Current Use, Perceived Barriers, and Learning Preference of Point of Care Ultrasound (POCUS) in the Emergency Medicine in Qatar - A Mixed Design

Use of Point-of-Care Ultrasound in Home vs Non-home Medical Care Physicians in Japan

OBJECTIVES

To compare the use of point-of-care ultrasound between physicians providing home medical care and other physicians in Japan.

DESIGN

A cross-sectional comparative study.

SETTING AND PARTICIPANTS

The participants were members of 3 societies related to home medical care in Japan.

METHOD

A web-based survey was conducted between April and June 2024 to assess use of point-of-care ultrasound, physicians' training history and needs in this technique, ultrasound machine availability and types, and barriers and facilitators for wider adoption.

RESULTS

Overall, 692 physicians (461 providing home medical care) participated. There were more point-of-care ultrasound users among those providing home medical care (75.9% vs 67.1%; P = .014). There was no significant difference in training history (34.3% vs 36.4%; P = .587), but training needs were significantly greater among home medical care providers (80.9% vs 66.7%; P < .001). This group also had better access to ultrasound machines (53.6% vs 35.5%; P < .001), with higher personal ownership rates and handheld device usage (29.1% vs 4.8%, P < .001; 59.7% vs 13.2%, P < .001). The main barrier was insufficient training opportunities, especially for home care providers (61.6% vs 51.5%; P = .011), followed by inadequate training environments (46.4% vs 32.9%; P = .001), challenges in image acquisition (59.0% vs 37.2%; P < .001), and interpretation skills (51.4% vs 32.9%; P < .001). Facilitators included improved access to ultrasound machines and increased training opportunities and available mentors, with home care providers significantly emphasizing training opportunities (71.2% vs 62.3%; P = .019).

CONCLUSIONS AND IMPLICATIONS

Home medical care providers were more likely to use point-of-care ultrasound and have better access to machines; however, they faced barriers related to skills and training opportunities. As handheld devices become prevalent, systematic training in this technique is becoming essential.

Exploring knowledge, attitude and confidence in point-of-care ultrasound among emergency physicians and radiologists in Jordan: a cross-sectional study

OBJECTIVE

This study explored POCUS knowledge, attitudes, confidence, barriers, enablers, and their associated factors among radiologists and emergency physicians in Jordan.

METHODS

A cross-sectional questionnaire-based study covered five sections: socio-demographics, knowledge, attitude, confidence, and barriers and enablers. Summary statistics, correlation, and regression analyses were performed.

RESULTS

A total of 164 physicians participated, with an average age of 33.8 (± 7.69) years; 52.4% were radiologists and 47.6% were emergency physicians. Participants exhibited good knowledge, attitudes, and confidence. Higher attitude scores (β = 0.28; p < 0.001) and having a POCUS machine (β = 1.70; p = 0.01) were associated with higher knowledge. Higher knowledge (β = 0.64; p < 0.001) predicted better attitudes, while attitude (β = 0.21; p = 0.01), specialty radiologist (β = 8.5; p < 0.001), age (β = 0.23; p < 0.001), and number of monthly scans (β = 0.01; p = 0.01) predicted confidence.

CONCLUSION

Radiologists and emergency physicians in Jordan demonstrated good POCUS knowledge, attitudes, and confidence. Specialty and usage frequency influenced these factors. Future studies should explore training effects on skill acquisition. The study found different factors that are associated with knowledge, attitude, and confidence levels such as specialty, frequency of using POCUS, and the levels of knowledge, attitude and confidence. Future studies, including large prospective studies and/or experimental studies that examine the effect of training on skill acquisition among various healthcare professionals are warranted.

From novice to proficient: a longitudinal study of POCUS skill development through a hybrid certification program in the United Arab Emirates

BACKGROUND

Point-of-care Ultrasound (POCUS) is rapidly becoming an indispensable tool in a wide range of medical specialties. To ensure that practicing physicians are fully equipped with the skills required, there is a need to expand comprehensive training opportunities, particularly in the Middle East and North Africa region. This study evaluates the effectiveness of a novel year-long hybrid POCUS certification program aimed at enhancing the confidence and competency of practicing physicians in the United Arab Emirates (UAE).

METHODS

A prospective cohort study was conducted involving 12 practicing physicians enrolled in a one-year, part-time hybrid POCUS program. The program consisted of six modules that integrated online educational units, in-person workshops, and supervised clinical practice. Eligibility criteria for the program required participants to be licensed physicians with access to an ultrasound machine that had image storage capabilities within their healthcare setting. Participants' confidence was assessed through self-reported surveys at four evaluation points. Competency was evaluated using the Ultrasound Competency Assessment Tool (UCAT) at three evaluation points, while ultrasound image quality was assessed throughout the program. Repeated measures of analysis of variance (ANOVA) were used to analyze changes in confidence and competency over time. Spearman's correlation coefficients were calculated to examine the relationship between confidence and competency scores.

