Cardiac Point-of-Care Ultrasound: State of

the Art in Medical School Education

Amer M. Johri, MD, MSc, FRCPC, FASE, Joshua Durbin, MD, MSc,
Joseph Newbigging, MD, CCFP(EM), FCFP, Robert Tanzola, MD, FRCPC,
Ryan Chow, BSc, Sabe De, MD, FRCPC, and James Tam, MD, FRCP(C), FACC, Kingston and London, Ontario;
and Winnipeg, Manitoba, Canada

The development of small, user friendly, handheld ultrasound devices has stimulated the growth of cardiac
point-of-care ultrasound (POCUS) for the purpose of rapid, bedside cardiac assessment. Medical schools
have begun integrating cardiac POCUS into their curricula. In this review the authors summarize the variable
approaches taken by several medical training programs with respect to duration of POCUS training,
prerequisite knowledge, and methods of delivering these skills (including e-learning, hands-on training, and
simulation). The authors also address issues related to the need for competency evaluation and the limitations
of the technology itself. The studies reviewed suggest that undergraduate education is a viable point at which
to introduce basic POCUS concepts. (J Am Soc Echocardiogr 2018;-:---.)

Keywords: Point-of-care ultrasound, POCUS, Handheld ultrasound, Teaching, Guidelines

Cardiac point-of-care ultrasound for the purpose of rapid, bedside
cardiac assessment has changed practice. A cardiac ultrasound study
performed at the point of care in this manner is distinct from transtho-
racic echocardiography (TTE), which is a formal diagnostic test with a
particular billing code, a standardized protocol, an advanced analytic
component, and archiving and documentation requirements defined
by rigorous accreditation standards for acquisition and reporting
(Table 1).3 Although cardiac POCUS does not yet have such a
body of literature and quality programming underpinning its perfor-
mance, it may complement TTE in an integrative manner not only
by accelerating the identification of disease but also by enhancing
the physical examination and as a teaching tool for understanding car-
diac anatomy and physiology.
The utility of cardiac ultrasound as a teaching tool is of particular inter-
est to medical school educators. Many medical schools have begun to
incorporate novel teaching protocols that include cardiac ultrasound in
their curricula. The American Society of Echocardiography (ASE) also
defined its position by stating that POCUS may be viably integrated
into medical school curricula and may be used by noncardiologists and
nonsonographers.4 However, at this time, there is no standardized curric-
ulum or universal testing benchmark for cardiac ultrasound at this level.
Although the ASE is currently in the midst of developing such a recom-
mended curriculum, the intent of this review is to summarize published
reports to date of medical schools reporting their experiences in teaching
cardiac POCUS. The intent is not to develop a training guideline but to
summarize the literature that would underpin such a future effort.
For the purposes of this review, POCUS refers to the cardiac
setting. Other terms used in the literature referring to cardiac
POCUS include focused cardiac ultrasound and handheld cardiac ultra-
sound (HHU). We do not use the terms mini-echocardiography nor
pocket echocardiography, in order to distinguish POCUS from limited
standard TTE, which is a test that can be converted to a full protocol
during the course of the study by a trained operator as dictated by the
lesion encountered (Table 1). Formal standard TTE has a body of liter-
ature associated with appropriateness, quality control, accreditation,
archiving, and certification that is beyond the scope of this review.
WHAT DO WE TEACH? CURRENT GOALS OF CARDIAC
POCUS MEDICAL SCHOOL EDUCATION

From the Department of Medicine, Cardiovascular Imaging Network at Queen’s
(CINQ) (A.M.J., J.D., R.C.), the Department of Emergency Medicine (J.N.), and
the Department of Anesthesia (R.T.), Queen’s University, Kingston; the
Department of Medicine, Cardiology, University of Western Ontario, London
(S.D.), Ontario; and the Department of Medicine, Section of Cardiology,
University of Manitoba, Winnipeg, Manitoba (J.T.), Canada.
Dr. Amer Johri is funded by a Heart and Stroke Foundation Phase I Career Award.
This work was supported by the Canadian Society of Echocardiography POCUS
Committee.
Conflicts of Interest: None.
Reprint requests: Amer M. Johri, MD, MSc, FRCPC, FASE, Kingston General Hos-
pital, Watkins 1C, Room 4.1.312, 76 Stuart Street, Kingston, ON K7L 2V7, Canada
(E-mail: amerschedule@gmail.com).
0894-7317/$36.00
Copyright 2018 by the American Society of Echocardiography.
https://doi.org/10.1016/j.echo.2018.01.014
The ASE and the European Association of Echocardiography both
assert that POCUS should not be considered as a substitution for
either the clinical examination or standard echocardiography.2,5
Rather, such scans should be demonstrated to provide diagnostic
value when used as adjuncts to a clinical examination.6-9 Because
fundamental clinical examination skills have been shown to
develop during medical school, POCUS training during this time
may therefore have the most significant impact.
An overview of the current literature demonstrates significant vari-
ability in the design of the curricula used by medical schools, ranging
from no teaching to highly extensive teaching in all years and all blocks
of education. When used by most medical schools, the overall goals of
teaching POCUS appear to be summarized as follows: (1) introduction
of the concept of ultrasound relatively early in medical education,
including demonstration of common imaging views, correlation with
anatomy, and physical examination skills; (2) development of scanning
1
2 Johri et al Journal of the American Society of Echocardiography
- 2018

Abbreviations
techniques to a basic level of ages, whereas image interpretation was only lackluster. In contrast,
competence; and (3) recognition some studies implemented educational goals aimed equally at image
ASE = American Society of and differentiation between acquisition and quantitative diagnosis.14-16
Echocardiography normal anatomy and basic pa- Beyond the performance of image acquisition, some schools use
HHU = Handheld cardiac thology. cardiac POCUS and general ultrasound teaching to facilitate the
ultrasound With these goals in mind, the learning of basic cardiology concepts such as the physical examination
majority of studies introducing in the medical school curriculum. One such application is the use of
OSAUS = Objective
POCUS education to medical POCUS to assess right atrial pressure through visualization of the infe-
Structured Assessment of
Ultrasound Skills
students have stressed curricula rior vena cava, analogous to the physical examination technique of ju-
intended to educate students in gular veins.17 Visualization of cardiac valve structure and function
POCUS = Point-of-care making qualitative diagnoses of may also allow the teaching of auscultation and differentiation of car-
ultrasound specific pathologies (such as the diac murmurs and heart sounds.18
TTE = Transthoracic presence or absence of pericar-
dial effusion) and developing Summary. Currently, medical schools are using cardiac ultrasound
echocardiography
scanning technique, as opposed to teach anatomy, physical examination, and basic image acquisition
to making quantitative diagnoses of severity.6-8,10-13 In some studies, and to introduce recognition of simple disease pathology such as peri-
image acquisition and scanning technique using handheld devices cardial effusion and valvular regurgitation.
took precedence over the recognition of specific pathologies. A
preliminary curriculum created by Ho et al.13 focused primarily on
teaching fundamental POCUS theory and image acquisition and WHEN DO WE START? PREREQUISITE KNOWLEDGE
only briefly focused on clinical pathologies and diagnosis. Their curric- BEFORE POCUS TEACHING
ulum was justified with the notion that diagnosis and interpretation
require extensive time and clinical experience to acquire, whereas Creating a time frame for introducing POCUS education depends on
HHU technique and image acquisition can be learned within a brief consideration of prior knowledge. For example, an upper-year stu-
training program. Eighty-two percent of the students enrolled in the dent with prior education in cardiology and/or ultrasound imaging
study were deemed successful in their ability to acquire the correct im- would have an advantage over a novice first-year student without

