Ultrasound in undergraduate medical education: a systematic and critical review

Validated, Consensus-Based Second- and Third-Trimester Sonographic Learning Objectives for the Obstetrics Clerkship

OBJECTIVE

 Currently, there are no established guidelines for obstetric ultrasound training at the core medical student clerkship level. Our objective was to develop practical, consensus-based learning objectives in second- and third-trimester ultrasound and assess the feasibility of implementing these objectives into a clinical curriculum.

STUDY DESIGN

 Using the modified Delphi approach, a panel of expert stakeholders (n = 23) was assembled to reach consensus on the proposed learning objectives. A model curriculum was created consisting of a video tutorial, in-person training, and an optional tracker and piloted at two academic medical centers. Participant perception of acquired ultrasound skills and the program were assessed using a modified, previously validated survey. Pre- and postprogram survey responses were compared using the Chi-squared test of association. A p-value of <0.05 was considered statistically significant.

RESULTS

 The expert panel reached consensus on five learning objectives to include determination of fetal number and presentation, assessment of fetal heart rate, determination of placental location, assessment of amniotic fluid volume, and a general understanding of the biophysical profile and its indications. A total of 26 students participated in the piloted curriculum. On completion, a majority of participants reported improved confidence in understanding and performing prenatal ultrasound in the second and third trimesters (p < 0.05). The majority of participants valued a hands-on ultrasound curriculum.

CONCLUSION

 We propose practical, consensus-based learning objectives for second- and third-trimester sonography during the core clerkship with demonstrated feasibility in a two-center pilot program.

KEY POINTS

· Ultrasound is a valuable skill for medical students.. · Specific learning objectives in obstetric ultrasound are currently lacking.. · We propose consensus-based objectives and a model curriculum.. · A two-center pilot study demonstrated efficacy..

Students' and junior doctors' perspectives on radiology education in medical school: a qualitative study in the Netherlands

BACKGROUND

Modern medicine becomes more dependent on radiologic imaging techniques. Over the past decade, radiology has also gained more attention in the medical curricula. However, little is known with regard to students' perspectives on this subject. Therefore, this study aims to gain insight into the thoughts and ideas of medical students and junior doctors on radiology education in medical curricula.

METHODS

A qualitative, descriptive study was carried out at one medical university in the Netherlands. Participants were recruited on social media and were interviewed following a predefined topic list. The constant comparative method was applied in order to include new questions when unexpected topics arose during the interviews. All interviews were transcribed verbatim and coded. Codes were organized into categories and themes by discussion between researchers.

RESULTS

Fifteen participants (nine junior doctors and six students) agreed to join. From the coded interviews, four themes derived from fifteen categories arose: (1) The added value of radiology education in medical curricula, (2) Indispensable knowledge on radiology, (3) Organization of radiology education and (4) Promising educational innovations for the radiology curriculum.

CONCLUSION

This study suggests that medical students and junior doctors value radiology education. It provides insights in educational topics and forms for educational improvement for radiology educators.

Best Practices for Point of Care Ultrasound: An Interdisciplinary Expert Consensus

Despite the growing use of point of care ultrasound (POCUS) in contemporary medical practice and the existence of clinical guidelines addressing its specific applications, there remains a lack of standardization and agreement on optimal practices for several areas of POCUS use. The Society of Point of Care Ultrasound (SPOCUS) formed a working group in 2022 to establish a set of recommended best practices for POCUS, applicable to clinicians regardless of their training, specialty, resource setting, or scope of practice. Using a three-round modified Delphi process, a multi-disciplinary panel of 22 POCUS experts based in the United States reached consensus on 57 statements in domains including: (1) The definition and clinical role of POCUS; (2) Training pathways; (3) Credentialing; (4) Cleaning and maintenance of POCUS devices; (5) Consent and education; (6) Security, storage, and sharing of POCUS studies; (7) Uploading, archiving, and reviewing POCUS studies; and (8) Documenting POCUS studies. The consensus statements are provided here. While not intended to establish a standard of care or supersede more targeted guidelines, this document may serve as a useful baseline to guide clinicians, leaders, and systems considering initiation or enhancement of POCUS programs.

Teledidactic Versus Hands-on Teaching of Abdominal, Thoracic, and Thyroid Ultrasound-The TELUS II Study

BACKGROUND

The worldwide COVID-19 pandemic has initiated a change in medical education and the development of new teaching concepts has become inevitable to maintain adequate training.

OBJECTIVE

This pilot study aims to compare teledidactic teaching with traditional face-to-face teaching for abdominal, thoracic, and thyroid ultrasound.

DESIGN

Concurrently, a teledidactic and a face-to-face ultrasound course were held. The students completed seven 90-min modules using mobile ultrasound probes (Butterfly IQ). Each module consisted of a lecture, a demonstration of probe guidance, and independent training.

PARTICIPANTS

A total of thirty medical students took part in the study and were randomly assigned to a teledidactic and a face-to-face group.

MAIN MEASURES

An objective structured assessment of ultrasound skills (OSAUS) was performed as a pre-test and as the final exam and ultrasound images obtained during the exam were evaluated using the brightness mode quality ultrasound imaging examination (B-QUIET) scale.

KEY RESULTS

No significant difference between the two cohorts on the OSAUS final exam was shown (p > 0.05 in all modules). There was a significant difference in the assessment of the images in the focused assessment with sonography for trauma (FAST) (p 0.015) and aorta (p 0.017) modules. Students in the teledidactic group performed better in both modules, scoring 33.59 (± 2.61) out of 44 in the module FAST (face-to-face group 30.95 (± 1.76)) and aortic images averaged 35.41 (± 2.61) points (face-to-face group 32.35 (± 3.08)).

CONCLUSIONS

A teledidactic course for abdominal and thoracic ultrasound examinations is equally effective to traditional face-to-face teaching in this pilot study. Digital implementation with a portable ultrasound machine could be a great opportunity to promote ultrasound education worldwide and over great distances.

Teaching Medical Students Rapid Ultrasound for shock and hypotension (RUSH): learning outcomes and clinical performance in a proof-of-concept study

BACKGROUND

Point-of-care ultrasound (POCUS) is a critical diagnostic tool in various medical settings, yet its instruction in medical education is inconsistent. The Rapid Ultrasound for Shock and Hypotension (RUSH) protocol is a comprehensive diagnostic tool, but its complexity poses challenges for teaching and learning. This study evaluates the effectiveness of a single-day training in RUSH for medical students by assessing their performance in clinical scenarios.

METHODS

In this prospective single-center observational proof-of-concept study, 16 medical students from Saarland University Medical Center underwent a single-day training in RUSH, followed by evaluations in clinical settings and on a high-fidelity simulator. Performance was assessed using a standardized scoring tool and time to complete the RUSH exam. Knowledge gain was measured with pre- and post-training written exams, and diagnostic performance was evaluated with an objective structured clinical examination (OSCE).

RESULTS

Students demonstrated high performance in RUSH exam views across patients (median performance: 85-87%) and improved scanning times, although not statistically significant. They performed better on simulators than on live patients. Written exam scores significantly improved post-training, suggesting a gain in theoretical knowledge. However, more than a third of students could not complete the RUSH exam within five minutes on live patients.

CONCLUSIONS

Single-day RUSH training improved medical students' theoretical knowledge and simulator performance but translating these skills to clinical settings proved challenging. The findings suggest that while short-term training can be beneficial, it may not suffice for clinical proficiency. This study underscores the need for structured and possibly longitudinal training programs to ensure skill retention and clinical applicability.

Point-of-Care Ultrasound training in undergraduate education in the European Union: current situation and perspectives

BACKGROUND

Given the widespread use of Point-of-Care UltraSound (PoCUS) in clinical practice, with ultrasound machines becoming more portable and affordable, recommendations and position statements from ultrasound societies now promote teaching PoCUS in the undergraduate curriculum. Nevertheless, surveys about PoCUS teaching in European medical schools are lacking. This survey aims to overview the current and future undergraduate PoCUS courses in the European Union (EU).

RESULTS

A questionnaire was sent to medical schools in 26 of the 27 countries of the EU; Luxembourg is the only country without a medical school. The survey was completed by the dean or a member of the medical school with knowledge of the medical curriculum. Of the 58 medical schools from 19 countries that responded to the survey, 18 (31.0%) from 13 (68.4%) EU countries reported the existence of an undergraduate PoCUS curriculum and a further 16 (27.6%) from 12 (41.4%) EU countries intended to offer it in the future. No significant difference was observed between the current and future PoCUS curricula regarding its content and purpose. Less than 40 h of theoretical teaching is provided in all the medical schools and less than 40 h of practical training is provided in 12 (75%) of the 16 medical schools which answered this specific question. Of the 40 (69%) surveyed medical schools that do not currently teach PoCUS, 20 (50%) intend to offer PoCUS courses in the future.

