Deconstructing the Extended Focused Assessment with Sonography in Trauma (E-FAST) as a Roadmap for Longitudinal Integration of Point of Care Ultrasound Education Within Undergraduate Medical Education.

Deconstructing the Extended Focused Assessment with Sonography in Trauma (E-FAST) as a Roadmap for Longitudinal Integration of Point of Care Ultrasound Education Within Undergraduate Medical Education - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Med Sci Educ . 2025 Jan 29;35(3):1673–1681. doi: 10.1007/s40670-025-02298-8 Deconstructing the Extended Focused Assessment with Sonography in Trauma (E-FAST) as a Roadmap for Longitudinal Integration of Point of Care Ultrasound Education Within Undergraduate Medical Education Cherie Tator 1, ✉ , Maria Maldonado 2 , Nadia Ismail 1, 2 , Kiyetta H Alade 3 , Alan Riley 3 Author information Article notes Copyright and License information 1 Huffington Department of Education, Innovation and Technology, Baylor College of Medicine, School of Medicine, One Baylor Plaza, Houston, TX 77030 USA 2 Department of Medicine, Baylor College of Medicine, Internal Medicine, One Baylor Plaza, Houston, TX 77030 USA 3 Department of Pediatrics, School of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA ✉ Corresponding author. Accepted 2025 Jan 17; Collection date 2025 Jun. © The Author(s) under exclusive licence to International Association of Medical Science Educators 2025. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. PMC Copyright notice PMCID: PMC12228866  PMID: 40625932 Abstract Point-of-care ultrasound (POCUS) has been embraced by most medical specialties, yet undergraduate medical education still has difficulty incorporating POCUS skill development and assessment. While much of the existing literature focuses on specific POCUS and/or ultrasound topics, the feasibility as well as ensuring POCUS topics are relevant to all undergraduate medical education (UME) learners are often left unaddressed. The authors outline a novel, outcomes-driven, longitudinal POCUS curriculum designed around a “deconstructed” Extended Focused Assessment with Sonography in Trauma (E-FAST) exam, which facilitated purposeful integration of POCUS and medical imaging topics into organ system-based foundational courses. Curriculum development strategies specific to POCUS will be reviewed, including reverse curriculum design, emphasis on assessment, and identifying POCUS topics relevant to most undergraduate medical students while avoiding specialty specific preferences. This roadmap aims to assist other institutions in developing their own programs to teach POCUS within the broader scope of modern ultrasound practices. Keywords: POCUS, Competency-based education, Curriculum design, Educational innovation, Medical ultrasound education Introduction Initially confined to consultative roles performed by sonographers or radiologists, ultrasound has now expanded to include clinician bedside examinations and procedures. Commonly called point-of-care ultrasound (POCUS), it allows clinicians to conduct immediate image acquisition and interpretation at the bedside, facilitating rapid diagnosis, treatment, and procedural guidance [ 1 ]. Many descriptive titles for POCUS have evolved which are often used interchangeably and inconsistently within literature and clinical practice. For this paper, we refer to POCUS broadly, focusing on foundational principles utilized by clinicians of a variety of specialties at the bedside, which contrasts with more specialized forms of traditional Diagnostic Imaging or Consultative Sonography performed by sonographers, radiologists, and non-radiology subspecialists with more comprehensive imaging and reporting protocols. Given the breadth of content and potential applications of POCUS, determining when content should be introduced in medical school and for what purpose remains a large hurdle for POCUS curriculum development [ 2 – 4 ]. From the focus on broad applicability to students and practicality of implementation, we will outline the creation of a novel, outcomes-based POCUS curriculum at our institution. We strive to provide a framework for other institutions to utilize to create a deliberate and impactful learning experience that presents POCUS within the broad spectrum of modern ultrasound use and that students will carry forward into clerkships, residency, and beyond. Current State of Point-of-Care Ultrasound in Undergraduate Medical Education A national survey conducted in 2020 found that 57% of the 154 responding medical schools included POCUS in their curriculum, although there was significant variation in the curriculum and a lack of standardization [ 2 ]. Most POCUS education was limited to pre-clinical years (years 1 and 2) and focused on enhancing pre-clinical topics such as anatomy and physical exam skills. A small percentage (8%, n = 10) included a longitudinal 4-year curriculum [ 2 ]. Due to the varied approaches to implementing POCUS in undergraduate medical education (UME), approaches to POCUS competency assessments are just as varied. A scoping review of assessment methods in UME published in 2023 identified that there are inconsistent assessment methods across institutions and most evaluate knowledge rather than skills, i.e., the actual performance of ultrasound [ 5 ]. Without an accepted or defined set of UME POCUS competencies, a standardized method for assessing UME