Integration of ultrasound in medical School: Effects on Physical Examination Skills of Undergraduates

'Teaching should always be a little bit interesting for the teachers, too': Preceptor experiences of co-teaching ultrasound in a clinical skills course

PURPOSE

Medical schools increasingly incorporate ultrasound into preclinical curricula but face barriers including financial constraints, shortages of qualified instructors, and limited curricular space. This study explored how integrating ultrasound co-teaching into an existing first-year clinical skills course influenced preceptors' teaching experiences and characterized areas for curricular improvement.

METHODS

Ultrasound instructors rotated through classrooms during small-group physical examination skills sessions with 110 medical students, joining physical examination preceptors who taught remaining session content. Twelve ultrasound and traditional preceptors' experiences were characterized through focus group interviews paired with inductive thematic analysis.

RESULTS

Four themes were identified. First, the shared classroom fostered vicarious learning and novel instruction techniques but could feel disruptive to teaching. Second, ultrasound integration prompted physical examination preceptors to adopt a learner role. Third, students appeared to associate ultrasound with anatomy and physiology more than physical examination. Finally, ultrasound integration carries multiple logistical considerations.

CONCLUSIONS

Co-teaching ultrasound within clinical skills courses can promote learning and was associated with multiple effects on faculty preceptors and the teaching process. Those planning similar initiatives should consider strategies to optimize preceptor experiences, minimize disruptive potential, and promote connections between ultrasound and physical examination content.

Casual detection of an abdominal aortic aneurysm thanks to a trainee-made ultrasound with two subsequent "domino" diagnoses: case report and insights on the role of ultrasound courses

Early detection of abdominal aortic aneurysm (AAA) is crucial as untreated lesions can be life-threatening. We describe the case of a fortuitous ultrasound (US) detection of AAA by a trainee which allowed two subsequent "domino" diagnoses. A 69 y.o. male underwent US to evaluate prostate and bladder. He was a heavy smoker affected by hypertension and dyslipidemia. An endocrinology resident and ultrasound trainee started the exam accidentally from the epigastrium and found a fusiform aneurysmal lesion. Subsequent computed tomography (CT) scan confirmed the diagnosis of AAA and incidentally revealed a colon adenocarcinoma and a diffuse non-Hodgkin lymphoma. This case report underlines the importance of extending the abdominal US examination to the aorta in patients over 60 years of age (especially in those people with multiple risk factors for AAA) and emphasizes the critical role of organizing hands-on-patient US courses with a multidisciplinary approach to optimize the training of future sonographers.

Safety and efficacy of ultrasound-guided percutaneous flexor retinaculum release of the ankle: an anatomical study

Background

Tarsal tunnel syndrome (TTS) is a condition in which the tibial nerve (TN) (or its terminal branches) is compressed by the flexor retinaculum (FR) and the deep fascia of the abductor hallucis muscle at the tarsal tunnel, causing symptoms that negatively impact the patient's quality of life, including numbness, a sensation of a foreign object, coldness, and pain. FR release via microtrauma using needle-knife has proven to be effective in China and is widely used by clinicians. The traditional acupotomy, however, is the "blind knife" treatment, which cannot guarantee patient safety due to risk of injury to important structures, particularly the neurovascular bundle. Compared with the conventional treatments, ultrasound-guided percutaneous FR release possesses noteworthy advantages including high efficacy and safety.

Methods

Percutaneous release of the FR was performed on 51 formalin-fixed specimens. The specimens were divided into two groups: an ultrasound-guided acupotomy pushing group comprising 20 legs (group U) and a nonultrasound-guided acupotomy pushing group comprising 31 legs (group N). After high-frequency ultrasound exploration, those with clear vascular imaging were included in group U; otherwise, they were included in group N. The FR was released percutaneously, soft tissue was dissected layer by layer, and anatomical data were recorded.

Results

There no cases of injury in group U (0%) and four in group N (12.9%). Among the different intervention methods, there were no significant differences in tissue injury types (χ2=2.80; P=0.09). The percentage of released FR in group U was 80.00% while that in group N was 61.29% (χ2=1.977; P=0.16), which did not represent a significant difference between the two groups. However, group U had a significantly greater release length than that in the group N (t=3.359; P=0.002), indicating that the flexor release length guided by ultrasound is significantly greater than the unguided one.

Conclusions

Ultrasound-guided percutaneous release of the FR using a needle-knife can provide greater length and percentage of released FR while maintaining a comparable safety rate to the unguided procedure.

Lung ultrasound teaching in medical education: a pilot study at a Brazilian medical school

OBJECTIVE

To evaluate cognitive learning, ability to perform and interpret lung ultrasound exams, and self-perception of learning among medical students after a short pedagogical intervention at a medical school in Brazil.

METHODS

An experimental pilot study was conducted with medical students at different stages of their education (basic cycle, clinical cycle, and medical internship). The participants underwent a cognitive test before and after the intervention, a practical test, a test to recognize lung ultrasound pathologies, and a qualitative evaluation test at the end of the intervention. Statistical analysis was performed using a significance level of p < 0.05.

