Statement

Point-of-care ultrasound (POCUS) has been introduced across a number of medical specialities, with emerging research showing promising results. We anticipate that POCUS will have an increasingly important place for specific indications within primary care over the coming years, supporting general practitioners to meet the health needs of their patient populations. We recommend that all general practitioners receive training in POCUS that is tailored to the needs of their healthcare context. This training should be delivered during general practitioners’ residency and continuing medical education programmes. Where evidence supports the use of POCUS in diagnosis, qualified general practitioners should be appropriately financed for its use in clinics, house calls and community healthcare. We support ongoing efforts to gather evidence for best practice use of POCUS and to explore the long-term effects of POCUS use on diagnosis within primary care.

Background

POCUS is defined as ‘ultrasonography brought to the patient and performed by the provider in real time’ (Díaz-Gómez et al., Reference Díaz-Gómez, Mayo and Koenig2021). It is designed to answer a specific clinical question or to perform a specific procedural aim and is not a replacement for a formal ultrasound examination or screening (Andersen et al., Reference Andersen, Holden, Vela, Rathleff and Jensen2019a; Díaz-Gómez et al., Reference Díaz-Gómez, Mayo and Koenig2021). POCUS has been shown to be useful to rule in or rule out medical emergencies, to diagnose conditions of low to moderate complexity and to monitor acute and chronic illnesses independent of hospital infrastructures (AAFP, 2016; Andersen et al., Reference Andersen, Holden, Vela, Rathleff and Jensen2019a; Colli et al., Reference Colli, Prati, Fraquelli, Segato, Vescovi, Colombo, Balduini, Della Valle and Casazza2015; Genc et al., Reference Genc, Ryk, Suwała, Żurakowska and Kosiak2016; Myklestul et al., Reference Myklestul, Skonnord and Brekke2020; Sorensen and Hunskaar, Reference Sorensen and Hunskaar2019). Effective use of POCUS has been demonstrated in numerous clinical specialities for a wide range of indications, including those relating to: internal organs, such as the heart, lungs, and kidneys; musculoskeletal, soft tissue and vascular conditions; and pregnancy (AAFP, 2016; Andersen et al., Reference Andersen, Brodersen, Davidsen, Graumann and Jensen2020; Díaz-Gómez et al., Reference Díaz-Gómez, Mayo and Koenig2021; Dietrich et al., Reference Dietrich, Goudie, Chiorean, Cui, Gilja, Dong, Abramowicz, Vinayak, Westerway, Nolsøe and Chou2017; Løkkegaard et al., Reference Løkkegaard, Todsen, Nayahangan, Andersen, Jensen and Konge2020; Rodríguez-Contreras et al., Reference Rodríguez-Contreras, Calvo-Cebrián, Díaz-Lázaro, Cruz-Arnés, León-Vázquez, del Carmen Lobón-Agúndez, Palau-Cuevas, Henares-García, Gavilán-Martínez, Fernández-Plaza and Prieto-Zancudo2022; Sorensen and Hunskaar, Reference Sorensen and Hunskaar2019). Exposure to and popularity of POCUS during undergraduate medical training has increased over the past decade (Dinh et al., Reference Dinh, Fu, Lu, Chiem, Fox and Blaivas2016; Touhami et al., Reference Touhami, Merlo, Hohmann and Essig2020).

