A Call for Point-of-Care Ultrasound Fellowship Training
Programs for General Internal Medicine in Canada
Katie Wiskar, MD
, Irene W. Y. Ma, MD, PhD
, Shane Arishenkoff, MD
, Robert Arntfield, MD
Division of General Internal Medicine, University of British Columbia, Vancouver, BC, Canada;
Division of General Internal Medicine,
University of Calgary, Calgary, AB, Canada;
Division of Critical Care Medicine, University of Western Ontario, London, ON, Canada
Author for correspondence: Katie Wiskar:
13 July 2020; Accepted after revision: 19 October 2020; Published: 21 June 2021
Point-of-care ultrasound (POCUS) offers numerous benefits and is recognized as an important
competency within Internal Medicine (IM). Despite this, a significant educational gap exists,
owing in large part to a lack of expertly trained faculty and structured training opportunities. A
robust POCUS training program requires not only technical excellence among faculty but also
leadership with expertise in program creation and administration, quality assurance, medical
education, and research. A dedicated 6- to 12-month POCUS fellowship model in programs
with well-established infrastructure allows for the development of these competencies and the
establishment of a network of key POCUS contacts, and prepares trainees to create or expand
POCUS programs at their centers. We propose that the expansion of dedicated General IM
POCUS fellowships in Canada is imperative to addressing this educational bottleneck and
shaping the future leaders of Canadian IM POCUS.
Léchographie au point d’intervention (POCUS) offre de nombreux avantages et est considérée
comme une compétence importante en médecine interne. Pourtant, il existe une lacune importante
au chapitre de la formation, attribuable en grande partie au manque d’enseignants qualifiés et
doccasions de formation structurée. Un programme de formation solide sur la POCUS exige
non seulement une excellence technique parmi le corps professoral, mais aussi un leadership
démontrant une expertise dans la création et ladministration de programmes, lassurance de
la qualité, léducation médicale et la recherche. Un modèle de formation complémentaire de 6
à 12mois consacrée à la POCUS dans des programmes dont l’infrastructure est bien établie
permet d’acquérir ces compétences et détablir un réseau de personnes-ressources clés sur la
POCUS, et prépare les personnes en cours de formation à créer ou à élargir des programmes
sur la POCUS dans leur centre. Nous proposons qu’il soit impératif délargir les formations
complémentaires sur la POCUS en médecine interne générale au Canada pour remédier à ce
goulot d’étranglement en matière de formation et façonner les futurs chefs de file de la POCUS
en médecine interne au Canada.
C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e V o l u m e 1 6 , I s s u e 2 , 2 0 2 1 31
GIM Practice
CJGIM_2_2021_177932.indd 31CJGIM_2_2021_177932.indd 31 07/06/21 3:48 PM07/06/21 3:48 PM
Appropriate integration of point-of-care ultrasound (POCUS)
into the practice of medicine has been shown to offer a multitude
of benefits, including improved diagnostic accuracy, improved
clinical outcomes, reduced procedural complications, and cost
Given these potential benefits, POCUS is increasingly
recognized and endorsed both nationally and internationally as
an important Internal Medicine (IM) competency.
POCUS presents a unique educational challenge. POCUS
expertise encompasses not only technical proficiency but also a
deep understanding of test characteristics, Bayesian reasoning,
clinical integration, scalability, and an awareness of potential pitfalls
and limitations of each scan. It is recognized that appropriate
training is necessary to achieve and maintain proficiency in
POCUS, and that this may mitigate any potential harms.
well-supported POCUS training program, therefore, requires
program infrastructure and support for quality assurance
activities and medical education in addition to technical expertise
and scanning instruction.
A recent scoping review identified
longitudinal curricula, continued feedback/quality assurance,
and expert instruction as key tools for optimal POCUS education
across levels and specialties.
There is currently a significant and ongoing gap in IM
POCUS training needs. It is concerning that the majority of
IM residents are already using POCUS in their clinical practice
despite low self-reported skills and knowledge.
educational leadership is urgently needed in IM programs across
Canada and worldwide.
The fellowship model of POCUS training has been successfully
employed in other disciplines to solve this educational bottleneck.
Both Emergency Medicine and Critical Care now have many
well-established POCUS fellowship programs.
The creation of
dedicated General Internal Medicine (GIM) POCUS fellowships
is a critical step and will help develop a cohort of national leaders
within Canadian IM POCUS.