RESULTS

Participants demonstrated significant improvements in both confidence and competency. Mean total confidence scores increased from 64.0 (SD = 9.9) pre-program to 81.3 (SD = 6.7) post-program (p < 0.001). The UCAT scores improved from 64.9 (SD = 13.5) in module two to 78.9 (SD = 3.6) in module six (p < 0.001). The UCAT scores for cardiac and lung applications showed the most consistent improvement, while the scores for first trimester ultrasound demonstrated the least improvement. Ultrasound image quality scores demonstrated a positive trend over time with a clear learning trajectory marked by three distinct phases. There was a significant association between ultrasound image quality scores and the number of completed ultrasound scan assignments (p < 0.001) for all applications except for first trimester ultrasound, indicating the need for curriculum enhancement in this area. A moderate positive correlation was observed between post-module four confidence scores and module six competence scores (r = 0.585, p = 0.059), however, this correlation was not statistically significant.

CONCLUSION

This comprehensive hybrid POCUS program effectively enhanced confidence and competency among practicing physicians. The structured approach, which integrates theoretical knowledge, hands-on practice, and ongoing longitudinal feedback, presents a promising model for POCUS education. These findings inform the development of similar programs, potentially improving POCUS adoption and patient care globally.

CLINICAL TRIAL NUMBER

Not applicable.

A Multi-step Integrative Workflow Implementation to Improve Documentation of Point of Care Ultrasound in Medical Intensive Care Unit

Point of care ultrasound (POCUS) provides quick bedside assessment for diagnosing and managing life-threatening conditions in critical care medicine. There has been increasing interest in developing infrastructure to archive images, record clinical interpretation, assess quality, and recoup revenue for POCUS. We present a simple workflow by systems integration of electronic medical record, ultrasound machines, picture archiving, and communication system to facilitate POCUS documentation and billing. We recorded a trend on the number of POCUS performed before and after introduction of the structured integration. We observed and recorded a linear increase over time post-intervention. Our innovative and integrated POCUS workflow is an effective way to document and bill POCUS.

Barriers to and facilitators of point-of-care ultrasound utilization among physicians, nurse practitioners, and nurses in Japan: a comparative study

BACKGROUND

Point-of-care ultrasound (POCUS) is a valuable skill for generalist physicians, nurse practitioners (NPs), and nurses; however, its utilization remains limited. This study was performed to investigate the current status, barriers, and facilitators of POCUS implementation among physicians, NPs, and nurses in family and hospital medicine in Japan and to identify differences in influencing factors between physicians and NPs/nurses.

RESULTS

A web-based survey was distributed via the mailing lists of four major academic societies in general medicine in Japan-the Japanese Society of Hospital General Medicine, the Japan Primary Care Association, the Japanese Association for Home Care Medicine, and the Japan Society of Nurse Practitioner-from April to June 2024. The respondents included physicians, NPs, and nurses affiliated with these societies. Responses from other professions, duplicate entries, and incomplete surveys were excluded from the analysis, resulting in 913 valid responses (692 physicians and 221 NPs/nurses). Physicians reported a higher POCUS implementation rate than NPs/nurses (73.0 vs. 63.4%, p = 0.006). The top two barriers were consistent across both groups: lack of training opportunities (p = 0.385) and lack of image acquisition skills (p = 0.369). However, NPs/nurses reported significantly greater barriers than did physicians, including lack of mentors (p < 0.001), lack of interpretation skills (p = 0.007), lack of confidence (p < 0.001), poor access to ultrasound devices (p < 0.001), and absence of institutional guidelines (p < 0.001). The top facilitators for both groups were good access to ultrasound devices (p = 0.078) and increased training opportunities (p = 0.240), with no significant differences between them. Compared with physicians, NPs/nurses expressed a significantly higher demand for nearby mentors (p < 0.001), institutional support (p < 0.001), and POCUS certification (p = 0.005).

CONCLUSIONS

There is currently a lack of POCUS training opportunities across all professional roles. To promote POCUS adoption among NPs and nurses, it is essential to develop mentorship programs, establish institutional guidelines, and create an environment that enables NPs and nurses to perform POCUS confidently through measures such as certification programs.

Performance of ChatGPT in emergency medicine residency exams in Qatar: A comparative analysis with resident physicians

Introduction

The inclusion of artificial intelligence (AI) in the healthcare sector has transformed medical practices by introducing innovative techniques for medical education, diagnosis, and treatment strategies. In medical education, the potential of AI to enhance learning and assessment methods is being increasingly recognized. This study aims to evaluate the performance of OpenAI's Chat Generative Pre-Trained Transformer (ChatGPT) in emergency medicine (EM) residency examinations in Qatar and compare it with the performance of resident physicians.

Methods

A retrospective descriptive study with a mixed-methods design was conducted in August 2023. EM residents' examination scores were collected and compared with the performance of ChatGPT on the same examinations. The examinations consisted of multiple-choice questions (MCQs) from the same faculty responsible for Qatari Board EM examinations. ChatGPT's performance on these examinations was analyzed and compared with residents across various postgraduate years (PGY).

