Bahner, David P. MD; Royall, Nelson A. MD
Medical ultrasonography has expanded rapidly since Karl Dussik1 first used sonography in medical experiments in 1942, and Inge Edler conducted the first true cardiac application of the technology in 1954 by using A-mode echocardiography.2 In the last 50 years, however, technological advancements, including the miniaturization of electronics, have outpaced their respective integration into medicine. This gap is perhaps most obvious in the integration of medical technology into the medical education system. In recognition of this problem, medical training programs have attempted to integrate technologies, including computerized tomography (CT) and magnetic resonance imaging (MRI), as well as electronic lifestyle devices (e.g., personal digital assistants and smartphones) and computer software, into the education paradigm.3,4
In particular, focused ultrasonography has developed parallel to the miniaturization of electronics and now has a number of highly sensitive and specific diagnostic and therapeutic applications.5 Ultrasound already has a well-defined role in many fields, including emergency medicine, obstetrics–gynecology, and anesthesiology, and its uses are growing as the technology and research continue to develop.6–9 Validated examples of applications include the Focused Assessment with Sonography for Trauma (FAST) protocol, focused transthoracic echocardiography, focused duplex ultrasonography for lower extremity venous thromboembolism, noninvasive volume assessment, pneumothorax or lung consolidation, soft-tissue fluid collections, and ultrasound-guided procedures.10–17 As a sign of physicians’ growing interest in and use of ultrasonography, focused medical ultrasonography education is becoming increasingly integrated into physician residency training programs.6,8,9 For example, the Accreditation Council for Graduate Medical Education requires that all emergency medicine residency training programs provide residents with procedural competency in bedside ultrasound.9
As the evidenced-based applications for focused ultrasonography in standard-of-care practices increase, there have been efforts to integrate focused ultrasonography into medical school curricula.18–32 Results from these efforts demonstrate that among participating medical students there is both a high level of satisfaction with the material and an interest in additional focused ultrasonography training during medical school.18,21,24,28,32,33 The courses previously described have low total time requirements of students, generally requiring 5 to 30 hours of total commitment over several weeks.18,19,24–26 Multiple studies have demonstrated that these basic ultrasound programs focusing on general ultrasound physics, terminology, knobology, and image acquisition are capable and feasible of providing the basic ultrasound understanding required for novice users within first- through fourth-year medical school curricula.18,21,27,32 Early data indicate a possible relationship between focused ultrasonography training in medical school curricula and improved physical examination accuracy.23,27,31,32
Ultrasound Training at The Ohio State University College of Medicine
Ultrasound training for medical students began at The Ohio State University College of Medicine (OSU COM) in 2000. Our initial efforts mirrored programs described in the literature, providing approximately 10 to 20 training hours spread over a four-week rotation during the fourth year of medical school. These early curricula familiarized medical students with portable ultrasound and focused on ultrasound-guided vascular access for central and peripheral vascular catheters in addition to the FAST protocol. Overwhelming interest from OSU COM students and Ohio State University Medical Center (OSUMC) faculty led to the development of additional focused ultrasound programs within anatomy, preclinical course adjuncts, and senior clinical skills courses.
Currently, OSU COM offers a vertical ultrasound curriculum with required and selective programs within each of the four medical school years. The courses teach progressively advanced training in ultrasound physics, terminology, knobology, and focused ultrasound protocols. The third- and fourth-year medical student programs predominately address ultrasound image interpretation compared with a focus on ultrasound acquisition within first- and second-year programs. Graduated experience in focused ultrasound allows third- and fourth-year medical students to perform focused ultrasonography under faculty supervision during clinical rotations at OSUMC.
Rapid expansion of ultrasound opportunities at OSU COM led to an interest among students and Department of Emergency Medicine faculty to develop an advanced ultrasound program specifically for fourth-year medical students with a curriculum typically reserved for resident and fellow programs. In the following sections, we describe the details of the OSU COM advanced ultrasound training program for fourth-year students, including the course objectives, participants, faculty, course requirements, and assessment practices. We provide an overview of the program outcomes to date, and we close with a discussion of the successes and challenges of developing and implementing the program.
