First Year Medical Students, Personal Handheld Ultrasound Devices, and Introduction of Insonation in Medical Education

First insights of integrating the Bonn Internship Curriculum for Point-of-Care Ultrasound (BI-POCUS): progress and educational aspects

BACKGROUND

Point-of-care ultrasound (POCUS) is rapidly gaining prominence in various clinical settings. As its use becomes more widespread, there is a growing need for comprehensive ultrasound training in medical education to ensure that future healthcare professionals are proficient in this essential diagnostic tool.

OBJECTIVE

This study is the first attempt by the University of Bonn to seamlessly integrate ultrasound courses and the use of ultrasound devices into the regular activities of final year medical students and to evaluate the usage of these devices.

METHODS

A total of forty students in their practical year were provided with a hendheld ultrasound device for a period of four months. During this time, they were invited to take part in eight optional ultrasound courses in which they acquired images and those images were rated using a specially developed rating system. At the end of the tertial, students were able to take part in a voluntary survey on the use of the equipment.

RESULTS

Participation in the optional ultrasound courses was well received, with the Introduction and FAST module drawing the largest number of participants (29). Among the ultrasound images acquired by students, those of the lungs obtaining the highest rating, with 18.82 (SD ± 4.30) points out of 23 points, while the aorta and vena cava images scored lowest, with an average of 16.62 (SD ± 1.55) points. The overall mean score for all images was 17.47 (SD ± 2.74). Only 21 students responded to the survey. Of the participating students, 67% used the device independently four times or fewer during the tertial.

CONCLUSION

The study aimed to enhance the BI-POCUS curriculum by improving students' ultrasound skills during their practical year. However, device usage was lower than expected, with most students using it only once a month or less. This raises concerns about the justification of the effort and resources. Future initiatives will focus on technical improvements, better login data provision, and closer monitoring of usage and progress, emphasizing the need for practical ultrasound training in medical education.

Ultrasound Incorporation in Gross Anatomy Labs in a Master of Medical Sciences Program: A Mixed-Methods Analysis of Student Performance and Perception

OBJECTIVES

Teaching ultrasound imaging is on the rise in undergraduate medical anatomy education. However, there is little research exploring the use of ultrasound in preparatory graduate programs. The purpose of this study is to identify the effects of ultrasound imaging inclusion in a graduate gross anatomy course.

METHODS

Master of Medical Sciences students were enrolled in a prosection-based anatomy course that included pinned cadaver stations and an ultrasound station. Using ultrasound, teaching assistants imaged volunteers demonstrating anatomical structures students previously learned at cadaver stations. Students answered one ultrasound image question on each practical exam and were asked to participate in a pre- and post-course survey. Student practical and lecture exam scores and final course grades from the 2022 cohort were compared to a historical control cohort from 2021 via statistical analysis, including a survey administered to the 2022 cohort.

RESULTS

Two hundred students from the 2021 cohort and 164 students from the 2022 cohort participated in this study. Students in the 2022 cohort had significantly higher scores in 1 of the 5 practical exams (P < .05, d = .289), and 2 of the 5 written exams (P < .05, d = .207), (P < .05, d = .311). Survey data revealed increased (P < .05, d = 1.203) learning outcome achievement from pre-survey to post-survey in the intervention cohort. Students who correctly answered the ultrasound question performed significantly better on practical's 3 (P < .05) and 4 (P < .05) than those who missed the ultrasound question.

CONCLUSIONS

These findings suggest that ultrasound imaging in a cadaver lab is beneficial to graduate students' learning and understanding of gross anatomy.

Self-directed learning assessment practices in undergraduate health professions education: a systematic review

PURPOSE

The goal of this systematic review was to examine self-directed learning (SDL) assessment practices in undergraduate health professions education.

METHODS

Seven electronic databases were searched (PubMed, Embase, PsycINFO, ERIC, CINAHL, Scopus, and Web of Science) to retrieve English-language articles published between 2015 and July of 2022, investigating assessment of SDL learning outcomes. Extracted data included the sample size, field of study, study design, SDL activity type, SDL assessment method, number of SDL assessments used, study quality, number of SDL components present utilising the framework the authors developed, and SDL activity outcomes. We also assessed relationships between SDL assessment method and number of SDL components, study quality, field of study, and study outcomes.

