Focused Cardiac Ultrasound Training: Building Competency Through a Multimodal Curriculum

Dr. James K. Stoller:

Hello and welcome to MedEd Thread, a Cleveland Clinic Education podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hello, welcome to today's episode of MedEd Thread, an education podcast exploring how Cleveland Clinic Akron General Hospital is training its internal medical residents training to perform focused cardiac ultrasounds.

I'm your host, Dr. Tony Tizzano, director of student and learner health here at Cleveland Clinic in Cleveland, Ohio today.

I'm very pleased to have Dr. Zenab Laiq, cardiologist and cardiac imaging specialist at Cleveland Clinic's Akron General Hospital, here to join us.

Zenab, welcome to today's podcast.

Dr. Zenab Laiq:

Thank you for having me, Tony.

Dr. Tony Tizzano:

Our pleasure.

Also with us is Dr. Samuel Wiles, pulmonary critical care physician at Cleveland Clinic Akron General Hospital and associate director of its internal medicine residency program.

Sam, thank you for joining us today.

Dr. Samuel Wiles:

Thank you so much for having me, Tony.

Dr. Tony Tizzano:

Finally, we have Dr. Vasu Gupta, internal medicine resident and chief resident at Cleveland Clinic Akron General Hospital.

Vasu, thank you for joining us.

Dr. Vasu Gupta:

Thank you for having me, Tony.

Dr. Tony Tizzano:

To get us started, could each of you tell us a little bit about yourselves, your educational background, what brought you to the Cleveland Clinic, and your respective roles within the health system?

We can start with you, Sam.

Dr. Samuel Wiles:

Yeah, sure. So, I currently am employed as a pulmonary critical care physician at Akron General Medical Center.

I serve as one of the associate program directors and I'm in charge of the simulation-based activities for the residency program, including point-of-care ultrasound, procedural training, amongst some other initiatives that I spearhead.

Dr. Tony Tizzano:

Excellent. Zenab and you?

Dr. Zenab Laiq:

So, I am a general non-invasive cardiologist in Cleveland Clinic. I've been in this role for the last nine years. I'm also part of faculty for teaching internal medicine residents as well as students. And I have a special focus in cardiovascular imaging as well as cardio-oncology.

Dr. Tony Tizzano:

Excellent, Vasu?

Dr. Vasu Gupta:

I recently graduated from internal medicine residency from Cleveland Clinic Akron. Moved here three years ago from India. During my residency, I also graduated from clinicians educator track and currently I'm serving as a chief resident of internal medicine.

Dr. Tony Tizzano:

Well, congratulations and thank you for joining.

So, in today's segment, we'll explore how Akron General's internal medicine program is raising the bar for trainees by developing an innovative multimodal training curriculum to provide its residents with focused cardiac ultrasound skills to streamline and advance patient care.

So now can you please help us frame today's topic so our listeners understand the impetus for developing this program for your internal medicine residents?

Dr. Zenab Laiq:

Absolutely.

So focused cardiac imaging, particularly point-of-care ultrasound, it is a dynamic extension of physical examination. When I speak to the residents about it, I always say, this doesn't replace physical examination, but it only provides very timely, very rapid, real-time and bedside visualization of the heart.

It allows us to answer critical clinical questions and help us form a differential diagnosis and also guide treatment.

When we were developing this particular curriculum, we first conducted a needs assessment that identified a gap in internal medicine training. Almost 100% of our medicine residents, they expressed an interest in developing competency for this particular skill. 70% of our residents reported a lack of opportunity in their previous places of training or in their medical student years. 70% of our residents reported a lack of opportunity that was ever given to them. And there were a lot of residents who did not have any previous experience in focused cardiac ultrasound.

So while we do not have an absolute requirement to provide this for internal medicine boards or during our internal medicine residency, we did identify that this is a very important part of training and will really help us produce better residents and more competent residents.

And that was basically the foundation of this particular program that we developed.

Dr. Tony Tizzano:

Thank you very much, Zenab.

So, Sam, what does this bring to the table for our patients?