Table 1 Comparison of POCUS and traditional TTE, with a brief overview of technological capabilities and limitations, indications
for techniques, and operators

POCUS TTE

Operators Typically  Level II, level III echocardiographer (physician)1

 Nonsonographer  ARDMS (sonographer)
 Nonradiologist  Credentialing laboratory
 May be conducted by traditional expert (ePOCUS)
Indications Assessment of  Wide spectrum
 Valvular function (gross)  See available published guidelines*
 Pericardial effusion/tamponade
 LV function/thickness
 RV function
 IVC
 Expert consensus available2
Technological  Usually portable (<15 lb)  Full-service machine
capabilities  2D imaging  2D imaging
 Color Doppler  Color Doppler
 3D imaging
 Strain
 Pulsed-wave Doppler
 Continuous-wave Doppler
 Telemetry signal
 Contrast can be applied
Advantages  Portability  ‘‘Gold standard’’
 Accessibility  High-quality images
 Relatively inexpensive compared to  Standardized guidelines for examination and reporting
traditional TTE machines  Multiple techniques available (3D, strain, contrast)
 Immediacy of results  Archiving of imaging studies
Limitations  Lack of formal training benchmarks  Portability
 Paucity of guidelines  Access
 Technological limitations  Cost of machines greatly exceeds that of portable units
2D, Two-dimensional; 3D, three-dimensional; ARDMS, American Registry for Diagnostic Medical Sonography; IVC, inferior vena cava; LV, left ven-
tricular; RV, right ventricular.
*A list of published ASE guidelines is available at http://asecho.org/ase-guidelines-by-publication-date/.
Journal of the American Society of Echocardiography
Volume - Number -
HIGHLIGHTS
 POCUS can be used for rapid, bedside cardiac assessment.
 There is no guideline for a universal teaching curriculum for
medical students.
 This review summarizes common elements found in current
published POCUS programs.
 Programs reported use of e-learning, hands-on learning, and
competency evaluation.
such education. Phase 1 of a study conducted by Cawthorn et al.11
consisted of an 8-week (16-hour) POCUS training program for first-
year medical students. When assessing image interpretation skills, stu-
dents demonstrated an 86% increase in POCUS examination scores.
However, the absolute mean postintervention score was quite low at
61.3%. Furthermore, of the five pathologies students were required to
identify, significant improvement was observed for only two lesions
assessed: left ventricular hypertrophy and mitral regurgitation. This
observation was postulated to be attributed to a lack of prior knowl-
edge: first-year students had not undergone their cardiology teaching
rotation, and thus the effectiveness of the POCUS training protocol
was restricted by the students’ knowledge of cardiac anatomy and pa-
thology. Phase 2 of the study consisted of a similar 4-week training
curriculum totaling approximately 16 hours of training, except that
the target group was third-year medical students who had all
completed their cardiology training. Even with a condensed training
program, the third-year students were found to significantly improve
their POCUS skills, confirming the researchers’ notion that a strong
foundation had a priming effect facilitating POCUS education.
It has also been proposed that using traditional ultrasound ma-
chines before delving into POCUS using handheld machines could
be of benefit. Martinez et al.16 designed a curriculum for a 1-month
elective in emergency bedside ultrasound offered to third- and
fourth-year medical students that encompassed a variety of examina-
tions for emergency medicine (including POCUS). Each week, stu-
dents tried a different ultrasound machine; however, HHU devices
were not provided until the students demonstrated competence
with full-size ultrasound machines. Martinez et al. asserted that their
goal was to ensure that students built enough confidence interpreting
acquired images using the highest quality full-size screen before tran-
sitioning to a pocket-size device. Student reception to the elective was
positive, and the researchers concluded that students gained profi-
ciency in ultrasound acquisition comparable with that of a resident
(postgraduate trainee). Although institutions looking to establish a
relatively brief or introductory curriculum for POCUS may not be
able to incorporate the necessary time and resources involved with
a full-service machine, those looking to use a longer duration curricu-
lum may want to consider the use of full-size ultrasound machines
before introducing HHU devices.
The ultrasound-integrated curriculum described by Hoppmann
et al.15 at the University of South Carolina School of Medicine takes
the principle of prior ultrasound experience and knowledge a step
further. This program places ultrasound as a foundational learning
pillar that is taught vertically over all 4 years of medical school, along-
side other fundamental and longitudinal skills, such as professional-
ism, quality, and patient safety. Image acquisition using traditional
ultrasound machines is taught in the first year of medical school,
with students focusing on using ultrasound images for anatomic
Johri et al 3
and physiologic learning purposes. Second-year medical students
are then taught to use ultrasound for pathology recognition, and
POCUS is introduced into their physical diagnosis modules. It is not
until the third year of medical school that students are finally provided
the opportunity to use HHU devices during their primary clerkships in
family medicine, internal medicine, and pediatrics. During this time,
students practice POCUS, as well as focused ultrasound of the
abdomen and pelvis. In addition to clinical implementation, students
are assessed for HHU acquisition ability at ultrasound stations during
their end-of-clerkship objective structured clinical examinations
before entering the fourth year. Likely because of the cumulative
experience in ultrasound and image acquisition, students score
remarkably well. These educators reported that students could ac-
quire good-quality images of the heart, inferior vena cava, abdominal
aorta, gallbladder, and urinary bladder. Students were able to capture
high-quality ultrasound images of the heart and vena cava, and when
scored against image interpretation, the researchers reported an
average interpretation score of 86% for 2014.15 Through the use of
a vertical curriculum, this study demonstrated the value of ultrasound
as an active learning tool when integrated within a primary medical
education model. The implementation of ultrasonography as a plat-
form to introduce new concepts in anatomy, physiology, pathology,
and physical examination diagnosis provided these medical students
with early exposure to imaging while introducing a useful clinical skill
that could be incorporated into future clinical practice.15
Summary. Cardiac ultrasound can be taught in all years of medical
school and in some schools is begun in the first year. Cardiac ultra-
sound as a teaching tool (i.e., anatomy teaching) and cardiac ultra-
sound as a diagnostic skill are distinct avenues of education.
Evidence suggests some perquisite cardiac knowledge is advanta-
geous in the performance of skills.
HOW MUCH TRAINING IS REQUIRED? CURRICULUM
DURATION
There is no clear consensus concerning the duration of cardiac
POCUS training required for postgraduate physicians, much less for
medical students. Of published accounts from medical schools, qual-
itative diagnosis-focused curricular designs have ranged in their dura-
tion from as little as a 2-hour training program to as long as
25 hours.6,12 Longer curricular types were generally the result of
more time provided for students to develop their image acquisition
skills through hands-on practice. For example, shorter courses offering
1.5 to 3 hours of hands-on training indicated that students were un-
able to significantly detect the presence of certain valvular pathol-
ogies.6,10 However, several studies demonstrated that students with
>5 hours of POCUS training afforded a significant improvement in
valvular pathology diagnosis.7,11,12 Considering that POCUS is
regarded as an operator-dependent technique by the ASE, the notion
that increasing practice time potentially correlates with increasing
diagnostic value is expected. However, with the presence of financial
concerns, resource commitments, and/or rigid scheduling, a POCUS
curriculum may have to be tailored to fit an individual school’s exist-
ing circumstances. A summary of POCUS curricula in various under-
graduate medical education programs may be found in Table 2.
HHU devices currently offer simplistic user interfaces and basic
controls.2,21,22 However, true mastery of HHU may actually be
more challenging than expected. Poorer image resolution,
4 Johri et al Journal of the American Society of Echocardiography
- 2018

