4-ab74-cb520ebaa758","order_by":9,"name":"Frédéric Rouyer","email":"","orcid":"","institution":"Geneva University Hospitals: Hopitaux Universitaires Geneve","correspondingAuthor":false,"prefix":"","firstName":"Frédéric","middleName":"","lastName":"Rouyer","suffix":""},{"id":321850679,"identity":"93ac7ab7-c5a3-4cd3-857b-4cce277b0ba2","order_by":10,"name":"Nils Siegenthaler","email":"","orcid":"","institution":"La Tour Hospital: Hopital de la Tour","correspondingAuthor":false,"prefix":"","firstName":"Nils","middleName":"","lastName":"Siegenthaler","suffix":""},{"id":321850680,"identity":"1cac3fb4-489c-4855-b594-3d2979fdba6e","order_by":11,"name":"Olivier Grosgurin","email":"","orcid":"","institution":"Geneva University Hospitals: Hopitaux Universitaires Geneve","correspondingAuthor":false,"prefix":"","firstName":"Olivier","middleName":"","lastName":"Grosgurin","suffix":""}],"badges":[],"createdAt":"2024-06-21 09:14:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4616323/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4616323/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":61177706,"identity":"dbb191a6-8d1e-4f7b-8da5-4ff92a40152d","added_by":"auto","created_at":"2024-07-26 15:55:31","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35780,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStudy Flow chart\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4616323/v1/dbe96c8d21a1b35936ebfba3.jpg"},{"id":61177707,"identity":"1c073fd1-7092-404d-a904-ef6d21f7c268","added_by":"auto","created_at":"2024-07-26 15:55:32","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":45653,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSelf-assessed competence in POCUS by study group\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4616323/v1/5b66d75840435aaeaff2c97d.jpg"},{"id":61177711,"identity":"291a8aef-7fb3-4936-b295-ebc27151b571","added_by":"auto","created_at":"2024-07-26 15:55:32","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":41025,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eExpert-assessed competence in POCUS by study group\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4616323/v1/a7601ac48ee659f3acf31d36.jpg"},{"id":61311004,"identity":"82cf117c-aacb-4c6e-a367-a62d9be5d190","added_by":"auto","created_at":"2024-07-29 11:02:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":633256,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4616323/v1/5e3dc7c8-cd99-470e-8692-19f9fd3b855a.pdf"},{"id":61177709,"identity":"ee995c65-c660-4c95-93b8-47028235c5c2","added_by":"auto","created_at":"2024-07-26 15:55:32","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":103197,"visible":true,"origin":"","legend":"","description":"","filename":"USMITutoringSupplementarymaterialsIEM.docx","url":"https://assets-eu.researchsquare.com/files/rs-4616323/v1/744ae215b841af11c0a31930.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003e\u003cstrong\u003eHeart and Lung Point-of-Care Ultrasonography Tutoring in Internal Medicine: a Randomized Controlled Trial\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn recent years, point-of-care ultrasonography (POCUS) has emerged as a useful tool in clinical practice, enabling clinicians to address basic diagnostic questions, guide procedures, and make decisions regarding immediate therapies (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The value of POCUS fundamentally relies on the skills of the operator as unthoughtful use may lead to unfounded reassurance, increased numbers of additional testing, incorrect diagnosis, and treatment (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). For this reason, minimal requirements for POCUS use in internal medicine have been established worldwide (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In Switzerland, certification exists for 15 POCUS modules, three of which are particularly relevant in internal medicine: emergency ultrasonography (E-FAST, gallbladder, kidneys and bladder, aorta and venous compression ultrasound), focused echocardiography, and thoracic ultrasonography (US). The modules are comprised of theoretical and practical coursework, followed by practical training through a total of 200 POCUS examinations. Half of these must be supervised by a certified POCUS instructor. In some instances, combining two modules reduces the total amount of required examinations to 100 per module.\u003c/p\u003e \u003cp\u003ePostgraduate curricula have been developed to familiarize young doctors with basic US investigations; most of them are exclusively composed of a theoretical and practical one-day course. While trainees significantly increase their competencies during the course (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), most of them experience a net loss of proficiency after 1\u0026ndash;2 years because of lack of practical training (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). A decline in skills is observed within the first weeks following the course (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and low engagement in practice is common as only 6% of participants perform at least 30 examinations six months after the course (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Lack of training, absence of direct supervision, and insufficient time were the main perceived barriers to learning and using POCUS in previous surveys among North American and European internists (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe aim of the present study was to investigate whether a structured longitudinal POCUS tutoring, including scheduled time slots for bedside direct supervision, could enhance POCUS use and skills retention among internal medicine residents 6 months after a theoretical and practical course.