Proactive Medicine: The “UCI 30,” an Ultrasound-Based Clinical Initiative From the University of California, Irvine
Fox, J. Christian MD; Schlang, Joelle R.; Maldonado, Graciela; Lotfipour, Shahram MD, MPH; Clayman, Ralph V. MD
Dr. Fox is director of instructional ultrasound, assistant dean of student affairs, and professor of clinical emergency medicine, Department of Emergency Medicine, University of California, Irvine School of Medicine, Irvine, California.
Ms. Schlang is a fourth-year medical student, University of California, Irvine School of Medicine, Irvine, California.
Ms. Maldonado is a first-year medical student, University of California, Irvine School of Medicine, Irvine, California.
Dr. Lotfipour is associate dean for clinical science education, professor of emergency medicine, and director, Emergency Medicine Research Associates Program, Department of Emergency Medicine, University of California, Irvine School of Medicine, Irvine, California.
Dr. Clayman is dean, School of Medicine, and professor of urology, University of California, Irvine School of Medicine, Irvine, California.
Funding/Support: None reported.
Other disclosures: None reported.
Ethical approval: Reported as not applicable.
Correspondence should be addressed to Dr. Fox, 19 Calle Gaulteria, San Clemente, CA 92673; telephone: (949) 842-2167; e-mail: firstname.lastname@example.org.
This article discusses the benefits of integrating point-of-care diagnostic ultrasound into the four-year medical school curriculum. Handheld ultrasound devices have been used to teach medical students at the University of California (UC), Irvine, since August 2010, and the article explains how the use of this inexpensive, safe, and noninvasive tool enhances the ability of a physician conducting a standard physical exam to confirm suspected findings and uncover other suspected pathology at a reasonable cost. The authors describe the ultrasound curriculum at UC Irvine and the process of its implementation. In the appendix to the article, the authors describe the specific diagnostic benefits of using a handheld ultrasound device for each element of the Stanford 25 physical exam. Their ultrasound-enhanced approach to the physical exam is referred to as the “UCI 30.” They make recommendations for how and when to integrate ultrasound into the physical exam. The article points out that early training of medical students in the use of ultrasound can avoid the diagnostic problems of ultrasound by maximizing students’ comfort and ability to obtain accurate ultrasound images for diagnostic and procedural purposes.
Teaching students to conduct a physical exam is a crucial, time-honored centerpiece of clinical medical education. However, the traditional method of performing the physical exam has not changed substantially since the introduction of the stethoscope and reflex hammer in the 1800s.1 Physicians use their hands and basic tools, while relying on mental images of the organs that lie beneath the skin. Unfortunately, this method frequently overlooks or falsely interprets findings.2 Correct diagnosis often depends on more expensive and potentially harmful imaging technologies.3
With recent technological innovations, handheld ultrasound provides a safe, portable, noninvasive, and cost-effective tool for rapidly collecting detailed diagnostic information at the point of service, whether hospital bedside or physician’s office.4 The University of California (UC), Irvine, teaching faculty values the recently described significance of the critical elements of the physical examination as expressed by the “Stanford 25” method.5 This approach specifies the amount of information that can be gleaned from a skillful basic physical examination as performed using the basic tools well known to physicians for centuries. Similar to all other medical schools, the UC Irvine faculty teaches the complete traditional physical examination techniques during the first two years of education. However, UC Irvine has used the Stanford 25 to facilitate the introduction of ultrasound to the physician’s office and the routine physical examination. We refer to our approach as the “UCI 30.” Although the physical exam should not be replaced, its union with ultrasound serves to enhance the diagnosis and treatment of disease in a highly personalized and proactive manner.
Others have observed and described the ability of medical students to effectively learn to use ultrasound from focused training courses.6–8 We believe that ultrasound training should accompany the instruction of the physical exam from the outset of medical school for all organ systems that ultrasound can effectively evaluate. This includes all parts of the Stanford 25 physical exam, as described in Appendix 1, with the exception of cerebellar testing. We recommend that ultrasound be used in evaluating all patients with any UCI 30 organ system for which there is reasonable clinical suspicion of pathology based on either the history or the physical exam. The additional information gleaned from the bedside ultrasound more precisely directs medical decision making and can save the patient the time, money, and radiation exposure that come with additional testing.
