Relative advantage
Participants reported that the use of PoCUS provided a ‘relative advantage’ in their clinical practice. PoCUS provided physicians with additional information that led to improved clinical decision making. The overarching value of PoCUS to rural practice was consistently expressed by participants with observations like, ‘it is a game-changer for small communities’ and ‘[I]t’s an incredibly important tool that I don’t think I can practice in rural Canada without any longer.’
Many participants referenced the advantage of PoCUS to improve system functioning, specifically by reducing the draw on formal imaging services. Several participants emphasized the convergence of information gained from the scans with the patient’s history, physical exam, and other diagnostics led to better decision making and transfer avoidance. Participants noted the value of PoCUS in diagnosing fractures and heart failure. Additionally, PoCUS was an invaluable visual guide for procedures, such as inserting a central line or IUD. One participant noted the value of this specifically for maternity care:
‘I wasn't sure [if] one of my… patients was breech. I didn't have to send her to the hospital, I could just do a quick office ultrasound… or if they couldn't find a fetal heart at 13 weeks when they should've been able to, they would send their patients to me instead of bothering the hospital. So, for obstetrical reasons, [I could] take the load off of the hospital.’
Within the context of COVID-19, several participants noted the advantage of doing lung PoCUS. Some participants noted that although a COVID-19 diagnosis is based on the presentation of clinical symptoms, ultrasound was helpful as it provided additional clinical information. As one participant noted,
‘[It] might not change anything you’re going to necessarily do. However, it might change the conversation that you have with the patient. You can say, “from what I’m seeing, I now more strongly believe that you have a viral pneumonia such as COVID.”’
Overall, participants in this study observed the simplification of their job due to PoCUS, and immediate feedback was extremely useful, particularly in communities without access to formal ultrasound services. As one participant noted,
‘But there are certain instances where you can get a positive [result], interpret it, make a clinical decision that changes the outcome and helps the patient a lot. So that’s where it really makes a difference for me.’
Participants pointed out that the use of PoCUS increased their confidence and empowered them to provide better patient care, which led to increased job satisfaction. As one participant noted, ‘[I]t brings you back to the bedside. And so, it brings back the humanity of medicine for me in many ways.’ The importance of care providers’ job satisfaction in health care sustainability has been well-recognized and documented and is now included in Institute for Healthcare Improvement’s (IHI) Quadruple Aim (along with better health outcomes, better satisfaction and lower costs).23,24 Others noted how the availability of PoCUS facilitated recruitment to low volume sites, with interested candidates reassured of having colleagues who are early-adopters of PoCUS in the communities.
Compatibility
Almost all participants in this study noted that the use of PoCUS was an extension of their generalist medical training and experience. Participants articulate their use of PoCUS as an extension of the physical exam or ‘extending the senses of a practitioner.’ This sense of compatibility was seen as foundational to widespread adoption due to low barriers to usage. A participant expressed, ‘I don’t want to lose the quality of the ultrasound being an extension of the physical exam because that, to me, lowers the barrier to people using it.’ Others expressed more directly their view of PoCUS as an extension of known skills. As one participant said:
‘I was teaching med students percussion… And I was like, this is just ultrasound, but old school… you’re basically using sound waves to try and detect fluid under a structure… And now, we have an ultrasound machine that can help us visualize what we were listening to before. [T]o me, that’s so powerful… We do need to make sure there’s safety that it’s being used in a safe way.’
For some, a sense of compatibility was reflected through the awareness of what their role vis-à-vis PoCUS was not: an equivalent or replacement of specialist diagnostic imaging. One physician pointed out, ‘a diagnostic scan is a very different kettle of fish with some very, very strict and clear parameters and is an incredibly useful tool. It’s just a different tool than point-of-care ultrasound.’ Participants recognize specialized diagnostic imaging to be outside of their scope of practice, training, and comfort. For Family Physicians, the use of PoCUS aligned with their generalist education and training and informed their practice boundaries regarding what they were not comfortable doing. As one participant observed:
‘I don't have a problem saying 'no, I'm not doing that. It's not safe'… I can't have that become the precedent or the kind of standard because it's not the standard of care… [L]ike the DVT is a classic example: we're trying to do the patient a favour, we're trying to save them from having to travel, but if you miss an actual DVT and they have a PE and die, you haven't done the patient a favor.’
