Using Hand-Held Ultrasound to Enhance Pre-Clinical

Medical School Curricula

Mary Beth Poston, MD, MSCR

University of South Carolina School of MedicineColumbia, SC

Workshop Outline• Background – Ultrasound in medical education

• integrated UltraSound Curriculum (iUSC) – Ultrasound Vertical Curriculum

• Ultrasound in the Pre-Clinical Years– Curriculum Content– Evaluation– Resources

Learning Objectives

• To discuss the new role of hands-on learning in medical education

• To demonstrate how one medical school has implemented a vertical curriculum in ultrasound technology

• To demonstrate specifically how this complements learning in the Pre-Clinical curriculum

• To demonstrate the ease with which these techniques can be taught and learned

Why Ultrasound?

Ultrasound in Medical Education

• Expansion of hands-on learning, simulation in education

• Using ultrasound as an adjunct to physical exam skills has been shown to be an acquirable skill for medical students– Identification of cardiac pathology– Abdominal ultrasound

• Ultrasound technology as part of some residency training programs– FAST exam in Emergency Medicine training

Comparison of Hand-Carried Ultrasound to Bedside Cardiovascular Physical ExaminationKopal SL, et al. Am J Cardiol 2005

• Two first year medical students

• 4 hrs of lecture and 14 hrs of hands-on experience

• Students outperformed 5 board-certified cardiologists in identifying cardiac pathology in 61 cardiac patients

• Students identified 75% of the pathologies and cardiologists identified 49%

British Medical Journal May 2008 – Feature Article on Ultrasound Education

Dr Giles Maskell, radiologist at the Royal Cornwall Hospital in Truro, believes ultrasonography should be taught to everyone in medical school: "It is a fantastic tool and every medical student should be taught to use ultrasound like they are taught to use a stethoscope”.

“This is already happening at one medical school in the United States. The University of South Carolina is pioneering a project to train all medical students in ultrasonography.”

iUSC

• Class of 2010, first fully trained in ultrasound vertical curriculum

• In 2006, USCSM introduced the ultrasound curriculum in the basic science years

• In 2007, this was expanded to the clinical years

USC-SOM Vertical Curricula

• Ethics and Professionalism• Genetics• Geriatrics• Nutrition• Substance Abuse• Ultrasound

Vertical Curriculum

• Defined as “the interdepartmental integration, in basic science courses and clinical rotations over the course of the four-year curriculum, of topical subject matters that transcend the purview of an individual USC-SOM department”

• Distinguishable from “horizontal integration” in that the latter attempts to teach similar preclinical topics simultaneously even if in different required courses

Vertical Curriculum - Oversight

• Overseen by individual VC directors• Also overseen by the Interdepartmental/

Interdisciplinary Integration Subcommittee of the Curriculum Committee, which – Conducts periodic reviews and updates of vertical

curricula– Ensures the integration of interdepartmental and

interdisciplinary educational efforts– Oversees initiation and maintenance of a curricular

tracking system

Vertical Curriculum - Tracking

• Mapping within curriculum data base helps with oversight

• Overarching and course specific objectives for each of the vertical curricula are included in the curriculum data base

• Methods of assessment are outlined in the curriculum data base

Vertical Curriculum - Ultrasound• M1 – taught in conjunction with Gross Anatomy and Physiology• M2 – expansion of M1 curriculum, coordinated with lecture

topics in Pathology/Pathophysiology and Physical Diagnosis• M3 – most core clerkships have an ultrasound learning

component and OSCE– IM – thyroid, central line placement– OB/Gyn – pregnancy with bleeding– Surgery – FAST exam– Family Medicine – AAA – Pediatrics - HOCM, situs inversus, dehydration

• M4 – Review of essential skills– Elective in emergency bedside ultrasound– Capstone workshop

Ultrasound in the Pre-Clinical Curriculum

M1 Curriculum

• Fall Semester – Gross Anatomy– Introductory lecture during Orientation– “Knobology”– Cardiac ultrasound– Neck ultrasound (carotid artery, internal jugular vein,

thyroid)– Pelvic ultrasound (urinary bladder)– Abdominal (hepatic, spleen, renal) ultrasound

• Evaluated with Objective Structured Clinical Examination (OSCE)

M1 Curriculum• Spring Semester – Physiology

– Vascular hemodynamics (introduces concepts of color flow and doppler to demonstrate direction of flow and measurement of velocity, recognition of arterial and venous wave forms)

– Cardiac hemodynamics (normal function) Wall and valve motion, flow through cardiac chambers

– Evaluating for cardiogenic shock: gross LV/RV function and size, gross valve function

• Evaluated with the addition of case-based multiple choice test questions to standard Physiology quizzes and tests

M2 Curriculum• Coordinated with Introduction to Clinical

Medicine (ICM)• Fall Semester: Physical Diagnosis

– All standard cardiac views– General abdominal ultrasound

• Pathophysiology– Abdominal aorta (AAA screen)– Lower extremity vascular (DVT screen)