CONCLUSION

Although the lack of teaching hours in curricula suggests that most PoCUS courses are introductory in nature and that medical students are possibly not trained to become autonomous in clinical practice, evaluating the feasibility and impact of PoCUS teaching on clinical practice should be promoted. The medical schools that intend to develop this curriculum should be encouraged to implement validated tools to objectively assess their programs and students' performances.

Development of a hybrid point-of-care ultrasound curriculum for first year medical students in a rural medical education program: a pilot study

BACKGROUND

The field of point-of-care ultrasound (POCUS) has advanced in recent decades due to the benefits it holds for medical providers. However, aspiring POCUS practitioners require adequate training. Unfortunately, there remains a paucity of resources to deliver this training, particularly in rural and underserved areas. Despite these barriers, calls for POCUS training in undergraduate medical education are growing, and many medical schools now deliver some form of POCUS education. Our program lacked POCUS training; therefore, we developed and implemented a POCUS curriculum for our first-year medical students.

METHODS

We developed a POCUS curriculum for first year medical students in a rural medically underserved region of the United States. To evaluate our course, we measured learning outcomes, self-reported confidence in a variety of POCUS domains, and gathered feedback on the course with a multi-modal approach: an original written pre- and post-test, survey tool, and semi-structured interview protocol, respectively.

RESULTS

Student (n=24) knowledge of POCUS significantly increased (pre-test average score = 55%, post-test average score = 79%, P<0.0001), and the course was well received based on student survey and interview feedback. In addition, students reported increased confidence toward a variety of knowledge and proficiency domains in POCUS use and their future clinical education and practice.

CONCLUSIONS

Despite a lack of consensus in POCUS education, existing literature describes many curricular designs across institutions. We leveraged a combination of student initiatives, online resources, remote collaborations, local volunteers, and faculty development to bring POCUS to our institution in a rural and medically underserved region. Moreover, we demonstrate positive learning and experiential outcomes that may translate to improved outcomes in students' clinical education and practice. Further research is needed to evaluate the psychomotor skills, broader learning outcomes, and clinical performance of students who take part in our POCUS course.

The Effectiveness of Different Teaching Modalities for the Detection of Heart Murmurs in Undergraduate Medical Education: A Review

One of the many physical exam skills introduced to medical students during their pre-clerkship education is cardiac auscultation, one purpose of which is to teach the detection and identification of heart murmurs. Cardiac auscultation with a stethoscope has been the standard method of teaching. Another method, point-of-care ultrasound (POCUS), has been recently introduced as another modality by which students learn to detect and identify murmurs. The emerging popularity of POCUS in undergraduate medical curricula has led many institutions to include it in their curricula; however, doing so is challenging. Not only is cost a major factor, but reorganizing curricula to allow sufficient time for POCUS training has proven to be difficult. Additionally, the presence of notable gaps in the literature regarding the efficacy of POCUS for teaching the detection and identification of heart murmur has increased scrutiny of its value. Studies that assessed teaching cardiac auscultation to medical students in their pre-clinical years via stethoscope have used different teaching methods. However, evaluation of these studies identified numerous limitations, one being little long-term retention of cardiac auscultation knowledge. Furthermore, several barriers to integration of POCUS in undergraduate medical education were identified. The purpose of this review is to synthesize the literature comparing the effectiveness of these different tools of a cardiac exam for detection of heart murmurs in undergraduate medical education and identify gaps in literature requiring future exploration.

Empowering Medical Students: Harnessing Artificial Intelligence for Precision Point-of-Care Echocardiography Assessment of Left Ventricular Ejection Fraction

Introduction

Point-of-care ultrasound (POCUS) use is now universal among nonexperts. Artificial intelligence (AI) is currently employed by nonexperts in various imaging modalities to assist in diagnosis and decision making.

Aim

To evaluate the diagnostic accuracy of POCUS, operated by medical students with the assistance of an AI-based tool for assessing the left ventricular ejection fraction (LVEF) of patients admitted to a cardiology department.

Methods

Eight students underwent a 6-hour didactic and hands-on training session. Participants used a hand-held ultrasound device (HUD) equipped with an AI-based tool for the automatic evaluation of LVEF. The clips were assessed for LVEF by three methods: visually by the students, by students + the AI-based tool, and by the cardiologists. All LVEF measurements were compared to formal echocardiography completed within 24 hours and were evaluated for LVEF using the Simpson method and eyeballing assessment by expert echocardiographers.

Results

The study included 88 patients (aged 58.3 ± 16.3 years). The AI-based tool measurement was unsuccessful in 6 cases. Comparing LVEF reported by students' visual evaluation and students + AI vs. cardiologists revealed a correlation of 0.51 and 0.83, respectively. Comparing these three evaluation methods with the echocardiographers revealed a moderate/substantial agreement for the students + AI and cardiologists but only a fair agreement for the students' visual evaluation.

Conclusion

Medical students' utilization of an AI-based tool with a HUD for LVEF assessment achieved a level of accuracy similar to that of cardiologists. Furthermore, the use of AI by the students achieved moderate to substantial inter-rater reliability with expert echocardiographers' evaluation.

Ultrasound versus videos: A comparative study on the effectiveness of musculoskeletal anatomy education and student cognition

Ultrasound imaging is a dynamic imaging technique that uses high-frequency sound waves to capture live images of the structures beneath the skin. In addition to its growing use in diagnosis and interventions, ultrasound imaging has the potential to reinforce concepts in the undergraduate medical curriculum. However, research assessing the impact of ultrasound on anatomy learning and student cognition is scarce. The purpose of this study was to compare the impact of ultrasound-based instruction versus narrated videos on students' understanding of anatomical relationships, as well as the role of intrinsic motivation, self-efficacy beliefs, and students' attitudes in this process. A booster course on anterior leg and wrist anatomy was offered to second-year medical students. A randomized controlled trial with a cross-over design allocated students to either an ultrasound-based teaching condition (cohort A) or a narrated anatomy video condition (cohort B). Next, participants were crossed to the alternative intervention. At the start of the study (T0), baseline anatomy knowledge, intrinsic motivation, self-efficacy beliefs, and spatial ability were measured. After the first intervention (T1) and at the end of the study (T2), both cohorts were administered an anatomy test, an intrinsic motivation scale, and a self-efficacy scale. In addition, each student was asked to fill out a perception survey after the ultrasound intervention. Finally, building on the cross-over design, the most optimal sequence of interventions was examined. A total of 181 students participated (cohort A: n = 82, cohort B: n = 99). Both cohorts performed comparably on the baseline anatomy knowledge test, spatial ability test, intrinsic motivation, and self-efficacy scale. At T1, cohort B outperformed cohort A on the anatomy test (p = 0.019), although only a small effect size could be detected (Cohen's d = 0.34). Intrinsic motivation and self-efficacy of both cohorts were similar at T1. At T2, the anatomy test, intrinsic motivation, and self-efficacy scale did not reflect an effect after studying either sequence of the interventions. Students reported favorably about the ultrasound experience, but also mentioned a steep learning curve. Medical students found the hands-on ultrasound sessions to be valuable, increasing their interest in musculoskeletal anatomy and ultrasound imaging. However, the addition of ultrasound did not result in superior spatial anatomy understanding compared to watching anatomy videos. In addition, ultrasound teaching did not have a major effect on student cognition. Ultrasound-based teaching of musculoskeletal anatomy is regarded as difficult to learn, and therefore it is hypothesized that too high levels of cognitive load might explain the presented results.

Ultrasound skills teaching in UK medical education: A systematic review

BACKGROUND

Sonography is increasingly integrated into medical curricula to prepare students for clinical practice. In 2022, we conducted a systematic review to explore the degree to which ultrasound skill acquisition is incorporated into undergraduate medial education in the United Kingdom.

METHODS

A search of Medline and Embase databases from 2003 to 2022 identified 15 relevant articles. Studies were included if they described ultrasound skills training in UK undergraduate medical education.

FINDINGS

A range of teaching methods were reported including didactic demonstrations, hands-on experience and combinations thereof. Portable machines were more common than cart-based machines, and most demonstrators were ultrasound-trained clinicians. Ultrasound teaching is well received, with improvements in confidence using ultrasound, motivation to learn anatomy and retention of knowledge.

