Preclerkship Point-of-Care Ultrasound: Image Acquisition and Clinical Transferability

Comparing Peer-Taught Student Tutors to Faculty-Taught Student Tutors in Educating Medical Students on Musculoskeletal Ultrasound

INTRODUCTION

In recent years, medical education has witnessed a shift in the integration of ultrasound into the preclinical years of medical school. Given the exponential increase in accessibility to ultrasound technology, students now have the opportunity to create peer learning groups in which ultrasound concepts can be taught from peer to peer, empowering students to work together to integrate ultrasound concepts early in their preclinical education. This project investigates the efficacy of peer-taught student tutors (PTSTs) in imparting the fundamentals of basic ultrasound techniques to first-year medical students in the setting of identifying and labeling upper extremity musculoskeletal (MSK) anatomy.  Methods: First-year medical students were instructed to identify volar forearm structures with an ultrasound probe. Students and instructors were given access to an ultrasound probe, ultrasound gel, an iPad, and a standardized patient. Students were taught either by an ultrasound instructor (UI) or PTST. After a hands-on demonstration by a UI or PTST, participating students were told to take screenshots and label their images as accurately as possible, identifying the aforementioned volar structures on a standardized patient without any feedback. The labeled screenshot images of volar structures were graded based on the ability to clearly visualize the intended structures.  Results: The results of this study compare the efficacy of PTSTs as educators of basic sonographic identification techniques with that of UI faculty members. A chi-square analysis was performed between the images obtained by the UI and PTST students, and there was no statistically significant difference in identification accuracy between the groups (p = 0.7538, 0.1977, 0.1812, 0.301). When using the Mann-Whitney U rank test, there remained no statistically significant difference between the accuracy of the students taught by STs compared to students taught by UIs (p = 0.7744, 0.09538, 0.07547, 0.1846). Another finding showed that students belonging to both teaching groups were generally not able to infer the pathology of volar wrist structures when given pathology identification questions regarding upper extremity ultrasound. Using chi-square with Yates correction, there is no sufficient evidence to justify an association between the ability to answer pathology-based ultrasound questions and instructor type (p = p = 0.6299, 0.8725).

CONCLUSIONS

This study supports the interpretation that the capability of first-year medical students to learn novice MSK sonographic identification is independent of whether the educator is a PTST or UI. This interpretation reveals a promising avenue toward the integration of the fundamentals of ultrasound identification early in medical education with little to no concern for the exhaustion of institutional resources. Along with the other well-documented benefits of the utilization of STs in medical school, a peer tutoring system centered on ultrasound skills designed in the way this study describes can be an effective, resource-sparing system that enhances medical students' sonographic capabilities early in their preclinical years.

Structured Cardiac Assessment Outperforms Visual Estimation in Novice Ultrasound Users: A Randomized Controlled Trial

BACKGROUND

Two evidence-based techniques to determine left ventricular (LV) systolic function are taught in emergency medicine curricula. The first is a "structured approach," which qualitatively evaluates LV fractional shortening, E-point septal separation, and LV diameter. The other is the "eyeball method," which qualitatively estimates the LV ejection fraction (LVEF).

OBJECTIVE

The aim of this study was to determine whether the structured approach or the eyeball method was superior for teaching LVEF estimation to novices.

METHODS

Medical students were recruited to participate in our randomized controlled trial. Participants were randomized to the structured approach group or eyeball method group and completed one of two 15-min educational modules. Participants subsequently interpreted 12 echocardiogram clips to determine LV function. The primary outcome was the percentage of correct interpretations as determined by a cardiologist.

RESULTS

Seventy-four participants were invited to participate and 32 completed the study (15 in the structured approach and 17 in the eyeball method groups). The majority (30 of 32 [93.75%]) were first- and second-year medical students with no prior ultrasound training. The mean time to complete the training was similar between groups (16.8 vs. 17.8 min; p = 0.66). The primary outcome of percent of correct interpretations was significantly higher in the structured approach group compared with the eyeball method group (88.9% vs. 73.0%; p < 0.01).

CONCLUSIONS

Training novice ultrasound users in a structured qualitative LV assessment method was more effective than the eyeball method. Learners were able to achieve high accuracy after a brief training intervention. These results may help inform best practices for undergraduate ultrasound curriculum development.

Videos of demonstration versus text and image-based material for pre-skill conceptualisation in flipped newborn resuscitation training for medical students: a pilot study

BACKGROUND

The flipped skills lab is a student-centred approach which incorporates pre-class preparation (pre-skill conceptualization) followed by repeated, hands-on practice for practical skills training. Objective measures of skills acquisition in the flipped literature are few and conflicting. The importance of pre-skill conceptualization in flipped skills training suggests that pedagogically informed pre-skill conceptualization can enhance outcomes.

METHODS

A mixed quasi-experimental study was conducted on 41 final year medical students who followed a flipped newborn resuscitation skills lab. Pre-class preparatory material covered conceptual and procedural knowledge. Students in the traditional group (n = 19) and those in the interventionalmental group (n = 22) received identical reading material covering conceptual knowledge. Procedural knowledge was shared with the interventional group as demonstration videos, while the traditional group received a PowerPoint presentation with text and images covering the same material. Knowledge acquisition was assessed by 20 single best answer questions before and after hands-on practice in the skills lab and skill performance was tested post-intervention with a simulated scenario. Students' perceptions were collected by survey. Quantitative data was analysed using Wilcoxon Signed Ranks test and Mann-Whitney U test as appropriate. Qualitative data was analysed by thematic analysis.