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study was a single-center randomized open-label superiority trial. Recruitment of participants took place at the general internal medicine service of the Geneva University Hospitals. At our institution, internal medicine residency consists of three years of postgraduate medical practice including several 4-month clinical rotations in external services, such as emergency medicine, intensive care, medical specialties and/or rehabilitation medicine. Residents usually spent two years in secondary hospitals before being integrated in our residency. Since 2019 a POCUS training program has been offered to the residents and at the outset of the study consisted of a pre-course e-learning and a single one-day hands-on supervised practical course focused on heart and lung US. Following this training, and after having obtained written informed consent, residents with little or no experience in POCUS were randomized in two groups with a 1:1 ratio by an independent investigator with no stratification nor block permutation. Participants allocated to the intervention arm were assigned to a certified POCUS tutor and time slots were scheduled for direct bedside supervision. Timeslots were agreed upon between trainees and supervisors through an agenda crosscheck; there was no allocation of dedicated time specifically for the purpose of the study. Participants allocated to the control arm were encouraged to practice supervised POCUS on a voluntary basis (i.e. standard of practice at our institution). In addition, in both groups, web-based indirect asynchronous supervision was provided through an electronic logbook (LogIC\u0026reg;, Reallience, Switzerland): participants performed POCUS independently and then sent the recorded and interpreted images and/or videos to the supervisors for validation. The intervention period started immediately after the practical course and lasted for 6 months. The trial design is schematically represented in Supplementary Fig.\u0026nbsp;1. The local ethics committee confirmed that the present study was exempt from the requirement for formal approval.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePrimary Outcome\u003c/h2\u003e \u003cp\u003eThe primary outcome was the proportion of residents who successfully completed at least 25 supervised POCUS examinations 6 months after inclusion. Results are presented for the total population and a pre-specified subgroup of clinical rotations. Because of their higher availability of POCUS machines, internal, emergency and intensive medicine rotations were considered as favourable rotations. All other clinical rotations (e.g. immunology, rehabilitation) were considered as unfavourable rotations for POCUS.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSecondary outcomes\u003c/h2\u003e \u003cp\u003eThe total number of POCUS examinations, self-assessed POCUS competencies, and expert-assessed proficiency were evaluated as secondary outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSelf-assessed competencies\u003c/h2\u003e \u003cp\u003eImmediately after the practical course and at the end of the 6-month intervention period, all participants were asked to answer a self-assessment survey (Supplementary Table\u0026nbsp;1). Global satisfaction, global competencies in POCUS use and specific self-assessed competencies in heart and lung US were evaluated with a 5-point Likert scale (1 = \u0026ldquo;Strongly disagree\u0026rdquo; to 3 = \u0026ldquo;Neutral\u0026rdquo; to 5 = \u0026ldquo;Strongly agree\u0026rdquo;). For the purpose of simplicity, answers were grouped in a dichotomic way, \u0026ldquo;Satisfied\u0026rdquo; or \u0026ldquo;Competent\u0026rdquo; (i.e. \u0026ldquo;Strongly agree\u0026rdquo; to \u0026ldquo;Agree\u0026rdquo;) or \u0026ldquo;Unsatisfied\u0026rdquo; or \u0026ldquo;Incompetent\u0026rdquo; (i.e. \u0026ldquo;Neutral\u0026rdquo; to \u0026ldquo;Strongly disagree\u0026rdquo;).