DISCUSSION

Obstacles to integration were noted including training, cost, curriculum time constraints and the issue of incidental pathology. One study demonstrated that anatomists with appropriate training could provide ultrasound teaching, reducing the need for clinicians or sonographers. Costs may be reduced by renting machines or purchasing portable/hand-held devices. Allowing access to machines during student's free time may address scheduling difficulties. A final recommendation is to pre-scan volunteers prior to the teaching session.

CONCLUSION

We have outlined approaches to ultrasound skills teaching and the inherent hurdles to this, as well as potential solutions. This may aid educators wishing to augment their curricula. Although there are relatively few studies from the United Kingdom, there is consensus that students enjoy the incorporation of ultrasound practice and believe it complements existing teaching, especially in a small group setting.

Ultrasound simulation training to meet the 2021 Royal College of Radiologists' curriculum for radiology trainees: South East London experience

AIM

To enhance ultrasound teaching delivery to radiology trainees using a simulation course matched to the 2021 Royal College of Radiologists (RCR) curriculum.

MATERIAL AND METHODS

An ultrasound simulation training course was designed for specialty trainees (ST) 1 in radiology, which was based on the 2021 RCR curriculum and covered the top ultrasound training priorities. The course was piloted initially on two occasions in a 1-day format to the August 2021 and the March 2022 ST1 intake trainees. Based on the feedback, a comprehensive 4-day course was developed and delivered between October and December 2022 for the August 2022 ST1 intake, funded by Health Education England. The outcomes measured were subjective trainee feedback using numerical scores and free text.

RESULTS

All King's College Hospital NHS Foundation Trust radiology ST1 trainees from the August 2021 to the August 2022 intake participated in ultrasound simulation training. The training matched the RCR curriculum and increased the trainees' confidence and competency in medical ultrasound.

CONCLUSIONS

Ultrasound simulation training can be successfully delivered to ST1 trainees to match the 2021 RCR curriculum and enhance training in medical ultrasound for radiologists.

OpNotes and Clinical Exercises: Activities to Enhance the Clinical Context of the Preclerkship Anatomy Dissection Laboratory

PROBLEM

Despite numerous pedagogical approaches and technologies now available for medical gross anatomy, students can find it difficult to translate what occurs in a dissection laboratory into the context of clinical practice.

APPROACH

Using complementary and collaborative approaches at 2 different medical schools, Virginia Commonwealth University (VCU) and University of Maryland (UM), we designed and implemented a series of clinical activities in the preclerkship medical gross anatomy laboratory that directly link dissected structures to clinical procedures. These activities specifically direct students to perform simulated clinically related procedures on anatomic donors during laboratory dissection sessions. The activities are called OpNotes at VCU and Clinical Exercises at UM. Each activity in the VCU OpNotes requires about 15 minutes of group activity at the end of a scheduled laboratory and involves faculty to grade the student responses submitted via a web-based-assessment form. Each exercise in UM Clinical Exercises also requires about 15 minutes of group activity during the schedule laboratory but does not involve faculty to complete grading.

OUTCOMES

Cumulatively, the activities in OpNotes and Clinical Exercises both brought clinical context directly to anatomical dissections. These activities began in 2012 at UM and 2020 at VCU, allowing a multiyear and multi-institute development and testing of this innovative approach. Student participation was high, and perception of its effectiveness was almost uniformly positive.

NEXT STEPS

Future iterations of the program will work to assess the efficacy of the program as well as to streamline the scoring and delivery of the formative components. Collectively, we propose that the concept of executing clinic-like procedures on donors in anatomy courses is an effective means of enhancing learning in the anatomy laboratory while concurrently underscoring the relevance of basic anatomy to future clinical practice.

Patients' experiences of being touched by their general practitioner: a qualitative study

OBJECTIVE

This study aimed to explore patients' experiences and perceptions of touch, as practised by their general practitioner during their medical appointment.

DESIGN

Qualitative study using grounded theory method, based on individual interviews. Data collection and analysis occurred iteratively; themes were identified using constant comparison.

SETTING

Recruitment among general practitioners' private practices and health centres in Ile-de-France.

PARTICIPANTS

Twenty-one patients aged 19-88 years old, interviewed between June 2018 and May 2019.

RESULTS

Physical examination was described as a ritual enabling the establishment of patients' and doctors' roles, the verification of the doctor's skills and the construction of a caring experience. Touch was also a media for the doctor to exercise power that the patient authorised. Finally, it had relational and emotional value.

DISCUSSION AND CONCLUSION

Physical examination is so internalised by the patients that it becomes unquestionable. It may be inappropriate when this touch does not belong to physical examination or on the contrary represents a proof of the doctor's humanity. The patient is not necessarily aware of the relational dimension that underpins touching and, in particular, clinical examination. This raises the question of why should doctor use it and how they can communicate about it, so that it may become an active tool in favour of trust and the construction of the relationship.

External validation of the ultrasound competency assessment tool

Objective

Point-of-care ultrasound (POCUS) is a core component of emergency medicine (EM) residency training. No standardized competency-based tool has gained widespread acceptance. The ultrasound competency assessment tool (UCAT) was recently derived and validated. We sought to externally validate the UCAT in a 3-year EM residency program.

Methods

This was a convenience sample of PGY-1 to -3 residents. Utilizing the UCAT and an entrustment scale, as described in the original study, six different evaluators split into two groups graded residents in a simulated scenario involving a patient with blunt trauma and hypotension. Residents were asked to perform and interpret a focused assessment with sonography in trauma (FAST) examination and apply the findings to the simulated scenario. Demographics, prior POCUS experience, and self-assessed competency were collected. Each resident was evaluated simultaneously by three different evaluators with advanced ultrasound training utilizing the UCAT and entrustment scales. Intraclass correlation coefficient (ICC) between evaluators was calculated for each assessment domain; analysis of variance was used to compare UCAT performance and PGY level and prior POCUS experience.

Results

Thirty-two residents (14 PGY-1, nine PGY-2, and nine PGY-3) completed the study. Overall, ICC was 0.9 for preparation, 0.57 for image acquisition, 0.3 for image optimization, and 0.46 for clinical integration. There was moderate correlation between number of FAST examinations performed and entrustment and UCAT composite scores. There was poor correlation between self-reported confidence and entrustment and UCAT composite scores.

Conclusions

We had mixed results in our attempt to externally validate the UCAT with poor correlation between faculty and moderate to good correlation with faculty to diagnostic sonographer. More work is needed to validate the UCAT before adoption.

Technical Difficulties: Teaching Critical Philosophical Orientations toward Technology

Issue: Technological innovation is accelerating, creating less time to reflect on the impact new technologies will have on the medical profession. Modern technologies are becoming increasingly embedded in routine medical practice with far-reaching impacts on the patient-physician relationship and the very essence of the health professions. These impacts are often difficult to predict and can create unintended consequences for medical education. This article is driven by a main question: How do we prepare trainees to critically assess technologies that we cannot foresee and effectively use technology to support equitable and compassionate care? Evidence: We translate insights from the philosophy of technology into a proposal for integrating critical technical consciousness in medical curricula. We identify three areas required to develop critical consciousness with regard to emerging technologies. The first area is technical literacy, which involves not just knowing how to use technology, but also understanding its limitations and appropriate contexts for use. The second area is the ability to assess the social impact of technology. This practice requires understanding that while technification creates new possibilities it can also have adverse, unintended consequences. The third area is critical reflection on the relationship between 'the human' and 'the technical' as it relates to the values of the medical profession and professional identity formation. Human and technology are two sides of the same coin; therefore, thinking critically about technology also forces us to think about what we consider 'the human side of medicine'. Implications: Critical technical consciousness can be fostered through an educational program underpinned by the recognition that, although technological innovation can create new possibilities for healing, technology is never neutral. Rather, it is imperative to emphasize that technology is interwoven with the social fabric that is essential to healing. Like medication, technology can be both potion and poison.

Exploring training needs of newly graduated medical doctors to inform the undergraduate simulation-based curriculum: a national Delphi consensus study

PURPOSE

Mastering technical procedures is a key component in succeeding as a newly graduated medical doctor and is of critical importance to ensure patient safety. The efficacy of simulation-based education has been demonstrated but medical schools have different requirements for undergraduate curricula. We aimed to identify and prioritize the technical procedures needed by newly graduated medical doctors.

METHODS

We conducted a national needs assessment survey using the Delphi technique to gather consensus from key opinion leaders in the field. In the first round, a brainstorm was conducted to identify all potential technical procedures. In the second round, respondents rated the need for simulation-based training of each procedure using the Copenhagen Academy for Medical Education and Simulation Needs Assessment Formula (CAMES-NAF). The third round was a final elimination and prioritization of the procedures.