Advanced Ultrasound Education for Medical Students
Beginning in the 2005 academic year, faculty with experience in emergency, procedural, and diagnostic ultrasound participated in the development of course objectives and course components for an advanced ultrasound training program for fourth-year students. Subsequent feedback from additional faculty in emergency medicine, internal medicine, anesthesiology, surgery, and radiology has since been used to adjust course objectives and components. The purpose of the course is to identify incoming fourth-year medical students pursuing specialty careers with previously established roles for focused ultrasonography and an interest in learning and teaching advanced ultrasound. Course objectives are (1) development of ultrasound proficiency at or near the level of mastery in basic ultrasound examinations, (2) development of knowledge in basic ultrasound physics, patient-specific contraindications, and evidence-based clinical uses of ultrasound, and requisite psychomotor skills for ultrasonography, (3) development of teaching skills required for focused ultrasonography, and (4) development of skills required to interpret innovations in ultrasound technology and study novel applications within medical ultrasonography.
The first group of fourth-year medical students enrolled in the advanced ultrasound training program in the 2005–2006 academic year. Participants in the program are selected according to the following criteria: (1) completion of all core requirements for third-year rotations (internal medicine, pediatrics, general surgery, obstetrics–gynecology, family medicine, neurology, and psychiatry), including successful completion of respective National Board of Medical Examiners shelf exams, (2) being actively enrolled in fourth-year rotations, and (3) applying to residency programs in fields that have accepted ultrasound applications (e.g., emergency medicine, general surgery, internal medicine). Students must apply for participation in the course, and then the course director reviews applicants’ credentials prior to acceptance and enrollment. Participants are enrolled in the yearlong elective rotation as part of the fourth-year medical school curriculum at OSU COM with an expected cumulative commitment of 148 hours over the 10-month enrollment. The curriculum is designed to allow students to fulfill course requirements outside of monthly rotation hours during weekday evenings, weekends, or interview months.
An emergency medicine physician with American Registry for Diagnostic Medical Sonography (ARDMS) certification and significant clinical and research experience as a sonographer led the development of the course and serves as the course director (D.P.B.). Eight adjunct faculty from OSUMC with significant ultrasound training and experience are recruited yearly to serve as ultrasound faculty for the program’s didactic lectures and hands-on sessions. Clinical experiences are predominately taught by the course director and OSUMC faculty within the surgical and medical intensive care units and emergency department. Lead faculty time commitment to the program is supported through general teaching requirements for OSUMC faculty and requires approximately 25 hours per month, including lecture preparation, hands-on training, administrative mentoring, and program logistics.
The program curriculum includes didactic instruction, journal club sessions, individual and group hands-on training, facilitating others’ mastery of ultrasound through teaching and acting as an ultrasound model, and the completion of a final project. A summary of the advanced ultrasound program course components is shown in List 1.
Each month, ultrasound faculty introduce a new focus in a two-hour didactic lecture emphasizing indications, contraindications, objectives, techniques, and sample image interpretations. Before the didactic lectures, participants complete adjunct one-hour teaching modules through an online, focused ultrasound video education subscription service, EMsono.34 Participants are also required to watch specific lectures created by faculty and emergency medicine residents at OSU COM, which are available through YouTube. These mandatory lectures provide participants with ultrasound basic science education encompassing concepts required for completion of the ARDMS Sonography Principles and Instrumentation Examination (SPI).
Participants engage in critical reviews of current ultrasound clinical evidence through student-led journal club sessions each month. Faculty members assign a journal article for each session, and students create a quiz on the article for participants to complete prior to the journal club. During journal club sessions, students formally present the assigned article for discussion. Faculty are present at the journal club sessions to stimulate discussion and provide clinical and basic science background on the content.
