‘Closed loop’ learning barriers prevent doctors from using life-saving bedside ultrasound

Many doctors abandon a potentially life-saving medical scanning technology soon after training, because systemic barriers prevent it from becoming part of their routine practice, a study has found.

Point-of-care ultrasound (POCUS) enables doctors to perform rapid bedside scans using a portable device. This can quickly reveal life-threatening problems – including heart failure, fluid in the lungs, or internal bleeding – that can often be treated if identified in time.

Although thousands of doctors in the UK are now trained to use POCUS, research, including the new study, shows that many do not continue to use it in practice after completing their training.

The urgent need to improve access to POCUS has been raised by several sources. Shock to Survival, a framework jointly produced by the British Cardiovascular and Intensive Care Societies, for example, highlights the critical role that the technology can play in diagnosing and managing conditions such as cardiogenic shock.

Evidence from Prevention of Future Deaths reports similarly indicates that point-of-care cardiac ultrasound has been underutilised in assessing critically ill patients with shock, and that this has led to cases where opportunities for timely, potentially life-saving intervention were missed.

The new study, by researchers at the Universities of Cambridge and Exeter, and Royal Papworth Hospital in Cambridge, identifies six “vicious cycles” that explain why POCUS is being underused.

The root causes include limited expert support and workplace cultures that discourage less experienced clinicians from scanning. Researchers found that these factors created patterns of behaviour that inhibited the use of POCUS, even in settings where equipment and training opportunities were available.

“POCUS is being underused internationally, but it still feels like a problem that many people are unaware exists,” lead author Professor Riika Hofmann, from the University of Cambridge, said. “A lot of time and money is being spent on training, but if the working culture of hospitals doesn’t support it, that investment risks being wasted.”

“Our study is the first to explain why POCUS is not being integrated into everyday medical care. Unless we address this at the level of underlying culture, it won’t be used as intended, and lives could be lost.”

Co-author Dr Nicola Jones, from Royal Papworth Hospital, said: “Failure to utilise POCUS in the assessment of critically ill patients may contribute to missed opportunities for timely, potentially life-saving intervention. This has led to growing calls for a deeper understanding of the barriers to its use. Our study seeks to address those concerns directly.”

The researchers conducted interviews and focus groups with clinicians involved in the national Focused Intensive Care Echocardiography (FICE) training programme, which supports healthcare professionals to use POCUS to assess heart function in patients with serious circulatory compromise. The participants included a range of professionals, from those just beginning to develop their scanning skills to those with extensive experience, as well as others involved in delivering or supporting its use in clinical practice.

Although the research revealed some practical barriers to using point-of-care ultrasound, such as difficulties scanning particular types of patient, the standout finding was that these challenges tended to interlink and reinforce one another. The study identifies six cycles, or “closed loop problems”, which hinder the technology’s uptake.

One loop, for example, stems from the fact that trainees’ early efforts to use POCUS did not always produce high-quality scans. This fed scepticism among experienced clinicians about how much they should be using the technology, which in turn dented the trainees’ confidence and made them reluctant to use it.

Another cycle involves expertise. With few trained specialists available and limited protected learning time, trainees often struggled to get expert feedback on their scans. This limited their progress and, as a result, the development of a bigger pool of experts who could support future trainees.

A third loop relates to workplace norms. In some departments, scanning was not part of routine care and senior staff were resistant to its use. Trainees also worried about  “treading on the toes” of senior colleagues who saw scanning as their responsibility. Without encouragement, they backed away from using POCUS, reinforcing the very norms that discouraged them in the first place.

To help break these cycles, the researchers propose three practical steps that could improve POCUS uptake without adding strain to overstretched health services.

1. Vary exposure: Instead of relying on repeated encounters with similar types of patients to master the art of POCUS scanning, the study recommends giving trainees access to a wider variety of scan images. A shared, international image bank, the authors suggest, would help develop their instincts for spotting cases where something looks amiss.
    
2. Seize teachable moments: Consultants should spot “teachable moments” that arise naturally during ward rounds or clinical discussions. These are brief windows in which a scan or image review can be undertaken, helping trainees to build their skills and confidence over time.
    
3. “Power up” learning. Hospitals could make better use of existing forums – such as quality assurance meetings – where clinicians already explain and debate scan results. These settings are valuable learning spaces where trainees would gain insights into expert reasoning and decision-making.

“These are scalable, sustainable solutions that could work even in very busy hospitals,” Hofmann said. “If we can halt the cycles we identified here, we should be able to increase the number of confident POCUS users and maximise the benefits for patients.”

The study is published in Advances in Health Sciences Education.