RESULTS

Overall student rating of the intervention was positive with ratings of 4.54 and 4.46 out of 5 by the traditional group and the experimental group respectively. Post-intervention skill performance in the experimental group was significantly better (p < .05) in the interventional group (M = 87.86%, SD = 5.89) than in the traditional group (M = 83.44, SD = 5.30) with a medium effect size (r = .40). While both groups showed significant knowledge gains, only students in the experimental group showed a statistically significant gain in procedural knowledge (p < .05) following the flipped skills lab. Finally, while both groups self-reported feeling more knowledgeable and confident following the intervention, the level of confidence was superior in the experimental group.

CONCLUSIONS

Flipping the skills lab with pre-skill conceptualisation combining text-based conceptual knowledge and video-based procedural knowledge followed by simulation-based hands-on practice improves procedural knowledge and skills acquisition in newborn resuscitation training for medical students. This study shows that in addition to temporal benefits, pedagogically informed pre-skill conceptualization can confer procedure-specific cognitive and emotional benefits supporting skills acquisition.

Comparing the Effectiveness and Image Quality of Musculoskeletal Ultrasound of First-Year Medical Students After Training by Student Tutors Versus Ultrasound Instructors: A Pilot Study

Background

Ultrasound is a vital part in many medical schools’ curriculum. Although there is strong support for the use of student tutors (STs), there is a lack in gauging their effectiveness with more difficult organ systems such as the musculoskeletal (MSK) system. We aim to determine the effectiveness of using STs versus expert ultrasound instructors (UIs) when teaching MSK ultrasound.

Methodology

Medical students were recruited to participate in an MSK workshop to identify superficial volar arm structures (radial nerve, radial artery, median nerve, ulnar artery, ulnar nerve) using Butterfly iQ. In total, 14 participants were taught by STs and 10 participants were taught by UIs. Participants imaged the five structures and answered surveys gauging their confidence via five-point Likert scales.

Results

There was no significant difference in confidence or identification accuracy for all five structures between the two groups. However, there was a significant difference in confidence in the understanding of basic ultrasound concepts in favor of the UI group (p < 0.05). A greater number of students were more confident in identifying all five structures when taught by STs, but more students correctly identified the structures when taught by UIs.

Conclusions

The results on confidence could be due to positive peer perception. Both groups scored relatively high in their identification accuracies, promoting the successful use of STs. The successful use of STs in teaching MSK ultrasound opens the possibility to developing peer-led ultrasound curriculum on more complex ultrasound topics in the future.

Adaptation of an anatomy graduate course in ultrasound imaging from in-person to live, remote instruction during the Covid-19 pandemic

Health concerns during the Covid-19 pandemic required the adaptation of a lecture-laboratory course in ultrasound imaging for graduate students from an in-person to a live, remote learning format. The adaptation of in-person lectures to live, remote delivery was achieved by using videoconferencing. The adaptation of in-person laboratory sessions to live, remote instruction was achieved in the first half of the course by providing a hand-held ultrasound instrument to each student who performed self-scanning at their remote locations, while the instructor provided live instruction using videoconferencing. In the second half of the course, the students transitioned to using cart-based, hospital-type instruments and self-scanning in the ultrasound laboratory on campus. The aim of this study was to measure the success of this adaptation to the course by comparing assessment scores of students in the live, remote course with assessment scores of students in the in-person course offered in the previous year. There were no statistically significant differences in the assessment scores of students in the two courses. The adaptation of a course in ultrasound imaging from an in-person to a live, remote learning format during the Covid-19 pandemic described here suggests that contrary to the prevailing view, ultrasound imaging can be taught to students without in-person instruction. The adapted course can serve as a model for teaching ultrasound where instructors and learners are physically separated by constraints other than health concerns during a pandemic.

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.

First year internal medicine residents' self-report point-of-care ultrasound knowledge and skills: what (Little) difference three years make

BACKGROUND

With increasing availability of point-of-care ultrasound (POCUS) education in medical schools, it is unclear whether or not learning needs of junior medical residents have evolved over time.

METHODS

We invited all postgraduate year (PGY)-1 residents at three Canadian internal medicine residency training programs in 2019 to complete a survey previously completed by 47 Canadian Internal Medicine PGY-1 s in 2016. Using a five-point Likert scale, participants rated perceived applicability of POCUS to the practice of internal medicine and self-reported skills in 15 diagnostic POCUS applications and 9 procedures.

RESULTS

Of the 97 invited residents, 58 (60 %) completed the survey in 2019. Participants reported high applicability but low skills across all POCUS applications and procedures. The 2019 cohort reported higher skills in assessing pulmonary B lines than the 2016 cohort (2.3 ± SD 1.0 vs. 1.5 ± SD 0.7, adjusted p-value = 0.01). No other differences were noted.

CONCLUSIONS

POCUS educational needs continue to be high in Canadian internal medicine learners. The results of this needs assessment study support ongoing inclusion of basic POCUS elements in the current internal medicine residency curriculum.

An Introduction to Point-of-Care Ultrasound: Laennec to Lichtenstein

Point-of-care ultrasonography (POCUS) is rapidly evolving as a noninvasive adjunct to physical examination among various specialties. POCUS increases the sensitivity of conventional physical examination by providing the answers to simple clinical questions at the bedside. As such, it can reduce fragmentation of care and expedite management. In addition, using bedside ultrasound as the first-line investigation may eliminate unnecessary radiation and contrast exposure. The advent of highly portable and affordable ultrasound devices has made the use of POCUS more practical and user-friendly, making it the stethoscope of the 21st century. This review will provide an overview of the rationale for integrating POCUS into nephrology practice. We also discuss the current scope of POCUS practice and state of training.