ACTIONCARDS – one-page instructions framing POCUS use for family medicine physicians

Point-of-care ultrasound (POCUS) is widely used in many clinical specialties including family medicine [1]. The potential use in family medicine includes a great variety of clinical situations and related scanning modalities [2] [3]. However, for many scanning projections the frequency with which the scan is performed is low [4] [5] [6] making it difficult to develop routine and maintain scanning competence. Furthermore, the low pre-test probability of disease and less severe cases seen in patients in primary care may challenge the ability to recognize pathology on images. In addition, the working conditions in office-based family medicine leave little room for practice due to the timeframe of the consultation [7] and the lack of opportunities for collegial back-and-forth discussion and proctored scans.

There is no evidence or consensus as to how general practitioners (GPs) are best trained [8]. In Denmark, a group of researchers at Center for General Practice at Aalborg University and GPs organized in the Danish Society for Ultrasound in General Practice (DAUS) have developed a longitudinal basic POCUS training course, accounting for the specific learning challenges in office-based family practice. This basic ultrasound course was developed based on previous studies exploring the educational needs of GPs [5] [8] [9] [10].

The learning steps from novice to expert in relation to skills development have been explored extensively in health care research [11]. Educational research has described a need for structure and scaffolding in the beginning of a learning process to provide a safe environment for developing skills [12] [13]. To provide scaffolding, guidance and support during the learning, action cards were developed framing POCUS examinations to general practice. For a specific POCUS application the action cards state: (1) in which clinical situations the POCUS examination can be used, (2) which transducer and pre-set is recommended, (3) how the POCUS examination is performed, (4) How POCUS findings should be interpreted, (5) common pathological findings, (6) possible errors and common mistakes, and (7) how to integrate findings in a clinical context ([Fig. 1]).

Fig. 1 

The action cards are used repeatedly during training: First, as preparatory reading prior to the hands-on training sessions; second, for demonstration and instruction during training sessions, and third, to support course participants at home in the clinic in-between training sessions. This repetitive use of the action cards supports the participants’ development of both embrained and embodied knowledge [9].

The action cards were evaluated in a master thesis [14]. Eight GPs were interviewed about the use of action cards as a support tool when scanning in their general practice. Overall, they found them very useful in facilitating the use of POCUS. The action cards offered the opportunity to prepare for a scan or brush-up, provided guidance and corrections in case-of-doubt, and facilitated the completion of examinations as well as increased participants’ confidence in the results.

By framing relevant POCUS examination to the general practice setting, action cards may create a uniform understanding of POCUS use in primary care and thereby give the encoded and embedded knowledge that the healthcare system needs for a successful implementation of POCUS in primary care [9].

The actioncards are freely available in Danish on the Danish Doctors Handbook at https://www.sundhed.dk/sundhedsfaglig/laegehaandbogen/sundhedsoplysning/sundhedsoplysning/ultralyd-i-almen-praksis/. They have been developed by GPs and reviewed by a relevant specialists prior to the final evaluation process and publication in the Doctors Handbook. For ultrasound courses, the actioncards are supplemented with small instructive videos following the same structure.

Using action cards for POCUS training of GPs supports the GPs scanning technique and increases transparency about what and how GPs perform POCUS scans. We cordially invite others, who may be interested, to adapt the idea and we will be happy to assist in translations.

Camilla Aakjær Andersen, MD, PhD, Associated professor¹; Søren Kæseler Andersen, GP^{1, 2}; Thomas Løkkegaard, GP^{1, 2}; Ulrike Mehnert, GP^{1, 2}; Troels Mengel-Jørgensen, GP^{1, 2}; Torsten Rahbek Rudbæk, GP²; Nicolai Soll, GP²; Christian Stjernebjerg, GP²; Julie Jepsen Strøm, MD¹; Martin Bach Jensen, GP, PhD, Professor¹

¹ Center for General Practice at Aalborg University
² Danish Society for Ultrasound in General Practice (Dansk Almenmedicinsk Ultralyds Selskab, DAUS)

Corresponding author: 
Camilla Aakjær Andersen, [e-mail]

• References

• 1 Andersen CA, Holden S, Vela J. et al. Point-of-Care Ultrasound in General Practice: A Systematic Review. Ann Fam Med 2019; 17 (01) 61-69 DOI: 10.1370/afm.2330.
• 2 Andersen CA, Guetterman TC, Fetters MD. et al. General Practitioners' Perspectives on Appropriate Use of Ultrasonography in Primary Care in Denmark: A Multistage Mixed Methods Study. Ann Fam Med 2022; 20 (03) 211-219
• 3 American Academy of Family Physicians (AAFP). AAFP recommended curriculum guidelines for family medicine residents point of care ultrasound. 2016 Available from (Accessed 2 Feb 2019): https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint290D_POCUS.pdf
• 4 Andersen CA, Brodersen J, Davidsen AS. et al. The use and impact of point-of-care ultrasonography in general practice: a prospective observational study. BMJ Open 2020; 10 (09) e037664 DOI: 10.1136/bmjopen-2020-037664.
• 5 Andersen CA, Frandsen AK, Valentiner-Branth C. et al. Introducing point-of-care ultrasound in Danish general practice – elucidating the use through a medical audit. Fam Pract 2020; cmaa080 DOI: 10.1093/fampra/cmaa080.
• 6 Myklestul HC, Skonnord T, Brekke M. Point-of-care ultrasound (POCUS) in Norwegian general practice. Scand J Prim Health Care 2020; 38 (02) 219-225
• 7 Irving G, Neves AL, Dambha-Miller H. et al. International variations in primary care physician consultation time: A systematic review of 67 countries. BMJ Open 2017; 7 (10) e017902 DOI: 10.1136/bmjopen-2017-017902.
• 8 Andersen CA, Hedegård HS, Løkkegaard T. et al. Education of general practitioners in the use of point-of-care ultrasonography: a systematic review. Fam Pract 2020; cmaa140 DOI: 10.1093/fampra/cmaa140.
• 9 Andersen CA, Espersen M, Brodersen J. et al. Learning strategies of general practitioners striving to achieve point-of-care ultrasound competence: a qualitative study. Scand J Prim Health Care 2022; 40 (01) 67-77
• 10 Løkkegaard T, Todsen T, Nayahangan LJ. et al. Point-of-care ultrasound for general practitioners: a systematic needs assessment. Scand J Prim Health Care 2020; 38 (01) 3-11 DOI: 10.1080/02813432.2020.1711572.
• 11 Benner P. Using the Dreyfus Model of Skill Acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education. The Bulletin of Science, Technology and Society Special Issue: Human Expertise in the Age of the Computer 2004; 24 (03) 188-199
• 12 Savery JR. Overview of Problem-based Learning: Definisions and Destictions. Interdisciplinary Journal of Problem-Based learning 2006; 1 (01) DOI: 10.7771/1541-5015.1002.
• 13 Archer AL, Hughes CA. Explicit Instruction: Effective and Efficient Teaching. The Guilford Press. 2011
• 14 Evaluation of 1-page instructionenss as support tool for users of ultrasound in general practice. A qualitative study. Master thesis by medical student Michael Bjerring Kristensen, Main counselor Martin Bach Jensen Project counselor Camilla Aakjær Andersen. Aalborg University 2021 (in Danish).

Publication History

Article published online:
06 June 2023