Dr. Samuel Wiles:

Yeah, the importance of focused imaging in terms of cardiac ultrasound lies in the ability to perform several key assessment benefits in real time, one of them being real time hemodynamic assessment.

So point-of-care ultrasound echocardiography is the gold standard and the tool of choice for undifferentiated hypotension.

It allows us to kind of differentiate what potential causes of shock are occurring in a given patient, whether it be hypovolemic shock, cardiogenic shock, distributive shock, or obstructive shock.

And we can also directly evaluate left and right ventricular function and kind of clue us into some of the etiologies for symptomatology, including things like dyspnea.

So from a hemodynamic standpoint, again, gives us real time upfront data that we can use on the spot.

Second, it allows us to rapidly diagnose several different types of emergencies, particularly acute massive pulmonary embolism, which is now called high risk pulmonary embolism, as well as pericardial tamponade and to intervene in these sorts of cases.

On the other side of things, you can also do several different types of volume status assessments, some of them static and dynamic.

So in spontaneously breathing patients, we can accurately measure right atrial pressure.

In patients on ventilators and some other caveats to actual volume assessment, we can actually get a sense of whether patients are going to be volume responsive after we administer fluids, doing things like passive leg raises or administering small boluses and looking at how cardiac output changes in real time.

Procedurally, while it's not within the extent of most internal medicine resident programs, it also allows us to perform pericardiocentesis, though very rare in emergent situations such as in codes, and does provide that benefit.

The final thing that I think is being studied more readily and is becoming kind of more standard, particularly in the emergency room, is use of focused cardiac ultrasound during code blue scenarios.

There's this concept of pseudo PEA or pulseless electrical activity which isn't actually the heart completely stopping. For example, in a trauma patient that's severely hypovolemic and you may not be able to feel a pulse, you throw a probe on their chest, you see that their heart is contracting vigorously and that chest compressions won't actually help this patient.

So it really helps us in a variety of different manners.

Dr. Tony Tizzano:

So what you're saying really sounds like a tremendous augmentation of your physical diagnosis skills that you will more expeditiously pinpoint what's going on.

I mean, it sounds fabulous.

Dr. Samuel Wiles:

Absolutely.

Dr. Tony Tizzano:

So Vasu, please give us some sense of how this multimodal training curriculum was designed and how it's been executed.

Dr. Vasu Gupta:

Yeah, absolutely. So once we identified that there is a clear gap in need based on our needs assessment survey, we started with a pre-curriculum knowledge-based and confidence-based questionnaire or a survey to see where the current level of training lies.

Based on that information, we developed some goals and objectives which was to improve residents' confidence, to increase their knowledge about focused cardiac ultrasound by 20%. Also accurately diagnosing 7 out of 10 cases on our POCUS simulator.

And finally, and most importantly, to increase the motivation in the residents to perform more exams which we saw from them documenting on our online platform by increasing that number by 50% by the end of six months.

Given my background in clinician educator track, it was really important for us to develop something which is multimodal, which focuses on active learning rather than passive teaching and aligns with our goals and objectives.

So we started with online modules.

The American College of Physicians (ACP) has free online modules on basics of ultrasound and also on focused cardiac ultrasound that takes about an hour. Residents did that. That was followed by an in-person case-based learning lecture by a board-certified cardiologist, followed by supervised simulation-based training which Dr. Wiles started using our new focus simulator that the program got last year.

By integrating different modalities, we tried to make sure that there is active learning for the residents, so lots of moving parts, to say the least.

Dr. Tony Tizzano:

So, Sam, how has simulation come into the picture and what has it brought to this type of training for patients and residents?

Dr. Samuel Wiles:

Yeah, I think first off, and most importantly, it creates a safe environment for residents to learn a skill that is very technically challenging. Right. So it requires lots of fine motor skills, and it's not something you can just pick up and be good at in one day.

So because we have this high-fidelity mannequin, essentially, that allows us to go through individual cases of normal physiology, different forms of abnormal physiology, heart failure, valvular disorders, et cetera, it allows residents to see a breadth of different things that they may not see routinely while on a cardiac service, for example, particularly from an imaging standpoint.