RESULTS

In total, 107 experts from 21 specialties answered the first round: 123 unique technical procedures were suggested. Response rates were 58% and 64% in the second and the third round, respectively. In the third round, 104 procedures were eliminated based on the consensus criterion, and the remaining 19 procedures were included and prioritized. The top five procedures were: (i) insert peripheral intravenous catheter, (ii) put on personal protection equipment, (iii) perform basic airway maneuvers, (iv) perform basic life support, and (v) perform radial artery puncture.

CONCLUSION

Based on the Delphi process a final list of 19 technical procedures reached expert consensus to be included in the undergraduate curriculum for simulation-based education.

Using Kane's framework to build an assessment tool for undergraduate medical student's clinical competency with point of care ultrasound

INTRODUCTION

Point-of-care ultrasonography (POCUS) is a portable imaging technology used in clinical settings. There is a need for valid tools to assess clinical competency in POCUS in medical students. The primary aim of this study was to use Kane's framework to evaluate an interpretation-use argument (IUA) for an undergraduate POCUS assessment tool.

METHODS

Participants from Memorial University of Newfoundland, the University of Calgary, and the University of Ottawa were recruited between 2014 and 2018. A total of 86 participants and seven expert raters were recruited. The participants performed abdominal, sub-xiphoid cardiac, and aorta POCUS scans on a volunteer patient after watching an instruction video. The participant-generated POCUS images were assessed by the raters using a checklist and a global rating scale. Kane's framework was used to determine validity evidence for the scoring inference. Fleiss' kappa was used to measure agreement between seven raters on five questions that reflected clinical competence. The descriptive comments collected from the raters were systematically coded and analyzed.

RESULTS

The overall agreement between the seven raters on five questions on clinical competency ranged from fair to moderate (κ = 0.32 to 0.55). The themes from the qualitative data were poor image generation and interpretation (22%), items not applicable (20%), poor audio and video quality (20%), poor probe handling (10%), and participant did not verbalize findings (14%).

CONCLUSION

The POCUS assessment tool requires further modification and testing prior before it can be used for reliable undergraduate POCUS assessment.

Commentary on Ultrasound Instruction in Undergraduate Medical Education: Perspective from Two Students

BACKGROUND

Ultrasound integration in undergraduate medical education (UME) has been a focused endeavor in recent years. According to the American Institute of Ultrasound in Medicine, more than a third of all US medical schools have adopted a focused ultrasound training program for medical students. Medical student perspectives on best practices in ultrasound education are lacking in the literature.

CURRICULA EXPERIENCES

Two students' reflections are presented regarding two different didactic approaches, flipped classroom and self-study learning models, to teaching ultrasound in the pre-clinical medical education curriculum. Students present reflections on these didactic approaches to facilitate further improvement in ultrasound education curricula.

DISCUSSION

The self-directed learning model enabled students to learn foundational ultrasound exam techniques efficiently in a low-stress environment and subsequently optimized the efficiency of later faculty-led learning events. However, we noted that in both the flipped classroom and self-study learning models of education, the training on basic physical properties of ultrasound, tissue characteristics, and probe manipulation was limited.

CONCLUSION

A self-study learning model ultrasound curricula improves perceived learning efficiency and student confidence, especially when followed by faculty-guided didactics and scanning opportunities. We suggest a framework for ultrasound education curricula that includes components of both formats of ultrasound education alongside faculty-led sessions as an ideal model of ultrasound education. Further, we propose the added benefit of inanimate object scanning to optimize students' knowledge of waveform physics (image acquisition and physical properties of materials) early in the ultrasound education process.

Blind spots in medical education: how can we envision new possibilities?

As human beings, we all have blind spots. Most obvious are our visual blind spots, such as where the optic nerve meets the retina and our inability to see behind us. It can be more difficult to acknowledge our other types of blind spots, like unexamined beliefs, assumptions, or biases. While each individual has blind spots, groups can share blind spots that limit change and innovation or even systematically disadvantage certain other groups. In this article, we provide a definition of blind spots in medical education, and offer examples, including unfamiliarity with the evidence and theory informing medical education, lack of evidence supporting well-accepted and influential practices, significant absences in our scholarly literature, and the failure to engage patients in curriculum development and reform. We argue that actively helping each other see blind spots may allow us to avoid pitfalls and take advantage of new opportunities for advancing medical education scholarship and practice. When we expand our collective field of vision, we can also envision more "adjacent possibilities," future states near enough to be considered but not so distant as to be unimaginable. For medical education to attend to its blind spots, there needs to be increased participation among all stakeholders and a commitment to acknowledging blind spots even when that may cause discomfort. Ultimately, the better we can see blind spots and imagine new possibilities, the more we will be able to adapt, innovate, and reform medical education to prepare and sustain a physician workforce that serves society's needs.

The Use of Ultrasound in Undergraduate Medical Anatomy Education: a Systematic Review with Narrative Synthesis

This systematic review aimed to synthesize the literature on how ultrasound is currently used in anatomy education within medical schools. A systematic search of Ovid MEDLINE, Scopus, and Educational Resources Information Centre was conducted. Thirty-four relevant unique articles were included from the 1,272 identified from the databases and analyzed via narrative synthesis. Thematic analysis generated two domain summaries: "Successful Aspects of Ultrasound Teaching" and "Barriers to Implementation," each with additional subthemes, aimed to help educators inform best teaching practices from the current evidence base in this field.

International consensus conference recommendations on ultrasound education for undergraduate medical students

OBJECTIVES

The purpose of this study is to provide expert consensus recommendations to establish a global ultrasound curriculum for undergraduate medical students.

METHODS

64 multi-disciplinary ultrasound experts from 16 countries, 50 multi-disciplinary ultrasound consultants, and 21 medical students and residents contributed to these recommendations. A modified Delphi consensus method was used that included a systematic literature search, evaluation of the quality of literature by the GRADE system, and the RAND appropriateness method for panel judgment and consensus decisions. The process included four in-person international discussion sessions and two rounds of online voting.

RESULTS

A total of 332 consensus conference statements in four curricular domains were considered: (1) curricular scope (4 statements), (2) curricular rationale (10 statements), (3) curricular characteristics (14 statements), and (4) curricular content (304 statements). Of these 332 statements, 145 were recommended, 126 were strongly recommended, and 61 were not recommended. Important aspects of an undergraduate ultrasound curriculum identified include curricular integration across the basic and clinical sciences and a competency and entrustable professional activity-based model. The curriculum should form the foundation of a life-long continuum of ultrasound education that prepares students for advanced training and patient care. In addition, the curriculum should complement and support the medical school curriculum as a whole with enhanced understanding of anatomy, physiology, pathophysiological processes and clinical practice without displacing other important undergraduate learning. The content of the curriculum should be appropriate for the medical student level of training, evidence and expert opinion based, and include ongoing collaborative research and development to ensure optimum educational value and patient care.

CONCLUSIONS

The international consensus conference has provided the first comprehensive document of recommendations for a basic ultrasound curriculum. The document reflects the opinion of a diverse and representative group of international expert ultrasound practitioners, educators, and learners. These recommendations can standardize undergraduate medical student ultrasound education while serving as a basis for additional research in medical education and the application of ultrasound in clinical practice.

Evaluating knowledge, confidence, and self-efficacy of NPs and PAs in the emergency department: extended focused assessment using sonography in trauma

BACKGROUND

Developing and translating knowledge gained in the classroom into skills that are practiced in the clinical setting is an ongoing, iterative, and dynamic process. Health care clinicians require continually evolving knowledge, ongoing education, and hands-on skills practice particular to the specialty.

PURPOSE

This prospective observational study was conceived based on the existing evidence demonstrating that Point of Care Ultrasound (POCUS) is not routinely taught in nurse practitioner (NP) or physician assistant (PA) graduate programs. This study examines outcomes of an educational intervention aimed at improving knowledge, self-confidence, and self-efficacy of the Extended Focused Assessment using Sonography in Trauma (E-FAST examination) for both NPs and PAs working in emergency settings.

METHODOLOGY

Twenty participants attended a short course including both didactic learning and hands-on learning of the E-FAST examination. Participants rated themselves using a self-assessment tool for pre- and postintervention self-evaluation. The Wilcoxon signed-rank test was used to evaluate data. A second tool used to evaluate participants' hands-on use of the E-FAST examination is the Objective Structured Assessment of Ultrasound, in which participants were evaluated by clinical experts. These data were assessed using regression analysis.

RESULTS

Participants showed improvement on the pre/post course self-assessment tool. Participants also showed proficiency using ultrasound and analyzing images as evaluated by experts.