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eBlinded expert assessment\u003c/h2\u003e \u003cp\u003eThree months after the 6-month intervention period, the performances of participants were evaluated by blinded external POCUS experts. Participants were asked to perform focused echocardiography (i.e. parasternal views, apical four- and five-chamber views, subcostal 4-chamber view with IVC) and lung US (i.e. parasternal sagittal view and costophrenic recess) on one healthy volunteer and one patient with left ventricular systolic dysfunction. Participants and experts were blinded to the clinical data, experts were masked to the participants\u0026rsquo; allocation arm. POCUS competencies were evaluated by experts through an adapted version of previously published assessment tools(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) Global POCUS competencies were evaluated using a 3-point Likert scale (1 = \u0026ldquo;Some criteria obtained\u0026rdquo; to 3 = \u0026ldquo;All criteria obtained\u0026rdquo;), answers were grouped in \u0026ldquo;Competent\u0026rdquo; (i.e. \u0026ldquo;Most or All criteria obtained\u0026rdquo;) and Incompetent (\u0026ldquo;Some criteria obtained\u0026rdquo;). General autonomy was evaluated by experts using a 5-point Likert scale (1 = \u0026ldquo;I had to perform the exam\u0026rdquo; to 5 = \u0026ldquo;My presence is unnecessary\u0026rdquo;), answers were grouped in \u0026ldquo;Autonomous\u0026rdquo; (i.e. 3 = \u0026ldquo;Verbal correction from time to time\u0026rdquo; to 5 = \u0026ldquo;My presence is unnecessary\u0026rdquo;) and \u0026ldquo;Not Autonomous\u0026rdquo; (i.e. 1 = \u0026ldquo;I had to perform the exam\u0026rdquo; to 2 = \u0026ldquo;I have to talk them through and reposition the probe\u0026rdquo;). Quality of imaging was rated on a 6-point Likert scale ranging from (0 = \u0026ldquo;Not obtained\u0026rdquo; to 3 = \u0026ldquo;Suboptimal quality but interpretation possible\u0026rdquo; to 5 = \u0026ldquo;Good quality, meaningful interpretation easy\u0026rdquo;), answers were grouped in \u0026ldquo;Poor quality\u0026rdquo; (zero to two) and \u0026ldquo;Good quality\u0026rdquo; (three to five). Moreover, experts rated in a dichotomic way (yes/no) whether the quality of images allowed a meaningful interpretation of left ventricular systolic function (LVF), right ventricular dilatation (RVD), hypervolemia and pericardial effusion. Participants' conclusions regarding left ventricular systolic function (i.e., normal, mild to moderate dysfunction, severe dysfunction) were documented and compared to echocardiography results from a reference cardiologist, conducted within a maximum of one year prior to the evaluation.\u003c/p\u003e \u003cp\u003eThe collected data were subsequently included into the study database with double checking by an independent data service provider (Data Conversion Service SA, Geneva, Switzerland).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSample size\u003c/h2\u003e \u003cp\u003eBased on previous reports and local experience, we expected that the proportion of success in the control group would not exceed 20% (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) A sample size of 20 residents was calculated to detect a 60% difference in the primary outcome (alpha of 0.05; 0.90 of power). The sample size was increased to 22 participants to anticipate 10% of loss to follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical considerations\u003c/h2\u003e \u003cp\u003eBaseline participants\u0026rsquo; characteristics and characteristics of POCUS examinations are presented with descriptive statistics. Results of the primary outcome are presented in proportions, risk difference (RD), and number needed to supervise (NNS\u0026thinsp;=\u0026thinsp;1/RD). Differences in the primary outcome are compared with the Fischer exact test for non-parametric distribution. Number of supervised POCUS examinations are compared using the Wilcoxon Mann-Whitney test. Between-group differences in self- and expert-assessed competencies are compared with the Chi-squared or Fischer exact test, as appropriate. Data are visually presented in the form of bar graphs. The proportion of participants drawing the right conclusion on LVF are compared between study arms with the Fischer exact test. A two-sided p-value of 0.05 is used to infer statistical significance. All statistical analyses were performed using a standard software package (Stata, version. 16.1; StataCorp).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween January and May 2022, 27 general internal medicine residents were assessed for eligibility; due to extensive prior experience with POCUS, 4 of them were excluded and 23 residents were included in the study; 11 were allocated to the intervention group (55% of women, mean age of 29.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 years) and 12 to the control group (75% of women, mean age of 29.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 years). Follow-up ended on the 26th of January 2023. Baseline characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Participants had variable clinical experience in internal medicine (two to five years after medical graduation) and small or no previous experience in POCUS. All participants intended to specialize in internal medicine. Characteristics of POCUS tutors are available in Supplementary Table\u0026nbsp;3.