The majority of general pediatricians and pediatric trainees in our study responded that there were frequent opportunities to use POCUS in their clinical practice. However, most did not have the training, comfort, and tools necessary to perform POCUS.
This study represents one of few needs assessments of POCUS utility for general pediatricians both in training and in practice(14, 24). Residents universally scored POCUS more highly in terms of usefulness and, in fact, in subgroup analysis 25% of pediatric residents responded that they could identify opportunities to use POCUS multiple times a day in their clinical practice. Importantly, the majority of pediatric trainees are using POCUS in their clinical practice (52%), though few pediatric attendings are (6%), thus raising questions of supervision, safety and quality assurance. This disparity in POCUS training between trainees and faculty is found similarly in needs assessments of adult specialties (21, 25, 26) and is likely reflective of national trends as medical schools increasingly integrate POCUS into their curricula(7). This also underscores the urgency that pediatric residencies follow the trend led by medical schools and adult specialties in developing ultrasound curricula(26–28). Given the technical skill required for POCUS(29), new practitioners need skilled preceptors to oversee and hone this important clinical skill. We did not ask trainees in our study if they were using POCUS unsupervised, but currently the trainees at our institution only have access to POCUS machines in the emergency department, neonatal intensive care unit, and pediatric intensive care unit – all departments where they have access to trained POCUS preceptors. Currently, trainees in our institution are unable to practice POCUS in outpatient clinics or on the general pediatrics floors where they do not have access to POCUS machines. Although the residents in our study showed more interest in POCUS on average than practicing attendings, it is just as important that continuing medical education and accreditation be developed and made available beyond residency given that the vast majority of pediatric providers did not receive formal training in POCUS and may need to supervise trainees who are already using POCUS in clinical care.
Outpatient attendings perceived POCUS as less useful, on average, than those practicing in the inpatient setting. However, as seen in prior studies, perceived utility may change with increased exposure(30). Supporting this notion, family medicine is also heavily outpatient and clinical practice overlaps with pediatrics, yet other studies have found that graduates from family medicine programs where POCUS is taught continue to use POCUS in their clinical practice(31). Prior review articles on pediatric POCUS have focused on the role of POCUS in the practice of the pediatric hospitalist (1, 11, 15–17, 32). However, the majority of pediatric residents in our study were interested in POCUS, and over half of them planned to practice outpatient general pediatrics. As more pediatric residencies include ultrasound in their training, the role of POCUS in the pediatric outpatient setting may grow substantially.
The pediatricians in our study ranked the usefulness of specific POCUS applications differently than in prior studies focusing on internal medicine and family medicine. For example, in prior studies of internal medicine physicians, central line placement, paracentesis, and thoracentesis were the most highly ranked procedural POCUS applications(19, 33). However, in our study, central line placement was ranked among the least useful, along with arterial venous access and arthrocentesis. For diagnostic POCUS, cardiac POCUS, lung (particularly pleural effusion), DVT, and abdominal free fluid tend to be ranked most useful in prior surveys of adult practitioners(19, 20, 33), while for the pediatricians in our study, abdominal free fluid and cardiac applications were again ranked least useful. Interestingly, pediatricians ranked neck (lymph node vs abscess), advanced abdominal (appendicitis, intussusception, hypertrophic pyloric stenosis, cholecystitis) among the most useful diagnostic applications. These studies tend to be considered more advanced by POCUS experts (11, 15). While the POCUS literature for pediatric appendicitis(34, 35) and intussusception(36, 37) is growing, there is currently limited evidence to support the use of POCUS for differentiation of neck masses(3, 38, 39). Constipation was also ranked as a useful diagnostic application by pediatricians; however, there are currently only a handful of studies on the validity of measuring transrectal diameter in the diagnosis of pediatric constipation(40–42). Although these advanced applications may not have as broad support in the literature, their perceived utility in our study provides important insight into research gaps and ways in which POCUS could potentially impact the clinical practice and diagnostic capabilities among general pediatricians in the future. Designs of ultrasound curricula for pediatricians should combine the clinical needs identified by pediatricians with guidance from POCUS educational experts who are well versed in the evidence to support pediatric POCUS.
Limitations
Our study had a number of limitations. Our sample was limited to residents and pediatricians currently working at or trained by one center in one state, limiting generalizability. Our low response rate at 20%, although comparable to other published needs assessments(23, 43), may be a source of bias as it is possible that physicians and trainees with an interest or background in ultrasound may have been more likely to respond to a study about ultrasound, thus overestimating the demand for POCUS training and skewing our results. Indeed, in our barriers question, very few respondents (5%) endorsed a lack of interest in POCUS. There are few prior needs assessments specific to pediatrics, thus although our survey was based on published literature, it was not validated. In our survey, we asked respondents to rate individual applications on a Likert scale by asking what would be “the most useful to you in your clinical practice?”. It is possible that “usefulness” can mean different things to different people. To some it may mean frequency of use, to others it may mean sensitivity/specificity, and to others it may mean the degree to which it changes clinical management. The majority of the physicians in our study did not have formal POCUS training, therefore we were not able to ask more specifically about most used applications or about applications most likely to change management. It is possible, as seen in other studies, that as pediatricians get more exposure to POCUS they may rank POCUS applications differently(30, 31). Similar to prior studies(30) those with more experience with POCUS (residents) also showed more interest in using POCUS and gaining further training in POCUS.
Future Directions
We hope that our survey can serve as a starting point for additional focused needs assessments, either on a larger scale, or for use by other pediatric hospital groups who are trying to develop POCUS curricula for their pediatric practitioners. Future needs assessments focusing on general pediatric attendings who are already using POCUS in their clinical practice may provide valuable perspective on which applications are most useful, although given how few there are (6% of our sample) such a study may need to be national in scope. Further assessment of pediatricians and pediatric resident ultrasound experience and training needs on a national level are warranted to determine the extent to which POCUS should be a standard part of pediatric residency curricula and which applications should be prioritized.