Lessons Learned from the First Years of the POCUS Certificate Program at the University of Pittsburgh School of Medicine

Emily Lovallo, MD
Associate Professor of Emergency Medicine
Director of Ultrasound Services, UPP Emergency Medicine
Director of Ultrasound Education
University of Pittsburgh School of Medicine
Medical Director
Freedom House 2.0

By the time I joined the University of Pittsburgh School of Medicine in 2015, it already had an established but limited POCUS program, including some exposure during the Gross Anatomy course, and two mini-electives in POCUS to first- and second-year students. These were coordinated and staffed by a variety of faculty from the Departments of Emergency Medicine, OB/GYN, Radiology, and Critical Care. When one of the leads moved on 2 years later, I took over. The timing was optimal; I was a junior faculty member, felt more comfortable in my position, and had established relationships with faculty from across departments through various ultrasound activities.

While continuing with the established programming, I began deep diving our own medical school curriculum, as well as the POCUS programs in existence at other institutions. A quick post on the ACEP Ultrasound listserve, and a casual comment over a drink with a former attending at a reunion helped connect me with established leaders in ultrasound in medical education. Dr. Wilma Chan at UPenn was incredibly helpful in sharing their curriculum, as were smaller institutions with programs of a more limited scope. I took something of value from everyone that has published. Over the course of 8 months, I drafted and revised, with input from the students leading the Ultrasound in Medicine Interest Group for guidance on what might be feasible or not, what is now the longitudinal POCUS Certificate Program.  It was approved by the curriculum committee in 2019 and accepted its first round of applicants in May 2020.

I recognized that we did not have the bandwidth within our own Department of Emergency Medicine to run a POCUS program for all 160 students, nor the expertise and faculty numbers needed from other departments to do so. When I approached the Dean with my initial proposal, I made it clear that I wanted to start small and make sure we could deliver a quality product with good outcomes. Our inaugural class had 16 students (32 applicants), and we have increased annually since then as I have gained instructors and now have senior POCUS Certificate Program Students that serve as faculty at many of the workshops. I just accepted thirty-six students to the new class, from 56 applicants. This tells me that certainly there is a growing interest in POCUS, but it's not a priority for all students, or there is a good number that recognize that adding on another 15 hours of extra-curricular work is not for them. These numbers, and the disappointed emails back from the waitlisted students, will also help me in my next proposal to the school on how we can thoughtfully expand the program in the future.

What limiting the numbers of accepted students and the program being extra-curricular means is that the bunch I get are enthusiastic about it, committed to doing the required pre-work, and come to learn. It is one of the most rewarding experiences to serve as an educator for these students and has significantly helped me counter the burnout from the rest of my work. Their interests and paths to medical school are fascinating and variable, and although most of the faculty are from emergency medicine, only two of the POCUS students that have graduated so far have gone to my field for residency. This is ideal as these students will be POCUS leaders in their departments as residents and help expand the field and interest.

In keeping with the trend established by my predecessor, the support for the program and the faculty, fellows, and residents that teach hail from twelve different departments. This variability is incredibly beneficial for the students to have exposure to how POCUS is used outside of the Emergency Department, and for our departments to collaborate outside of medical education. Indeed, we now exchange educational opportunities for our fellows with cardiac anesthesia, pediatric emergency medicine, regional anesthesia, and sports medicine.

While much of the didactic work happens over the second year with content mirroring what is being covered in their organ system blocks (see timeline below), students do a variable amount of POCUS on their third-year clerkships, another component still in development, and most do a senior elective. This has been a highlight for our faculty and the students, who split time doing POCUS-related work, teaching, curriculum development, ED-based scanning shifts and scanning shifts with faculty from their department of future residency. The first- and second-year students love having a fourth-year student as their educator and hearing their stories about their own personal growth over the course of their medical education is affirming for both groups of students. There are two OSCE-style case-based POCUS exams during the second year of the Certificate Program which I now have senior students help administer and they value seeing how far they have come in terms of their knowledge and skill sets.

When the students return for that senior elective, the skills and knowledge loss is apparent in most of them. We are in the midst of piloting a year-long program with the current third years in an attempt to counter that loss, using the QStream platform to expose the students to POCUS content every few days. A mixture of POCUS and non-Certificate Program students were randomized equally into two cohorts and assigned two Qstream chapters (50 images per question bank): cardiac/vascular and lung/FAST. Cohorts complete their assigned chapter in the first half of their 3rd year, then switch and complete the other content in the second half of the year.  By integrating pre- and post-tests, we hope to measure impact and long-term retention of content.  This innovative approach to spaced education would not have come to fruition were it not for the students asking for something that was feasible given their time constraints while on clerkships, and a motivated fellow who saw this weakness in the curriculum and proposed a way to address it. This is another testament to the strength of having a team involved in the POCUS program development and evaluation.

Now at the start of the program’s fourth year I can reflect on its progress and future trajectory.  The Pitt curriculum and institution in general have a strong research focus, and many of the students are now pushing me to follow suit with regards to POCUS both in medical education and in their specific areas of interest.  In the next several years I’d anticipate being able to focus more on this as hopefully the year-to-year changes minimize.  That won’t happen right away though, as we just went through a curricular overhaul and there is now interest from the broader field of core educators to start transitioning from an extra-curricular POCUS program to an integrated one. We’ll add that to the “Two-year goals” list. These are good challenges to have.

PittMed POCUS Certificate Program Timeline Summary

MS- 2

• 12 ultrasound laboratory sessions
• Ultrasound in Medicine Interest Group (UMIG) meetings
• 2 POCUS practical exams at end of Fall and Spring terms

Est. Time required:
1.5 hours of online module review
12 hours of hands-on scanning lab
5 hours UMIG meetings
1 hour examination (2 x 30 min exams)
(19.5 hrs)

MS- 3

• Participate in Q-stream - App-based question bank focusing on POCUS image and clip review with accompanying pre-test, post-test and remote review session
• Demonstrate clinical use of POCUS in core clerkships (Specialty Care, OB/GYN, Anesthesiology, Surgery)

Est. Time required:
Outside of clerkships- est 4 hour additional commitment

MS- 4

• One POCUS elective, preferably POCUS Independent Study Elective