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Original Research

PA use of point-of-care ultrasound

A pilot survey

Rizzolo, Denise PhD, MS, PA-C; Krackov, Rachel PhD, MPAS, PA-C, RVS

Author Information
doi: 10.1097/01.JAA.0000533668.18568.e9
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Abstract

Beginning in the 1990s, technological advances led to smaller, more affordable ultrasound machines and the use of ultrasound by physicians outside of radiology. In 1999, the American Medical Association (AMA) supported the movement of advancing ultrasound technology, declaring that physician-performed focused sonography was within the scope of physician practice with appropriate training.1 Ultrasound is now used in most practice settings, including primary care.2 The two types of ultrasound examinations are:

  • diagnostic ultrasound performed by an ultrasound technologist in radiology
  • point-of-care (POC) ultrasound performed by a clinician during the patient-provider encounter.

Unlike a comprehensive diagnostic ultrasound examination, a POC ultrasound examination is an adjunct to the physical examination designed to answer specific diagnostic questions and to expedite care.3 Studies have shown that POC ultrasound can be learned easily, increases treatment efficiency, and achieves significant cost reduction in general clinical settings.4,5 Sixty-two percent of US undergraduate medical schools have some form of ultrasound training in their curricula.6 Twenty-seven percent of these programs include a fully integrated ultrasound curriculum consisting of 90 core POC ultrasound milestones that all medical students must achieve.7,8

In most states, PAs can perform the same procedures as their supervising physicians because they are trained in the medical model. Much research exists on POC ultrasound use by physicians but very little data focus on PAs and POC ultrasound. A literature search using search terms point of care ultrasound, physician assistant, and bedside ultrasound revealed only two articles that included PAs as POC ultrasound operators.9,10 No articles address the extent of POC ultrasound use by PAs.

This pilot study sought to determine PAs' views on and use of POC ultrasound. Questions focused on frequency of POC ultrasound use in daily practice, training, and skill confidence. For PAs who did not use POC ultrasound, questions focused on reasons why. Additionally, for respondents who were educators, the survey sought to determine if POC ultrasound was used in the curriculum.

METHODS

Subjects

Study subjects were a sample of convenience of 4 years of graduates from a private master's level PA program. Institutional review board approval was obtained before starting the study.

Instrument

The authors developed an anonymous voluntary survey of dichotomous and continuous variables focusing on PAs and their use of POC ultrasound. The survey consists of four sections addressing respondent demographic information, practice information, personal use of POC ultrasound, and views about POC ultrasound training and competency. One author is a registered vascular specialist with 15 years of ultrasound experience. The survey was reviewed by three independent clinicians, including a diagnostic and interventional radiologist for content validity. The survey took about 20 minutes to complete and subjects could discontinue it at any time without penalty. The survey was entered into Qualtrics and sent to the subject's e-mail account.

Procedures

The survey and invitation to participate were sent out via e-mail three times by the principal investigator. Subjects were allowed to complete the survey only once. No rewards were given for participation in the study.

Data analysis

SPSS version 23 software was used to analyze the data using descriptive statistics and frequency counts.

RESULTS

Demographics

Of the 101 e-mails sent, 52 of subjects responded, yielding a 51% return rate. The mean age was 39 years with a range of 29 to 58 years. Years in practice ranged from 5 to 29 with a mean of 12. Sixty-five percent of the respondents were female, 21% were male, and 14% preferred not to answer. Sixty-eight percent lived in the Northeast, 11% in the Southeast, 13% in the Midwest, 4% in the Northwest, 2% in the Southwest, and 2% in the noncontinental United States. Those who were in clinical practice were employed in a variety of practice settings.

Thirty-seven percent of the sample had medical experience before attending a PA program, with five of the subjects having experience as a radiologic technologist. One of these five subjects was credentialed by the American Registry for Diagnostic Medical Sonography (ARDMS).

POC ultrasound and current practice

Of the subjects surveyed, 26.9% used ultrasound in their practice, 65.4% did not, and 7.7% had used it in the past. Of those who are using ultrasound, 33.3% used it daily, 33.3% used it three to four times per week, 8.3% used it once or twice per week, 16.7% used it less than once a week, and 8.3% used it once a month. Of those who used ultrasound, 83.3% received on-the-job training, 8.3% went to a certification course, and 8.3% completed a musculoskeletal ultrasound course sponsored by Duke University. When asked if they felt confident in their ability to use ultrasound, 62% responded yes; 61.5% of those who responded yes felt that they were adequately trained. The top reasons listed for not feeling adequately trained were not having enough hands-on training and not having enough individual instruction.