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of participants by study group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (55%)\u003c/p\u003e \u003cp\u003e5 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (75%)\u003c/p\u003e \u003cp\u003e3 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29.6 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.9 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears since medical degree, n (%)\u003c/p\u003e \u003cp\u003e2 years\u003c/p\u003e \u003cp\u003e3 years\u003c/p\u003e \u003cp\u003e4 years\u003c/p\u003e \u003cp\u003e5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (27%)\u003c/p\u003e \u003cp\u003e1 (10%)\u003c/p\u003e \u003cp\u003e3 (27%)\u003c/p\u003e \u003cp\u003e4 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8%)\u003c/p\u003e \u003cp\u003e3 (25%)\u003c/p\u003e \u003cp\u003e3 (25%)\u003c/p\u003e \u003cp\u003e5 (42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears since first POCUS use, n (%)\u003c/p\u003e \u003cp\u003e0 years\u003c/p\u003e \u003cp\u003e1 year\u003c/p\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (36%)\u003c/p\u003e \u003cp\u003e5 (46%)\u003c/p\u003e \u003cp\u003e2 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (42%)\u003c/p\u003e \u003cp\u003e7 (58%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlanned specialisation\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eInternal medicine\u003c/p\u003e \u003cp\u003eEmergency medicine\u003c/p\u003e \u003cp\u003eInfectiology\u003c/p\u003e \u003cp\u003eGastro-enterology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (100%)\u003c/p\u003e \u003cp\u003e1 (9%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e1 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (100%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003cp\u003e1 (8%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain clinical rotation during study period\u003c/p\u003e \u003cp\u003eFavourable\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eUnfavourable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (36%)\u003c/p\u003e \u003cp\u003e7 (64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (58%)\u003c/p\u003e \u003cp\u003e5 (42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSD: standard deviation; POCUS: point of care ultrasonography; \u003csup\u003ea\u003c/sup\u003eTwo participants intended to obtain a double specialisation \u003csup\u003eb\u003c/sup\u003eInternal, Emergency and Intensive care medicine rounds were considered favourable clinical rotations.\u003c/p\u003e \u003cp\u003eOne participant in each group dropped out because of maternity leave. Twenty-one participants were included in the final analysis set for the primary outcome. All but one participant completed the post-program competencies self-assessment, whereas 9 participants in the intervention group and 11 participants in the control group completed the blinded expert assessment. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the study flow chart.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePrimary outcome\u003c/h2\u003e \u003cp\u003eThe proportion of participants obtaining at least 25 supervised examinations at 6 months was significantly higher in the intervention group. Seven participants in the intervention group (70%) versus zero (0%) in control group reached the primary outcome, corresponding to a risk difference of 70% (95% CI, 42 to 98%) and a number needed to supervise of 1.4 (95% CI, 1.0 to 2.4), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001. The difference remained significant in a worst-case scenario analysis where the drop out was classified as \u0026lsquo;failure\u0026rsquo; in intervention group and \u0026lsquo;success\u0026rsquo; in control group (risk difference 55% (95% CI, 23\u0026ndash;88%, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.01). Success seemed to be higher in a pre-specified subgroup of participants working mainly in POCUS-favourable clinical rotations, as reported in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrimary outcome by study group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRisk Difference, % (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNNS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-Value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrimary outcome, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70 (42 to 98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWCS, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (23 to 88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical rotation\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFavourable\u003csup\u003eb\u003c/sup\u003e, n (%)\u003c/p\u003e \u003cp\u003eUnfavourable, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/4 (75)\u003c/p\u003e \u003cp\u003e4/6 (66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/7 (0)\u003c/p\u003e \u003cp\u003e0/4 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75 (33 to 100)\u003c/p\u003e \u003cp\u003e66 (29 to 100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.02*\u003c/p\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003eFischer exact test; CI: confidence interval; NNS: number needed to supervise. WCS: worst-case scenario (drop out considered as failure in intervention arm and success in control arm); \u003csup\u003eb\u003c/sup\u003einternal, emergency and intensive care medicine rotations\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePOCUS examinations\u003c/h2\u003e \u003cp\u003eDuring the study period a total of 334 supervised POCUS examinations were performed by participants in the intervention group versus 6 examinations in the control group. The median number was significantly higher in the intervention group (27, interquartile range, IQR: 6 to 44) than in the control group (0, IQR 0 to 0; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). About half of the total examinations in the intervention group focused on the lungs and were justified by diagnostic purposes, as reported in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMedian number and characteristics of POCUS examinations by study group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention (N\u0026thinsp;=\u0026thinsp;334)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl (N\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of POCUS examinations, median (IQR)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eClinical rotation\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFavourable\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eUnfavourable\u003c/p\u003e \u003cp\u003e\u003cb\u003eInvestigation\u003c/b\u003e\u003c/p\u003e \u003cp\u003eLung\u003c/p\u003e \u003cp\u003eHeart\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (6 to 44)\u003c/p\u003e \u003cp\u003e39 (16 to 73)\u003c/p\u003e \u003cp\u003e28 (24 to 30)\u003c/p\u003e \u003cp\u003e13 (3 to 16)\u003c/p\u003e \u003cp\u003e14 (3 to 28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0 to 0)\u003c/p\u003e \u003cp\u003e0 (0 to 0)\u003c/p\u003e \u003cp\u003e0 (0 to 0)\u003c/p\u003e \u003cp\u003e0 (0 to 0)\u003c/p\u003e \u003cp\u003e0 (0 to 0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReason for POCUS, n (%)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eDiagnostic purpose\u003c/p\u003e \u003cp\u003eTraining\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e154 (46%)\u003c/p\u003e \u003cp\u003e180 (54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (100%)\u003c/p\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIQR: interquartile range; POCUS: point of care ultrasonography; \u003csup\u003ea\u003c/sup\u003eInternal, Emergency and Intensive medicine rounds were considered as favourable clinical rotations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSelf-assessment questionary\u003c/h2\u003e \u003cp\u003eAt follow-up, a higher proportion of participants in the intervention arm considered themselves globally competent for heart (60% versus 0%, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.003) and lung US (60% versus 25%, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.19), although the difference was statistically significant only for heart US. Between-group differences were particularly marked for heart applications (e.g. 90% versus 25% of participants considered themselves competent in LVF evaluation, p\u0026thinsp;=\u0026thinsp;0.004). Notably, compared to the pre-tutoring assessment, the intervention group showed an increased proportion of participants who perceived themselves as competent across all items, whereas the control group showed stability or even a decrease in the perceived competencies. Detailed results are reported in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and in Supplementary Table\u0026nbsp;4.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eExpert testing\u003c/h2\u003e \u003cp\u003eWhen evaluated by blinded external POCUS experts, a higher proportion of participants in the intervention group were considered autonomous (83% versus 33%, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.002), competent for the acquisition of images (83% versus 50%, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.034) and for the optimisation of images (83% versus 44% \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.034). The proportion of participants obtaining high quality images was higher in the intervention group for all focused echocardiographic views, with a difference reaching statistical significance for apical five-chamber (65% versus 11%, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.001), subcostal four-chamber (78 versus 44%, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.04) and subcostal inferior vena cava views (78% versus 26%, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.001). Furthermore, a higher proportion of participants obtained images allowing a meaningful interpretation of RVD (83% versus 39%, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.006), and volemia (72% versus 22%, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.003). There was no significant difference observed when testing for lung US. Complete results are reported in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and supplementary Table\u0026nbsp;5.