RESULTS

Of the 141 studies included, the majority of study participants were medical (51.8%) or nursing (34.8%) students. The most common SDL assessment method used was internally-developed perception surveys (49.6%). When evaluating outcomes for SDL activities, most studies reported a positive or mixed/neutral outcome (58.2% and 34.8%, respectively). There was a statistically significant relationship between both number and type of assessments used, and study quality, with knowledge assessments (median-IQR 11.5) being associated with higher study quality (p < 0.001). Less than half (48.9%) of the studies used more than one assessment method to evaluate the effectiveness of SDL activities. Having more than one assessment (mean 9.49) was associated with higher quality study (p < 0.001).

CONCLUSIONS

The results of our systematic review suggest that SDL assessment practices within undergraduate health professions education vary greatly, as different aspects of SDL were leveraged and implemented by diverse groups of learners to meet different learning needs and professional accreditation requirements. Evidence-based best practices for the assessment of SDL across undergraduate healthcare professions education should include the use of multiple assessments, with direct and indirect measures, to more accurately assess student performance.

Obstetric-Focused POCUS Training for Medical Students

Point of care ultrasound (POCUS) is rapidly expanding throughout the United States. Due to its ability to quickly and accurately diagnose and guide therapy for critical conditions, POCUS is becoming routine in many specialties, with established guidelines in fields such as emergency medicine and critical care 1, 2, 3. For example, a study entitled "Ultrasound Integration in Undergraduate Medical Education: Comparison of Ultrasound Proficiency Between Trained and Untrained Medical Students" initiated an Emergency Medicine POCUS curriculum for first-year medical students that showed an increase in ultrasound capability 4. In short, as POCUS becomes more common practice, medical schools are beginning to implement POCUS training into their undergraduate medical education; studies from these institutions demonstrate that implementing a formal ultrasound curriculum into preclinical medical education significantly increases medical students' POCUS capabilities4, 5 and assisted in their understanding and learning of anatomy 6, 7.

A Simulation Model for the Handheld Ultrasound Diagnosis of Pediatric Forearm Fractures

INTRODUCTION

Handheld ultrasound (HHU) devices have gained prominence in emergency care settings and post-graduate training, but their application in the diagnosis of pediatric fractures remains under-explored. The aim of this study is to evaluate the effectiveness and accuracy of an HHU device for diagnosing pediatric forearm fractures using a simulation model.

METHODS

The materials for the basic pediatric fracture model include turkey bones soaked in white vinegar to make them pliable, food-grade gelatine, and plastic containers. Ultrasound analysis of the models was done with an HHU device, Sonosite İViz US (FUJIFILM Sonosite, Inc.; Bothell, Washington USA). Four different fracture patterns (transverse fracture, oblique fracture, greenstick fracture, and a torus fracture) and one model without fracture were used in this study. Twenty-six Emergency Medicine residents sonographically evaluated different bone models in order to define the presence and absence of fracture and the fracture subtype. The participants' ability to obtain adequate images and the time taken to create and recognize the images were evaluated and recorded. After the sonographic examination, the residents were also asked for their opinion on the model as a teaching tool.

RESULTS

All participants (100%) recognized the normal bone model and the fracture, regardless of the fracture type. The consistency analysis between the practitioners indicated a substantial agreement (weighted kappa value of 0.707). The duration to identify the target pathology in fracture models was significantly longer for the greenstick fracture (78.57 [SD = 30.45] seconds) model compared to other models. The majority of participants (92.3%) agreed that the model used would be a useful teaching tool for learning ultrasound diagnosis of pediatric forearm fractures.

CONCLUSIONS

All participants successfully identified both the normal bone model and the presence of fractures, irrespective of the fracture type. Significantly, the identification of the greenstick fracture took longer compared to other fracture types. Moreover, the majority of participants acknowledged the model's utility as a teaching tool for learning ultrasound diagnosis of pediatric forearm fractures.

Development of a novel observed structured clinical exam to assess clinical ultrasound proficiency in undergraduate medical education

OBJECTIVES

A pilot study was performed to develop and test an observed structured clinical exam (OSCE) for clinical ultrasound in second-year medical students. The goal was to assess a longitudinal clinical ultrasound curriculum for medical students and to help determine readiness to perform ultrasound during clinical clerkships.