The OSU COM Clinical Skills Center, an 8,100-square-foot multipurpose simulation and clinical skills training center, serves as the primary site for group and individual hands-on ultrasound sessions. Hands-on sessions are held twice per month for three hours under direct faculty supervision and guidance. Participants perform ultrasound scans on live student models with ultrasound faculty present to provide individual feedback on technique, interpretation, and reinforcement of the clinical applications of the respective focused exam. Participants schedule additional ultrasound practice sessions at OSU COM Clinical Skills Center as needed with student models or ultrasound phantoms. Weekly intensive care unit teaching rounds supervised by ultrasound faculty at OSUMC provide hands-on clinical experience with common and infrequent diagnostic ultrasound correlates. Participants record and store ultrasound exams in a personal ultrasound digital portfolio categorized by exam performed and date. Supplemental Digital Table 1 (http://links.lww.com/ACADMED/A115) demonstrates the mandatory types of focused ultrasound exams. A minimum of five exams in each scanning category are required, including practice and clinical exams.
Acting as teacher and patient.
A unique educational component involves mandatory experiences teaching focused ultrasonography to medical students, residents, and fellows at OSUMC and acting as ultrasound live models for at least 10 cumulative hours during the year. For all ultrasound sessions scheduled through the Clinical Skills Center, program participants are available as ultrasound instructors. In addition, participants are live models for ultrasound scanning sessions for OSUMC student, resident, and faculty scanning sessions. The purpose of serving as live ultrasound models is to develop a patient-focused understanding of focused ultrasound exams and to stimulate interest in improved patient-centered scanning techniques among the program participants.
Participants’ course projects must either develop or research novel applications of medical ultrasound. Students select an appropriate OSUMC physician project advisor. Available topics for participants range from clinical or basic science research in medical ultrasonography to development and implementation of novel ultrasound teaching models at OSU COM for medical students and residents.
Program metrics and assessment
We use a multimodal grading approach to evaluate participants’ experiences and assess their fulfillment of the course objectives. Participants receive grades on monthly quizzes on an ultrasound focus introduced in the didactic lecture, monthly journal club quizzes, and attendance at didactic, journal club, and hands-on sessions. Additionally, students take a final practical and written exam to assess proficiency with required ultrasound foci (see List 2) and the ultrasound basic science knowledge component. In the practical exam, administered by the course director, a single participant performs the exams shown in List 2 on a student model, and faculty evaluate obtained ultrasound exam images and video using the previously published B QUIET method (Brightness mode Quality Ultrasound Image Examination Technique) shown in Supplemental Digital Table 1 (http://links.lww.com/ACADMED/A115).35 Finally, participants are evaluated for completion of required practice and clinical ultrasound scans, a written course project summary, a grand rounds presentation, and teaching and ultrasound model time requirements. Passing students receive a grade of honors, letter of commendation, or satisfactory.
Overview of Program Outcomes
To date, 150 fourth-year medical students have been enrolled across five academic years. Applications have increased from 14 students in 2005–2006 to over 40 per year from academic years 2009–2010 through the current 2012–2013. In 2009–2010, we established an enrollment limit of 40 students per year. Current student applications for the course are up to 60 students per year. Students participating in the course have matched into 20 different types of residency programs, with the most common in order being emergency medicine, anesthesiology, diagnostic radiology, internal medicine, and pediatrics.
In the 2009–2010 academic year, we began mandating an ultrasound case log system of the number and type of ultrasound exams performed by each individual enrolled in the course to ensure completion of exam requirements and aid curricular development. Figure 1 demonstrates participants’ recorded ultrasound exams by type from 2009 to 2010. In the 2009–2010 academic year, participants performed 3,242 cumulative ultrasound exams. Individuals completed a mean of 81, median of 78, with a range of 47 to 131 exams. As demonstrated by Figure 1, students most frequently performed the FAST exam, with a mean of 12 exams per participant and a maximum of 58 exams during the 2009–2010 academic year. There was not a performance requirement for renal ultrasonography until the 2010–2011 academic year. Figure 2 illustrates students’ standardized quiz performance, and Figure 3 shows average student performance on graded exercises during the 2009–2010 academic year.