The other benefit of this technology is that it actually allows our residents to have their own individual logins. And with these logins, they can go through the cases, they can capture images, they can make comments and document their findings, and then those can be saved, after which I can actually go back and review their images and give them feedback on what they thought was occurring, what was actually going on, as well as image acquisition features such as improving depth or gain or really how to optimize what they're looking at.

So the benefit from that standpoint is that I don't have to be in person all the time.

And it's a lot of individualized effort, being invested in their own education with the knowledge that they're going to be able to get that feedback and actually improve.

Dr. Tony Tizzano:

That's outstanding. So in your downtime, when you're not at the bedside and doing other things, you can sit back, review what residents have been doing, and actually see post real time, the quality of their skill set. Yep, that is absolutely fabulous.

So, Zenab, this was your bailiwick. I mean, this is what you trained as a cardiologist in, specializing in echocardiography.

How does this manner of training and the curriculum compare to what you experienced in your training as a cardiac imaging fellow?

Dr. Zenab Laiq:

Very different.

So I'll compare it first to my residency curriculum or how I trained as a resident. I graduated from my residency back in 2014 from University of Nebraska Medical Center, which was very academically driven and overall excellent training. But we did not have any dedicated time for cardiac ultrasound. We also did not have any curriculum.

It was basically, if you wanted to do it, if you wanted to invest time and education into it, you were allowed to do so.

But there wasn't anything that was offered to us from the faculty.

Then, when I started my cardiology fellowship, I very quickly realized that my skills, whether it was my skill to perform POCUS or have any basic idea of how to interpret cardiac imaging on echocardiography, they were very limited. Even when I talk about my cardiology fellowship, since you are a little bit more mature, people expect you to have that certain level of maturity and independence. So a lot of that learning is also on the go. There isn't four or five hours of dedicated lectures to echocardiography or focused cardiac ultrasound. So there was definitely a gap over there. But we trained with very heavy volumes for echocardiography. So you eventually get there as a cardiologist.

I'll also say that even though the residents who eventually train in critical care medicine, like Dr. Wiles and cardiology, they'll probably do more focused cardiac ultrasound than someone who prefers to do a hospitalist track or primary care or go into oncology, for example.

But this curriculum is very helpful to anyone who goes into any other line of medicine as well.

Pretty much anyone who graduates from internal medicine residency will be required to at least order an echocardiogram and interpret the findings.

And when we provide such kind of curriculum, it impressively increases their ability to not only perform, but to also interpret the report of an echocardiogram. So I think this was a high time that we started this curriculum. Emergency medicine residency, they, for example, already have something that is there. And if you think about it, a lot of hospitalists, they are also the ones who are dealing with patients the moment they walk into the hospital.

So again, very important that we provide this to our residents.

Dr. Tony Tizzano:

Did you ever have the opportunity to work with a simulation in your training, or did that come later?

Dr. Zenab Laiq:

That came in my cardiology fellowship.

I do not recall having that at all when I was an internal medicine resident.

Now, again, I'm an older graduate, so maybe Dr. Wiles had something like that, but I did not have that in my medicine training.

Dr. Samuel Wiles:

So for internal medicine, even having trained here at Cleveland Clinic, we actually didn't have a focused cardiac ultrasound curriculum, and we didn't have the ability to do much in terms of simulation with regards to the specific point-of-care field within ultrasound itself.

You know, we would do a lot of procedural training, but nothing to this extent.

Everything that I learned about cardiac ultrasound was through my fellowship.

And like I said, we've been fortunate enough to actually acquire the same mannequin that I had in my fellowship and training here, and it's been a great resource.

Dr. Tony Tizzano:

What an extraordinary time saver. I just for the attending physician and the learner as well.

So, Vasu, how have these efforts been viewed and received by residents and the attending staff as well?

Dr. Vasu Gupta:

It gave me immense joy to see residents being more confident and comfortable in performing these exams.

They were coming to a bedside with the ultrasound machine to perform those exams themselves without an attending telling them to do so.

And the same thing was also noticed by the attendings that, yeah, residents are really willing to do these just because they feel more comfortable. Now they feel confident in doing so. That was a big joy.