METHODS

The OSCE contained 40 tasks over 30 min in a one-to-one examiner to examinee environment using standardized patients covering cardiac, pulmonary, and inferior vena cava (IVC) ultrasound exams along with 6 critical diagnoses. Examinees were assessed using a binary checklist approach. A two-way ANOVA analysis was performed to determine if there were differences between the day and session the OSCE was administered. Results are presented as mean ± standard deviation.

RESULTS

One hundred fifty-two students were tested with an overall mean score of 64.9 ± 17.6%. Scores between the cardiac, IVC, and lung sections varied-67.8% ± 18.8%, 62.4% ± 26.2%, and 57.1% ± 20.6%, respectively. One hundred twenty-six (82.9%) answered at least one critical diagnosis incorrectly. Students in the late session performed better than the early session (1: 60% vs 2: 69%, p = .001).

CONCLUSIONS

Students performed better in later sessions. Additionally, the number of questions left blank at the end of the exam suggests that the length of the OSCE should be evaluated. Incorporating critical diagnoses was challenging for examinees. The proposed OSCE is a valuable assessment tool that could be adapted to assess student's readiness to use clinical ultrasound prior to clerkships.

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.

[Perspectives and Challenges of hand-held Ultrasound]

The use of handheld ultrasound devices from a technical and data protection point of view, device properties, functionality, documentation, indications, delegation of performance, applications by doctors, students and non-medical staff is examined and discussed.

Needs, Challenges, and Applications of Artificial Intelligence in Medical Education Curriculum

Artificial intelligence (AI) is on course to become a mainstay in the patient's room, physician's office, and the surgical suite. Current advancements in health care technology might put future physicians in an insufficiently equipped position to deal with the advancements and challenges brought about by AI and machine learning solutions. Physicians will be tasked regularly with clinical decision-making with the assistance of AI-driven predictions. Present-day physicians are not trained to incorporate the suggestions of such predictions on a regular basis nor are they knowledgeable in an ethical approach to incorporating AI in their practice and evolving standards of care. Medical schools do not currently incorporate AI in their curriculum due to several factors, including the lack of faculty expertise, the lack of evidence to support the growing desire by students to learn about AI, or the lack of Liaison Committee on Medical Education's guidance on AI in medical education. Medical schools should incorporate AI in the curriculum as a longitudinal thread in current subjects. Current students should understand the breadth of AI tools, the framework of engineering and designing AI solutions to clinical issues, and the role of data in the development of AI innovations. Study cases in the curriculum should include an AI recommendation that may present critical decision-making challenges. Finally, the ethical implications of AI in medicine must be at the forefront of any comprehensive medical education.

"Fun slipping into the doctor's role"-The relationship between sonoanatomy teaching and professional identity formation before and during the Covid-19 pandemic

The various psychological dimensions of professional identity formation (PIF) are an important aspect of the study course for undergraduate medical students. Anatomical learning environments have been repeatedly shown to play a critical role in forming such an identity; however, relevance of PIF during sonoanatomical training remains underexplored. At the end of their basic anatomy studies, third-semester medical students took part in a four-day block course on anatomy and imaging. Anatomical content was revised in small groups using peer teaching and imaging methods, including one hour of hands-on sonoanatomy sessions each day. On-site sonoanatomy was identified as an excellent format to support students' transition from the pre-clinical to clinical phase as medical experts-to-be. Students enjoyed practical exercises and the clinical input, which increased their interest in the medical profession and their academic studies. This study further examined the effects of the transition into an online-only format, necessitated by the current Covid-19 pandemic. A comparison was made between the quantitative and qualitative evaluation data, and the written results of examinations of several on-site (n = 1096, mean age = 22.4 years ± 2.18), and online-only cohorts (n = 230, mean age = 22.6 years ± 2.21). The online-only transition led to a reduction of all PIF-related variables measured, losing identity-related variables, increasing students' stress levels, and reducing their long-term academic performance. Together, this study demonstrates presence of PIF in undergraduate sonoanatomy teaching, and cautions against the uncritical online-only substitution of hands-on learning environments.