CONCLUSIONS

A short multimodal course can improve clinicians' knowledge, confidence, and self-efficacy in the use of POCUS and the E-FAST examination.

IMPLICATIONS

Hands-on education is a valuable tool for ongoing learning.

Virtual anatomy and point-of-care ultrasonography integration pilot for medical students

Despite its significant clinical use, there is no standardized point-of-care ultrasonography (POCUS) curriculum in undergraduate medical education. As Covid-19 abruptly mandated the use of virtual education, instructors were challenged to incorporate and improve POCUS education within these new constraints. It was hypothesized that integrating POCUS into anatomy via brief video lessons and a subsequent interactive virtual lesson would lead to an objective understanding of POCUS concepts, improved understanding of the corresponding anatomy, and subjective improvement of student confidence with POCUS. A cross-sectional descriptive study assessed first-year medical students' perspectives and performance before and after the interventions (n = 161). The intervention was split into two parts: (1) three optional 10-minute POCUS videos that reinforced anatomy concepts taught in the laboratory sessions, and (2) a subsequent two-hour interactive virtual session reviewing POCUS and anatomy concepts. Students completed a knowledge and confidence assessment tool before and after the interactive session. Survey responses (n = 51) indicated that 94% of students felt the optional videos improved their understanding of POCUS and were educationally valuable. One half of medical students (50%) indicated that the demonstrations improved their anatomy understanding. Initial self-reported confidence was low after the optional video lessons, despite an average score of 58% on the knowledge assessment (n = 130). However, confidence increased significantly along with an increase in score performance to 80% after the interactive session (n = 39, P < 0.01). Results suggest that the virtual integration pilot enhanced student learning of both anatomy and POCUS.

Does Point-of-Care Ultrasound Change the Needle Insertion Location During Routine Bedside Paracentesis?

BACKGROUND

Paracentesis is a bedside procedure to obtain ascitic fluid from the peritoneum. Point-of-care ultrasound (POCUS) improves the safety of some medical procedures. However, the evidence supporting its utility in paracentesis is limited.

OBJECTIVE

We aimed to assess if POCUS would yield a user-preferred site for needle insertion compared to conventional landmarking, defined as a ≥ 5 cm change in location.

DESIGN

This was a prospective non-randomized trial comparing a POCUS-guided site to the conventional anatomic site in the same patient.

PARTICIPANTS

Adult patients at Kingston Health Sciences Centre undergoing paracentesis were included.

INTERVENTIONS

Physicians landmarked using conventional technique and compared this to a POCUS-guided site. The paracentesis was performed at whatever site was deemed optimal, if safe to do so.

MAIN MEASURES

Data collected included the distance from the two sites, depth of fluid pockets, and anatomic considerations.

KEY RESULTS

Forty-five procedures were performed among 30 patients and by 24 physicians, who were primarily in their PGY 1 and 2 years of training (33% and 31% respectively). Patients' ascites was mostly due to cirrhosis (84%) predominantly due to alcohol (47%) and NAFLD (34%). Users preferred the POCUS-guided site which resulted in a change in needle insertion ≥ 5 cm from the conventional anatomic site in 69% of cases. The average depth of fluid was greater at the POCUS site vs. the anatomic site (5.4±2.8 cm vs. 3.0±2.5 cm, p < 0.005). POCUS deflected the needle insertion site superiorly and laterally to the anatomic site. The POCUS site was chosen (1) to avoid adjacent organs, (2) to optimize the fluid pocket, and (3) due to abdominal wall considerations, such as pannus. Six cases landmarked anatomically were aborted when POCUS revealed inadequate ascites.

CONCLUSIONS

POCUS changes the needle insertion site from the conventional anatomic site for most procedures, due to optimizing the fluid pocket and safety concerns, and helped avoid cases where an unsafe volume of ascites was present.

3-D modeling applications in ultrasound education: a systematic review

Ultrasound offers a real-time 2-D view of structures within the human body. While many medical education programs have already dedicated a portion of their curriculum to ultrasound, others are concerned about cost, accessibility and limits to student practice. Student benefit may be affected by cognitive errors, which are in part owing to the mental heuristics required to visualize a 3-D structure by interpreting a 2-D image. A possible solution to eliminating subjectivity in ultrasound interpretation is the use of 3-D models to augment the traditional 2-D ultrasound experience. PubMed, Embase and Web of Science were searched for primary literature exploring relationships between 3-D modeling applications and their use in ultrasound education. The search and review process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. Overall, 14 of the included 16 studies indicated a significant improvement in medical education of ultrasound with the intervention of 3-D modeling applications. This systematic review confirms that 3-D modeling applications benefit student learning in ultrasound education while illuminating the need for more research in this field.

Managing Incidental Findings Reported by Medical, Sonography and Other Students Performing Educational Ultrasound Examinations

The evolution of ultrasound imaging into a key technology for diagnostic practice has resulted in its incorporation into the education of medical students worldwide. Although the introduction of ultrasound into medical schools' curricula is relatively recent, training of sonographers and other ultrasound users is mature. Ultrasound is being used in a variety of learning environments and clinical settings, from courses in anatomy and physiology to clinical rotations where medical and other students may scan healthy volunteers or patients, sometimes with little to no supervision. Educators may be apprehensive about a perceived high likelihood that students will encounter unexpected findings during these sessions, which could distress the patient or ultrasound model as well as the student, and result in problems that would be more pronounced if such incidental findings are complex. Policies are needed to address how to manage incidental ultrasound findings that are identified during educational activities. This article summarizes the background and provides a framework for establishing and implementing a well-designed and thoughtful approach for dealing with incidental findings observed in volunteer subjects by medical students during training courses in ultrasound diagnostic scanning. Subject confidentiality should be respected, and review of incidental findings should be transparent without provoking unnecessary anxiety. It is the responsibility of the instructor or supervisor to ensure adequate clinical follow-up if indicated.

Association of a longitudinal, preclinical ultrasound curriculum with medical student performance

INTRODUCTION

Point-of-care ultrasound (US) is used in clinical practice across many specialties. Ultrasound (US) curricula for medical students are increasingly common. Optimal timing, structure, and effect of ultrasound education during medical school remains poorly understood. This study aims to retrospectively determine the association between participation in a preclinical, longitudinal US curriculum and medical student academic performance.

METHODS

All first-year medical students at a medical school in the Midwest region of the United States were offered a voluntary longitudinal US curriculum. Participants were selected by random lottery. The curriculum consisted of five three-hour hands on-sessions with matching asynchronous content covering anatomy and pathologic findings. Content was paired with organ system blocks in the standard first year curriculum at our medical school. Exam scores between the participating and non-participating students were compared to evaluate the objective impact of US education on performance in an existing curriculum. We hypothesized that there would be an association between participation in the curriculum and improved medical student performance. Secondary outcomes included shelf exam scores for the surgery, internal medicine, neurology clerkships and USMLE Step 1. A multivariable linear regression model was used to evaluate the association of US curriculum participation with student performance. Scores were adjusted for age, gender, MCAT percentile, and science or engineering degree.

RESULTS

76 of 178 students applied to participate in the curriculum, of which 51 were accepted. US curriculum students were compared to non-participating students (n = 127) from the same class. The US curriculum students performed better in cardiovascular anatomy (mean score 92.1 vs. 88.7, p = 0.048 after adjustment for multiple comparisons). There were no significant differences in cumulative cardiovascular exam scores, or in anatomy and cumulative exam scores for the gastroenterology and neurology blocks. The effect of US curriculum participation on cardiovascular anatomy scores was estimated to be an improvement of 3.48 points (95% CI 0.78-6.18). No significant differences were observed for USMLE Step 1 or clerkship shelf exams. There were no significant differences in either preclinical, clerkship or Step 1 score for the 25 students who applied and were not accepted and the 102 who did not apply.

CONCLUSIONS

Participation in a preclinical longitudinal US curriculum was associated with improved exam performance in cardiovascular anatomy but not examination of other cardiovascular system concepts. Neither anatomy or comprehensive exam scores for neurology and gastrointestinal organ system blocks were improved.