learners in POCUS is difficult to develop [ 1 , 5 ]. Without well-defined content parameters, POCUS runs the risk of being introduced from the perspective of those who teach it. For example, an emergency medicine physician may consider some topics more relevant than others and take a clinical perspective, whereas a radiologist may be more interested in complex anatomical relationships [ 6 ]. Availability bias could result in fragmented POCUS curricula negatively impacting broad applicability to students and, in turn, their long-term competency and eventual treatment decisions in future patient care [ 7 , 8 ]. Additionally, more typical barriers and limitations for more extensive POCUS curricula included lack of trained faculty, time constraints, equipment, funds, and/or availability of standardized patients [ 3 , 9 ]. More specialties are integrating POCUS within their Accreditation Council for Graduate Medical Education (ACGME) milestones but there are varying expectations of the lowest level of competency upon graduation from medical school. For instance, there are no POCUS ACGME milestones for internal medicine (IM), family medicine (FM), or pediatrics. In contrast, emergency medicine (EM) includes “describing indications for emergency ultrasound” as its lowest competency level, while general surgery lists a level one milestone as “performing basic operative steps in core operations/procedures of the Surgical Counsil on Resident Education curriculum,” which encompasses both Focused Assessment with Sonography in Trauma (FAST) and ultrasound for intravenous access [ 3 ]. Students interested in different subspecialities will have different needs for education, ranging from indication-based competencies to more procedural focused. Thus, it seems prudent to consider the diverse GME milestones when constructing outcomes, objectives, and consequently, when determining the components necessary for a generalizable UME POCUS curriculum. Teaching early learners about effective, safe POCUS skills is a daunting task, requiring the learner to simultaneously acquire anatomy proficiency, pathology identification, and tactile skills of manipulation of the sonographic device [ 10 , 11 ]. When designing a POCUS curriculum for UME, established comprehensive competency requirements for Diagnostic Imaging from organizations like The Commission on Accreditation of Allied Health Education Programs (CAAHEP) do not seem applicable to medical students’ needs [ 12 ]. Identifying POCUS curricular topics specific for use in undergraduate medical education has been a heavily covered topic in medical literature. Expert panels have published lists ranging from 90 to 332 POCUS topics relevant to UME curriculum [ 4 , 13 , 14 ]. While useful references, these proposed lists of topics for POCUS can be overwhelming and difficult to implement when developing a novel POCUS curriculum for a medical school. Framework for POCUS Integration in UME Curriculum For background purposes, Baylor College of Medicine School of Medicine is a large academic institution with multiple clinical affiliations and around 230 students per class divided on two campuses in Houston and Temple, Texas. We employed an iterative process of development and improvement, with later steps often prompting revisions to earlier ones (Fig. 1 ). We actively engaged local institutional curricular leaders, including deans and course directors, to collaboratively integrate POCUS into the broader UME curriculum effectively. In 2023, a similar framework was described to develop a POCUS program for general internists but in that construct POCUS was incorporated as a new skill to already practicing physicians, not as part of an integrated approach to teaching medical education students [ 15 ]. Our framework is distinct from the current literature in its ability to be both broad and generalizable while also remaining intentional in foundational applications and targeted in assessing student knowledge and performance. Fig. 1. Open in a new tab Framework for POCUS integration in UME curriculum. Framework outlining steps taken to build POCUS curriculum Step 1: Define Educational Outcomes for Learners Inspired by Kern’s Six-Step Approach to Curriculum Development, we began by defining the educational needs of our learners [ 16 ]. To achieve this, we employed two methods: analyzing career paths of students and reviewing literature to identify important curricular elements recognized by other experts. This comprehensive assessment of needs informed the subsequent steps in our curriculum development process. We compared local match rates with national data and took note of which specialties had the highest number of matches and considered which specialties utilize POCUS clinically [ 17 ]. Locally, the highest percentage match rates were IM (15%), pediatrics (11%), surgical (13%), anesthesiology (7%), and EM (5%). We next performed a literature search focusing on key words related to POCUS, ACGME, and Entrustable Professional Activities (EPA) with terms “POCUS” “POCUS graduate requirements,” “ACGME POCUS graduation requirements” “ACGME POCUS milestones” “EPA POCUS,” “UME POCUS competencies,” and “EPA POCUS competencies” from the years 2016–2022. We identified eight articles which included lists of curricular elements regardless of whether they were reported as undergraduate or graduate level, competencies, elements, topics, or