Table 2 Summary of medical school curricula with integrated POCUS curricula

University Program length Population Teaching objective Results

Imperial 2-hour hands- Five senior Determine if ‘‘pocket Using pocket echocardiography
College on tutorial medical echocardiography’’ improved improved clinical diagnosis over
London6 students, clinical diagnostic skills in a group and above history, physical, and
three of medical learners ECG findings.
residents
University 4 hours of POCUS 21 senior Students examined patients referred POCUS improved sensitivity to
of Oslo10 training medical for echocardiography with detect/assess MR, LVSF, and
students emphasis on auscultation followed RVSF. Detection of dilated LA, RA,
by POCUS effusions, AI, and AS did not
improve significantly.
Ben-Gurion 8-hour training Three POCUS on rheumatic valve injury and Good ability for students with brief
University7 senior complications training to detect rheumatic valve
medical injury. Modest ability to detect
students rheumatic heart disease
complications.
Norwegian 9-hour theoretical 30 senior Medical students were given pocket Medical students with minimal
University of and practical medical devices and trained to assess training were able to use personal
Science and training students LVSF, mitral annular excursion, devices to supplement standard
Technology8 pericardial effusion, B-lines, IVC physical examinations and were
diameter, hydronephrosis, bladder able to acquire adequate images
distension, gallstones, signs of and interpret them with great
cholecystitis, diameter of accuracy.
abdominal aorta, and ascites
Queen’s 16 hours over 8 weeks 12 first-year Develop and evaluate a novel Self-directed electronic modules are
University11 medical curriculum for POCUS in primary effective for teaching introductory
students medical education POCUS interpretation skills, while
45 senior Students randomized to one of expert-guided training is critical for
medical lecture-based training and hands-on developing scanning technique.
students scan training, Web-based training
and hands-on scan training, and fully
self-directed training with Web-based
modules and high-fidelity simulator
training
Medical 25 hours over 5 days Two medical Students were taught basic cardiac When used by briefly trained medical
University of students views and how to assess LVSF, and students, POCUS provides an
Lodz, Poland12 results from bedside POCUS and acceptable diagnostic value with
standard TTE were compared notable learning curve effect.
Chinese 2.5-hour lecture 133 senior Students were taught basic cardiac Most students were able to execute
University of Prematerials medical views; objective was to train common cardiac views fairly
Hong Kong13 (video and lecture) students students in diagnosis of common efficiently and had variable
cardiac pathology although generally favorable
success rates in identifying various
cardiac abnormalities.
University of Vertical curriculum All medical Ultrasound curriculum integrated into Ultrasound was effective for use in
South Carolina15 over 4 years of students primary medical education, with a active learning curriculum, platform
medical school enrolled vertical approach to content for curricular integration, and
Five or six delivery, with differential focus teaching of clinical skill.
laboratory depending on year of training;
sessions per students were taught a variety of
semester scans with the objective of using
ultrasound as both active learning
tool in addition to clinical skill
University 3-min prelecture 18 second- Determine efficacy of remote live Novice ultrasound users able to
of Kentucky19 on use of POCUS year medical mentoring via Google Glass vs obtain adequate imaging that was
and Google Glass students direct bedside teaching as tools for able to determine a healthy model’s
ultrasound training EF through telementored education
using Google Glass.
(Continued )
Journal of the American Society of Echocardiography Johri et al 5
Volume - Number -

Table 2 (Continued )
University Program length Population Teaching objective Results

Dalhousie 2-hour hands-on Six senior Determine if ACES provides sufficient Following a focused training process
University47 training medical curriculum for POCUS training using medical simulation, medical
students through the use of high-fidelity learners demonstrated an ability to
Six PGY 1–3 ultrasound simulator achieve a degree of competency to
residents both acquire and correctly interpret
cardiorespiratory POCUS findings
using a high-fidelity ultrasound
simulator.
Icahn School Four modules, 142 first-year Study designed to assess the impact Students and faculty members agree
of Medicine14 20–40 min medical of a POCUS curriculum on image that physical examination course is
Integrated students acquisition, interpretation, and the right time to introduce
ultrasound student and faculty perceptions of ultrasound, students demonstrated
curricula into the course proper use of ultrasound machine,
physical cardiac, thoracic, and abdominal
examinations system assessments.
University of 4-week ultrasound 41 senior Offer a focused emergency medicine Students gained significant
Maryland elective medical bedside ultrasound elective confidence with their ultrasound
School of students skills and thought that they would
Medicine16 use them in the future.

ACES, Abdominal and cardiothoracic examination by sonography; AI, aortic insufficiency; AS, aortic stenosis; ECG, electrocardiographic; EF,
ejection fraction; IVC, inferior vena cava; LA, left atrium; LVSF, left ventricular systolic function; MR, mitral regurgitation; PGY, postgraduate
year of residency training; RA, right atrium; RVSF, right ventricular systolic function.
Senior medical students are medical trainees in their final 2 years of undergraduate medical education.