Almost all participants noted that they limit the use of PoCUS to situations within generalist scope and training. In doing so, participants have a strong sense of caution not to exceed their expertise, recognizing the potential for significant clinical consequences. Moreover, participants extended their awareness of their generalist skillset to the application and interpretation of PoCUS:
‘So, there could be things that I'm missing, but I think I’m careful enough with my clinical judgment that I would never send somebody… out of the department where I’m clinically concerned and my scan is negative and then I just say, “oh well, my scan was negative so we're good”… I don't fully rely on my scanning to make decisions like that.’
For most participants in this study, there was an overall appreciation of PoCUS as a clinical tool that is used to answer specific 'yes-or-no' questions rather than a diagnostic test. When an unexpected finding did arise, participants noted the importance of a radiological consult. This was congruent with others who noted that a key attribute to rural PoCUS use was 'being honest about your limitations'.
Complexity
Participants in this study identified two levels of complexity in using PoCUS: technological complexity and a sense of social complexity arising out of the practice setting. The former was seen to be easily addressed with additional exposure to the technology, while solutions to the latter were less determined.
A. Technology complexity: familiarization period
Physicians expected a learning curve in getting acquainted with the new technology. Participants noted challenges with connectivity, including choice of connecting modality (Wifi, LAN, data). Other entry-level challenges included determining how to best physically incorporate the probe into the practice setting (‘…do people carry it, do you put it in your pocket? How do you bring it to the bedside?’) and incorporate into their daily workflow such as forgetting to charge the battery (of both the probe and the cell phone through which it works) and that the Clarius probe itself ‘can be finicky.’ In the context of COVID-19, others noted difficulty negotiating the use of the probe in a bag to ensure a sterile environment and navigating the cleaning protocol to mitigate COVID-19 transmission. Regardless of the simplicity of addressing the perceived technological challenges, most participants noted that they were less inclined to use the technology when confronted with any technological perturbations.
B. Social complexity: challenges of ensuring accurate clinical diagnosis
Although most participants in this study reported that PoCUS was straightforward to adopt and use with minimal instruction, they expressed practice setting complexities of ensuring accurate clinical diagnosis. Many participants mentioned that they had to constantly navigate the boundaries of their training, experience and the subsequent need to maintain ‘that index of clinical suspicion.’ Most participants had a high degree of caution around using findings from a scan alone in making clinical assessments, especially when the consequences of a false negative could be significant. Relatedly, participants stressed the importance of recognizing when a scan would not be helpful or 'knowing when to give up.' Several participants cautioned against ‘fishing expeditions’ due to the danger of ‘finding something you are going to misinterpret.’ Many participants referred to the value of 'healthy fear' or, as one participant noted, the importance of having 'respect for ultrasound before you start using it in your practice.' These social determinates of practice were imbued with social complexity and, some participants recognized the propensity for rural health care providers to 'go above and beyond.' Participants noted the tendency when working in low-resourced environments to 'get pressed into spreading ourselves thinner and thinner, working miracles with nothing' while realizing as well that adverse events 'end up on our shoulders.' Negotiating this tension came through as complexity of professional practice with regards to PoCUS.
C. Social complexity: negotiating the use of PoCUS scans
Participants expressed the social complexity of negotiating the function and use of PoCUS scans, which is traditionally a specialist domain. Formal scans are done upon the patients' arrival to a larger centre, regardless of the conclusively of the PoCUS scans done, to confirm the diagnosis and assess for progression. In some instances, formal imaging was deemed unnecessary based on the availability of the bedside scans. Formal scans were forgone in instances when there was an existing and trusting relationship between rural physicians and specialists: 'I sent a referral to the surgeon and said you know I've arranged formal imaging, but she, the surgeon, also knew that I had also done the fellowship and so she kind of took my word for it.' Although most agreed they would not make a specialist referral without an official scan, several mentioned they would include the results of a PoCUS to the radiologist as a rationale for an urgent scan.
