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Dr. James Hwang: received his doctorate in medicine from the University of Pittsburgh, and completed his emergency medicine residency at the University of California at San Diego. He also completed an emergency ultrasound fellowship at Yale University. He is currently a staff physician at Kaiser Permanente.
With all that ultrasound has to offer, there is no doubt that it is time to incorporate it not just into clinical practice but into medical school curricula. The American College of Emergency Physicians has been on board for a few years, releasing its Emergency Ultrasound Guidelines in 2008. The guidelines show its already wide reach, with classifications into clinical categories such as resuscitative, diagnostic, symptom- or sign-based, procedure guidance, and therapeutic and monitoring. (Ann Emerg Med 2009;53[4]:550;http://bit.ly/emUS.)
Despite its increasing availability, the question remains: When can we expect to see ultrasound's routine use in clinical practice by all specialties? The answer is probably when all physicians are trained in ultrasound, and that training should start in medical school.
Advances in technology have made bedside ultrasound an outstanding, readily available teaching tool. Ultrasound has been shown to help students explore and to reinforce concepts covered in anatomy and physiology.
The value of incorporating ultrasound into medical school education goes beyond love of it. Except for those going into surgical specialties, most medical students will never experience anatomy in the same manner again, and are more likely to apply their understanding of anatomy through imaging modalities such as ultrasound. Earlier exposure gives future clinicians a better foundation for understanding pathophysiology, and increases the likelihood of integration of ultrasound into daily practice. Bedside ultrasound can augment the history and physical exam, and help clinicians narrow their differential diagnoses and arrive at a correct diagnosis earlier and with less ancillary testing. (Crit Care Med 2004;32[8]:1798.) As technology continues to improve and industry responds more to the point-of-care market, bedside ultrasound will become more available and user-friendly.
Many have made the zero-sum argument in medical education, that adding material comes at the cost of existing material, and this may be a legitimate concern. Those who have begun the process of integration, however, find that ultrasound education can enhance subjects being taught rather than replace them. While some would argue it might be better taught during residency, the truth is that medical students have more time and are still undifferentiated in their focus. James Palma, MD, an assistant professor of emergency medicine at Uniformed Services University of the Health Sciences, noted teaching in residency benefits 10 to 15 physicians per class while teaching 100 to 150 medical students has a larger impact. Too often, adult learners become set in their ways, and have difficulty incorporating new skills. David Bahner, MD, an associate professor and the director of emergency ultrasound at Ohio State University, pointed out that time spent teaching ultrasound during residency is better spent on applications that provide time-sensitive information and directly affect clinical care than on fundamentals.
If the zero-sum argument must be upheld, then perhaps the time spent teaching cardiac auscultation should be replaced by bedside echocardiography. As early as 2005, Kobal et al demonstrated that two first-year medical students with 18 hours of ultrasound training were able to outperform five board certified cardiologists using standard physical exam in detecting cardiac abnormalities. (Am J Cardiol 2005;96[7]:1002.) A traditional criticism of ultrasound is that it is operator-dependent, but Dr. Bahner noted that this will be less of an issue, and even cease to exist, if medical schools are willing to incorporate ultrasound into their curricula.
This has been and will continue to be somewhat of a challenge. While ultrasound has significant face validity and medical student feedback is nearly uniformly positive, more substantive outcomes are difficult to identify and quantify. Ultrasound can be an effective teaching tool, and how it helps reinforce anatomical and physiologic concepts merits investigation. Unfortunately, medical schools may not be inclined to randomize their students into “integrated ultrasound” and “no integrated ultrasound” arms that would allow better assessment. Comparing medical schools that do and do not integrate ultrasound into their curricula might be a way to assess the effect, but the limitations and confounders in such comparisons would be many.
As more medical schools begin to integrate ultrasound into their curricula and the manner in which ultrasound is taught becomes more refined, opportunities for multicenter trials will gradually increase. While assessing whether ultrasound improves academic performance may be of value, Dr. Bahner said the true value may be how it changes the way future clinicians care for patients. Instead of asking whether ultrasound improves student scores on anatomy and physiology exams, the more relevant question may be whether integrating ultrasound increases the likelihood they will use it to reach more accurate, timely, and cost-effective diagnoses and to guide high-risk, invasive procedures.
Obtaining medical school curriculum time to teach ultrasound is always difficult. Richard Hoppmann, MD, at the University of South Carolina School of Medicine, recommends looking for small windows where ultrasound can be included, and allowing student feedback to drive further opportunities. He advised finding allies within the medical school to champion its integration. While some faculty may wonder if they can learn ultrasound well enough to teach, it is a fundamental skill in numerous specialties, and will not lose relevance. And medical schools are realizing they need to teach ultrasound or be left behind, Dr. Bahner said. With increasing institutional anand faculty buy-in, ultrasound can be integrated into the curriculum.
At the University of South Carolina, ultrasound is introduced during student orientation, before medical school even begins. Aside from being taught in preclinical courses such as anatomy and physiology, ultrasound also is featured in the introduction to clinical medicine course and included in the observed structured clinical exams (OSCEs) at the conclusion of clinical clerkships in internal medicine (thyroid scan, ultrasound-guided central line placement), family medicine (abdominal aortic aneurysm scan), obstetrics/gynecology (transabdominal scanning in pregnancy), and surgery (Focused Assessment with Sonography in Trauma scan).
Dr. Palma noted that “one of the big benefits of longitudinal integration is that it allows instructors to avoid falling into the trap of trying to teach the students everything all at once.” At OSU, ultrasound is introduced during the preclinical years, and all medical students review ultrasound basics, and are exposed to cardiac and FAST scanning and procedural ultrasound during the third-year Clinical Skills Immersion Experience. To build on this, all fourth-year students at OSU must attend ultrasound lectures and hands-on scanning sessions that focus on the approach to the undifferentiated patient.
For interested students, OSU even offers an advanced curriculum for developing future sonologists over the four years of medical school. Dr. Palma has similar plans, beginning with fourth-year medical students, and hopes to add ultrasound to the earlier years. While vertical integration into the medical school curriculum is ideal, Michael Stone, MD, of Highland Hospital in Oakland, CA, said what works for one institution might not for others given financial resources, number of qualified instructors, and timing of curriculum reform, but that would be the long-term goal. If ultrasound can be integrated in a longitudinal manner, then it can become more than just a teaching tool but also an effective clinical tool that can be incorporated into daily practice.
Exposing medical students early and longitudinally to ultrasound builds a widespread foundation of knowledge in ultrasound, and allows residency training to focus on applications that directly affect patient care, cost, and safety. The ACEP guidelines provide clear and informative recommendations on emergency ultrasound education in medical school. (Ann Emerg Med 2009;53[4]:550; http://bit.ly/emUS.) Next spring, the First World Congress on Ultrasound in Medical Education sponsored by the Society of Ultrasound in Medical Education and the World Interactive Network Focused on Critical Ultrasound will be held in Columbia, SC, so educators and sonologists can share, network, and determine the next steps to integrate bedside ultrasound into routine clinical practice for all specialties.
While these institutions are leading the way, as Michael Blaivas, MD, notes, 15 to 16 more medical schools will need to integrate ultrasound into their curricula before this need is pushed to the foreground. Thanks to physician leaders like Drs. Hoppmann, Bahner, and Palma, more medical students are being taught bedside ultrasound and how to approach patients differently. Ultrasound should be a standard in medical student education, and with these efforts, there is reason to hope it soon will be.