Bringing anatomy to life: Evaluating a novel ultrasound curriculum in the anatomy laboratory

As point-of-care ultrasound (POCUS) invades medical specialties, more students covet earlier ultrasound (US) training programs in medical school. Determining the optimal placement and format in the curriculum remains a challenge. This study uses student perceptions and confidence in interpreting and acquiring images to evaluate the effectiveness of an US curriculum and assesses their performance on US content. A unique US curriculum was incorporated into first-year clinical anatomy at Tufts University School of Medicine (TUSM). Students completed surveys evaluating changes in US confidence and perceptions. Mean ratings on pre- and post-surveys were compared using Mann-Whitney U tests. Performance on US examination questions was evaluated. Two independent evaluators coded narrative responses and NVivo software was used to identify common themes. Two hundred eleven students completed the US curriculum. Students reported higher post-curriculum mean confidence ratings on US comprehension, operation, image acquisition, artifact recognition, and normal image interpretation (P < 0.0001). US reinforced anatomy concepts and clinical correlates (9.56, ±0.97 SD; 9.60, ±1.05). Students disagreed with items stating learning US is too difficult (1.2, ±2.2) and that it interferes with learning anatomy (0.68, ±1.7). Students scored above passing on practical US knowledge questions, supporting survey data, and the relation to learning spatial relationships. Qualitative analysis identified seven major themes and additional subthemes. Limited integration of US breaks barriers in students' perceptions and confidence in performing POCUS. The TUSM US curriculum is a natural marriage of anatomy and POCUS applications, serving as a template for medical schools.

Effectiveness of Ultrasound Cardiovascular Images in Teaching Anatomy: A Pilot Study of an Eight-Hour Training Exposure

The present study aimed to evaluate the students’ progress in evaluating ultrasound (US) and cadaveric cardiac images and long-time retention of information. First-year medical students were invited to participate in four two-hour online lectures during one week voluntarily. The students were trained to recognize cardiovascular anatomical structures on US and cadaveric images during the intervention. The participants’ abilities to identify specific anatomical structures were tested before, immediately after and six months after the training. A group of second-year students without US training participated as a control group and filled the same test once. Ninety-one first-year students agreed to participate, and forty-nine completed all three tests. The performances in the correct identification of cardiovascular structures on the US images significantly improved after the training but significantly decreased after six months. In the intervention group, the accurate identification of cardiovascular structures was significantly higher on cadaveric images (80% vs. 53%, p-value < 0.0001, n = 91 at post-training; 70% vs. 33%, p-value < 0.0001, n = 49 at 6 months after training). The correct answers percentage score in the control group varied from 6.7% to 66.7% for US cardiovascular anatomical without a significant difference than the intervention group (p-value = 0.7651). First-year students’ knowledge of heart US anatomy proved less effective than cadaveric images, significantly improved after training and decreased over time, indicating the need for repetition reinforcement.

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.

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.

Issues in Teaching Vascular Anatomy: Thoughts and Suggestions from the Clinician's Point of View

The role of anatomy in modern curricula is under reform due to competency of other rapidly evolving subjects and the rapid evolution of several practical aspects and applications dictating modernization of teaching methods as well as of teaching demands. Moreover, modern practice of medicine has put the arterial and vascular system in the center of numerous minimally invasive techniques. Therefore, regardless of their specialty, most doctors should have a very clear and precise knowledge of the vascular anatomy and the basic access techniques from the early years. This viewpoint commentary reflects the experience of the two authors in applying the principles and content of surgical vascular anatomy in undergraduate anatomy teaching and discusses the rationale of this. Moreover, it is suggested that cadaveric dissections should be modified with emphasis on standard surgical vascular exposures and the multidisciplinary teaching of vascular anatomy as a means not only to gain optimal long-term knowledge retention, but also to emphasize through realistic examples on the practical clinical value of vascular anatomy.

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 Use of Handheld Ultrasound Devices in Emergency Medicine

Purpose of Review

Ultraportable handheld ultrasound (HHU) devices are being rapidly adopted by emergency medicine (EM) physicians. Though knowledge of the breadth of their utility and functionality is still limited compared to cart-based systems, these machines are becoming more common due to ease-of-use, extreme affordability, and improving technology.

