Undergraduate Ultrasound Curriculum: Essential considerations

INTRODUCTION:

The essential considerations for including diagnostic ultrasound in under graduate medical curriculum include initial cost and space for establishing dedicated ultrasound lab, lack of trained faculty, and limited time availability in already extremely busy medical curriculum. On the other hand, including ultrasound can help in learning normal anatomy in pre-clinical years. Including ultrasound in the medical curriculum will also reinforce student’s physical examination skills including correlation of traditional palpation of the thyroid gland to its location with ultrasound. It can help in palpation of normal organs and abnormal masses and corelating these with ultrasound. During clinical years ultrasound can help at point of care, also including “FAST” scans. The basic ultrasound physics and knobology should be a vital part of developing such a curriculum. The diagnostic ultrasound curriculum should also include, the general indications and limitations of ultrasound as well as emphasis on the safety aspects. The curriculum should also include standard methods for the reporting and documentation of results along with storage of images.

Ultrasound in undergraduate medical education has gained increasing popularity during last decade across the world, but few comprehensive undergraduate ultrasound programs are described in the literature till now. There are even fewer programmes that are based on educational needs or supported by evidence. Ultrasound education at many medical schools is taught using existing or adapted courses that were originally designed for clinicians, or sonographers. Presently, there is no standard undergraduate ultrasound curriculum even in USA. Additionally, there is no standardized method for assessments of students. The students and educators are also not informed about the content and structure of such curricula. This can lead to learn curriculum that is irrelevant for level of training or is not practical for future medical practice.

There seems a consensus that universities across United Kingdom should incorporate ultrasound into its undergraduate medical school curriculum. Many surveys in recent years have shown that no medical student opposed the potential of new curriculum. Students and educators agree that using ultrasound as a teaching tool would help improve anatomy learning especially in cardio-vascular, abdominal and pelvic areas. Ultrasound is also valuable in teaching peripheral nerve anatomy. However, peripheral nerve blocks are a higher-order procedure involving multiple skills that should be limited to specific specialists. There is large evidence confirming that ultrasound enhances a medical student’s understanding of anatomy and physiology and improves physical examination skills [3-4].

During phase1 clinical skills, the ultrasound-guided vascular access, presence of pleural effusion, detecting abdominal aortic aneurysm, presence of intra-abdominal fluid are important to learn. The advanced clinical applications including, deep-vein thrombosis (DVT), pneumothorax, assessment of cardiogenic shock, peripheral nerve blocks, ectopic pregnancy, and thyroid masses can be included in late phase2 or resident level curricula.

DISCUSSION:

In USA Medical schools incorporating ultrasound in to their curricula, students and other trainees are taught the point‐of‐care or clinical ultrasound model, which is distinct from the traditional model involving sonographers to perform image acquisition and radiologists to perform interpretation. In point‐of‐care ultrasound, clinicians perform focused ultrasound examinations to answer a clinical question and use their findings in real‐time patient care. [6].

Medical schools have started incorporating ultrasound into their undergraduate degree program, but the appropriateness of such curriculum and its ability to meet the individual needs of each institution is usually not evidence based. Furthermore, extensive ultrasound curriculum integration is the exception in Canadian medical schools. Although 67% of medical schools surveyed in one Canadian study offered ultrasound instruction, half of these schools provided only one to five hours of ultrasound teaching, and 67% taught ultrasound in the final two years of medical school as part of a clinical rotation [1]. Similar findings were seen in the United States where 61% offered such instruction, with only 18% of those schools making it a priority [2].

Introduction of basic ultrasound concepts at the earliest stages of medical school allows for a diverse foundation of ultrasound-specific cognitive and motor skills that are later transferable to more demanding clinical applications preformed at a higher cognitive load. Ultrasound education has been incorporated into anatomy, physiology, and physical examination courses. Studies have shown an increase in knowledge as well as student satisfaction in anatomy courses that integrate ultrasound. The same advantage is seen in physical diagnosis courses using ultrasound. In fact, several studies show that medical students and junior trainees using ultrasound can more reliably diagnose diseases than cardiologists and surgeons [7].

There is a desire for an undergraduate ultrasound curriculum that complements anatomical, physiological, and clinical teaching. This involves a more extensive and integrated curriculum than what is currently being offered at most medical schools, as well as an earlier introduction into the curriculum. The highly positive response from medical learners is consistent with data available from the UK [3].

Most of medical educators’ favour clinical ultrasound teaching to medical students for learning anatomy as well as reinforce their physical exam skills, such as correlating traditional palpation of the thyroid to its anatomical location with ultrasound. Educators also expressed a desire for standardized assessments to ensure competency and safe application of ultrasound. Such a tool has been developed and is undergoing external validation [5].

Some interesting ultrasound images showing conditions that can help identifying conditions during undergraduate medical education.

REFERENCES:

1. Bedside ultrasound education in Canadian medical schools: a national survey. Steinmetz P, Dobrescu O, Oleskevich S, et al. https://journalhosting.ucalgary.ca/index.php/cmej/article/view/36646 Can Med Educ J. 2016;7:78–86. [PMC free article] [PubMed]
2. The state of ultrasound education in US medical schools: results of a national survey. Bahner DP, Goldman E, Way D, Royall NA, Liu YT. Acad Med. 2014;89:1681–1686. [PubMed]
3. Introduction of ultrasound into gross anatomy curriculum: perceptions of medical students. Brown B, Adhikari S, Marx J, et al. J Emerg Med. 2012;43:1098–1102. [PubMed]
4. Undergraduate student perceptions of the use of ultrasonography in the study of “living anatomy” Ivanusic J, Cowie B, Barrington M. Anat Sci Educ. 2010;3:318–322. [PubMed]
5. Facilitated development of an objective assessment tool for point-of-care ultrasound performance in undergraduate medical education. [Sep;2016 ];Black H, Sheppard G, Metcalfe B, et al. Cureus. 2016 8:636.[PMC free article] [PubMed]
6. Kendall JL, Hoffenberg SR, Smith RS. History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Crit Care Med 2007; 35(suppl):S126–S130.
7. Kobal SL, Trento L, Baharami S. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol 2005; 96:1002–1006.

Figure1: Small Liver with irregular margins and a large ascites in patient with cirrhosis secondary to chronic hepatitis C.

Figure2: Enlarge Liver with increased echogenicty in a patient with diffuse fatty infiltration.

Figure3: 2D and colour doppler ultrasound of the liver showing obliteration of the IVC with a large intra-luminal thrombus.

Figure 4: Sub-costal view of the heart with anechoic fluid surrounding the heart in a patient with pericardial effusion.

Figure5: Ultrasound image of the abdominal aorta showing diffuse enlargement in patient with abdominal aortic aneurysm.

Figure 6: Ultrasound image of the right lower thorax in a patient with trauma showing pleural effusion.

Figure7: Ultrasound image of a patient with right upper quadrant pain showing a large stone in the gallbladder lumen.