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this randomized controlled trial following a hands-on heart and lung POCUS course, we tested a 6-month structured POCUS tutoring program versus usual practice in internal medicine residents. In the intervention arm, there was a significant increase in the proportion of residents obtaining at least 25 supervised examinations and in the absolute number of supervised POCUS examinations. This trial succeeds to prove the feasibility and superiority of a tutoring program for POCUS supervision in comparison to the standard of practice in our and many institutions. Whereas participants in control group were strongly encouraged to seek supervision, only a few of them did so. Indeed, low rate of practice is usually observed after practical POCUS courses, as reported in a previous study in which only 6% of participants performed 30 examinations six months after the course (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInterestingly, the increased number of prompted examinations appears to enhance perceived and observed proficiency in heart but not lung US. In contrast to our observations concerning the skills in lung US, a previously published study including 28 internal medicine residents, randomized to a standard POCUS curriculum (i.e. a half-day theoretical and practical course followed by 5 one-hour lecture and hands-on sessions) versus 20 additional hours of bedside supervision focused on lung US has demonstrated a significant increase in proficiency in the intervention group after 6 months (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Divergence in results may be related to the level of assessed competency complexity: participants were asked to demonstrate 23 different lung US competencies, whereas only three simple lung competencies were tested by our assessment tool and were reached by most participants in both groups. The benefit of a structured supervision may thus be particularly important for the acquisition of complex POCUS skills. Considering the maintenance of complex POCUS skills, our observation of the loss in the perceived global competencies regarding heart ultrasound in the control group (Supplementary table 4) was also observed in previous studies. In a prospective cohort study including 23 medical students trained in POCUS examination (didactic lectures and hands-on practice on healthy volunteers), the authors reported a decline in image acquisition skills for heart (i.e. parasternal short and long axis, IVC) but not lung US (i.e. lung sliding) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Another randomized controlled trial involving 21 critical care fellows failed to demonstrate a statistically significant rise in 6-month POCUS knowledge and skills following 8-hour of refresh training, incorporating 6 hours of scheduled bedside supervision (assessment tool ranging from 0 to 200 points, higher value indicating greater competence). It is worth noting that all participants were enrolled in a fellowship POCUS curriculum, which encompassed learning modules, in-class lectures, and hands-on training, resulting in an increase in competency scores for all participants. This increase was more pronounced in the intervention group but the between-group difference did not reach statistical significance, possibly due to insufficient statistical power (median increase of 18 (IQR, 3.8 to 38) versus 31 (IQR, 21 to 46) in control and intervention group respectively, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.09).(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCritical care physicians were the pioneers in POCUS implementation and previous studies focused mostly on critical care fellows (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Our study is notable for implementing POCUS tutoring during internal medicine residency, a setting with lower level of familiarity with POCUS. The availability of devices and the exposure to a favourable environment for ultrasound utilisation is important for supporting the acquisition of skills. In our subgroup analysis, we observed an incremental benefit when residents were in a clinical rotation with higher availability of US devices (i.e. emergency, critical care and internal medicine). Ultrasonography devices alone without supervision slots are however insufficient, as demonstrated by the extremely low rate of POCUS examinations in control group, despite a greater proportion of participants with favourable rotations. Two previous trials of internal medicine residents randomized to receive personal handheld US devices or not, observed no differences in skills acquisition(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Consequently, to facilitate skills acquisition in POCUS and to maintain proficiency, in addition to basic training, students should benefit from structured supervision in an environment conducive to the application of this knowledge and equipped with the necessary tools for this task.