Relatedly, most respondents reported minimal ‘pushback’ from specialists and received helpful support for PoCUS in rural settings. As one noted, ‘I’d say that the vast majority of specialists that have been consulted where ultrasound is part of the clinical picture have been excited that we’re doing bedside ultrasounds’. Others noted specialists’ understanding of rural, low-resource practice settings and an appreciation that local providers do ‘whatever [they] can.’ Although most respondents had positive consultation experiences, many also noted hearing otherwise from colleagues: ‘I’m also aware of situations where it hasn’t been as positive.’ The minority of respondents who experienced a lack of support from regional specialists noted that the lack of support seemed to be due to the protocol of only reading images generated by Ultrasound Technicians. This created a sense of resignation for these providers.
Trialability
In the context of PoCUS, ‘trialability’ addresses the introduction into rural practice and the organic emergence of practice patterns, protocols and the capacity to ‘course correct’ based on observable process outcomes. As PoCUS is a relatively new protocol for generalist care providers, participants appreciated the emergence of practice patterns and for conventions to be developed in an iterative way that responds to the realities of rural practice. Participants noted the need to seek clarity and/or solution on the following areas: integrating PoCUS into regular workflow patterns, financial considerations for using PoCUS (billing codes for generalist PoCUS use and subsidizing providers for technology and education), and creating clarity around the legal implications of PoCUS scans including regulatory guidance and accreditation.
A. Financial pressures associated with PoCUS uptake
Participants diverged on the ease with which they incorporated PoCUS into the context of their clinical practice based on whether they practiced in a fee-for-service or alternative payment setting. PoCUS learners expressed challenges with needing more time at the start to learn PoCUS (‘[W]hen you're still learning, it can slow you down. When you're really adept, then it's like you're pulling it out on every patient because it's what you're using instead of a stethoscope, basically'). Consistently, those in an Alternative Payment Program (APP), or those in a salaried position, reported ease in integrating PoCUS into their practice. Conversely, those in a fee-for-service setting found the additional time required to learn and use PoCUS was incompatible with the efficiency of their practice. Additionally, a participant noted:
‘[T]here’s definitely people that I'm seeing in a family practice context where I'm not telling them I have an ultrasound… because it's going to double the length of the appointment, and I can't do that when I have a full waiting room. … It just makes my life so much more stressful when I have a whole bunch of people that now you're getting further and further behind, and it’s so uncomfortable to be working on that situation.’
Several participants in a fee-for-service environment noted a perceived advantage of creating billing codes for PoCUS scans to incentivize practice (such as in Ontario and Quebec): ‘if you want something to get done, put a billing code on it, it'll start getting done.’
Participants noted the value of funding for the technology itself, and many are wary of the financial barriers involved in keeping current with PoCUS. Many participants noted that they would not have a probe if the subsidy for the probes and training from the Rural Coordination Centre of BC were unavailable. Participants saw value to training programs, beyond scanning and reading images to including ‘the ability to not be overconfident.’ Some noted the amount of personal expenditure that would be incurred to improve efficiency and patient care: ‘[Y]ou provide better patient care but you won't get any more remuneration, you'll actually take a bit of a pay [cut] to pay it off and then the training and stuff to do with it…’ Others noted the technological imperative towards improvement and obsolescence, which can be challenging due to financial barriers of keeping up-to-date with the technology.
B. Liability and accreditation
Several study participants queried their legal liability for scans that lead to a course of care, particularly when the objective of the scan may be to seek information to reduce unnecessary transfers out of the community. One participant asked specifically ‘[D]oes this suffice in place of a formal ultrasound? Am I putting myself at legal liability by doing a AAA screen and saying, "Well, they're negative?”’ Participants also noted a lack of guidance from professional bodies and the perception of the aversion to address the issue:
‘The college has no policy on ultrasound. And they need one, they need to decide what's in line - what's the scope of practice and what isn't. And they may be forced to do that very shortly here.
Another participant noted ‘the college is going to have to issue a statement on their thoughts on point-of-care ultrasound replacing other modalities.’