penetration, and processing power may result in greater difficultly for
novice examiners to acquire and interpret adequate images.2
Furthermore, because POCUS viability is operator dependent,
adequate image acquisition skills will decline if not practiced consis-
tently. Some educators report approaches that incorporate intensive
POCUS training into the standard curriculum as solutions to these
challenges.14,15 Nelson et al.,14 at the Icahn School of Medicine at
Mount Sinai, introduced a mandatory POCUS curriculum for the
entire first-year student body. Students were first taught basic ultra-
sound instrumentation on HHU devices and POCUS (as well as
focused thoracic ultrasound and focused abdominal ultrasound) later
in the curriculum as an adjunct to the physical examination module.
By teaching POCUS and other HHU techniques alongside the phys-
ical examination, the class had higher cardiac assessment scores than
could be achieved with physical examination alone.14
In contrast, a study by Charron et al.23 was unsuccessful in training
emergency physicians with HHU devices to perform reliable POCUS
using a brief 2-day training curriculum containing didactic cases and
hands-on practice with volunteers. In a correspondence to the study,
Gillon et al.24 recommended that future POCUS training curricula
should be combined with a longitudinal support system even after
training is complete to maintain and enhance skills. This highlights
an important challenge that faces POCUS education: ongoing quality
control and the transition to clinical practice.
Maintenance of competence of POCUS skills is essential but re-
mains a challenge. Kimura et al.18 outlined the issue of postgraduate
medical residents’ losing their skills without adequate ongoing use
of POCUS. Despite undergoing an extensive training program
throughout postgraduate internal medicine residency, which
included documentation of proficiency in a limited set of ultrasound
tasks, physicians rapidly lost their skills over the next few years
without practice. This study confirmed conventional wisdom that
without investment in equipment immediately after training and
use of practice, that knowledge and skill will be rapidly lost.
Frequent reaffirmation of their imaging and interpretative skills is vital.
Summary. The duration of teaching cardiac ultrasound image
acquisition and pathology recognition is highly variable. Given that
evidence suggests that there is attrition of skills, standardization of car-
diac ultrasound performance at the medical school level may inform
the need for ongoing quality benchmarks.
HOW IS CARDIAC ULTRASOUND TAUGHT IN MEDICAL
SCHOOLS? METHODS
The ASE recommends three core components of POCUS educa-
tion: didactic education, hands-on training, and image interpretation.2
Didactic education is currently used extensively to teach fundamental
POCUS material before hands-on training. Fundamental material
included the following curricular topics: ultrasound physics, relevant
cardiac physiology and anatomy, and pathologic versus normal states.
Didactic education offers the benefit of face-to-face interaction with
instructors to directly answer questions pertaining to theory and tech-
nique as they arise.2
Electronic learning (e-learning), involving the use of online multi-
media and/or interactive programs, is considered beneficial when
used as an adjunct to supplement didactic learning.4 E-learning has
a number of benefits. Students are allowed geographic portability to
complete course work via Internet access and the flexibility of work-
ing through material at their own pace.25 Furthermore, e-curricular
designs generally require fewer resource commitments, such as class-
room bookings and/or instructors.25 As such, many POCUS curricu-
lums have used ‘‘booster resources’’ that are intended to supplement
any material learned from a lecture.7 Stokke et al.10 used a novel cur-
riculum that incorporated e-learning when teaching medical students
6 Johri et al
to diagnose valvular disease using HHU devices. An online precourse
module was provided containing a number of ultrasound loop exam-
ples, as well as an overview of cardiac anatomy and pathology.
Students demonstrated a significant increase in sensitivity to detect
valvular disease when a physical examination incorporating
POCUS was compared with a standard physical examination with
a stethoscope alone (64% vs 40%). It was also noted by the re-
searchers that this training curriculum allowed more efficient learning.
Course time was relatively much shorter (only 4 hours of training to-
tal, not including booster modules) than similar didactic curricular
types, but student improvement was comparable with curricular de-
signs of greater length. The researchers surmised that this observation
was due to the presence of the online modules, which compensated
for a shorter training time.
Other studies have reinforced the idea that the use of e-learning may
provide a viable alternative to didactic lectures as a means of introducing
students to POCUS and teaching fundamental knowledge.2,10,11,15 As
part of an investigation into developing a novel POCUS curriculum,
Cawthorn et al.11 investigated how a didactic learning module and direct
hands-on ultrasound training compared with an e-learning module with
hands-on training or independently directed high-fidelity simulation for
teaching fundamental POCUS material to third-year medical students.
Following either online or didactic training, students would then train
with HHU devices to develop image acquisition skills independently
or with the guidance of expert sonographers. Curricular topics between
the didactic and e-learning programs were identical, with both programs
teaching POCUS fundamentals, cardiac anatomy, basic ultrasound
views, and a number of chosen pathologies to interpret. Students
were then evaluated upon their image interpretation abilities and using
an online multiple-choice examination, researchers found no significant
difference in learned interpretation among the educational interven-
tions. Furthermore, there were no significant differences in mean scan-
ning accuracy, while the mean image quality score of the e-learning/
simulation program was significantly lower than the other two.
Researchers postulated that these findings indicate an online module
may be a viable option to teach POCUS if personnel resources are
limited.
Millennial medical students have a strong propensity for the use of
Web- and social media–based curricula.26-28 Authors from The Ohio
State University supplemented an ultrasound curriculum with ‘‘push
technology,’’ whereby educational content was delivered to users’
mobile devices through the use of Twitter and Facebook. This pilot
study demonstrated that these technologies may represent effective
teaching and engagement tools to deliver content in a novel way and
in real time.26 Flipped classroom approaches to medical education
with POCUS have also been demonstrated, chiefly using Facebook
as a secure learning resource for groups of students to participate in
learning activities following traditional educational methods.27 The in-
vestigators of a randomized trial incorporating this post hoc training
demonstrated similar levels of knowledge retention after 6 weeks
compared with students without access, but they also found that stu-
dents appreciated this new teaching approach and were more satisfied
with their learning activities.27 Such Web-based activity could play a
role in ongoing quality control and maintenance of knowledge.
However, accurately documenting and reviewing the quality of the
myriad of Web- and social media–based tools for POCUS is a challenge
given the ever evolving nature of this format, which may or may not be
peer reviewed for accuracy and appropriateness. During the writing of
this review, commonly used hashtags demarcating POCUS-related
tweets included #POCUS, #FOAMed (free open-access medical edu-
cation), and #FOAMus (free open-access medical ultrasound). The
Journal of the American Society of Echocardiography
- 2018
Twitter handle @POCUSJournal and the corresponding app offer
peer-reviewed case reports. A case-based HHU iBook is also available.
The ASE POCUS task force is developing an online modular curricu-
lum at the present time with components spanning the use of POCUS
for teaching anatomy, physical examination, image acquisition, testing,
and basic disease interpretation (personal communication). The intent
is to create a ‘‘menu’’ of teaching modules that may be selected by med-
ical educators and students on the basis of the differing needs of their
existing curriculum and stage of study throughout the medical school
program.
HANDS-ON PRACTICE AND SIMULATION FOR DEVELOPING
IMAGE ACQUISITION SKILLS
When teaching students how to operate ultrasound devices for im-
age acquisition, hands-on practice with live patients is considered
of utmost importance in developing necessary clinical skills. Live pa-
tients offer a more realistic experience of a diagnostic setting, as stu-
dents can become accustomed to various body types that reflect
typical clinical practice (cardiac size, chest wall structure, patient
cooperation, etc). Also, with the accompaniment of a sonographer
instructor, feedback and troubleshooting can be provided immedi-
ately to students focusing on technique. Depending on when
hands-on POCUS education is implemented, or the number of
learners in a particular class, some curricula may require students
to practice on one another before actual patients, as clinical etiquette
has not yet been taught (similar to how students are encouraged to
practice using their stethoscopes on one another before clinical
internship). Although practicing POCUS skills on one another in stu-
dent groups may not replicate the ‘‘real-world’’ application of
POCUS, there are some derived benefits: the ability for significant
repetition, a lower stress environment, and lower potential financial
and manpower costs incurred when procuring real patients. Group
size has varied among pilot studies; Ho et al.13 used groups of four
or five students, whereas Stokke et al.10 used one-on-one practice.
No evidence was provided about an ideal group size, but it has
been generally assumed that hands-on sessions work best in smaller
groups. Prospective studies may look to investigate how group size
affects learning, as well as how many instructors per student are
required.
Schools with integrated ultrasound curricula (including POCUS),
such as the University of South Carolina School of Medicine or the
Icahn School of Medicine at Mount Sinai, start implementing
hands-on ultrasound practice as early as the first year of medical
school.14,15 The University of South Carolina School of Medicine
delivers an intensive, integrated, 4-year ultrasound curriculum to its
medical students, while researchers at the Icahn School of Medicine
at Mount Sinai incorporated an integrated POCUS program for just
its first-year medical students. Similar to the University of South
Carolina School of Medicine, ultrasound scanning sessions were coor-
dinated with gross anatomy modules and basic pathology assessment.
However, students were provided HHU devices (Vscan; GE
Healthcare, Little Chalfont, United Kingdom) immediately, rather
than starting with traditional ultrasound technology and eventually
moving to HHU devices in later years. Unlike Hoppman et al.,15
Nelson et al.14 emphasized a curriculum directed toward the practical
utility of handheld ultrasound in a diagnostic setting. In this respect,
the ultrasound curriculum at the Icahn School of Medicine may repre-
sent a more feasible approach to POCUS curricular implementation,
rather than a 4-year broad ultrasound program.
Journal of the American Society of Echocardiography
Volume - Number -
The ASE considers POCUS simulation platforms to be suitable ad-
juncts to hands-on training but emphasizes that the majority of hands-
on training should be performed on live patients.2 With an increased
interest in patient safety, a trainee’s access to hands-on practice may
be limited. Simulation platforms therefore provide a suitable alterna-
tive that does not put a patient at the risk of a novice physician and al-
lows the trainee to develop confidence in scanning before patient
interactions. There are several advantages of simulation technology.
For example, a simulation-based POCUS curriculum also has the
advantage of facilitating a standardized student assessment.
Simulation technology has also been praised for its ability to display
a wide variety of pathologies. These tools can now provide a wide li-
brary of pathologies that may be rare or difficult to find in real patients.
Although not yet a replacement for the challenge of generating images
on the diversity of real patient anatomy, simulators can provide early
learners with a rudimentary image generation experience and serve as
a starting point before real patient encounters. However, when ulti-
mately comparing ultrasound simulation platforms with traditional,
supervised, hands-on practice on patients, there have been variable re-
sults with respect to skill acquisition. A previous study demonstrated
that hands-on simulator training alone provided only modest improve-
ment to scanning technique compared with instructor-led training.11 It
was suggested that this observation was likely due to an experienced