\u003c/p\u003e \u003cp\u003eOur study has some limitations. First, the study was powered only for the primary outcome and secondary outcomes must be considered as exploratory, due to the small sample size. Second, supervision time slots were scheduled in addition to clinical activity; unavailability of tutors or trainees may have influenced the success rate, even if this is expected to lower the magnitude of the observed effect. Clinical POCUS rotations with dedicated time has been suggested as a valuable solution and must be explored in further trials(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Third, both groups experienced drop-outs due to maternity leave, reflecting the pragmatic design of the trial. However, results maintained statistical significance in our worst-case scenario sensitivity analysis.\u003c/p\u003e \u003cp\u003eOur study has several strengths. First, while the use of POCUS in internal medicine is experiencing exponential growth, there are few studies addressing the challenge of achieving and maintaining proficiency. This study contributes to the subject with high quality data. Second, participants underwent a rigorous and comprehensive learning process, overseen by a team of supervisors, all certified by the Swiss Society of Ultrasound in Medicine (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://sgum-ssum.ch/\u003c/span\u003e\u003cspan address=\"https://sgum-ssum.ch/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e, Supplementary Table\u0026nbsp;3). Third, in contrast to prior studies, external POCUS experts were involved in the study to maintain assessor blinding and mitigate the risk of bias, thereby reinforcing the robustness of our assumptions.\u003c/p\u003e \u003cp\u003eIn conclusion, our findings highlight the feasibility and need for a structured supervision following a hands-on course to improve both the use and proficiency of POCUS, especially for complex tasks and POCUS applications requiring advanced visuospatial skills, such as focused echocardiography.\u003c/p\u003e \u003cp\u003eThe low level of supervised examinations and competency in the control group raises serious doubts regarding the relevance of POCUS single courses without further supervision. Structured POCUS tutoring can significantly enhance training and practice, providing a solid foundation for a practical and safe use of POCUS. Dedicated supervision time slots for trainees during acute medicine clinical rounds may further increase the success rate.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis study was founded by the Sennart fondation. The founder was not involved in the research project.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eEthical approval and informed consent\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eExemption from ethical approval was confirmed by the local ethics committee. Informed consent was obtained prior study inclusion.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLeidi A, Rouyer F, Marti C, Reny JL, Grosgurin O. Point of care ultrasonography from the emergency department to the internal medicine ward: current trends and perspectives. Intern Emerg Med. 2020.\u003c/li\u003e\n\u003cli\u003eUltrasound Guidelines: Emergency, Point-of-Care and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med. 2017;69(5):e27-e54.\u003c/li\u003e\n\u003cli\u003eMoore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364(8):749-57.\u003c/li\u003e\n\u003cli\u003eMa IWY, Arishenkoff S, Wiseman J, Desy J, Ailon J, Martin L, et al. Internal Medicine Point-of-Care Ultrasound Curriculum: Consensus Recommendations from the Canadian Internal Medicine Ultrasound (CIMUS) Group. J Gen Intern Med. 2017;32(9):1052-7.\u003c/li\u003e\n\u003cli\u003eTorres-Macho J, Aro T, Bruckner I, Cogliati C, Gilja OH, Gurghean A, et al. Point-of-care ultrasound in internal medicine: A position paper by the ultrasound working group of the European federation of internal medicine. Eur J Intern Med. 2019.\u003c/li\u003e\n\u003cli\u003eTurner EE, Fox JC, Rosen M, Allen A, Rosen S, Anderson C. Implementation and assessment of a curriculum for bedside ultrasound training. J Ultrasound Med. 2015;34(5):823-8.\u003c/li\u003e\n\u003cli\u003eKimura BJ, Sliman SM, Waalen J, Amundson SA, Shaw DJ. Retention of Ultrasound Skills and Training in \u0026quot;Point-of-Care\u0026quot; Cardiac Ultrasound. J Am Soc Echocardiogr. 2016;29(10):992-7.\u003c/li\u003e\n\u003cli\u003eRappaport CA, McConomy BC, Arnold NR, Vose AT, Schmidt GA, Nassar B. A Prospective Analysis of Motor and Cognitive Skill Retention in Novice Learners of Point of Care Ultrasound. Crit Care Med. 2019;47(12):e948-e52.\u003c/li\u003e\n\u003cli\u003eRajamani A, Miu M, Huang S, Elbourne-Binns H, Pracher F, Gunawan S, et al. Impact of Critical Care Point-of-Care Ultrasound Short-Courses on Trainee Competence. Crit Care Med. 2019;47(9):e782-e4.\u003c/li\u003e\n\u003cli\u003eWong J, Montague S, Wallace P, Negishi K, Liteplo A, Ringrose J, et al. Barriers to learning and using point-of-care ultrasound: a survey of practicing internists in six North American institutions. Ultrasound J. 2020;12(1):19.