learning objectives [ 3 , 4 , 6 , 13 , 14 , 18 – 20 ]. From these articles, a comprehensive list of curricular elements was developed for consideration. We calculated a frequency score for each curricular element based upon how often it was listed and its recommendation level among the reviewed literature. An expert consensus panel at Baylor College of Medicine, consisting of a registered diagnostic medical sonographer, a pediatric cardiologist, and a pediatric emergency medicine physician was formed. The expert panel reviewed each curricular element for its appropriateness and broadest applicability in UME education and then proposed which year the curricular element should be introduced. Curricular elements which had high scores and full consensus from the expert panel were included. We then created outcomes aimed at providing UME students with a strong foundation in POCUS regardless of their eventual career path which will be presented in step 3. Step 2: Assess the Present State of POCUS Curriculum Within Your Institution At our institution, we found a similar pattern of POCUS education introduced in the pre-clinical years without aligned objectives across courses and with limited integration into the clinical curriculum. Our goal was to integrate POCUS education throughout the entirety of traditional UME training, identifying defined outcomes, uniformity of objectives, and avoiding unnecessary repetition [ 21 – 23 ]. As part of a larger curriculum redesign to problem- and competency-based education, we shifted from live lectures to asynchronous and incorporated assessments to ensure objectives were being taught adequately. The initial expert consensus panel described earlier recruited a multidisciplinary team of instructors comprised of IM, Pediatrics, Anesthesiology, EM, Cardiology, and Critical Care physicians with extensive POCUS experience. For additional instructors, the institution utilized a combination of volunteer efforts (including from GME trainees) and dedicated POCUS faculty educators. We also piloted an interdisciplinary educational collaboration utilizing local sonography school faculty and students as hands-on workshop facilitators. We evaluated published literature describing POCUS integration within UME and considered which educational strategies would best fit our curriculum [ 2 , 6 , 10 , 18 – 20 , 24 ]. We based this on the defined educational needs and our previous experiences with asynchronous modules and hands-on workshops. The literature describes various educational strategies for teaching POCUS, including didactic lectures, online modules, hands-on workshops, and bedside instruction in clinical settings [ 5 , 6 , 18 , 20 ]. These methods can be delivered virtually online, or in person either live, asynchronously, or a hybrid of both. Based on published and local experiences, POCUS coordinated with gross anatomy and physical examination courses has been shown to enhance students’ understanding of these topics [ 6 , 18 , 21 , 24 ]. As technology continues to advance, artificial intelligence (AI) may provide new opportunities for teaching POCUS and assessing student performance via image acquisition assistance and/or more objective image quality grading [ 9 , 25 ]. We designed workshops with small groups with one physician or sonographer instructor for every four to six students to ensure effective learning [ 26 ]. To optimize teacher-to-student ratios and the overall workshop experience, we used a flipped classroom strategy with pre-requisite online asynchronous modules and supplementary, near-peer, interprofessional educators (senior sonography students) during targeted times in the curriculum, i.e., Introduction to POCUS Scanning workshop, and Abdominal and Pelvic Scanning workshop [ 27 , 28 ]. Obtaining resources is frequently cited as a barrier in the existing literature, and we encountered similar challenges. Like any complex program, it takes collaborative support from multiple stakeholders. In the earliest phase, a medical director and assistant director were recruited and hired to work with the dean on an initial proposal to justify resource allocation and need for this educational program. The team consulted with institutions that had successful POCUS programs and reviewed literature to shape the proposal. Our class size is fairly large and because of our curriculum framework we opted to purchase a variety of equipment to support our on-campus activities. Initial start-up funding for the program was from directed charitable funding and used to purchase four ultrasound machines, 30 handheld probes, several intravenous task trainers, two high-fidelity simulators, and other supplies. Some institutions with successful POCUS programs recruited sonographers so this model was implemented at our campus. A registered diagnostic medical sonographer with experience in program management and curriculum development/innovation was recruited and hired to be a member of POCUS course leadership, particularly for content development, simulation design, and hands-on instruction. FTE for protected faculty time was also part of the initial proposal to assist with content development and to ensure a core group of instructors at the workshops. In phase 2, directors, faculty, and a sonographer were recruited and hired and additional equipment was purchased for launch of the curriculum at the regional campus. As