Dr. Tony Tizzano:

So do you think that even among the attending staff who may not have had this sort of training, there might even be a reason for them to say, hey, I can see the value and the utility of this.

Is there an opportunity for them as well to pursue this?

Dr. Samuel Wiles:

Yeah, I would say the majority, at least from a pulmonary critical care standpoint, of our staff down at Akron are trained in point of care or focused cardiac ultrasound.

Obviously, there's varying levels of comfort, but I think it's a major push to expand that just even further beyond pulmonary critical care and cardiology into hospital medicine.

I've been working closely with some of our academic teaching hospitalists to develop a curriculum for them to start doing these things so that they can learn and can actually supervise and give feedback to residents in the future.

Again, it's a very challenging skill to acquire and requires a lot of time investment, but I think that's the end goal of what we're doing.

Dr. Tony Tizzano:

Yeah, I think that's outstanding. I know in my own training, which we're not going to go into how long ago that was, but we had some very masterful physicians at Ohio State with auscultation, and it used to astonish us as a class of what he could listen to and diagnose and then compare to what echocardiography was doing was very, very close.

But I would guess that that skill set might be declining somewhat and this tool is now perhaps a necessary one.

Zenab, what do you think for training across the board?

Dr. Zenab Laiq:

I remember when I was in my cardiology fellowship, we acquired these handheld focused ultrasounds, and they were available to other departments as well.

But a device is only useful if you have training for this, and we have talked about it across other specialties.

So, for example, if we have a critically ill patient post bypass or post any kind of heart surgery overnight, if that patient is on a cardiac surgery service and you need an ultrasound in a rapidly declining patient, the time it takes for our sonographer to come from home and do the ultrasound is approximately 30 minutes or so.

So we have discussed this with our cardiothoracic surgery team whether it would be feasible and practical for us to train our cardiovascular or cardiothoracic nurse practitioners, who are usually the first call or overnight people available.

It's a very valuable tool, but again, it's only useful if people are adequately trained for it.

And if there is a program, I'm really hoping that when Vasu stays for another year and Dr. Wiles, hopefully for many, many years, that we can extend this across other specialties, because the time is there now that this is the time that we do it.

Dr. Tony Tizzano:

Yeah, I might even hazard a guess that as we are a growing population in terms of body size and habitus, that perhaps a stethoscope may not be adequate at times to look at some of the things that you might be able to hear in a person who's 100 pounds soaking wet, but in someone who's 300 pounds may be a more difficult exam to begin with.

And you need a technology that can bring to the table the information you need.

So when you look at where you're at now, this is for all of you. What do you see on the horizon for this kind of training? Different populations or what's out there?

Dr. Vasu Gupta:

Looking forward, we are hoping to have more interprofessional collaboration, not just within internal medicine residency, which includes internists, critical care and cardiology people, but also between different subspecialties.

For example, as Dr. Laiq mentioned, emergency medicine, they have a well-established POCUS curriculum.

So hoping to learn something from them and hoping to teach and give something to them would be one thing.

And hopefully at some point, once we have this well established, to create a POCUS elective out of it for our internal medicine residents so that they can get a dedicated week to learn, focus and to perform POCUS.

Dr. Tony Tizzano:

And you think that would be adequate time? What would you say to that, Sam?

Dr. Samuel Wiles:

Yeah, I think so. And kind of piggybacking off of what Vasu said, I think professional collaboration is extremely important. Developing this curriculum is a lot of time and effort. And because we are a large enterprise, people are doing these things at different hospitals.

So there's actually a POCUS task force that's been initiated by some of our colleagues over at Fairview, where we have the opportunity to share ideas, share materials, collaborate on workshops, have residents from different specialties and different hospital systems come together and practice these things and really kind of do it as a group of physicians, not just inside the Cleveland Clinic itself.

Going forward, if this curriculum rolls out, I foresee it being developed for other areas of point of care ultrasound, particularly lung ultrasound, vascular ultrasound, abdominal ultrasound. Because it's really multimodal organ assessment that allows us to really hone in our differentials.

For example, if we're thinking about a pulmonary embolism and you see somebody with a dilated weak right ventricle and they have a concurrent DVT, that allows you to proceed to treatment almost immediately rather than waiting for the gold standard CT scan or something along those lines. So by combining these modalities, different organs, I think we're really going to improve our patient care substantially.