We propose that dedicated GIM POCUS fellowships should
span at least 6, ideally 12, months. A high volume and variety of
case exposure are necessary to develop the technical expertise
in image acquisition, interpretation, and integration across a
wide range of IM POCUS applications. Relevant applications
include, but are not limited to, thoracic, abdominal, vascular,
and musculoskeletal scanning; hemodynamics and focused
cardiac ultrasound; and ultrasound for procedural guidance. The
core deliverable from a fellowship, however, is not individual
POCUS mastery but the skills to scale this mastery to the
masses through POCUS program creation, predominantly in
academic centers. Engaging in longitudinal training in a POCUS
fellowship imparts fluency in the core infrastructure required
of POCUS programs: quality assurance, administration and
program management, hospital and interdisciplinary relations,
and medical education. As an example, quality assurance refers
to processes set in place for an independent trained expert to
review scans performed by learners in a timely fashion, so that
both patient safety and education can be optimized. To do so
requires technology that enables storing and reporting scans,
a method for integrating POCUS reports with other clinical
information, and expert faculty who can spend dedicated time
reviewing images. Fellowship-trained POCUS experts are
well-positioned to coordinate the multiple aspects of robust
quality assurance programs in their own centers, a skill that
may be lacking in those who have focused only on establishing
personal expertise through stand-alone commercially available
POCUS training courses. Finally, participation in a GIM POCUS
fellowship will also offer the opportunity to connect with key
players in POCUS from multiple specialties nationally and
internationally and develop valuable professional relationships.
Cross-disciplinary collaboration with specialties in which the
POCUS fellowship model is well-established will be crucial as
GIM programs evolve.
We recognize that some trainees may want to pursue
additional POCUS training targeted to personal mastery and
enhancing their own practice in a community setting. In these
cases, consideration may be given to a shorter timeline (1–3
months), with a focus on clinical and technical excellence and
establishing ties to an expert POCUS community.
The 5-year timeline of Canadian GIM training lends itself
exceptionally well to the POCUS fellowship model. Given the
flexibility of the fifth year of training, there is an opportunity
to dedicate significant time and energy for developing expertise
in a niche area such as POCUS. The funding of the fifth year of
training removes the financial barrier that is typically encountered
by trainees in other disciplines who often must choose between
juggling POCUS training with their base specialty training or
doing a self-funded year of POCUS during their early practice.
Currently, to our knowledge, there are only two programs in
Canada supporting exclusively GIM-focused POCUS fellowships,
though other centers have provided excellent training to the
current group of Canadian IM POCUS leaders via fellowships
initially designed for other disciplines. One has been in place
since 2017 (University of Calgary), and another is due to start in
July 2020 (University of British Columbia). Graduates of these
programs will possess not only expert technical skills but will also
be equipped to disseminate IM POCUS and provide leadership
in their respective institutions. Though these programs are still
in their infancy, we can learn from the successes and struggles
of POCUS fellowships in other disciplines to efficiently create
robust training opportunities. However, further development
of GIM POCUS fellowship across Canada is imperative, as the
need for POCUS leaders far outstrips this capacity.
32 V o l u m e 1 6 , I s s u e 2 , 2 0 2 1 C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e
A call for point-of-care ultrasound fellowship training programs
CJGIM_2_2021_177932.indd 32CJGIM_2_2021_177932.indd 32 07/06/21 3:48 PM07/06/21 3:48 PM
POCUS is a disruptive technology that has the power to
profoundly alter and improve the way we take care of patients.
Given the breadth and depth of the practice of IM, the potential
applications for POCUS are many and are constrained primarily
by a lack of expert faculty to provide training, leadership, and
By engaging in a GIM fellowship model of POCUS
training, we can address the current educational bottleneck and
create a strong group of national leaders. The time has come to
mobilize the collective intellect and resourcefulness of the GIM
community to bring the power of POCUS into the hands of IM
trainees and clinicians across the country.
Conflicts of Interest and Disclosures
Funding Information
Not funded.
1. Maw AM, Hassanin A, Ho PM, Mcinnes MDF, Moss A, Juarez-Colunga
E. Diagnostic accuracy of point-of-care lung ultrasonography and chest
radiography in adults with symptoms suggestive of acute decompensated
heart failure a systematic review and meta-analysis. JAMA Netw Open.
2. Schmidt G, Koenig S, Mayo P. Shock: Ultrasound to guide diagnosis and
therapy. Chest. 2012;142(4):1042–8.
3. Kanji HD, Mccallum J, Sirounis D, Macredmond R, Moss R, Boyd JH.
Limited echocardiography—Guided therapy in subacute shock is associated
with change in management and improved outcomes. J Crit Care.