we continue to build out the curriculum, we review the cost–benefit and modify our proposal to meet our needs; for example, we have moved from FTE for our core faculty to a stipend system. While conducting a thorough cost–benefit analysis supported by extensive background research has proven effective for us, we acknowledge that funding strategies may vary across institutions. Step 3: Map the Design Following the principles of “Understanding by Design” and reverse curriculum design, we started by utilizing the information from steps 1 and 2 of our framework [ 29 ]. We identified the most broadly applicable POCUS goals for UME students and from there we identified what the outcomes would be in the first 2 years. This foundation was utilized to create educational objectives which assessments should directly address (Fig. 2 ). MCQ assessments were developed to measure students’ knowledge based on asynchronous modules, and hands-on assessments were created to measure students’ ability to perform skills after attending workshops. The inclusion of skills-based assessments led to the addition of deliberate practice sessions where students signed up for voluntary practice with the high-fidelity simulator in a four to one group with one of the POCUS experts. Fig. 2. Open in a new tab Outcomes and objectives. Framework for the goals of POCUS in UME and the outcomes and objectives for the first and second year After development of our assessments, we then developed our modules and workshops. We met with course developers, course directors, and deans to align our elements with the foundational sciences curriculum (Fig. 3 ). As we reviewed the POCUS curricular elements and grouped them with the courses which are systems- or organ-based, we identified a central theme, the protocol Extended Focused Assessment with Sonography in Trauma (E-FAST). Fig. 3. Open in a new tab Curricular integration across the first 18 months. POCUS curriculum threaded through a longitudinal integration of systems-based courses in the first 18 months. *E-FAST is apparent with the introduction of each organ in the courses corresponding to a region included in the E-FAST protocol; I-AIM structure was implemented for each module Deconstructing the E-FAST Protocol The E-FAST protocol was originally developed for triage of trauma patients and has broad applicability across multiple disciplines including some of the most popular ACGME programs, including EM, surgical subspecialties, IM, and pediatrics. We “deconstructed” the E-FAST protocol into its component parts, based on organ systems, including cardiac, pulmonary, abdominal, and pelvic imaging. With the fundamental components of the E-FAST separated, we were able to be more intentional when integrating the POCUS curriculum over the first year with modules and workshops focused on specific organ systems (Fig. 4 ). In early modules and during organ system blocks, we also provided context for the clinical use of the E-FAST protocol. By including perspective on the impact of POCUS imaging within the broader scope of ultrasound and medical imaging, we were able to introduce patient safety and diagnostic accuracy issues, thereby broadening the applicability of our curriculum. Our last asynchronous module in the first year then “reconstructed” E-FAST by reviewing each region as part of the larger protocol in the form of cases and image review with a review on machine operation and image optimization techniques. Fig. 4. Open in a new tab “Deconstructed E-FAST” timeline. Timeline demonstrating E-FAST deconstruction throughout the first year and its integration with coursework and skills labs The unifying theme of the “deconstructed E-FAST” provided cohesion to the POCUS curriculum and created guardrails for curricular elements. It allowed us to focus on our identified curricular elements and we were less distracted by invitations or impulsiveness to teach other ultrasound elements not included in the E-FAST, e.g., musculoskeletal or thyroid. As we considered how to more effectively integrate the “deconstructed” E-FAST, we found the “I-AIM” model (Indication, Acquisition, Interpretation, and Medical decision-making) of POCUS education to be particularly useful and incorporated it as the template for each of our asynchronous modules [ 30 , 31 ]. We are in the process of integrating our longitudinal curriculum throughout the clinical years. We are collaborating with clerkships that utilize POCUS as a clinical tool and have previously implemented some form of POCUS education for medical students. Use of the E-FAST protocol has allowed us to continue measures expanding into clerkship and transitions to Residency and gave us strategy for shaping content delivery over time while emphasizing foundations integral to POCUS regardless of specialty. Our goal is to ensure that our longitudinal objectives are met within their existing POCUS education and, where necessary, request refinements. The ultrasound assessment tool we collaborated on is in a pilot phase in EM currently. Additionally, we aim to emphasize and assess procedural skills and the later stages of the I-AIM model of POCUS education, focusing on acquisition, interpretation, and medical decision-making. We are also collaborating with the Transitions to Residency course directors to build POCUS sessions that will be the culmination of the four years of modules, workshops, and