Dr. Tony Tizzano:

So we're bringing much more to the table. So Zenab, what do you think? What would you add?

Dr. Zenab Laiq:

Yes, so they touched upon the more long term goal and how they'd like to see it. I have a little bit smaller goal here. I would really like to incorporate some newer teaching methods because even during the lectures I was realizing that the residents, they respond very well to visuals.

The imaging, it's a very dry subject. If you think about ultrasound, everything is black and white. So I very quickly realized that to make it understandable, to make it interesting, the use of 3D models is very well received.

So I'm really hoping that when next year we do our session for the newer residents, I will hopefully have some 3D models that are specifically designed for echo imaging. That's my first goal for at least our program. And then I'm really just hoping to expand it to others.

I mean, it's also a teaching task for me how to be a better teacher as a cardiologist. And it's like an evolving role. And I can tell you how excited I am for this because it's really, really rewarding when you are doing your ICU rounds and you have a resident who already knows something that you didn't expect that resident to know just because they had their nice simulator session with Dr. Wiles and attended a lecture.

So it's just a very rewarding thing as an educator and as a teacher.

Dr. Tony Tizzano:

So when you mention models, are you talking about physical models or virtual models?

Dr. Zenab Laiq:

They are actually physical models.

So you basically, I can just explain it to you. So you make a 3D model of the heart and then you make cuts that simulate cuts of an ultrasound scanner on a view.

So for example, if I want to give you a four chamber view, I will take that cut across the four chamber of the heart and split the heart and show it to the resident that this is how a four chamber view is obtained.

And I can't tell you, coming from someone who actually had to learn it just in the head, like, oh, this is how the heart model is behaving. Heart just doesn't stand in the chest like the Valentine heart. This is not how it looks in the chest.

So it took me a while to sort of know how the heart moves and how the atria are so much more posterior than the ventricles.

So it takes a lot of time when you start scanning. So when I was teaching, I didn't have the 3D model at that time. So I used basically paper cuts. And I had just one plastic model that I used. And I was trying to show them how we make the cuts for four chamber versus two chamber versus the short axis.

And then I realized, you know, we can probably come up, you know, the Cleveland Clinic has a lot of research, so from next year, I'm just going to graduate to the 3D models that already come with these cuts so that I don't have to draw them on paper, just explain it that way.

So that's really what my goal is for next year.

Just to make it a little bit more interesting, more colorful, and more understandable.

Dr. Tony Tizzano:

Well, I can see where that would be very helpful.

And believe it or not, even in OB-GYN, when I would be showing women ultrasounds of their babies, I would be looking at the heart and trying to get a four chamber view and looking at where the aorta comes out.

And by no means the level of intricacy that you bring to the table, but it was still something we knew we had to find and looking for this and that kind of defect.

So given all of this, are there any questions that I didn't ask that you think are important for our listeners to know?

Samuel?

Dr. Samuel Wiles:

I think that, you know, one thing for our listeners to recognize is that implementing it again requires a lot of effort.

And there's also the problem with quality control.

So we're fortunate enough to have the mannequin, but as our residents start going and capturing these images on real patients, we have to make sure that they're adequate images and that the interpretations are correct before they make it into the patient chart.

So there's a lot of technology surrounding that through various systems, having the ability to have the residents be able to capture save real time images on actual patients and then go to a database so that they can be reviewed by a cardiologist, a pulmonary critical care physician, and then say, hey, you're spot on. Let's upload these into Epic, or these are the things that I would change in documentation.

I think that's really important in the future as we start expanding this and really giving residents ownership of it.

Dr. Tony Tizzano:

That's a fabulous, fabulous thought.

Well, thank you so much, Zenab, Sam and Vasu. This was a wonderfully insightful podcast.

To our listeners, if you would like to suggest an education topic to us or comment on an episode, please email us at Education@ccf.org.

Thank you very much for joining, and we look forward to seeing you on our next podcast. Have a wonderful day.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, Stitcher, Spotify, or wherever you get your podcasts.

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