instructor being able to provide constructive feedback, whereas no
such feedback exists in a simulation platform. Therefore, it was pro-
posed that a hybrid simulation/instructor-led training program has
the potential to provide the most benefit.
Augmented reality is a novel technology that makes use of a device
interface such as a smart phone or wearable technology to superim-
pose computer-generated virtual images over real-world objects as
seen by the user and is of emerging interest among medical ultra-
sound educators for not only imaging acquisition but for simulating
various clinical scenarios. A study by Russell et al.19 evaluated the
feasibility of a preliminary POCUS curriculum in which medical stu-
dents wore an integrated augmented reality device (Google Glass) for
real-time education by a remotely located instructor. After a brief
introduction to the HHU device, students were instructed to obtain
a parasternal long-axis view to approximate ejection fraction. A group
instructed solely using Google Glass obtained adequate images of
quality similar to another group of students taught directly by a live
instructor. An augmented reality–based curriculum represents an op-
tion for distance curricula for which expertise may not be local. Other
novel methods to enhance manual dexterity and image acquisition
skills will continue to evolve rapidly: for example, a semiautomated
or even artificially intelligent program embedded in a handheld de-
vice could precisely guide probe angles, correct image quality, and
provide a diagnosis at the point of care. ‘‘Gamification’’ is also being
explored as a way to stimulate accuracy of probe manipulation.
There are currently no rigorous studies demonstrating outcomes in
medical student learning using these emerging techniques.
Summary. The methodology for teaching POCUS to medical stu-
dents is highly variable, with no standard techniques or curricula.
Tools include traditional lectures, hands-on imaging guided by ex-
perts, and/or the use of simulation. The extent of disease interpreta-
tion is also variable, ranging from only assessment of normal to
integration within a clinical context. E-learning of POCUS includes
traditional online modules, but this image-based topic particularly
lends itself to social media networking educational tools used by a
new generation of digitally savvy learners.
Johri et al 7
COMPETENCY EVALUATION
POCUS and handheld ultrasound units are increasingly being used
within primary medical education as both a teaching tool and a clin-
ical skill, in addition to clinical practice for diagnoses and management
of pathological states. The quality and performance of these imaging
studies are highly operator dependent, and as a result, reliable and
viable assessments of trainee competence are necessary to ensure
their safe use in clinical settings.29
The International Federation for Emergency Medicine POCUS
curricular guidelines outline three core competencies critical to the
performance of POCUS: image acquisition, interpretation, and clin-
ical integration of findings to direct patient care.30 When assessing im-
age acquisition, competency was in some cases assumed when a
trainee had performed a specified number of practice examinations,
ranging from 25 to 300 depending on imaging study and organiza-
tion.31,32 Further evidence demonstrates that true competency
should be assessed by direct observation by an expert reviewer
using examination-dependent checklists.33,34 Image interpretation
may be assigned a metric score to assess recognition in addition to
a trainee assessment of image adequacy for diagnoses. Finally,
simulation-based experiences may be used to assess the integration
of these studies to direct patient care. These assessment methods
are largely institution dependent and include traditional testing via
formal assessment (i.e., objective structured clinical examinations),
simulation models, videotape review, direct observation of skills,
overreading by experienced sonographers, monitoring of trainee er-
ror rates using quality assurance processes, and reaching a predeter-
mined number of scans.35,36
Current evidence shows the best outcomes in validity and reli-
ability with the incorporation of task-specific checklists and a global
rating scale to assess good clinical practice.37,38 Todsen et al.29 demon-
strated good reliability and validity with the Objective Structured
Assessment of Ultrasound Skills (OSAUS), in which a generic scale
was implemented to score competence in POCUS. Operators were
scored on the following categories: applied knowledge of ultrasound
equipment, image optimization, systematic examination, image inter-
pretation, and documentation of the examination (scan). Physicians
were recorded performing ultrasound examinations, and their tech-
nical performance and their ultrasound images were assessed using
the OSAUS scale by two consultant radiologists subspecialized in ul-
trasound examinations. The authors report that OSAUS scores could
successfully discriminate among different levels of training and expe-
rience and that higher scores additionally correlated well with
numbers of correct diagnoses.29
Acute care POCUS certification is currently in development for
operators beyond medical school in both the United States and
Canada. In many jurisdictions, as an extension of the physical exam-
ination analogous to use of a stethoscope, no specific certification is
required. In Canada, the Royal College of Physicians and Surgeons
has recently formally recognized certification for advanced use of
POCUS as an area of focused added competence (J. Tam, AFC
Chair of Adult Echocardiography at the Royal College of Physicians
and Surgeons of Canada, personal communication). The require-
ments include competency-based postgraduate training as well as
maintenance of competence. Similarly, the National Board of
Echocardiography is beginning to develop a critical care examination
with use of POCUS as an area of competence. No such certification is
currently available at the medical school level. Although the ASE is
currently developing curricular material targeted toward medical
8 Johri et al
students, there are no certification plans available. However, the rec-
ommendations and guidelines outlined for the accreditation of educa-
tional programs in diagnostic medical sonography as defined by the
Joint Review Committee on Education in Diagnostic Medical
Sonography could be adapted for a POCUS curriculum.39
Summary. There are no formal or national standardized
competency-based benchmarks for medical students, though some
schools create and implement evaluation particular to their program
using an objective structured clinical examination or the OSAUS.
Current certifications in POCUS are specialty specific at the postgrad-
uate level.
WHAT ARE THE LIMITATIONS FACED BY MEDICAL
SCHOOLS FOR TEACHING POCUS?
Technology Limitations
Currently, there are technical limitations with the use of POCUS if us-
ing a handheld device or smaller portable device compared with a
‘‘full service’’ machine. The transducer is not yet the same on a
portable unit as on the larger formalized ultrasound machines.3
Complex image enhancement and artifact reduction capabilities
have not yet been reproduced on the pocket machines, but vendors
continue to rapidly improve the technology. Current handheld de-
vices have significantly lower screen resolution and screen size, adding
increased difficulty to use by the untrained operator. The abilities to
zoom, alter the ultrasound beam focus, narrow the sector width,
adjust dynamic range, use harmonic imaging, optimize imaging
studies for enhanced contrast, alter grayscale, or optimize transducer
frequency are currently lacking in the portable technology.2 As the
handheld units demonstrate, there is a trade-off between size and
technology, with smaller devices containing fewer features than tradi-
tional machines, though this will likely change with further miniatur-
ization of technology. These limitations make the identification of
subtle findings inappropriate for POCUS use at the moment.2 Data
have demonstrated that although POCUS has important limitations
for the imaging of pericardial constriction, pulmonary hypertension,
and diastolic dysfunction, operators and units were able to reliably
identify left ventricular enlargement, hypertrophy, systolic function,
left atrial enlargement, right ventricular enlargement and systolic func-
tion, pericardial effusion, and inferior vena cava size.2 Other potential
limitations of POCUS include the use of these images to draw conclu-
sions and guide patient care without ongoing mechanisms of
archiving, quality control, and skill evaluation. For example, off-axis
imaging and foreshortening of the imaging axis from the apical views
may be interpreted incorrectly which may lead to inappropriate pa-
tient care and management. A full discussion of these important lim-
itations balanced against advantages of cardiac POCUS is beyond the
scope of this review.2
Diagnostic Limitations
An important limitation is the lack of published accounts regarding the
diagnostic accuracy of POCUS use by medical students. Also, we were
not able to incorporate work done by all schools using POCUS if there
were no published accounts available. However, the general literature
on the accuracy of POCUS use by operators other than medical stu-
dents can be briefly summarized. The published literature reports
both generalized descriptive analyses and traditional statistical
methods to demonstrate accuracy of POCUS examinations using
Journal of the American Society of Echocardiography
- 2018
rates of concordance and discordance between POCUS and transtho-
racic echocardiographic studies.40-43 Descriptive analyses, using scale
anchors such as poor, fair, moderate, good, and excellent agreement,
were found to describe the rates of concordance and discordance
between POCUS and gold-standard transthoracic echocardiographic
studies. A limited number of published studies detailing the rates of
concordance and discordance of POCUS studies compared with stan-
dard TTE were available, and these demonstrate good concor-
dance.40-43 One study performed by Cullen et al.40 was able to
identify the assessment of left ventricular function and presence or
absence of regional wall motion abnormalities as one source of discor-
dance, with POCUS assessments overestimating the presence of
regional wall motion abnormalities. This study also found that with
the exception of discordance found at regional wall motion assess-
ment, the majority of discordance was attributed to POCUS studies
underestimating cardiac pathology rather than overestimating.40
One study reported difficulty in imaging right ventricular function
by POCUS compared with standard TTE, concluding, unsurprisingly
that TTE produces higher quality images than POCUS.41 These studies
taken together, generally suggest that POCUS and traditional TTE
have good, but not excellent, rates of concordance for the
assessment of cardiac structure and function.40-43 Further work
documenting medical student proficiency is required.
Personnel Resource Limitations
A challenge to implementing a sustainable POCUS program in med-
ical education can be the insufficient volume and availability of expert
faculty members. Those faculty with POCUS expertise may
frequently be involved in POCUS education at the faculty develop-
ment and postgraduate level and may have limited availability to
accommodate the high volume of undergraduate learners. Cardiac
POCUS expertise can be found in numerous disciplines, and identi-
fying faculty champions from emergency medicine, anesthesiology,
internal medicine, in addition to cardiology, can expand faculty re-
sources. Engaging postgraduate residents from these disciplines to
be POCUS teachers can expand the pool of instructors as well as
contribute to resident competencies as teacher and POCUS expert.
Another solution is to consider nonphysician experts such as sonogra-
phers as instructors. However, rotation through a busy echocardiogra-
phy laboratory can place additional burden on professionals who do
not have formal training as educators. Confusion with respect to the
goals of training also occurs. Targeting more intensive training on a
smaller group of medical student ‘‘super-users’’ or using upper-year
students already trained has potential to create a pool of peer tutors
who can also contribute to the implementation of a curriculum to a
large mass of students with few faculty members. It should be
cautioned however that at least one published account of peer-to-
peer teaching resulted in an increase in the false positive rate, when
tested at the postgraduate level.44
Legal, Ethical, Philosophical Considerations
The focus of this review was to assess the current state of cardiac
POCUS teaching in medical schools, and many aspects, including
legal, financial, philosophical, and ethical uses of POCUS, are beyond
its scope. However, these are important considerations requiring
further inquiry. On one hand, the handheld POCUS device is heralded
as the new stethoscope,45 and on the other, practical issues such as the
amount of training, guidelines for use, and storage and documentation
recommendations, are not yet established. The current approach of
Journal of the American Society of Echocardiography Johri et al 9
Volume - Number -