Several participants raised the issue of accreditation within the emerging practice environment. Participants in this study expressed a desire for PoCUS training to be normalized and accessible by accrediting PoCUS. Participants often express ‘[PoCUS] should be part of and embedded into the training of anybody who's doing bedside care.’ However, participants are concerned about accrediting PoCUS, which can lead to additional barriers to using PoCUS:
‘Well, I actually hope it doesn't get more regulated, to tell you the truth. I hope it doesn't become [accredited]. I think… it is accessible to everyone [now]. We were trained to use it and know what we're doing. And if we don't know what we're doing, we ask for help.’
Further arguments were made against accreditation due to the value of real-time and real-world PoCUS training over courses ‘using standardized patients with no pathology.’ Underlying most arguments against accreditation was the sentiment that most physicians know their limitations and know when they need help and relying on this knowledge keeps the onus of responsibility on the individuals as opposed to with the system. A final argument against accreditation of PoCUS was a pragmatic one regarding standardized Continuing Medical Education and the difficulty that may pose for many rural providers if it occurred outside of the community and required time away from practice. Not all participants argued against accreditation, with some seeing the value to standardized Continuous Quality Improvement and the potential advantage of increased acceptance by specialists.
Observability
A. Improvement to clinical care
Observable results of rural PoCUS to clinical practice were noted by everyone who participated in the study. Most interview participants shared anecdotes of positive responses from patients due to the immediate information provided on their clinical condition. This was particularly observed with maternity patients who could be easily reassured about the viability of a pregnancy or the in-utero position of a baby at term. The position of the fetus at term is a significant piece of information for those in rural communities that may not have the capacity to support breech deliveries. In all instances, the capacity of a simple scan to avoid referral out of the community for formal imaging was appreciated.
Participants who participated in this study described PoCUS as a 'game changer', 'essential to rural practice', 'I could never go back', 'amazing potential' and 'better decision-making.' These positive comments are not surprising as participants in this study volunteered their time to receive and learn to use the subsided probes and took the time to volunteer in this study. Thus, participants in this study were naturally predisposed to being rural PoCUS champions. As one participant described, they are those who had 'drunk the Kool-Aide.' The two quotes below capture the transformative impact PoCUS has on rural health care:
‘[I]t’s hard to know where to start. [T]here’s very rarely a day goes by that it isn’t helping with care in a substantial way.’
‘I just want to leave you guys with the impression that point-of-care ultrasound is a game-changer for these small communities.’
B. Peer-to-Peer Quality Improvement Initiatives
The final layer of 'observability' for participants in this study was gained through mentorship and Quality Improvement (QI) initiatives, with the caveat that all participants noted the lack of such formal programs. This lack of observability in their rural PoCUS practice was noted, namely the idea of ‘you don’t know what you don’t know because you are always working solo.” Almost all participants voiced the value of mentorship and formal review of scans, suggesting that isolated work made improvement difficult.
To this end, participants developed informal networks and peer support to assess the quality of their work and created processes such as parallel studies. For example one participant explain, ‘I’m the only one in most the places where I work who’s comfortable making a diagnosis or ruling out a diagnosis using lung ultrasound. So, what I do is I often order a chest x-ray in parallel.’ Others relied on ‘scanning and scanning again’ while most took advantage of peer review by other physicians in their community. As one participant noted, ‘we're always helping each other out. Someone can call me from the clinic and say, "Hey, could you help me with the scan?" or "What do you think of this?"’ Others took a more formal approach of accessing funding for local training and dedicated teaching time. Some participants noted the strategy for reaching a ‘critical mass’ of PoCUS users in their community to be a stable resource for others who want to develop or maintain their skills.
A smaller group of respondents recalled accessing provincial resources for support, including the Rural Urgent Doctors In-aide (RUDI), a virtual practice support line staffed by physicians who offered guidance with PoCUS. Others noted opportunities through UBC's Coaching and Mentoring Program (CAMP) for one-on-one support. Others access supportive provincial experts for feedback on scans, although in an ad-hoc way. These additional resources allow rural physicians to develop their skills further and further demonstrate the value and utility of PoCUS in their clinical practice.