4. Liu RB, Donroe JH, McNamara RL, Forman HP, Moore CL. The practice and
implications of finding fluid during point-of-care ultrasonography: A review.
JAMA Intern Med. 2017;177(12):1818–1825.
5. Havelock T, Teoh R, Laws D, Gleeson F. Pleural procedures and thoracic
ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax.
2010;65(Suppl. 2).
6. Testa A, Francesconi A, Giannuzzi R, Berardi S, Sbraccia P. Economic
analysis of bedside ultrasonography (US) implementation in an Internal
Medicine Department. Intern Emerg Med. 2015;10(8):1015–24. http://dx.doi.
7. Ma IWY, Arishenkoff S, Wiseman J, et al. Internal medicine point-of-care
ultrasound curriculum: Consensus recommendations from the Canadian
Internal Medicine Ultrasound (CIMUS) group. J Gen Intern Med.
8. Soni N, Schnobrich D, Mathews B, et al. Point-of-care ultrasound for
hospitalists: A position statement of the Society of Hospital Medicine. J Hosp
Med. 2019;14:E1–6.
9. Ma IWY, Cogliati C, Bosch FH, et al. Point-of-care ultrasound for internal
medicine: An international perspective. South Med J. 2018;111(7):439–43.
10. Our Statement in Support of Point-of-Care Ultrasound in
Internal Medicine | ACP [Internet]. [cited 2020 Jun 2]. Available
11. LoPresti CM, Jensen TP, Dversdal RK, Astiz DJ. Point-of-care ultrasound for
internal medicine residency training: A position statement from the alliance
of academic internal medicine. Am J Med. 2019;132(11):1356–60. http://
12. Torres-Macho J, Aro T, Bruckner I, et al. Point-of-care ultrasound in internal
medicine: A position paper by the ultrasound working group of the European
federation of internal medicine. Eur J Intern Med. 2020;73(December
13. Blehar DJ, Barton B, Gaspari RJ. Learning curves in emergency ultrasound
education. Acad Emerg Med. 2015;22(5):574–82.
14. Blanco P, Volpicelli G. Common pitfalls in point-of-care ultrasound: A
practical guide for emergency and critical care physicians. Crit Ultrasound J.
15. Orde S, Slama M, Hilton A, Yastrebov K, McLean A. Pearls and pitfalls in
comprehensive critical care echocardiography. Crit Care. 2017;21(1):1–10.
16. Ambasta A, Balan M, Mayette M, et al. Education indicators for internal
medicine point-of-care ultrasound: A consensus report from the Canadian
Internal Medicine Ultrasound (CIMUS) group. J Gen Intern Med.
17. Moses A, Weng W, Orchanian-Cheff A, Cavalcanti RB. Teaching point-of-
care ultrasound in medicine. Can J Gen Intern Med. 2020;15(2):13–29. http://
18. Ailon J, Mourad O, Nadjafi M, Cavalcanti R. Point-of-care ultrasound as a
competency for general internists: A survey of internal medicine training
programs in Canada [Internet]. Can Med Educ J. 2016;7(2):e51–69. Available
19. Schnobrich DJ, Gladding S, Olson APJ, Duran-Nelson A. Point-of-
care ultrasound in internal medicine: A national survey of educational
leadership. J Grad Med Educ. 2013;5(3):498–502.
20. Watson K, Lam A, Arishenkoff S, et al. Point of care ultrasound training
for internal medicine: A Canadian multi-centre learner needs assessment
study. BMC Med Educ. 2018;18(217):1–8.
21. Baston CM, Wallace P, Chan W, Dean AJ, Panebianco N. Innovation through
collaboration: Creation of a combined emergency and internal medicine
point-of-care ultrasound fellowship. J Ultrasound Med. 2019;38(8):2209–15.
22. Buchanan B, Hobbs H, Arntfield R. Fellowship training in critical care
ultrasound. Can J Anesth. 2018;65(7):847–9.
23. Blaivas M, Theodoro DL, Sierzenski P. Proliferation of ultrasound
fellowships in emergency medicine: How do we ensure future experts are
expertly trained? [1]. Acad Emerg Med. 2002;9(8):863–4. http://dx.doi.
24. Wong J, Montague S, Wallace P, et al. Barriers to learning and using
point-of-care ultrasound: A survey of practicing internists in six North
American institutions. Ultrasound J. 2020;12(1).
C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e V o l u m e 1 6 , I s s u e 2 , 2 0 2 1 33
Wiskar K et al.
CJGIM_2_2021_177932.indd 33CJGIM_2_2021_177932.indd 33 07/06/21 3:48 PM07/06/21 3:48 PM