Figure 1 A potential approach to integrating cardiac ultrasound teaching during medical school. In this potential approach, the intro-
duction of cardiac ultrasound could be modular to complement established training goals. If anatomy and physiology are taught early,
cardiac ultrasound may help in the spatial understanding of structure and basic cardiac function. Introduction to machine functioning
(‘‘knobology’’) can also begin at this stage. In the middle years of medical school, following introduction of the cardiovascular system,
or simultaneously, ultrasound images of basic disease types can be introduced. Image acquisition skills can begin with the goals of
recognizing basic pathology such as pericardial effusion, left ventricular dysfunction, aortic stenosis, and mitral regurgitation. For
senior-year medical students, cardiac ultrasound may help in learning auscultation skills and be taught as an adjunct to the cardiac
physical examination. Fluid status assessment (inferior vena cava) and basic lung views can be introduced. Understanding of how
cardiac POCUS can integrate within the care pathway and complement existing imaging technology could be studied. Advanced-
level imaging will be dictated by specialty needs, several of which have formal certification programs.
the ASE’s POCUS task force and the Canadian Society of Currently there are no published legal accounts related to pocket-
Echocardiography POCUS committee is to consider cardiac sized imaging device use by medical students. However, this impor-
POCUS use by medical students to be a tool to help teach anatomy, tant discussion needs to begin. As this is a review of current literature,
to enhance the cardiovascular physical examination, and to serve as we are not positioned to provide legal recommendations but suggest
an introductory skill that may complement existing care approaches further research into the use of POCUS considering the following as-
following further development of specialty-specific skills at the post- pects related to the legal issues: (1) What is the role of the operator to
graduate level. To this end both societies are working toward establish- explain to the patient, and other members of the care team, that the
ing tools for introducing medical students to cardiac POCUS through scan being obtained is for physical examination purposes or point of
the development of a curriculum. Given that medical students may care testing, as opposed to formal echocardiography? (2) How should
further differentiate into areas of specialization during residency pro- cardiac POCUS scans be documented, stored, archived, compared?
grams that require skills in only particular aspects of the cardiac ultra- (3) Are all cardiac POCUS scans part of the physical examination,
sound protocol, the final level of ultrasound training should be left to or are some considered diagnostic testing? How do we decide? (4)
those specialty programs (i.e., emergency, anesthesia, critical care, in- Should medical students be applying technology for the assessment
ternal medicine, and cardiology have different ultrasound certification of their patients or should this be considered a delegated act?
programs). Should this application be supervised (overreading) or unsupervised?
10 Johri et al Journal of the American Society of Echocardiography
- 2018