The ultrasound program at UC Irvine was introduced to first-year students at the medical school beginning in August 2010 and included Web-based lectures, peer instruction, and standardized testing. The Web-based lectures were posted on an Apple iTunes U (university) account, allowing for rapid, reliable media dissemination of the material. Weekly one-hour practice sessions, conducted during four-hour blocks to optimize the use of faculty and fourth-year student volunteers, were held for 16 weeks of the academic year. Senior medical students who took an elective ultrasound course and additional ultrasound training served as peer instructors, keeping the student:instructor ratio to an optimal level of 4:1. Faculty members supervised peer instruction by closed-circuit television and helped when needed. Image acquisition and interpretation skills were evaluated with a written multiple-choice exam and a practical exam administered to each student. Students who received ultrasound training showed significant improvements on these measures compared with those without training.9
Appendix 1 describes the specific diagnostic benefits of using a handheld ultrasound device for each element of the Stanford 25 physical exam. We hypothesize that this modality will provide a powerful tool to each graduating physician to empower people to better understand and prolong their health, while providing an opportunity to attend to both harbingers and early stages of a disease long before the onset of symptoms, thereby attending to the first two tenets of public health: (1) determine disease risk and invoke measures to preclude disease development, and (2) diagnose/treat disease before the onset of debilitating symptoms.
Bedside Ultrasound: Implications for the Future
At UC Irvine, since 2010 we have integrated point-of-care ultrasound into the four-year medical school curriculum. Students in each year gain increasing facility with this modality starting in their first year with normal anatomy and physiology and progressing in subsequent years with increasing exposure to a wide array of sonographic pathology. The curriculum also includes practice performing ultrasound-guided peripheral IV insertion in the third and fourth years. We believe that this inclusion of ultrasound into the routine curriculum provides our graduating physicians with a valuable, safe, and inexpensive tool to enhance the growth of predictive, preventative, participatory, personalized (P4) medicine as embodied in Auffray and colleagues’10 description of P4 medicine. We hypothesize that this proactive approach to the standard physician evaluation will empower individuals to prolong and protect their health, thereby ensuring their productivity and promoting their quality of life while limiting debility and delaying their entry into the health care system. Much work remains to test this concept, the first step of which is to equip a cadre of newly minted physicians with these advanced diagnostic skills that can be employed routinely in their office.
With the integration of ultrasound into the traditional physical exam, physicians are provided a safe, portable, and noninvasive tool to enhance their ability to detect medical problems and immediately confirm suspected findings at a reasonable cost. The capability to obtain and use this additional information is invaluable not only in the office but also in almost any medical setting, whether the intensive care unit, the emergency department, or the field (e.g., rural villages abroad or sites of natural disasters). However, to maximally harness the many potential applications and benefits of this simple technology at the bedside, students must be trained early in its use. By incorporating ultrasound into all four years of medical school curricula, students maximize their comfort and ability to obtain accurate images and use these images for diagnostic and procedural purposes. Early training can also avoid the diagnostic pitfalls of ultrasound and neutralize the operator dependency of the technology. These students then graduate with another tool to take with them to their residency training, armed with the skills to use this device and enhance their practice of medicine.
As the technology has advanced, the cost of entry-level ultrasound units has plummeted, from $50,000 to $7,000 to, most recently, under $200 in just five years.11 Many still see the general dissemination of this technology to all medical students as revolutionary; we think it merely evolutionary. It is our belief that, in short order, given the progress in digital technology and the power of cloud source information, ultrasound will spread from the physician’s office into the home of the general population and may well become as commonplace as today’s thermometer. The old adage of “physician, heal thyself” will thus transform into “people, heal yourselves” as each person becomes ever more capable of enhancing and prolonging his or her own state of health with today’s rapidly evolving mobile medical digital technology and advances in noninvasive point-of-service modalities, such as ultrasound.
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