Ultrasonography in undergraduate medical education: a comprehensive review and the education program implemented at Jichi Medical University

The concept of point-of-care ultrasound has been widely accepted owing to the development of portable ultrasound systems and growing body of evidence concerning its extensive utility. Thus, it is reasonable to suggest that training to use this modality be included in undergraduate medical education. Training in ultrasonography helps medical students learn basic subjects such as anatomy and physiology, improve their physical examination skills, and acquire diagnostic and procedural skills. Technological advances such as simulators, affordable handheld devices, and tele-ultrasound systems can facilitate undergraduate ultrasound education. Several reports have indicated that some medical schools have integrated ultrasound training into their undergraduate medical curricula. Jichi Medical University in Japan has been providing medical students with ultrasound education to fulfill part of its mission to provide medical care to rural areas. Vertical integration of ultrasound education into a curriculum seems reasonable to ensure skill retention and improvement. However, several issues have hampered the integration of ultrasound into medical education, including a lack of trained faculty, the need to recruit human models, requisition of ultrasound machines for training, and limited curricular space; proposed solutions include peer teaching, students as trained simulated patients, the development of more affordable handheld devices, and a flipped classroom approach with access to an e-learning platform, respectively. A curriculum should be developed through multidisciplinary and bottom-up student-initiated approaches. Formulating national and international consensuses concerning the milestones and curricula can promote the incorporation of ultrasound training into undergraduate medical education at the national level.

A comparison of handheld and standard ultrasound in Swiss medical students

BACKGROUND

The use of ultrasound (US) within healthcare has inspired the development of new US technology. There have been few studies comparing the use of handheld US to standard US for medical education. This research aims to determine whether a handheld US device can provide a comparable primary learning experience to that of a standard US machine.

METHODS

Over two days of instruction, participants were taught and evaluated on core US fundamentals. The standard group received instruction on standard US machines, while the handheld group received instruction on handheld US devices. Participants completed a qualitative survey regarding their experience. Six hundred and four images were obtained and graded by two emergency medicine physicians.

RESULTS

A total of 119 Swiss medical students were enrolled in our study. There was no statistically significant difference in the US assessment measurements, except for faster endpoint septal separation (EPSS) vascular setup time in the handheld group (P=0.001). There was no statistically significant difference in participants' perceived difficulty of US learning (P=0.198), comfort level (P=0.188), or self-estimated capability to perform US in the future (P=0.442). There was no statistically significant difference in the percentage of correctly obtained images (P=0.211) or images that were clinically useful (P=0.256). The median quality score of images obtained by the standard group was eight compared to seven in handheld group (P<0.01).

CONCLUSION

Our data suggest a handheld US machine can perform as well as a standard US machine as an educational tool despite sacrifices in image quality.

The Current Status of Ultrasound Education in United States Medical Schools

OBJECTIVES

Ultrasound is used by nearly every medical specialty. Medical schools are integrating ultrasound education into their curriculum but studies show this to be inconsistent. The purpose of this study was to provide an updated description of ultrasound in the curricula of United States Accredited Medical Schools (USAMS).

METHODS

In 2019, USAMS curricular offices were contacted. Institutions were asked about the presence of ultrasound curriculum and for contact information for faculty involved with education. Schools reporting ultrasound curriculum were surveyed regarding details of their curriculum.

RESULTS

Two hundred USAMS were contacted with a response rate of 84%. Of 168 schools, 72.6% indicated they have an ultrasound curriculum. For schools with a curriculum, 79 (64.8%) completed our survey. The majority of survey respondents, 66 (83.5%), indicated having mandatory ultrasound. Ultrasound is primarily integrated into courses (73.8% in basic science courses, 66.2% in clinical skills courses, and 35.4% in clinical rotations). Emergency medicine physicians accounted for 54.7% of course directors. Ten or fewer faculty participate in education in 68.4% of schools and mostly as volunteers. Dedicated machines for education were reported by 78.5% of schools.

CONCLUSIONS

Compared to prior studies, this study had a higher response rate at 84%, and more schools reported ultrasound in their curricula. Emergency medicine represents the majority of leadership in ultrasound education. Despite increased integration of ultrasound into American medical school curricula, its instruction is still inconsistent.

Ultrasound's Impact on Preclinical Medical Student Neurology Unit Grades: Findings After 2 Years

OBJECTIVES

Ultrasound is a valuable tool for anatomy education, but limited evidence exists for using ultrasound to teach neuroanatomy and neurophysiology. Previous work demonstrated a potential increase in medical knowledge in preclinical medical students participating in a neurology ultrasound workshop, however, without comparison to a control group. After 2 years, we assessed how a neurology ultrasound workshop affected the medical knowledge of participating preclinical medical students compared to a traditional curriculum control group.

METHODS

This quasiexperimental study compared academic performance of ultrasound workshop participants to nonparticipant classmates. The primary outcome was the overall neurologic disorders unit total score. An analysis of covariance was conducted to test for statistically significant differences while controlling for the average quiz score.

RESULTS

A total of 360 medical students were included in the study. The intervention group (n = 57) showed no significant difference in the total unit score (F = 3.206; P = .074), with averages for the control and experimental groups being 87.3% ± 5.0% and 88.4% ± 4.8%, respectively. Additionally, anatomy practical scores and written final examination scores were not significantly different between groups (F = 1.035; P = .310; F = 2.035; P = .155).

CONCLUSIONS

Participation in a neurologic disorders ultrasound workshop did not appear to be correlated with improved curricular performance in our cohort. Further research should continue to assess ultrasound workshops in other organ systems to elucidate the relationship between learning ultrasound and the impact on medical school academic performance.

Why do pre-clinical medical students learn ultrasound? Exploring learning motivation through ERG theory

BACKGROUND

In recent years, point-of-care ultrasound (POCUS) has become an essential field of medical education. Bedside ultrasound has become a necessary skill for clinical physicians. Previous studies have already discussed the importance of advancements in ultrasound education. However, learning motivations for ultrasound education have seldom been analyzed in the literature. For medical students, learning ultrasound could have a relevance for their future career. The Existence, Relatedness and Growth (ERG) theory extended Maslow's hierarchy of needs through these three concepts. This theory has been widely used in the workplace to analyze employee job performance but has not yet been applied in medical education. In this study ERG theory was applied to analyze pre-clinical medical students' learning motivation toward ultrasound education.

METHOD

This mixed method study used online questionnaires consisting of open-ended questions as a data collection tool, and based on these results, both qualitative and quantitative analysis were conducted. Participants answered a series of neutral and open-ended questions regarding their motivations to learn ultrasonography. After data collection, a three-step analysis was conducted based on the grounded theory approach. Finally, the results of the thematic coding were used to complete additional quantitative analysis.

RESULTS

The study involved 140 pre-clinical medical students, and their responses fell into 13 specific categories. The analysis demonstrated that students' motivations toward ultrasound education were unbalanced across the three ERG domains (F = 41.257, p < .001). Pairwise comparisons showed that students mentioned existence motivation (MD = 39.3%; p < .001) and growth motivation (MD = 40.7%; p < .001) more frequently than relatedness motivation. However, there was no significant difference between existence motivation and growth motivation (MD = - 1.4%; p = .830).

CONCLUSION

The results revealed that students placed a high value on existence and growth needs rather than relatedness based on the survey. In addition, the findings suggest that ERG theory can be a useful tool to conduct medical education motivation analysis.

Tackling the void: the importance of addressing absences in the field of health professions education research

Many processes and practices in the field of health professions education have been based more on tradition and assumption than on evidence and theory. As the field matures, researchers are increasingly seeking evidence to support various teaching and assessment methods. However, there is a tendency to focus on a limited set of topics, leaving other areas under-examined and limiting our understanding of the field. By explicitly examining areas that are undescribed, i.e. absences in the literature, researchers and scholars have the potential to enrich our practice and our field's understanding of what counts as legitimate research. Using the theoretical framework of Bourdieu's concept of field, we conducted an instrumental case study of three published research projects that each had a finding of absence. We examined each case individually, and then analyzed across cases. Our dataset included published papers, peer-review feedback, and reflective notes. Each of the cases interrogated a different form of absence: absence of content, absence of research, and absence of evidence. While the typology suggests that each absence was different, there were similarities across cases in terms of challenges in 'proving' the reality of the absence and some disbelief or discomfort with accepting the findings as rigorous and/or legitimate. Absence research has potential to add to our theoretical and methodological approaches to the field. This type of research is potentially an exciting and productive new way for scholars to shed light on aspects of health professions education that have received limited attention to date.