Use of POCUS has been increasing in primary care (Myklestul et al., Reference Myklestul, Skonnord and Brekke2020; Touhami et al., Reference Touhami, Merlo, Hohmann and Essig2020), with a strong interest among residents in family medicine to incorporate POCUS training into the family medicine curriculum (Peng et al., Reference Peng, Micks, Braganza, Sue, Woo, Rogers, Freedman, Lewis, Hu, Varner and Patel2019; Andersen, et al., Reference Andersen, Hedegård, Løkkegaard, Frølund and Jensen2021b). Indications for POCUS vary between countries, shaped by the requirements of local health systems, the scope of primary care and training of general practitioners. Benefits of POCUS within primary care include its portability, ease of operation, high acceptability amongst patients and high user satisfaction amongst both patients and doctors (Andersen et al., Reference Andersen, Davidsen, Brodersen, Graumann and Jensen2019b; Andersen et al., Reference Andersen, Brodersen, Rudbæk and Jensen2021a; Iacob et al., Reference Iacob, Saftoiu, Bumbulut, Georgescu and Badea2016). POCUS can increase doctor confidence and studies suggest it can increase accuracy in diagnosis (Leidi et al., Reference Leidi, Saudan, Soret, Rouyer, Marti, Stirnemann, Reny and Grosgurin2022). POCUS therefore has the potential to improve patient outcomes through a rapid initiation of effective treatment and a reduction in referrals to secondary care for investigations, specialist clinics and hospitalisation.(Colli et al., Reference Colli, Prati, Fraquelli, Segato, Vescovi, Colombo, Balduini, Della Valle and Casazza2015; Andersen et al., Reference Andersen, Brodersen, Davidsen, Graumann and Jensen2020). POCUS has the potential to reduce health inequalities and empower general practitioners who work in rural, remote, under-resourced or underserved settings (Lo et al., Reference Lo, Frauendorf, Wischke, Schimmath-Deutrich, Kersten, Nuernberg, Nuernberg and Jenssen2022; Kornelsen et al., Reference Kornelsen, Ho, Robinson and Frenkel2023; Tanael, Reference Tanael2021). We are supportive of further structured exploration and research in this area.

However, the use of POCUS in primary care is not without limitations. As with other physical examinations (eg, pulmonary auscultation and thyroid palpation), accuracy of POCUS is user-dependent (Díaz-Gómez et al., Reference Díaz-Gómez, Mayo and Koenig2021; Dietrich et al., Reference Dietrich, Goudie, Chiorean, Cui, Gilja, Dong, Abramowicz, Vinayak, Westerway, Nolsøe and Chou2017; Diprose et al., Reference Diprose, Verster and Schauer2017). Compared with auscultation/clinical examination alone, focused use of POCUS has the potential to ensure higher levels of diagnostic accuracy and reduce risk of harm (Diprose et al., Reference Diprose, Verster and Schauer2017). Without adequate training and continuous utilisation, POCUS can lead to false reassurance, underdiagnosis, misdiagnosis, overdiagnosis and overtreatment (Andersen et al., Reference Andersen, Holden, Vela, Rathleff and Jensen2019a. Leidi et al., Reference Leidi, Rouyer, Marti, Reny and Grosgurin2020). Training should be stepwise and ongoing, including adequate coverage of anatomy and physiology, procedural techniques and communication skills including standardised reporting of clinical findings, and the impact of findings on medical decision-making in primary care (AAFP, 2016; Andersen et al, Reference Andersen, Hedegård, Løkkegaard, Frølund and Jensen2021b; Andersen, et al., Reference Andersen, Guetterman, Fetters, Brodersen, Davidsen, Graumann and Jensen2022; Homar et al., Reference Homar, Gale, Lainscak and Svab2020). Maintaining competency will be an important aspect of ongoing use of POCUS within a generalist speciality (EFUMB, 2006). More research is required to identify best practice in training, methods of assessment and quality improvement, including avoidance of overdiagnosis, within the context of primary care.

Medicolegal considerations vary across countries and frequently change. This will require providers and institutions to understand local regulatory requirements and legal frameworks to mitigate the potential risks of POCUS. Even, the stethoscope, a tool routinely used by physicians for over 200 years, has its limitations and failings (Arts et al., Reference Arts, Lim, van de Ven, Heunks and Tuinman2020). Reviews of POCUS-associated litigation within secondary care have not identified cases relating to the use of POCUS, but rather to the lack of POCUS use when the technology was available (Blaivas and Pawl, Reference Blaivas and Pawl2012; Conlon et al., Reference Conlon, Yousef, Mayordomo-Colunga, Tissot, Fraga, Bhombal, Suryawanshi, Villanueva, Siassi and Singh2022; Reaume et al., Reference Reaume, Farishta, Costello, Gibb and Melgar2021). Assessing medicolegal risk is a preventative process to avoid harm, whether to the patient, provider or institution. Efforts must be made to gather evidence for guidelines on appropriate (and inappropriate) use of POCUS within primary care, in addition to the long-term impact on patient prognosis. We anticipate that specific regulatory frameworks for POCUS in General Practice are likely to evolve with an increased emphasis on quality and safety. We support the development of licensure and availability of General Practitioners to undertake POCUS in countries where this is not currently available.