Point-of-care ultrasound (POCUS) continues to evolve as an essential adjunct to clinical examination not only in the acute care setting but also in other disciplines such as critical care medicine, internal medicine, and pediatrics. As this modality continues to evolve, a comprehensive training curriculum is an important foundation in medical education to acquire and enhance this skill set.[1] It is well established that medical training using simulation has many advantages when compared to traditional training techniques.[2] To our knowledge, the current literature on POCUS simulation as a training tool is limited.

There is a wide array of simulation and clinical integration strategies for POCUS training. Common approach often begins with workshops and conferences with didactics, phantom, and live models to simulate bedside skills and techniques; this often translates to further learning at the bedside by scanning patients with clinically indicated diagnoses or chief complaints. Competency, as established by various oversight governing bodies such as the American Academy of Emergency Physicians (ACEP), is then based on achieving specific milestones for knowledge and skill acquisition.[3] However, learning at the bedside without an adequate amount of experience early on in training can often create a stress-induced environment which can be detrimental to the learning environment and potentially harm the patient.

The purpose of this activity is to outline potential strategies and techniques for POCUS simulation.  Our intention is to highlight the integrative approach of POCUS simulation into training curricula.

Currently, available literature to support the efficacy and effectiveness of simulation in POCUS is lacking. Furthermore, it is uncertain as to whether the knowledge and skills acquired through simulation can translate to achieve competency and proficiency by the learner.[4]

Since medical simulation has been well-proven to enhance the learner's baseline knowledge and skill, the development of a clinically-integrated POCUS curriculum can serve to improve the learner's experience and achieve their fitness to incorporate this skill into practice.[5] 

Recent literature revealed that learners who spent time on a simulator where they could repeat tasks without the clinical pressures of scanning at the bedside responded positively to this approach.[1] Clinical scenarios with live models, phantoms, and simulator mannequins with abnormal pathology can significantly augment the learners' POCUS education. 

In this regard, an approach to curriculum development of simulation-based POCUS should include establishing comprehensive learning objectives. One such objective commonly used in medical and health care education is Bloom's taxonomy of learning, which emphasizes three main categories: knowledge, skills, and attitudes. Knowledge commonly reflects the assimilation of learned information. The skills category denotes the development of psychomotor and coordinated aspects of machine and examiner interaction. Attitudes represent the combination of knowledge and skills as it relates to learner integration of the concepts into clinical decision-making and professional behavior.[6]

Currently, there are no standardized guidelines for simulation in POCUS training. However, as recent literature for POCUS training education continues to improve, the integration of simulation lacks in these guidelines.[7] An approach to incorporate simulation into POCUS training includes utilizing a combination of didactics, practice-based simulation, clinical-based simulation, quality assurance, and feedback as well as an assessment of competency. 

A basic foundation of POCUS training is, to begin with, didactics to introduce the learner to this modality. This introductory portion of the training can be regarded as vital since it involves becoming familiar with the ultrasound machine and applying this skill to acquiring the desired image.  In this regard, the ACEP policy guidelines on POCUS suggest that rotating between skill and practice improves trainee and faculty engagement.[3] Didactics are often utilized as a precursor to bedside skill training with a live or phantom trainer. It intends to allow the learner to practice acquired concepts repeatedly without having to consider the clinical setting and patient discomfort while guided by real-time feedback. This approach inevitably increases the confidence of the learner before integrating the skill into the simulated clinical setting.  

Once an adequate level of comfort is achieved, subsequent opportunities for clinical simulation or supervised bedside training are necessary. This may include live patient scans with an expert supervising the session. However, as mentioned previously, the bedside patient training approach may have a negative effect due to the stress-induced environment and expectations of the learner.  Therefore, it preferrable to utilize clinical scenarios in a controlled environment to simulate bedside clinical training. This allows for real-time feedback by the supervising expert to enhance the development of learner skills and techniques. Furthermore, this can augment psychomotor training, learner positioning, interpersonal skill, and professionalism as well as educating patients and family as it relates to their clinical presentation. Appropriately designed cases can be used to assess a trainee's ability to recognize both common and rare diagnoses and demonstrate reproducible image acquisition and interpretation.[8] While it is well recognized that simulation-based learning cannot replace clinical experience, it can serve as a valuable adjunct to comprehensive POCUS training.[9] 

Simultaneous quality assurance of images acquired by the trainee is also an essential part of POCUS training. This oversight can be done during a supervised scan, whether by simulation or during clinical management. If this is not possible, immediate quality assurance of the images acquired and submitted by the learner should be completed in a timely fashion.  A subsequent review of acquired images can also be completed by expert sonographers to provide the trainee with feedback that reinforces learned concepts and skills. 

By definition, measurement of competency is intended to assess baseline knowledge of POCUS technique and skill. This often includes evaluating the trainee's understanding of the ultrasound equipment utilized in the acquisition of quality images for clinical integration and management of patient care. Assessment of competency may be done by written examination that emphasizes basic ultrasound concepts in the clinical setting based on POCUS applications that are central to the common clinical encounters (i.e., focused cardiac ultrasound for chest pain).