Handheld Ultrasound Devices and the Training Conundrum: How to Get to “Seeing Is Believing”

Although the ‘‘stethoscope’’ was developed almost 200 years ago by Rene-Theophile-Hyacinthe Laennec and is unquestionably the foundation for classical teaching of the diagnostic physical examination, it is also true that generations of medical students have been exposed to this misnomer. The stethoscope, hung proudly around every medical student’s neck, is indeed a ‘‘stethophone,’’ as it allows listening (steth = chest, phone = sound) to the human body rather than truly seeing (scope = to look in) into it. 1 Recent developments in ultrasound technology have resulted in miniaturization of ultrasound devices, which can be readily carried in a lab coat pocket and used at the bedside to generate high-quality ultrasound images of cardiac structure and function. 2 These devices can provide immediate feedback and extend the information base of the traditionally acquired history and physical examination, contributing to improved cardiac differential diagnosis formulation. 3,4 By visualizing cardiac anatomy and dynamics immediately, using a true stethoscope, the user can refine clinical decision making and optimize the choice of further testing and treatment. 5 Indeed, the use of these devices in routine clinical practice, akin to the manner in which the traditional stethoscope has been used, may potentially enhance, expedite, and improve costefficient care. 6 However, as this technology has only very recently evolved, there is as of yet no standardized approach for teaching the skills necessary to use these devices optimally, nor is there a systematic approach to assessment of the learner’s capabilities and the impact on patient care. Historically, the knowledge base necessary to use the more sophisticated conventional ultrasound scanners has been acquired only at the postgraduate and specialty training levels, at which programmatic instruction and assessments are well established, with numerous accreditation bodies providing benchmarks for expertise and ‘‘quality control.’’ Traditionally, ultrasound assessments have been performed on large scanners located in imaging areas within radiology, cardiology, and obstetrics departments. With the advent of portable scanners in the 1990s, it became possible to scan patients in real time at the ‘‘point of care,’’ and many other specialties such as emergency medicine, surgery, critical care, and others began to embrace ultrasound technology and change their practices. 7 Thus, a technology innovation enabled diverse new groups of users to perform focused ultrasound assessments, which has been further accelerated by the most recent technologic development of ‘‘handheld’’ or ‘‘pocket-sized’’ ultrasound units. Indeed, point-of-care ultrasound can be viewed as a ‘‘disruptive’’ innovation, changing the paradigm of consultative imaging by specialists to one whereby imaging may be performed at the bedside by the clinicians directly responsible for a patient’s care. This activity has the potential advantage not only to enhance the rapidity of imaging access but also to improve the imaging examination through focused acquisition and interpretation guided by the diagnostic context formulated by the consultant directly evaluating the patient. These miniaturized ultrasound devices truly provide widespread opportunity to extend the physical examination of both novice and expert caregivers by seeing directly into the body at the bedside. The equipment is now readily available, at a price point that is not prohibitive to potential mainstream users. The key issue, then, is the development of appropriate training and education of caregivers in their use, so that they will benefit patients, through enhanced cost-effective delivery of care, and not harm them through underdiagnosis or overdiagnosis. Approaches to point-of-care assessments of patients with portable, handheld ultrasound (HHU) units and their integration into both medical teaching and clinical practice are in the ‘‘emergent’’ and ‘‘early adoption’’ stages of new technology. Several medical organizations have recently developed expert consensus and guideline documents aimed at introducing and guiding the use of HHU, particularly as it pertains to cardiac imaging. The American Society of Echocardiography has recognized that these devices are capable of performing focused cardiac ultrasound (FCU) assessments as an adjunct to the physical examination. Whereas HHU describes a portable miniaturized ultrasound device that can be used to examine any organ or system in the body, FCU is specifically defined as a focused examination of the cardiovascular system performed by a physician using ultrasound (at the bedside with an HHU device) as an adjunct to the physical examination to recognize specific ultrasonic signs that represent a