Figure 2 Examples of POCUS used as an educational tool during medical school. (A) Parasternal long-axis view of the heart and
corresponding pathologic specimen (B) to correlate anatomy with functional imaging. (C) Subcostal view of the heart showing a peri-
cardial effusion (PE) which can be introduced as part of a discussion of intracardiac pressures and hemodynamics (D). (E) Short-axis
view of the of heart demonstrating thickening due to infiltrative disease, in this case related to cardiac amyloid histology (F). (G) Simul-
taneous visualization of structures contributing to auscultatory findings may assist in understanding and auditory skill acquisition of
heart sounds (H). Panel (C) is reproduced from Cenkowski et al.20 with permission, panel (E) is reproduced from Wilkinson48 with
permission, panel (F) depicts intermediate magnification micrograph of senile cardiac amyloidosis and is reproduced here through
a CC BY-SA 3.0 Creative Commons license (Copyright 2011 Michael Bonert; https://commons.wikimedia.org/wiki/User:Nephron.
You are free to share and adapt this image as per the CC BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0/legalcode).
LV, Left ventricle; LVOT, left ventricular outflow tract; PEff, pericardial effusion; RA, right atrium; RV, right ventricle.
Journal of the American Society of Echocardiography
Volume - Number -
Currently there is little published evidence dealing with the legal
aspects of cardiac POCUS use.
Summary. Current limitations faced by medical schools for teach-
ing cardiac POCUS include the limitations of the technology and
the lack of knowledge related to its diagnostic accuracy in the hands
of undergraduates. Other important limitations include personnel re-
sources to teach skills and a lack of legal and philosophical discourse.
CURRENT RECOMMENDATIONS
Currently there are no randomized trials demonstrating that teaching car-
diac POCUS at the medical student level is advantageous over teaching at
the postgraduate level. However, despite this lack of evidence, POCUS
training at the medical student level continues to be implemented by pro-
gram directors across North America and is in fact in demand by
trainees.28,46,47 For example, when the vice deans of Canadian medical
schools were polled, they overwhelmingly (77% of the 13 responding
schools) responded that there is a need to incorporate POCUS training
programs into their primary medical education.47 Similarly, of the re-
sponding Canadian medical schools, more than half had already inte-
grated POCUS into their undergraduate medical education.47
The goal of this review was to review published accounts of this
emerging trend and summarize common elements found in these pro-
grams, rather than create a training recommendation document. These
elements may serve as a framework for program directors wishing to
create POCUS curricula within their schools or for organizations such
as ASE to create a standardized curriculum. Although there are currently
no standardized guidelines for creating a novel POCUS education pro-
gram for medical schools, common or useful elements gleaned by the au-
thors of this review were noted to be (1) prerequisite knowledge: cardiac
physical examination or anatomic didactic and laboratory teaching; (2)
skills: hands-on training with ultrasound units, image acquisition, and
interpretation training; (3) evaluation: competency-based assessments;
(4) goals: teaching of cardiac POCUS aimed at enhancing cardiac phys-
ical examination skills or augmenting anatomic learning; (5) scope: the
principle that cardiac POCUS training at the medical student level serve
as a basic introduction with further specialty-tailored skill development at
the postgraduate level; and finally (6) context: provision of an under-
standing of how cardiac POCUS integrates into clinical care flow
pathway, appropriateness, limitations, and relation to advanced or formal
imaging such as echocardiography.
Following review of the review of various medical schools, we
noted a highly varied approach to the timing and programming of
medical school teaching in general, so any attempt to build a standard-
ized cardiac POCUS curriculum may be most successful if it is
modular, allowing topics to be introduced at variable times as felt
best by program directors. Figure 1 demonstrates a potential
approach to incorporating POCUS into the medical school curricu-
lum on the basis of a synthesis of reports reviewed herein. Figure 2
provides some potential cardiac POCUS images as archetypal exam-
ples for various learning contexts. This review may serve as a starting
point for development of a standardized global curriculum for teach-
ing cardiac POCUS to medical students.
CONCLUSIONS
There continues to be a shift toward earlier introduction of POCUS in
medical education. The studies reviewed suggest that undergraduate
education is a viable point at which to introduce basic POCUS
Johri et al 11
concepts in their own right and as learning tools. Current approaches
to the duration of undergraduate training, methodology of teaching,
and evaluation are highly variable. Common themes include the
use of POCUS as a tool to teach anatomy, to enhance the physical
examination, and as an introductory diagnostic skill in anticipation
of further subspecialty development.
An ASE-designed medical school curriculum will consist of six on-
line expanded modules based on this work which will appear under
the Education tab on the ASE website (asecho.org) with a planned
launch date for the beta version of June 2018 (Johri, personal commu-
nication, 2018).
REFERENCES
1. Ryan T, Berlacher K, Lindner JR, Mankad SV, Rose GA, Wang A. COCATS
4 Task Force 5: training in echocardiography. J Am Coll Cardiol 2015;65:
1786-99.
2. Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ.
Focused cardiac ultrasound: recommendations from the American Soci-
ety of Echocardiography. J Am Soc Echocardiogr 2013;26:567-81.
3. Liebo MJ, Israel RL, Lillie EO, Smith MR, Rubenson DS, Topol EJ. Is pocket
mobile echocardiography the next-generation stethoscope? A cross-
sectional comparison of rapidly acquired images with standard transtho-
racic echocardiography. Ann Intern Med 2011;155:33-8.
4. Via G, Hussain A, Wells M, Reardon R, ElBarbary M, Noble VE, et al. In-
ternational evidence-based recommendations for focused cardiac ultra-
sound. J Am Soc Echocardiogr 2014;27:683.e1-33.
5. Sicari R, Galderisi M, Voigt JU, Habib G, Zamorano JL, Lancellotti P, et al.
The use of pocket-size imaging devices: a position statement of the Eu-
ropean Association of Echocardiography. Eur J Echocardiogr 2011;12:
85-7.
6. Panoulas VF, Daigeler AL, Malaweera AS, Lota AS, Baskaran D,
Rahman S, et al. Pocket-size hand-held cardiac ultrasound as an adjunct
to clinical examination in the hands of medical students and junior doc-
tors. Eur Heart J Cardiovasc Imaging 2013;14:323-30.
7. Shmueli H, Burstein Y, Sagy I, Perry ZH, Ilia R, Henkin Y, et al. Briefly
trained medical students can effectively identify rheumatic mitral valve
injury using a hand-carried ultrasound. Echocardiography 2013;30:
621-6.
8. Andersen GN, Viset A, Mjolstad OC, Salvesen O, Dalen H, Haugen BO.
Feasibility and accuracy of point-of-care pocket-size ultrasonography per-
formed by medical students. BMC Med Educ 2014;14:156.
9. Mjolstad OC, Dalen H, Graven T, Kleinau JO, Salvesen O, Haugen BO.