Recent Findings

Images obtained with HHU are comparable to those obtained with traditional machines but create unique issues regarding billing and data management. HHU devices are increasingly used successfully to augment the education of practitioners-in-training, by emergency physicians in austere environments, and in the burgeoning fields of "tele-ultrasound" and augmented reality scanning.

Summary

This review seeks to describe the current state of use of HHU devices in the emergency department (ED) including device overview, institutional concerns, unique areas of use, recent literature since their adoption into clinical EM, and their future potential.

Team-Based Ultrasound Objective Structured Practice Examination (OSPE) in the Anatomy Course

The clinical use of ultrasound has dramatically increased, necessitating early ultrasound education and the development of new tools in ultrasound training and assessment. The goal of this study was to devise a novel low-resource examination that tested the anatomical knowledge and technical skill of early undergraduate medical students in a gross anatomy course. The team-based ultrasound objective structured practice examination (OSPE) was created as a method for assessing practical ultrasound competencies, anatomical knowledge, and non-technical skills such as teamwork and professionalism. The examination utilized a rotation of students through four team roles as they scanned different areas of the body. This station-based examination required four models and four instructors, and tested ultrasound skills in the heart, abdominal vessels, abdominal organs, and neck regions. A Likert scale survey assessed student attitudes toward the examination. Survey data from participants (n = 46) were examined along with OSPE examination grades (n = 52). Mean and standard deviations were calculated for examination items and survey responses. Student grades were high in both technical (96.5%). and professional (96.5%) competencies with structure identification scoring the lowest (93.8%). There were no statistical differences between performances in each of the body regions being scanned. The survey showed that students deemed the examination to be fair and effective. In addition, students agreed that the examination motivated them to practice ultrasound. The team-based OSPE was found to be an efficient and student-favored method for evaluating integrated ultrasound competencies, anatomical knowledge, team-work, and professional attributes.

Point-of-care ultrasound augments physical examination learning by undergraduate medical students

BACKGROUND

Little is known about the impact of the provision of handheld point-of-care ultrasound (POCUS) devices on physical examination skills of medical students.

METHODS

We describe an educational initiative that comprised a POCUS workshop followed by allocation of a POCUS device to medical students for use over the subsequent 8 weeks. They were encouraged to scan patients and correlate their physical examination findings. A mobile instant messaging group discussion platform was set to provide feedback from instructors. Physical examination skills were assessed by means of clinical examination.

RESULTS

210 final-year medical students from the University of Hong Kong participated in the programme. 46.3% completed the end of programme electronic survey: 74.6% enjoyed using the POCUS device, 50.0% found POCUS useful to validate physical examination findings and 47.7% agreed that POCUS increased their confidence with physical examination. 93.9% agreed that the programme should be incorporated into the medical curriculum and 81.9% would prefer keeping the device for longer time from 16 weeks (45.6%) to over 49 weeks (35.3%). Medical students who participated in the POCUS programme had a higher mean score for abdominal examination compared with those from the previous academic year with no POCUS programme (3.65±0.52 vs 3.21±0.80, p=0.014), but there was no statistically significant difference in their mean score for cardiovascular examination (3.62±0.64 vs 3.36±0.93, p=0.203).

CONCLUSION

The POCUS programme that included provision of a personal handheld POCUS device improved students' attitude, confidence and ability to perform a physical examination.

Point-of-Care Ultrasound

Purpose of the Review

Point-of-care ultrasound using small ultrasound devices has expanded beyond emergency and critical care medicine to many other subspecialties. Awareness of the strengths and limitations of the technology and knowledge of the appropriate settings and common indications for point-of-care ultrasound is important.

Recent Findings

Point-of-care ultrasound is widely embraced as an extension of the physical exam and is employed in acute care and medical education settings. Echocardiography laboratories involved in education must individualize training to the intended scope of practice of the user. Advances in artificial intelligence may assist in image acquisition and interpretation by novice users.

Summary

Point-of-care ultrasound is widely available in a variety of clinical settings. The field has advanced substantially in the past 2 decades and will likely continue to expand with advancement in technology, reduced cost, and improved opportunities to assist new users.