RESULTS

A total of 42 students were included in the study, with a median age of 23 years and a predominance of males. The mean score of the pre-intervention cognitive test was 2.97 ± 0.87, and that of the post-intervention test was 6.57 ± 1.41, showing significant improvement (p < 0.001). The score of the practical test and that of the recognition of pathologies test also showed significant improvement after the intervention. There was no significant difference in execution time between the groups. Students in the clinical cycle had a better self-perception of learning.

CONCLUSIONS

Theoretical teaching and practical training of lung ultrasound in a short pedagogical intervention can improve cognitive performance, practical skills, and interpretation of the exam. The level of learning achievement was higher among more advanced students in medical education. Additionally, the students in the clinical cycle had a better perception of their learning.

POCUS increases successful placement of peripheral arterial lines in neonates by less experienced providers

To assess success of peripheral arterial line (PAL) placement after implementing a point-of-care ultrasound (POCUS) program in a neonatal intensive care unit. This was a retrospective chart review of infants who underwent successful PAL placement from January 2019 to March 2021. Outcomes included first-attempt success and the number of attempts with and without the use of POCUS. Among 80 PALs, 36% were POCUS-guided. All POCUS-guided lines were placed by providers with < 5 years neonatology experience. Among infants ≥ 2.5 kg, the use of POCUS was associated with fewer attempts compared to non-POCUS PAL placement (1 vs. 2, p = 0.035).     Conclusions: Use of POCUS for PAL placement was associated with fewer attempts for successful placement in infants ≥ 2.5 kg by providers with less neonatology experience compared with traditional method. What is Known: • Arterial line placement in neonates has been traditionally done by palpation and can be technically challenging. • POCUS is an emerging tool in the NICU with increasing number of less clinically experienced providers in the NICU having access to ultrasound. What is New: • Use of POCUS by less experienced clinicians for arterial line placement resulted in fewer attempts compared to the traditional landmark-based approach in a cohort of neonates.

Implementing a Sports Ultrasound Curriculum in Undergraduate Medical Education

ABSTRACT

The utilization of sports ultrasound in the clinical practice of sports medicine physicians is growing rapidly. Simultaneously, ultrasound is being increasingly implemented as a teaching tool in undergraduate medical education. However, a sports ultrasound curriculum for medical students has not been previously described. In this article, we describe methods as well as barriers to implementing a sports ultrasound curriculum at the medical school level. Recommended content for the curriculum also is discussed. While educational goals and resources will vary among institutions, this article may serve as a general roadmap for the creation of a successful curriculum.

Point-of-Care Ultrasonography in Internal Medicine: Limitations and Pitfalls for Novice Users

Point-of-care ultrasound (POCUS) is increasingly being adopted in the field of internal medicine, leading to the development of POCUS curricula in undergraduate and postgraduate medical education programs. Prominent internal medicine societies and organizations worldwide recognize the expanding utilization of POCUS by internal medicine physicians, emphasizing the need for practitioners to be aware of both its benefits and limitations. Despite the growing enthusiasm for POCUS, clinicians, particularly those with limited clinical experience, must be cautious regarding its inherent limitations and the potential impact on their clinical practice. This review aims to outline the limitations and potential drawbacks of POCUS for medical students, residents, and internists who wish to stay abreast of the escalating use of POCUS in internal medicine and have a desire, or have already commenced, to incorporate POCUS into their practice. Additionally, it provides recommendations for enhancing POCUS proficiency to mitigate these limitations.

Undergraduate ultrasound training: prospective comparison of two different peer assisted course models on national standards

BACKGROUND

A thorough knowledge of sonography is essential in clinical practice. Therefore, sonography training is increasingly incorporated into the medical school curriculum, entailing different course models. The question arises which model is most effective to convey sustained sonographic skills.

METHODS

Two different peer-assisted learning (PAL) sonography course models were developed as part of a clinical prospective study. The course content was based on the national resident curriculum of the German Society for Ultrasound in Medicine (DEGUM). Model A consists of a 10-week course and model B of a two-day compact course. Each model entailed 20 teaching units (TU). A script was used to prepare for each unit. Two modified OSCE exams of the ultrasound skills (max = 50 points per exam) were performed during the last teaching unit to assess the competence level. For subjective self-assessment and model evaluation, a questionnaire with a 7-point Likert scale was employed.

RESULTS

A total of 888 students of the 3rd year participated as part of a voluntary elective in the study (744 in model A and 144 in model B). In the exams, participants in model A (median 43 points) scored significantly higher than those in model B (median 39; p < 0.01). Participants in model A (mean 1.71 points) obtained significantly higher mean competency gain scores in subject knowledge than model B (mean 1.43 points; p < 0.01) participants. All participants were satisfied with the course concept (A: mean 1.68 vs. B: mean 1.78 points; p = 0.05), the teaching materials (A: mean 1.81 vs. B: mean 1.69 points; p = 0.52), and the tutor's didactic skills (A: mean 1.24 vs. B: mean 1.15 points; p < 0.05).