Ultrasound as a Learning Tool in Bachelor-Level Anatomy Education

Point of care ultrasound (POCUS) has become an increasingly common diagnostic tool in the clinical environment. As a result, it is being used earlier for medical students in Undergraduate Medical Education (UME) as a learning tool for the basic sciences including gross anatomy. There is little literature, however, to support its utility for basic science education in students currently seeking a bachelor's degree. This study consisted of fourteen currently enrolled bachelor students with previous instruction in human anatomy and physiology. Students participated in an ultrasound didactic and an interactive ultrasound experience with volunteers. Before and after this session, students were asked to complete an assessment measuring their spatial understanding of the human anatomy and their ability to locate structures using ultrasound. Wilcoxon's signed-rank tests comparing assessment scores showed significant improvement on both portions of the assessment. Based on this improvement, we suggest that ultrasound is a valid educational tool which can be used at the bachelor-level to effectively enhance students' learning of anatomy and provide hands on experience with modern technology. Further research with larger samples will be necessary to determine whether it would supplement or replace more traditional teaching modalities.

Ultrasound as a Learning Tool in Bachelor-Level Anatomy Education

Point of care ultrasound (POCUS) has become an increasingly common diagnostic tool in the clinical environment. As a result, it is being used earlier for medical students in Undergraduate Medical Education (UME) as a learning tool for the basic sciences including gross anatomy. There is little literature, however, to support its utility for basic science education in students currently seeking a bachelor's degree. This study consisted of fourteen currently enrolled bachelor students with previous instruction in human anatomy and physiology. Students participated in an ultrasound didactic and an interactive ultrasound experience with volunteers. Before and after this session, students were asked to complete an assessment measuring their spatial understanding of the human anatomy and their ability to locate structures using ultrasound. Wilcoxon's signed-rank tests comparing assessment scores showed significant improvement on both portions of the assessment. Based on this improvement, we suggest that ultrasound is a valid educational tool which can be used at the bachelor-level to effectively enhance students' learning of anatomy and provide hands on experience with modern technology. Further research with larger samples will be necessary to determine whether it would supplement or replace more traditional teaching modalities.

The Evolution of Educational Technology in Veterinary Anatomy Education

"All learning is in the learner, not the teacher." Plato was right. The adage has passed the test of time and is still true in an era where technology accompanies us in not only professional but also recreational life every day, everywhere. On the other hand, the learner has evolved and so have the sources being used to satisfy curiosity and learning. It therefore appears intuitive to embrace these technological advances to bring knowledge to our pupils with the aim to facilitate learning and improve performance. It must be clear that these technologies are not intended to replace but rather consolidate knowledge partly acquired during more conventional teaching of anatomy. Veterinary medicine is no outlier. Educating students to the complexity of anatomy in multiple species requires that three-dimensional concepts be taught and understood accurately if appropriate treatment is to be set in place thereafter. Veterinary anatomy education has up to recently walked diligently in the footsteps of John Hunter's medical teaching using specimens, textbooks, and drawings. The discipline has yet to embrace fully the benefits of advancement being made in technology for the benefit of its learners. Three-dimensional representation of anatomy is undeniably a logical and correct way to teach whether it is through the demonstration of cadaveric specimen or alternate reality using smartphones, tablets, headsets or other digital media. Here we review some key aspects of the evolution of educational technology in veterinary anatomy.

Point-of-Care Ultrasound (POCUS) for the Cardiothoracic Anesthesiologist

Point-of-Care Ultrasound (POCUS) is a valuable bedside diagnostic tool for a variety of expeditious clinical assessments or as guidance for a multitude of acute care procedures. Varying aspects of nearly all organ systems can be evaluated using POCUS and, with the increasing availability of affordable ultrasound systems over the past decade, many now refer to POCUS as the 21^st-century stethoscope. With the current available and growing evidence for the clinical value of POCUS, its utility across the perioperative arena adds enormous benefit to clinical decision-making. Cardiothoracic anesthesiologists routinely have used portable ultrasound systems for nearly as long as the technology has been available, making POCUS applications a natural extension of existing cardiothoracic anesthesia practice. This narrative review presents a broad discussion of the utility of POCUS for the cardiothoracic anesthesiologist in varying perioperative contexts, including the preoperative clinic, the operating room (OR), intensive care unit (ICU), and others. Furthermore, POCUS-related education, competence, and certification are addressed.

Efficacy of an Integrated Hands-On Thyroid Ultrasound Session for Medical Student Education

As ultrasound has gained popularity with improving technology and ease-of-use, a push has been made to integrate ultrasound into the medical school curriculum. Many institutions are reporting one- to four-year integrated ultrasound curricula to augment anatomy and pathophysiology teaching. Our goal was to integrate a thyroid ultrasound scanning session into the endocrinology block of our institution’s medical school curriculum to enhance medical student understanding of thyroid anatomy and pathophysiology. We conducted a prospective, single-center cohort (pre-experimental) study to evaluate student performance and knowledge acquisition using a pretest-posttest design. These multimodal sessions, consisting of a didactic, hands-on scanning sessions, and knowledge integration tests, covered ultrasound technique and thyroid evaluation and advanced to diagnosing an abnormal thyroid and working up a thyroid nodule. There were 26 to 27 second-year medical students per session who rotated between three stations proctored by credentialled physicians. Students participated in hands-on scanning of patients with or without thyroid pathology at each station. Out of the 209 students who participated in the ultrasound sessions, 114 (54.5%) consented to participate in the research project and completed both the pretest and posttest. Test data from the 114 students showed a mean pretest score of 57.5% ± 14.6% and the mean posttest score of 73.9% ± 17.4%. They had a 16.5% ± 19.6% (p < 0.001) increase in score between the two tests. Our study demonstrates that a multimodal thyroid ultrasound scanning session is an effective tool to augment the medical school endocrinology curriculum and to improve students’ knowledge of thyroid anatomy, pathophysiology, and diagnostic workup of thyroid nodules.

Implementing ultrasound sessions to highlight living anatomy for large medical student cohorts

Background

There is an intrinsic link between radiology and anatomy and the importance of being able to convert knowledge from 3D structure to 2D image, and vice versa. Medical students must learn how to use anatomical knowledge to interpret radiological images, and with the increasing use of point-of-care ultrasound in clinical practice, the ability to interpret ultrasound scans is becoming more of a core skill for graduating doctors.

Rationale

Several recent systematic reviews of the literature have been undertaken showing the benefits of incorporating ultrasound in anatomy teaching, including appreciation of the dynamic nature of living anatomy, better understanding of anatomical structure, and improved motivation to study. However, there is a lack of consensus in the way ultrasound teaching should be incorporated into undergraduate medical anatomy.

Approach

This article reflects on a pilot of integrating ultrasound into the medical undergraduate anatomy teaching in the School of Anatomy at the University of Bristol. It shares the experience and how some of the challenges cited in the literature have been approached.

Recommendation

To help others negotiate the challenges of implementing this valuable teaching experience, a 'Six Step Model' for developing a live ultrasound pilot for undergraduate medical anatomy is offered: Expertise, Education, Ethics, Environment, Equipment, Enlist.

The Impact of an Ultrasound Curriculum on the Accuracy of Resident Joint Line Palpation

BACKGROUND

Ultrasound education has been used as a tool to help improve physical examination skills. However, its utility in increasing accuracy of joint line palpation has yet to be investigated.

OBJECTIVE

To evaluate the accuracy of resident palpation and identification of the lateral knee joint line before and after introducing a musculoskeletal ultrasound (MSUS) curriculum.

DESIGN

Cohort study.

SETTING

A physical medicine and rehabilitation (PM&R) residency program at an academic institution.

PARTICIPANTS

Seventeen PM&R residents.

INTERVENTIONS

Residents underwent a knee-focused MSUS workshop.

MAIN OUTCOME MEASURES

Distance from needle placement to joint line confirmed with ultrasound.

RESULTS

All residents demonstrated improved accuracy in lateral knee joint line palpation after completing a knee-focused MSUS workshop, with statistically significant (P < .05) improvement in postgraduate year (PGY) 2 (P = .02), PGY-3 (P = .04), and across all residents (P = .001).

CONCLUSIONS

MSUS education significantly improved lateral knee joint line palpation accuracy in resident physicians.

Integration of Lung Point-of-care Ultrasound into Clinical Decision Making for Medical Students in Simulated Cases

Background

Point-of-care ultrasound (POCUS) has an emerging presence in medical student education; however, there is limited evidence that this translates into appropriate clinical care. We aimed to evaluate the ability of medical students to integrate newly obtained POCUS knowledge into simulated clinical cases.

Methods

We conducted an observational study of medical students participating in a mandatory rotation during their clinical years. Students in small groups underwent formalized lung POCUS lectures and hands-on training. Students participated in simulated “dyspnea” cases focused on either congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD). They were observed for critical actions including elements related to medical decision-making and ultrasound use and interpretation. Ultrasound-specific written knowledge was gauged with a short assessment after the first lecture and at week 4.