assessments. While existing literature describes many variations on incorporating POCUS curriculum, our design offers a targeted approach that can be assessed across all 4 years of UME [ 2 , 9 , 14 , 15 , 27 ]. Step 4: Implement, Evaluate, and Integrate Improvement Strategies In July 2023, we instituted our novel POCUS curriculum for year 1 students and continue to integrate the curriculum from foundational to clinical as this group of learners progresses through their four years of education. Students were motivated to complete the modules because of the MCQs in the course assessments, and to attend the workshops and hands-on assessments to earn participation points. Most students even attended the voluntary extra practice sessions but a decline in participation was noted from fall to spring. We are adding a pass/fail hands-on assessment next year and anticipate an increase in attendance for voluntary extra practice as a result. We adhered to the college’s quality assurance process for review of our multiple-choice questions. Each question was reviewed based on a minimum threshold determined by our college to decide whether a question performed well, needed revision, or full rewrite. The hands-on assessments were recorded, and there were several recommendations to address after reviews were conducted. The hands-on assessment rubric has been reviewed and revised and a supplemental guide is being developed to assist faculty when completing the rubric. The images acquired during the hands-on assessment were reviewed and parameters for an acceptable image were compiled. These parameters will be reviewed before future assessments to minimize variability among assessors defining a passing image. We hope to share insights from these assessments in the future. For program evaluation, we utilized post-workshop faculty debriefs and voluntary student evaluations to solicit feedback and impressions. Debriefs provided time for all involved faculty, staff, and POCUS leadership to review the sessions, and to provide recommendations for best practice in future iterations. Student feedback forms asked for their impressions of the strengths and weaknesses of the various workshops. We have added questions to determine the motivating factors for students to attend deliberate practice after identifying the decrease in attendance from one term to the next. We hope to share insights from our findings in the future. Evaluations revealed that while optimizing the teacher-to-student ratio, we observed that as the number and variety of instructors increased, there was significant variation in content delivery and teaching style among instructors. To address this, we expanded our pre-workshop training sessions and revised our session objectives to more specifically reflect the relevant organ systems. To reinforce standardization during the workshops, we created scripted instructional guides as references for instructors to use as cue cards. We are also incorporating post-module and post-activity surveys in the next iteration. We aim to use these insights to further refine our curriculum, and share our findings with other institutions, contributing to the development of national benchmarks for POCUS competency among UME students. Step 5: Design Future Phases Once we have integrated POCUS into the clerkships, we will focus our attention on adding electives. There is a POCUS elective already at our institution, and we will continue to partner with and collaborate on the growth and development of our 4-year goals through this additional direction. Over time, we may build out a pathway for POCUS from the combination of the main POCUS curriculum, a minimum number of electives and other activities such as scholarship or volunteerism at our workshops. Conclusions To assist institutions developing a new POCUS curriculum or updating an existing one, we offer a framework with steps tailored to student needs, available resources, and the current UME curriculum. For institutions facing significant barriers, implementing smaller components gradually may be a more manageable approach. It is essential to consider educational outcomes and ACGME competencies for relevant subspecialties to enhance the educational experience of all medical students, regardless of their future career path. We hope that our experience and proposed framework will help other institutions develop a POCUS curriculum that meets their specific needs, regardless of their current state of POCUS education. Acknowledgements We would like to thank Dr. Nital Appelbaum, Dr. Jose Diaz-Gomez, and Christy Moore, RDMS/RVT, for their invaluable mentorship in the development of our POCUS curriculum and guidance in creating assessment methods. Funding The authors did not receive support from any organization for the submitted work. The authors have no relevant financial or non-financial interests to disclose. Declarations Competing Interests The authors declare no competing interests. Footnotes Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Díaz-Gómez JL, Mayo PH, Koenig SJ. Point-of-care ultrasonography. N Engl J Med. 2021;385:1593–602. 10.1056/NEJMra1916062. [ DOI ] [ PubMed ] [ Google Scholar ] 2. Russell FM, Zakeri B, Herbert A, et al. The state of point-of-care ultrasound training in undergraduate medical education: findings from a national survey. 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