Examples of projects completed as part of the course requirement include clinical studies evaluating trauma ultrasound education methods for residents, development of ultrasound adjuncts for first-year medical students during the anatomy course, and an online video tutorial for ultrasound physics as a preparation tool for the ARDMS SPI. Research projects from the course have yielded first-author publications in various journals and conference presentations by participants. Completed educational projects have yielded multiple permanent curricular components, including ultrasound anatomy correlate sessions for first-year anatomy and physical exam courses, an ultrasound interest group within the OSU COM, an ultrasound Olympics (a skills and interpretation competition in focused ultrasonography) amongst all OSU COM medical students, an organized ultrasound student model pool consisting of first- through fourth-year students, and a group of fourth-year medical student proctors available for resident and medical student ultrasound sessions.
Assessment of Advanced Ultrasound Training
Benefits and successes
Since introducing early ultrasound training in 2000, OSU COM has benefited from integrating ultrasound training into the medical school curriculum. To our knowledge, there are only two U.S. medical schools that have published efforts to develop a four-year ultrasound curriculum.19,25 The course described here is novel in its efforts to (1) develop an advanced ultrasound curriculum for medical students, (2) assess preliminary feasibility of advanced ultrasound training within the medical school curriculum, and (3) create a faculty-supported structure for medical students’ independent ultrasound research and education projects. The success of our graduates demonstrates that students have the ability to develop an advanced understanding of medical ultrasonography within a structured curriculum. Furthermore, the projects developed by medical students within this program demonstrate the ability of students with appropriate faculty support to perform quality research and develop educational programs at a level traditionally reserved for residents and faculty.
The fourth-year ultrasound program at OSU COM is far advanced in comparison with any previously described medical school ultrasound curriculum. Wayne State University School of Medicine,19 for example, reported an ultrasound curriculum for first-year medical students with an educational model that comprised short lectures followed by voluntary hands-on time. Their participants were evaluated using a single exam at the end of the course on an ultrasound phantom.19 Perhaps our curriculum is more comparable to ultrasound training programs for residents. In 2008, the Council of Emergency Medicine Residency Directors defined their recommendations for an emergency medicine resident program ultrasound curriculum.36 Their model recommended an introductory day lecture on ultrasound basics and knobology, followed by two weeks or 80 hours of hands-on time in a dedicated ultrasound rotation. The model also includes didactic sessions reviewing technical and evidenced-based practices, readings from journals, and computer-based activities. The model defined ultrasound “competency” as a resident’s completion of (1) a faculty-led image review, (2) a practical exam on each focused exam, (3) a written proficiency exam, and (4) at least 150 focused examinations. The advanced ultrasound training program for fourth-year medical students at our institution is similar in scope and implementation to this recommended model for residents. A particular benefit of medical-school-level ultrasound training is that, compared with residents who often work at least 80 hours per week, fourth-year medical students typically have more limited clinical responsibilities.
From our experience and analysis of the program, advanced ultrasound training in medical school curricula may be feasible in providing early access to and understanding of the rapidly growing field of focused ultrasonography. Implementing this training as an elective rotation has ensured that participants have adequate time reserved for the course requirements and allows only students with particular interest and potential use of focused ultrasound to be enrolled. We have yet to empirically study the feasibility and efficacy of the program as a component within the medical school curriculum, although the growing student interest in the program and their successful completion of ultrasound examinations are encouraging.
Cost of the program has been particularly limited given the availability of existing ultrasound equipment. Although portable ultrasound machines range from $30,000 and $60,000, we were able to use ultrasound machines previously obtained for the OSUMC Clinical Skills Center. We have enjoyed substantial institutional support through participation by OSUMC faculty in developing and completing the course objectives. However, specific requirements for operating the course are minimized because any faculty member from a specialty which uses focused ultrasound could potentially serve as the course director. Online resources for ultrasound are also broadly available and can serve to standardize focused ultrasound education and minimize the need for additional resources.
Challenges and future directions
Providing clinical exposure for students remains the predominant challenge for an ultrasound curriculum. Opportunities for students to use ultrasound in the clinical setting remain limited most likely because many faculty are unfamiliar with focused ultrasound. Our experience has shown that students perform a majority of clinical examinations during emergency medicine, critical care, and trauma surgery rotations at our institution. Not surprisingly, OSUMC faculty in these disciplines have a high adoption rate of and familiarity with specific ultrasound applications. The result is that clinical, focused ultrasound experience for medical students predominately occurs in emergent indications, such as procedural guidance, FAST, and obstetrics–gynecology. Medical student exposure to other focused examinations (e.g., focused echocardiography, biliary, ophthalmologic) is more difficult to obtain. This remains a major challenge within our curriculum.
