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For years, point-of-care ultrasound (POCUS) training in internal medicine residency programs operated without a shared playbook. Individual programs built their own curricula, borrowed from emergency medicine frameworks, or offered little structured training at all. That changed in December when a consensus paper published in the American Journal of Medicine established the first expert- and evidence-based core curriculum for POCUS in internal medicine residency programs in the US.

A panel of 14 POCUS experts used a modified Delphi process to reach consensus on 12 diagnostic and six procedural indications for residency training, covering scenarios such as dyspnea, shock, and chest pain, along with procedural guidance for thoracentesis and other bedside interventions.

The curriculum is a milestone for trainees. But for the thousands of hospitalists already in practice who received no formal POCUS training during residency, it raises a harder question: What comes next for them?

Training Alone Won’t Close the Gap

“The biggest challenges are faculty capacity and time,” said Bryan Broderick, MD, MEHP, assistant professor of medicine in the Division of Pulmonary and Critical Care Medicine and associate program director of the internal medicine residency at Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey. “Many attendings were not trained in POCUS, and even those who are comfortable often struggle to find protected time for teaching.”

Broderick’s program uses a longitudinal, competency-based curriculum that combines foundational knowledge, hands-on bedside scanning with real patients, and formal assessment. The new consensus paper, he said, largely reinforces the direction his program was already moving, toward more deliberate practice, real-time feedback, and competency-based assessment.

But programs like his are not the norm. Faculty development remains what Broderick called “the true rate-limiting step for most programs.” At Robert Wood Johnson University Hospital, the approach has been to integrate attendings into the same experiential curriculum as residents, with direct observation and real-time feedback at the bedside, and to lean on collaboration with pulmonary and critical care faculty who bring advanced expertise.

The Volume Problem

Even hospitalists who are trained and credentialed face a practical barrier that no curriculum can solve on its own: patient volume.

“When I am seeing 18-plus patients there is no time to use POCUS, so I end up ordering other tests to give me the information I need or referring to radiology, which is more expensive, to perform the test that I need done,” said Precious Barnes, DO, MS, a hospitalist at Skagit Regional Health in Mount Vernon, Washington.

Barnes is one of few hospitalists at her institution credentialed to use POCUS. She uses it regularly for central line placement and bedside procedures, and she sees the clinical value clearly. The math, though, doesn’t always work. When she’s running her own team without residents, high census pushes POCUS out of the workflow entirely. Working with residents gives her extra hands and extra time, but that isn’t always the case.

“Physicians are well practiced in learning a lot of information and complex concepts in a short amount of time,” Barnes said. “I think that physicians with practice can pick up the usage of POCUS and if it is used on a week-to-week basis it becomes easier and the physician becomes faster at using it, but the biggest hindrance is time vs the volume of patients.”

The learning, in other words, isn’t the barrier. The system is. And when volume wins, the skills erode.

“Doctors like to be proficient in what they do,” Barnes said. “Most of the time if they are not proficient, they will not use a tool or perform a procedure because when dealing with people one needs to be precise.”

Barnes sees her institution trying to address this. Her hospital offers POCUS courses at least once a year and encourages attending physicians to participate, though only residents are required to attend. Focused training on one or two clinical areas rather than a broad overview is more likely to build real proficiency, she said.

“It is difficult to learn all of the aspects of the body using POCUS, but if it is focused on one or two similar areas and then the physician is able to practice regularly, I think that it is feasible,” Barnes said.

Workflow Is the Bottleneck

Kameswari Maganti, MD, a professor in the Division of Cardiovascular Disease, Department of Medicine, at Rutgers Robert Wood Johnson Medical School, said the curriculum conversation misses a bigger problem. “Despite structured training, only a minority of hospitalists routinely incorporate POCUS into practice independently,” Maganti said. “Workflow, not just education, is a key limiting factor.”

A hospitalist managing undifferentiated dyspnea might benefit enormously from a focused bedside exam to distinguish between heart failure, pneumonia, or volume depletion. But performing and documenting that exam requires additional time, device access, image archiving, and interpretation confidence, all within an already compressed rounding schedule.

Limited device access, documentation requirements, and a lack of seamless image integration into the electronic medical record compound the problem. Maganti’s own cardiology division has tried to address this by identifying “POCUS champions” among both faculty and senior fellows to act as on-site experts and mentors.

Institutions that successfully implement POCUS more broadly typically establish credentialing pathways and quality assurance processes to maintain both technical skill and interpretive accuracy over time, she said.

A 5- to 10-Year Horizon

Broderick said he expects POCUS to become a core skill for internal medicine physicians, though universal implementation isn’t here yet.

“Adoption will likely continue over the next 5-10 years, driven by trainee expectations, increasing clinical utility, and the growing availability of handheld devices,” he said. “Implementation will remain uneven unless we address key barriers like faculty training and resource variability across programs.”

The depth of training may also need to vary by career path. Skills needed for hospitalists or intensivists look different from those entering outpatient-focused fields, Broderick said.

No disclosures reported.