Results

A total of 62 students participated and were observed during simulations. All groups correctly identified and treated CHF in the simulated case. Most groups (7 out of 9) attempted to use ultrasound in the CHF case; five groups correctly recognized B-lines; and four groups correctly interpreted B-lines as pulmonary edema. No groups used ultrasound in the COPD case.

Conclusion

Most students attempted to use ultrasound during simulated CHF cases after a brief didactic intervention; however, many students struggled with clinical application. Interestingly, no students recognized the need to apply ultrasound for diagnosis and management of COPD. Future studies are needed to better understand how to optimize teaching for medical students to improve translation into POCUS skills and improved clinical practice.

[Current state of under- and postgraduate education in abdominal ultrasonography at German university hospitals. A panel study over 20 years]

OBJECTIVE

 In Germany, there is no standardized ultrasound training. This study aims to provide a survey into the current state of abdominal ultrasonography training at German university hospitals as well as a comparative analysis of the results from studies conducted in 1999 and 2009.

METHODS

 Chief gastroenterologists from Germany's 34 university hospitals were invited to respond to a postal survey asking about technical equipment, the number of ultrasound scans, the role of professional societies and undergraduate as well as postgraduate training. The response rate was 79 %. In addition, 1183 medical students from 34 faculties completed a complementary online teaching evaluation.

RESULTS

 At university hospitals, abdominal ultrasonography is conducted in an increasingly interdisciplinary context. Today, 29 % of university hospitals have interdisciplinary ultrasound centers. The study shows that the number of available ultrasound machines has increased - each hospital has an average of 5.2 systems. This is an increase of 30 % in comparison to 2009 and of 27 % in comparison to 1999. However, the willingness to invest in modern ultrasound machines has decreased. The total number of ultrasound scans as well as the number of contrast-enhanced ultrasound scans have steadily increased over the past years - with a maximum increase of 28 % between 2009 and 2018. The German Society of Ultrasound in Medicine (DEGUM) is increasingly present at university hospitals. It has further strengthened its prominent role in quality assurance and specialist training. Today, 96 % of the chief gastroenterologists are members of DEGUM and 89 % have obtained further qualification offered by the society. Concerning the duration of the training, the number of mandatory examinations and the amount of supervision, there are still considerable differences among the departments. On average, more doctors are trained per department and year. A 6-month full-time training has been established at most hospitals. Sonography enjoys a high standing among students and the findings show a strong readiness for work in that field. The number of practical courses and students has been increasing over the past years. However, there is often an imbalance between the number of courses offered and students who want to enroll.

CONCLUSIONS

 Training conditions have improved for medical staff as well as students despite the fact that there are still considerable differences in quality among the hospitals. The number of ultrasound scans is steadily increasing in all departments. The study did not show any adequate improvement in the availability of technical equipment. The German Society of Ultrasound in Medicine (DEGUM) has further strengthened its leading position in the field of sonography.

Ultrasound Curricula of Student Education in Europe: Summary of the Experience

Background Despite the increasing role of ultrasound, structured ultrasound teaching is only slowly being integrated into the curricula of medical schools and universities all over Europe.

Aim To survey the current situation at European universities regarding the integration of ultrasound in student medical education and to report on models of student ultrasound training from selected European universities.

Methods A questionnaire survey focusing on the implementation of curricular ultrasound education was sent out to the 28 presidents of the national ultrasound societies of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), who were asked to distribute the questionnaires to the medical universities of their countries.

Results Overall, 53 questionnaires were returned from 46 universities in 17 European countries. In most of the universities (40/46 universities, 87%), the theoretical background of ultrasound is taught. However, in only a minority of universities is ultrasound integrated in anatomy courses (8/46 universities, 17%) or basic science courses (16/46 universities, 35%). Practical skills in ultrasound are taught in 56% of the universities (26/46 universities) and tested in a practical exam in seven of the responding universities (15%). The number of hours in which ultrasound was taught ranged from one to 58 (mean, seven). The respondents reported that lack of time and limited faculty funding were major hurdles.

Conclusion According to our survey, only a minority of European universities has integrated ultrasound into the preclinical curriculum thus far. Future EFSUMB initiatives will continue to promote the introduction of ultrasound as an integrative part of the core curriculum of student medical education, and the preparation of proper teaching material.

Obstetric ultrasound: where are we and where are we going?

Diagnostic ultrasound (DUS) is, arguably, the most common technique used in obstetrical practice. From A mode, first described by Ian Donald for gynecology in the late 1950s, to B mode in the 1970s, real-time and gray-scale in the early 1980s, Doppler a little later, sophisticated color Doppler in the 1990s and three dimensional/four-dimensional ultrasound in the 2000s, DUS has not ceased to be closely associated with the practice of obstetrics. The latest innovation is the use of artificial intelligence which will, undoubtedly, take an increasing role in all aspects of our lives, including medicine and, specifically, obstetric ultrasound. In addition, in the future, new visualization methods may be developed, training methods expanded, and workflow and ergonomics improved.

Learning musculoskeletal anatomy through new technologies: a randomized clinical trial

Objective:

to investigate the influence of the application of new methodologies on learning and the motivation of students of the Anatomy discipline.

Method:

randomized, longitudinal, prospective, intervention study. Sixty-two students were recruited to assess the impact of different methodologies. The sample was randomized to compare the results of teaching with a 3D atlas, ultrasound and the traditional method. The parameters were assessed through a satisfaction evaluation questionnaire and anatomical charts. Repeated measures ANOVA was used to determine statistical significance.

Results:

in terms of the usefulness of the seminars, 98.1% of the students considered them to be very positive or positive, stating that they had stimulated their interest in anatomy. The students who learned with the 3D atlas improved their understanding of anatomy (p=0.040). In general, the students improved their grades by around 20%.

Conclusion:

the traditional method combined with new technologies increases the interest of students in human anatomy and enables them to acquire skills and competencies during the learning process.

Confidence Level and Ability of Medical Students to Identify Abdominal Structures After Integrated Ultrasound Sessions

Purpose

Determine the confidence level and ability of first year medical students to identify abdominal structures using a wireless portable ultrasound scanner.

Methods

The students were assessed for their confidence and ability to perform abdominal ultrasound. The 5-point Likert survey included questions on their perception about ultrasound as a resource for learning anatomy, physical examination skills, and the quality of the pre-session instructions. Data was also recorded by the faculty about the students’ ultrasound skills and confidence. Goodman and Kruskal's gamma was used to demonstrate an association between the students’ ability to identify the structures and the self-reported student confidence level.

Results

Most of the students had confidence and were able to identify the liver, kidney, and urinary bladder, while almost half of them needed faculty help them to identify the inferior vena cava and aorta. The spleen and gall bladder were the most difficult to locate even for the very confident students. The perception of supervising faculty was that the confidence level was low in most of the students and only 13–20% of students felt “very confident” about performing ultrasound. Almost 37% needed encouragement and support and almost 10% of the students were not willing to try to locate difficult organs. Some students started locating the ureteric jet and portal vein. Most of the students agreed that ultrasound is an excellent resource for learning anatomy and physical examination skills. All students suggested having more ultrasound sessions.

Conclusion

Most of the students feel confident about performing ultrasound and they perceive that ultrasound can enhance their basic sciences and physical examination skills.

The Canadian Medical Student Ultrasound Curriculum: A Statement From the Canadian Ultrasound Consensus for Undergraduate Medical Education Group

OBJECTIVES

This study sought to establish by expert review a consensus-based, focused ultrasound curriculum, consisting of a foundational set of focused ultrasound skills that all Canadian medical students would be expected to attain at the end of the medical school program.

METHODS

An expert panel of 21 point-of-care ultrasound and educational leaders representing 15 of 17 (88%) Canadian medical schools was formed and participated in a modified Delphi consensus method. Experts anonymously rated 195 curricular elements on their appropriateness to include in a medical school curriculum using a 5-point Likert scale. The group defined consensus as 70% or more experts agreeing to include or exclude an element. We determined a priori that no more than 3 rounds of voting would be performed.

RESULTS

Of the 195 curricular elements considered in the first round of voting, the group reached consensus to include 78 and exclude 24. In the second round, consensus was reached to include 4 and exclude 63 elements. In our final round, with 1 additional item added to the survey, the group reached consensus to include an additional 3 and exclude 8 elements. A total of 85 curricular elements reached consensus to be included, with 95 to be excluded. Sixteen elements did not reach consensus to be included or excluded.

CONCLUSIONS

By expert opinion-based consensus, the Canadian Ultrasound Consensus for Undergraduate Medical Education Group recommends that 85 curricular elements be considered for inclusion for teaching in the Canadian medical school focused ultrasound curricula.