• Evaluating based on Web-based modules with multiple choice questions, “open book” multiple choice quiz

M2 Curriculum (ICM)

• Spring Semester – Pathophysiology– Pelvic ultrasound (female gynecology)– Vascular ultrasound (inferior vena cava for volume

status estimation)– Cardiogenic shock– Ultrasound guided procedures – (uses ultrasound phantoms)

• Evaluated with OSCE

Delivery of Course ContentUltrasound Labs

• Primarily hands-on labs: 1 hour groups– May have brief (max 30 minutes, usually less than

10 minutes) pre-lab lecture/demonstration– Occasional (usually no more than 1/semester)

longer classroom lecture for complex topics– Group size of ~ 20 students, 4 faculty preceptors,

4-5 standardized patients– 2-4 “open lab sessions”/semester, 2 hours each,

staffed by iUSC faculty (1 or 2 faculty per session)

Web-based Modules

• Cover a wide range of topics from ultrasound physics to specific clinical indications

• Demonstrate relevant technique plus discuss evidence based guidelines for use of ultrasound in the clinical setting

• Include ultrasound images and loops• Generally 12-15 minutes in length

Web-based Module:Demonstration

• http://media.med.sc.edu/ultrasound_institute/M2/11B/player.html

Pre-Clinical Ultrasound Curriculum Assessment of Skills

• OSCE is standard testing format with standardized patients, M1-M4

• Must demonstrate – Understanding of technology (M1-M4)– Ability to acquire images (M1-M4)– Ability to interpret findings in context of patient

history and physical exam (M3-M4)– Ability to use findings appropriately in planning

patient care (M3-M4)

Additional Measures in Pre-clinical Curriculum: Standard Multiple Choice

Questions• May be incorporated into quizzes and tests for

the course with which the curriculum is paired• Can create “stand-alone” quizzes• Can incorporate questions with other learning

materials (web-based modules)• Questions usually include cases and/or images

Pre-Clinical Ultrasound CurriculumAssessment of Impact

• Student surveys/Focus Groups

• Controlled studies

Survey/Focus Group Questions: % Strongly Agree/Agree

M1 M2Year

07 08 09Year

07 08 09US enhanced my ability to learn basic Gross Anatomy (M1)/allowed for increased clinical correlation with basic science instruction (M2)

94 88 61 81 94 90

US faculty is knowledgeable 98 100 95 95 99 100I found the hands on lab sessions with standardized patients helpful in learning US

97 97 88 91 100 87

I found the open lab sessions (practicing scanning each other) helpful in learning US

96 100 83 58 55 88

I found the overall educational experience in US enhanced my medical education

100 95 90 85 97 96

I would like to see more US in the curriculum 92 76 50 70 84 64Able to achieve a basic skill level (M1)/improve my US scanning skills (M2) 100 100 97 87 96 94M2 ONLY: Found online learning modules helpful US enhanced skill/understanding of the physical exam

40 51 3878 92 90

Controlled Study of Comparative Performance on Gross Anatomy Multiple

Choice Quiz• 3 predefined dissection groups:

– Group A: Anterior wall– Group B: Viscera– Group C: Posterior wall

• Half of each group randomly assigned to additional abdominal ultrasound exposure during abdominal dissection

Controlled Study of Comparative Performance on Gross Anatomy Multiple

Choice Quiz• Performance on 25 question quiz compared

– Questions from pre-existing test bank utilized in the usual fashion

– Prior to test administration, Ultrasound and Gross Anatomy faculty reviewed quiz and identified 6 questions thought to be related to Ultrasound Concepts

Controlled Study of Comparative Performance on Gross Anatomy Multiple

Choice Quiz: Results– Intervention group (n=53)– Control group (n=50)

– Multiple comparisons explored (US vs no US within and across dissection groups) without a clear pattern of significant differences (though in most comparisons US scores slightly higher)

– Additional comparisons planned controlling for overall Gross Anatomy grade

Mean difference (+/- SD) Significance

All 25 questions 0.786(+/-1.597) ns

19 “non US” questions 0.397(+/- 0.96) ns

6 “US” questions 0.355(+/-1.79) P<0.1

Resources: Faculty Recruitment and Development

• Faculty are across many clinical specialties:– Emergency Medicine– Internal Medicine and related subspecialties– Family Medicine– Pediatrics– Radiology

• Recruited on the basis of interest• Offered brief course in basic US (via our EM

department or iUSC), additional training sessions occur sporadically

• Most learning is “on the job”

Learning Objectives - Revisited

• You should now– Understand the new role of hands-on learning in medical

education– Know how one medical school has implemented a vertical

curriculum in ultrasound technology• And have the confidence to consider such at your own institution

– See the ease with which these techniques can be taught and learned

Thank You! Ultrasound Demonstration Available

Many thanks to Victor Rao, Lance Paulman, Erika Blanck, Duncan Howe, Stanley Fowler and Richard Hoppmann