Reasons for PAs not using ultrasound in practice included “My practice does not own a machine” (50%), “My practice does not have the finances to buy a machine” (8.3%), “I don't feel that I have the time to learn how to use an ultrasound machine” (8.3%), “My practice does not have a provider who is experienced in training the staff on how to use ultrasound” (25%), and “I will be taking a course this summer” (8.3%). Of the 65.4% of respondents who did not use ultrasound in their practice, 35.3% were interested in bringing POC ultrasound to their practice; 64.7% were not interested. Table 1 lists the reasons subjects gave for lack of interest in bringing POC ultrasound into their practices.

T1
TABLE 1.:
Reasons PAs are not interested in integrating POC ultrasound into their practice

Future of POC ultrasound

When asked if PAs should have standardized training in POC ultrasound, 67.7% responded yes. Table 2 lists where respondents thought this training should take place.

T2
TABLE 2.:
Where PAs should be trained in POC ultrasound

When asked if PAs should be nationally certified in using POC ultrasound, 35.2% of respondents said yes with the following agencies granting certification: National Commission on Certification of Physician Assistants (42.9%), American Institute of Ultrasound in Medicine (14.3%), American Registry for Diagnostic Medical Sonographers (28.6%), a newly created independent POC ultrasound credentialing body (7.1%), and individual societies (7.1%).

POC ultrasound and PA education

Only one of the subjects was in PA education. Ultrasound was taught as part of the radiology class. The participant's program had no specific POC ultrasound course.

DISCUSSION

Recent studies have demonstrated significant interest in the use of POC ultrasound by physicians and residents in diverse practice areas.2,3,11 The Accreditation Council for Graduate Medical Education (ACGME) now requires ultrasound education for emergency medicine, internal medicine, radiology, and obstetrics/gynecology.6 Several surveys and review articles address POC ultrasound training and competency for undergraduate medical students.6,7,12,13 To our knowledge, this pilot study is the first survey that examines the use of POC ultrasound by PAs. Only 34% of our respondents use or have used ultrasound in their practices and only 35% of those who do not use ultrasound were interested in learning. Reasons for lack of interest fell into two broad categories: lack of pertinence to the respondent's practice area and challenges associated with learning POC ultrasound.

Our results indicate that more research is needed into the applicability of POC ultrasound to all PA practice areas. Recent PA workforce studies show that more PAs work in specialty areas than in primary care; more NPs work in primary care than specialties.14-16 In our study, most respondents worked in primary care, which may have skewed the perceived pertinence results. Development of a survey with a much larger sample size is necessary to determine a more accurate level of PA interest in POC ultrasound.

More research addressing the nature of PA training in POC ultrasound also is necessary. Unlike physicians and NPs, PAs have the flexibility to practice in any area. Determining what POC ultrasound examinations should be included in a core POC ultrasound curriculum for PAs is complicated. Future research on POC ultrasound training for PAs should focus on:

  • which examinations are pertinent, based on the most common PA practice areas
  • where and when training should take place
  • barriers to implementation
  • how to determine competence.

In our study, most respondents who favored standardized POC ultrasound training for PAs felt that it should take place in PA programs. Only one respondent in this study was an educator; however, the respondent's program did not include POC ultrasound in the curriculum.

LIMITATIONS

Limitations of this study include a small selected sample from one institution and a 51% response rate, thus limiting the generalizability. Additionally, only one respondent was a PA educator. Therefore, this research should not be generalized to PA programs and more research is needed on POC ultrasound in PA curricula.

CONCLUSION

Our pilot study is one of the first to determine PAs' views of POC ultrasound and will help to develop a larger survey addressing the nature of POC ultrasound for PAs, as well as training and competence issues. If our physician counterparts are using POC ultrasound to improve patient care, PAs should consider learning and integrating it into our practices. More research is needed to determine exactly how to achieve this goal.

REFERENCES

1. American Medical Association. Privileging for ultrasound imaging H-230.960. https://policysearch.ama-assn.org/policyfinder/detail/credentialing%20ultrasound?uri=%2FAMADoc%2FHOD.xml-0-1591.xml. Accessed February 9, 2018.
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12. Fox JC, Schlang JR, Maldonado G, et al. Proactive medicine: the “UCI 30,” an ultrasound-based clinical initiative from the University of California, Irvine. Acad Med. 2014;89(7):984–989.
13. Baltarowich OH, Di Salvo DN, Scoutt LM, et al. National ultrasound curriculum for medical students. Ultrasound Q. 2014;30(1):13–19.
14. Morgan P, Everett CM, Humeniuk KM, Valentin VL. Physician assistant specialty choice: distribution, salaries, and comparison with physicians. JAAPA. 2016;29(7):46–52.
15. Hooker RS, Brock DM, Cook ML. Characteristics of nurse practitioners and physician assistants in the United States. J Am Assoc Nurse Pract. 2016;28(1):39–46.
    16. Fraher EP, Morgan P, Johnson A. Specialty distribution of physician assistants and nurse practitioners in North Carolina. JAAPA. 2016;29(4):38–43.
    Keywords:

    point-of-care ultrasound; physician assistant; bedside; ultrasound; training; technology

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