Routinely adding ultrasound examinations by pocket-sized ultrasound de-
vices improves inpatient diagnostics in a medical department. Eur J Intern
Med 2012;23:185-91.
10. Stokke TM, Ruddox V, Sarvari SI, Otterstad JE, Aune E, Edvardsen T. Brief
group training of medical students in focused cardiac ultrasound may
improve diagnostic accuracy of physical examination. J Am Soc Echocar-
diogr 2014;27:1238-46.
11. Cawthorn TR, Nickel C, O’Reilly M, Kafka H, Tam JW, Jackson LC, et al.
Development and evaluation of methodologies for teaching focused car-
diac ultrasound skills to medical students. J Am Soc Echocardiogr 2014;
27:302-9.
12. Filipiak-Strzecka D, John B, Kasprzak JD, Michalski B, Lipiec P. Pocket-size
echocardiograph—a valuable tool for nonexperts or just a portable device
for echocardiographers? Adv Med Sci 2013;58:67-72.
13. Ho AM, Critchley LA, Leung JY, Kan PK, Au SS, Ng SK, et al. Introducing
final-year medical students to pocket-sized ultrasound imaging: teaching
transthoracic echocardiography on a 2-week anesthesia rotation. Teach
Learn Med 2015;27:307-13.
14. Nelson BP, Hojsak J, Dei RE, Karani R, Narula J. Seeing is believing: eval-
uating a point-of-care ultrasound curriculum for 1st-year medical students.
Teach Learn Med 2017;29:85-92.
12 Johri et al
15. Hoppmann RA, Rao VV, Poston MB, Howe DB, Hunt PS, Fowler SD, et al.
An integrated ultrasound curriculum (iUSC) for medical students: 4-year
experience. Crit Ultrasound J 2011;3:1-12.
16. Martinez JP, Sommerkamp SK, Euerle BD. How we started an elective in
emergency bedside ultrasound. Med Teach 2015;37:1063-6.
17. Rizkallah J, Jack M, Saeed M, Shafer LA, Vo M, Tam J. Non-invasive bedside
assessment of central venous pressure: scanning into the future. PLoS One
2014;9:e109215.
18. Kimura BJ, Sliman SM, Waalen J, Amundson SA, Shaw DJ. Retention of
ultrasound skills and training in ‘‘point-of-care’’ cardiac ultrasound. J Am
Soc Echocardiogr 2016;29:992-7.
19. Russell PM, Mallin M, Youngquist ST, Cotton J, Aboul-Hosn N, Dawson M.
First ‘‘glass’’ education: telementored cardiac ultrasonography using Goo-
gle Glass—a pilot study. Acad Emerg Med 2014;21:1297-9.
20. Cenkowski M, Johri AM, Pal R, Hutchison J. Early signs of tamponade may
be detected by cardiac point-of-care ultrasound. POCUS J 2017;2:24-5.
21. Seraphim A, Paschou SA, Grapsa J, Nihoyannopoulos P. Pocket-sized
echocardiography devices: one stop shop service? J Cardiovasc Ultrasound
2016;24:1-6.
22. Mirabel M, Celermajer D, Beraud AS, Jouven X, Marijon E, Hagege AA.
Pocket-sized focused cardiac ultrasound: strengths and limitations. Arch
Cardiovasc Dis 2015;108:197-205.
23. Charron C, Templier F, Goddet NS, Baer M, Vieillard-Baron A. Difficulties
encountered by physicians in interpreting focused echocardiography us-
ing a pocket ultrasound machine in prehospital emergencies. Eur J Emerg
Med 2015;22:17-22.
24. Gillon S, Walker D, Jones N. Barriers to focused echocardiography educa-
tion. Eur J Emerg Med 2016;23:75-6.
25. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical ed-
ucation. Acad Med 2006;81:207-12.
26. Bahner DP, Adkins E, Patel N, Donley C, Nagel R, Kman NE. How we use
social media to supplement a novel curriculum in medical education. Med
Teach 2012;34:439-44.
27. Hempel D, Haunhorst S, Sinnathurai S, Seibel A, Recker F, Heringer F,
et al. Social media to supplement point-of-care ultrasound courses: the
‘‘sandwich e-learning’’ approach. A randomized trial. Crit Ultrasound J
2016;8:3.
28. Durbin J, Johri AM, Sanfilippo AJ. Does the addition of ultrasound
enhance cardiac anatomy learning in undergraduate medical education?
POCUS J 2017;2:7-8.
29. Todsen T, Tolsgaard MG, Olsen BH, Henriksen BM, Hillingso JG, Konge L,
et al. Reliable and valid assessment of point-of-care ultrasonography. Ann
Surg 2015;261:309-15.
30. International Federation for Emergency Medicine. IFEM point-of-care ul-
trasound curriculum guidelines 2014. Available at:. http://www.ifem.cc.
Accessed November 8, 2016.
31. American College of Emergency Physicians. Emergency ultrasound guide-
lines. Available at: http://www.acep.org. Accessed November 8, 2016.
32. Cheitlin MD, Alpert JS, Armstrong WF, Aurigemma GP, Beller GA,
Bierman FZ, et al. ACC/AHA guidelines for the clinical application of
Journal of the American Society of Echocardiography
- 2018
echocardiography. A report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines (Commit-
tee on Clinical Application of Echocardiography). Developed in collabo-
ration with the American Society of Echocardiography. Circulation
1997;95:1686-744.
33. Jang TB, Ruggeri W, Dyne P, Kaji AH. The learning curve of resident phy-
sicians using emergency ultrasonography for cholelithiasis and cholecys-
titis. Acad Emerg Med 2010;17:1247-52.
34. Hertzberg BS, Kliewer MA, Bowie JD, Carroll BA, DeLong DH, Gray L,
et al. Physician training requirements in sonography: how many cases
are needed for competence? AJR Am J Roentgenol 2000;174:1221-7.
35. Emergency ultrasound guidelines. Ann Emerg Med 2009;53:550-70.
36. Henneberry RJ, Hanson A, Healey A, Hebert G, Ip U, Mensour M, et al. Use
of point of care sonography by emergency physicians. CJEM 2012;14:
106-12.
37. Sultan SF, Iohom G, Saunders J, Shorten G. A clinical assessment tool for
ultrasound-guided axillary brachial plexus block. Acta Anaesthesiol Scand
2012;56:616-23.
38. Ahmed K, Ashrafian H, Hanna GB, Darzi A, Athanasiou T. Assessment of
specialists in cardiovascular practice. Nat Rev Cardiol 2009;6:659-67.
39. Commission on Accreditation of Allied Health Education Programs. Stan-
dards and Guidelines for the accreditation of educational programs in
diagnostic medical sonography. Available at: http://www.jrcdms.org/
pdf/DMSStandards.pdf. Accessed January 5, 2018.
40. Cullen MW, Blauwet LA, Vatury OM, Mulvagh SL, Behrenbeck TR,
Scott CG, et al. Diagnostic capability of comprehensive handheld vs trans-
thoracic echocardiography. Mayo Clin Proc 2014;89:790-8.
41. Testuz A, Muller H, Keller PF, Meyer P, Stampfli T, Sekoranja L, et al. Diag-
nostic accuracy of pocket-size handheld echocardiographs used by cardi-
ologists in the acute care setting. Eur Heart J Cardiovasc Imaging 2013;
14:38-42.
42. Kitada R, Fukuda S, Watanabe H, Oe H, Abe Y, Yoshiyama M, et al. Diag-
nostic accuracy and cost-effectiveness of a pocket-sized transthoracic
echocardiographic imaging device. Clin Cardiol 2013;36:603-10.
43. Prinz C, Voigt JU. Diagnostic accuracy of a hand-held ultrasound scanner
in routine patients referred for echocardiography. J Am Soc Echocardiogr
2011;24:111-6.
44. Wilkinson JS, Barake W, Smith C, Thakrar A, Johri AM. Limitations of
condensed teaching strategies to develop hand-held cardiac ultrasonogra-
phy skills in internal medicine residents. Can J Cardiol 2016;32:1034-7.
45. Solomon SD, Saldana F. Point-of-care ultrasound in medical education—
stop listening and look. N Engl J Med 2014;370:1083-5.
46. Prager R, McCallum J, Kim D, Neitzel A. Point-of-care ultrasound in un-
dergraduate medical education: a survey of University of British Columbia
medical student attitudes. UBCJM 2016;7:12-6.
47. Steinmetz P, Dobrescu O, Oleskevich S, Lewis J. Bedside ultrasound edu-
cation in Canadian medical schools: a national survey. Can Med Educ J
2016;7:e78-86.
48. Wilkinson J. Cardiac amyloidosis using on routine hand-held ultrasound.
POCUS J 2016;1:3.