CONCLUSION

These results suggest that sonography-specific competency may be obtained through different course models, with a model stretching over several weeks leading to a higher competence level. Further research should assess the long-term retention of the skills obtained in different models.

Long-Term Effectiveness and Sustainability of Integrating Peer-Assisted Ultrasound Courses into Medical School-A Prospective Study

INTRODUCTION

Ultrasound diagnostics is an important examination method in everyday clinical practice, but student education is often inadequate for acquiring sufficient basic skills. Individual universities have therefore started integrating (extra)curricular training concepts into medical education. This study aimed to evaluate sustainable skills development through participation in peer-assisted ultrasound courses.

METHODS

From 2017, students in the clinical part of medical school could opt for extracurricular peer-assisted ultrasound courses. Depending on the format (10-week course/2-day compact course) these comprised 20 teaching units focusing on abdominal and emergency ultrasonography. Students attending compulsory workshops at the start of their practical year were enrolled in this study, allowing for a comparison between the study group (attended ultrasound course) and the control group (did not attend ultrasound course). Competency from two out of four practical exams (subjects: "aorta", "gallbladder", "kidney" and "lung") was measured, and a theory test on the same subject areas ("pathology recognition") was administered. Additional questions concerned biographical data, subjective competency assessment (7-point Likert scale), and "attitude to ultrasound training in the curriculum".

RESULTS

Analysis included 302 participants in total. Ultrasound courses had been attended on average 2.5 years earlier (10-week course) and 12 months earlier (2-day compact course), respectively. The study group (n = 141) achieved significantly better results than the control group (n = 161) in the long-term follow-up. This applies both to practical exams (p < 0.01) and theory tests (p < 0.01). After course attendance, participants reported a significantly higher subjective assessment of theoretical (p < 0.01) and practical (p < 0.01) ultrasound skills.

CONCLUSIONS

Peer-assisted ultrasound courses can sustainably increase both theoretical and practical competency of medical students. This highlights the potential and need for standardised implementation of ultrasound courses in the medical education curriculum.

Comparing the Effectiveness and Image Quality of Musculoskeletal Ultrasound of First-Year Medical Students After Training by Student Tutors Versus Ultrasound Instructors: A Pilot Study

Background

Ultrasound is a vital part in many medical schools’ curriculum. Although there is strong support for the use of student tutors (STs), there is a lack in gauging their effectiveness with more difficult organ systems such as the musculoskeletal (MSK) system. We aim to determine the effectiveness of using STs versus expert ultrasound instructors (UIs) when teaching MSK ultrasound.

Methodology

Medical students were recruited to participate in an MSK workshop to identify superficial volar arm structures (radial nerve, radial artery, median nerve, ulnar artery, ulnar nerve) using Butterfly iQ. In total, 14 participants were taught by STs and 10 participants were taught by UIs. Participants imaged the five structures and answered surveys gauging their confidence via five-point Likert scales.

Results

There was no significant difference in confidence or identification accuracy for all five structures between the two groups. However, there was a significant difference in confidence in the understanding of basic ultrasound concepts in favor of the UI group (p < 0.05). A greater number of students were more confident in identifying all five structures when taught by STs, but more students correctly identified the structures when taught by UIs.

Conclusions

The results on confidence could be due to positive peer perception. Both groups scored relatively high in their identification accuracies, promoting the successful use of STs. The successful use of STs in teaching MSK ultrasound opens the possibility to developing peer-led ultrasound curriculum on more complex ultrasound topics in the future.

Cochrane's risk of bias tool for non-randomized studies (ROBINS-I) is frequently misapplied: A methodological systematic review

OBJECTIVES

We aimed to review how 'Risk of Bias In Non-randomized Studies-of Interventions' (ROBINS-I), a Cochrane risk of bias assessment tool, has been used in recent systematic reviews.

STUDY DESIGN AND SETTING

Database and citation searches were conducted in March 2020 to identify recently published reviews using ROBINS-I. Reported ROBINS-I assessments and data on how ROBINS-I was used were extracted from each review. Methodological quality of reviews was assessed using AMSTAR 2 ('A MeaSurement Tool to Assess systematic Reviews').

RESULTS

Of 181 hits, 124 reviews were included. Risk of bias was serious/critical in 54% of assessments on average, most commonly due to confounding. Quality of reviews was mostly low, and modifications and incorrect use of ROBINS-I were common, with 20% reviews modifying the rating scale, 20% understating overall risk of bias, and 19% including critical-risk of bias studies in evidence synthesis. Poorly conducted reviews were more likely to report low/moderate risk of bias (predicted probability 57% [95% CI: 47-67] in critically low-quality reviews, 31% [19-46] in high/moderate-quality reviews).

CONCLUSION

Low-quality reviews frequently apply ROBINS-I incorrectly, and may thus inappropriately include or give too much weight to uncertain evidence. Readers should be aware that such problems can lead to incorrect conclusions in reviews.