We have also learned that, with more advanced ultrasound training in medical school, our graduates were likely to have significantly greater ultrasound training compared with their peers or faculty in residency programs. Although this can certainly be an advantage, some graduates had limited opportunities to use ultrasound early in residency because of others’ lack of experience. A potential solution to this challenge would be for students to obtain a certification to validate their advanced ultrasound training, allowing them to use ultrasound in a more independent fashion earlier in their residency training. Unfortunately, physician applicants for ARDMS certification currently must complete a recommended 800 clinical ultrasound examinations, a substantial undertaking at any training level.37
Future directions for the program must focus on improving clinical exposure for the numerous focused ultrasound examinations and improving evaluation techniques. Clinical exposure to certain accepted, focused ultrasound examinations, such as focused echocardiography in code situations, lung parenchyma and pleural space evaluations, and even intraoperative applications, represent a significant opportunity for expanded hands-on experiences. We also plan to develop an improved case log system for ultrasound examinations, allowing graduates to create a “virtual portfolio,” which could be used to demonstrate proficiency with specific, focused ultrasound examination after medical school graduation. A major focus for the program in the future will be validation and feasibility studies for the course components and the overall program in achieving long-term educational benefit.
A critical problem facing medical educators is how and when new technologies and innovations should be integrated into the medical education system. For example, CT, invented by Godfrey Hounsfield38 in 1973, has become the gold standard diagnostic modality for a majority of pathologies. Although medical schools have integrated the clinical indications for CT into their preclinical and clinical curricula, the role for teaching a majority of CT image interpretation and basic radiation physics principles still primarily rests on residency and fellowship programs. In fact, rather than attempting to integrate CT competency into their curricula, almost all medical schools and residency programs have deferred advanced radiation knowledge and image interpretation to specialists such as radiologists and medical physicists.
Integration of ultrasound knowledge into the medical education continuum has also been latent until recently. Miniaturization of ultrasound machines, rapid improvements in visualization software, and reproducible clinical research demonstrating definitive clinical roles for portable ultrasound have made ultrasound proficiency of more importance than ever before for physicians. As a sign of a growing need for ultrasound education within the medical education system, a large group of professional organizations, including the American College of Emergency Physicians, the American College of Surgeons, and the American College of Physicians, advocate that the role of a physician should be to both perform and interpret focused ultrasound examinations. The need for physicians to perform and interpret focused ultrasound examinations differentiates the integration of ultrasound training into the medical education system as compared with traditional imaging modalities, such as X-ray, CT, MRI, and nuclear medicine.
Expectations of residency training programs are already high and are constrained by increasingly stringent training hour restrictions and faculty costs. Incorporating focused ultrasonography training into the medical school curriculum is one possible way to adhere to training recommendations without increasing the educational requirements for residency programs. Given focused ultrasound training outcomes within medical schools to date, the integration of this technology may also improve other aspects of medical education, including physical examination and physiology.22,26,30,31
An advanced ultrasound curriculum has the potential to prepare students to use focused ultrasound from the beginning of residency training and to alleviate an additional educational burden for residency programs. The advanced curriculum developed at OSU COM familiarizes fourth-year medical students with critical ultrasound concepts, such as artifact recognition, psychomotor skill acquisition, and image interpretation, that are necessary for proficient, focused ultrasound use. As technologies continue to develop at a rapid pace, we believe the integration of these advancements into the medical education paradigm is necessary for future physicians who will require more sensitive and specific bedside methods for diagnosis than auscultation, percussion, and palpation.
Acknowledgments: The authors wish to thank Sharon Pfeil for her dedicated work as the program administrator, Stacy Baker for her work as a program coordinator, and Dr. Eric Adkins for his work as assistant ultrasound director at The Ohio State University College of Medicine.
Other disclosures: None.
Ethical approval: Ethical approval was obtained from The Ohio State University behavioral and social sciences institutional review board.
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