\u003c/li\u003e\n\u003cli\u003eOlgers TJ, Azizi N, Bouma HR, Ter Maaten JC. Life after a point-of-care ultrasound course: setting up the right conditions! Ultrasound J. 2020;12(1):43.\u003c/li\u003e\n\u003cli\u003eFinn EM, Zwemer EK, Stephens JR, Dancel R. The State of Internal Medicine Point-of-Care Ultrasound (POCUS) Fellowships in the United States and Canada. Am J Med. 2023;136(8):830-6.\u003c/li\u003e\n\u003cli\u003eBell C, Wagner N, Hall A, Newbigging J, Rang L, McKaigney C. The ultrasound competency assessment tool for four-view cardiac POCUS. Ultrasound J. 2021;13(1):42.\u003c/li\u003e\n\u003cli\u003eMillington SJ, Arntfield RT, Guo RJ, Koenig S, Kory P, Noble V, et al. The Assessment of Competency in Thoracic Sonography (ACTS) scale: validation of a tool for point-of-care ultrasound. Crit Ultrasound J. 2017;9(1):25.\u003c/li\u003e\n\u003cli\u003eMatthews L, Contino K, Nussbaum C, Hunter K, Schorr C, Puri N. Skill retention with ultrasound curricula. PLoS One. 2020;15(12):e0243086.\u003c/li\u003e\n\u003cli\u003eSuzuki R, Kanai M, Oya K, Harada Y, Horie R, Sekiguchi H. A prospective randomized study to compare standard versus intensive training strategies on long-term improvement in critical care ultrasonography proficiency. BMC Med Educ. 2022;22(1):732.\u003c/li\u003e\n\u003cli\u003eBeraud AS, Rizk NW, Pearl RG, Liang DH, Patterson AJ. Focused transthoracic echocardiography during critical care medicine training: curriculum implementation and evaluation of proficiency*. Crit Care Med. 2013;41(8):e179-81.\u003c/li\u003e\n\u003cli\u003eBuesing J, Weng Y, Kugler J, Wang L, Blaha O, Hom J, et al. Handheld Ultrasound Device Usage and Image Acquisition Ability Among Internal Medicine Trainees: A Randomized Trial. J Grad Med Educ. 2021;13(1):76-82.\u003c/li\u003e\n\u003cli\u003eKumar A, Weng Y, Wang L, Bentley J, Almli M, Hom J, et al. Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial. J Hosp Med. 2020;15(2):e1-e6.\u003c/li\u003e\n\u003cli\u003eHayward M, Chan T, Healey A. Dedicated time for deliberate practice: one emergency medicine program\u0026apos;s approach to point-of-care ultrasound (PoCUS) training. CJEM. 2015;17(5):558-61.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"POCUS, ultrasound, internal medicine, tutoring, skill retention, proficiency","lastPublishedDoi":"10.21203/rs.3.rs-4616323/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4616323/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e In recent years, point-of-care ultrasonography (POCUS) has been integrated into internal medicine practice with most curricula composed of a single course. Despite competency acquisition during the course, a significant decline in proficiency occurs in the subsequent weeks due to a lack of regular practice and training. This study aims to evaluate the impact of a structured POCUS tutoring, on POCUS use and skills retention at 6 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e In this randomized controlled trial, internal medicine residents were enrolled after completing a practical course focused on heart and lung ultrasonography. Residents assigned to the intervention group were paired with a tutor, and time slots were scheduled for bedside direct supervision over the following 6 months. The primary outcome was the proportion of residents who successfully completed at least 25 POCUS examinations six months after inclusion. Secondary outcomes included self- and blinded-expert-assessed POCUS competency skills.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eBetween January and May 2022, 23 residents were included in the study. The intervention significantly increased the proportion of participants reaching the primary outcome (70% versus 0%; \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) with a median of 27 (interquartile range, IQR, 6 to 44) supervised examinations performed versus 0 (IQR 0 to 0) in intervention and control arm respectively; \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001. After 6 months, proficiency was higher for most heart imaging but not for lung imaging, as assessed through self-assessment by participants or independently by blinded experts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Structured POCUS supervision significantly enhances the number of POCUS examinations and proficiency at 6-months, particularly in applications requiring greater visuospatial skills.\u003c/p\u003e","manuscriptTitle":"Heart and Lung Point-of-Care Ultrasonography Tutoring in Internal Medicine: a Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-26 15:55:27","doi":"10.21203/rs.3.rs-4616323/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a8ea99c1-2a55-40e5-8ffd-c36433368a90","owner":[],"postedDate":"July 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-29T10:54:18+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-26 15:55:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4616323","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4616323","identity":"rs-4616323","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}