Results

The study included 238 emergency department residents from PGY1 to PGY4 and compared their performances with ChatGPT. ChatGPT scored consistently higher than resident groups in all examination categories. However, a notable decline in passing rates was observed among senior residents, indicating a potential misalignment between examination performance and practical competencies. Another likely reason can be the impact of the COVID-19 pandemic on their learning experience, knowledge acquisition, and consolidation.

Conclusion

ChatGPT demonstrated significant proficiency in the theoretical knowledge of EM, outperforming resident physicians in examination settings. This finding suggests the potential of AI as a supplementary tool in medical education.

Facilitators, barriers, and changes in POCUS use: longitudinal follow-up after participation in a national point-of-care ultrasound training course in Japan

BACKGROUND

POCUS training courses are effective at improving knowledge and skills, but few studies have followed learners longitudinally post-course to understand facilitators, barriers, and changes in POCUS use in clinical practice. We conducted a prospective observational study of physicians who attended 11 standardized POCUS training courses between 2017 and 2019 in Japan. Physicians who attended a standardized POCUS course were surveyed about their current frequency of POCUS use of the heart, lung, abdomen, and lower extremity veins, and perceived barriers and facilitators to POCUS use in clinical practice.

RESULTS

Data were analyzed from 112 completed surveys (response rate = 20%). A majority of responding physicians were faculty (77%) in internal medicine (69%) affiliated with community hospitals (55%). The mean delay between course attendance and survey response was 50.3 months. A significant increase in POCUS use from < 1 to ≥ 1 time per week was seen for all organ systems after 50 months post-course (p < 0.01). Approximately half of course participants reported an increase in the frequency of cardiac (61%), lung (53%), vascular (44%), and abdominal (50%) ultrasound use. General facilitators of POCUS use were easy access to ultrasound machines (63%), having a colleague with whom to learn POCUS (47%), and adequate departmental support (46%). General barriers included lack of opportunities for POCUS training (47%), poor access to ultrasound machines (38%), and limited time for POCUS training (33%). In the group with increased POCUS usage, specific facilitators reported were enhanced POCUS knowledge, improved image acquisition skills, and greater self-confidence in performing POCUS. Conversely, the group without increased POCUS usage reported lack of supervising physicians, low confidence, and insufficient training opportunities as specific barriers.

CONCLUSIONS

Approximately half of physicians reported an increase in cardiac, lung, vascular, and abdominal POCUS use > 4 years after attending a POCUS training course. In addition to improving access to ultrasound machines and training opportunities, a supportive local clinical environment, including colleagues to share experiences in learning POCUS and local experts to supervise scanning, is important to foster ongoing POCUS practice and implementation into clinical practice.

Barriers to Point-of-Care Ultrasound Utilization Among Emergency Medicine Residents in Riyadh, Saudi Arabia

BACKGROUND

Point-of-care ultrasound (POCUS) is increasingly recognized as a valuable diagnostic tool in emergency medicine (EM). This study aimed to identify barriers to POCUS utilization among EM residents in the Riyadh region.

MATERIALS AND METHODS

An observational cross-sectional study was conducted among 116 EM residents from various training centers in Riyadh. Data were collected through self-administered questionnaires assessing demographics, ultrasound (US) training, perceived barriers, and facilitators to POCUS usage. Statistical analysis included descriptive statistics, multiple response dichotomy analysis, and multivariable linear regression.

RESULTS

The majority of residents had completed US training and recognized the importance of POCUS in emergency settings. However, significant barriers were identified, including time constraints and logistical challenges. Multivariable regression analysis revealed associations between residents' training status, beliefs in incentives, anticipated POCUS use, and perceived barriers.

CONCLUSION

This study highlights the importance of addressing barriers to POCUS integration into residency programs. Efforts should focus on optimizing training, addressing workflow challenges, and enhancing residents' confidence in POCUS utilization. Targeted interventions tailored to specific clinical contexts may facilitate greater acceptance and integration of POCUS into routine practice.

Point-of-Care Ultrasound in the Emergency Department: Training, Perceptions, Applications, and Barriers from Different Healthcare Professionals

Background

Point-of-care ultrasound (POCUS) is a valuable tool that assists in diagnosis and management of patients in the emergency department (ED) while being cost-efficient and without the use of ionizing radiation. To discern the opinions and perceptions of ED staff about POCUS applications and barriers, we conducted a cross-sectional survey of employees of 12 EDs in North Texas.

Methods

Participants completed a 20-item online survey about POCUS with questions pertaining to four domains: (1) employee and training information, (2) perceived benefits, (3) common applications, and (4) barriers to use. Out of 805 eligible ED employees, 103 completed the survey (16.1% response rate).

Results

The results indicated a generally positive perception of POCUS among all employee types. Physician had significant exposure and training of POCUS than non-physician group ( p < 0.001). Physicians tend to find cardiac assessments more useful for clinical management than non-physicians (47% vs. 23%, p = 0.01), while non-physicians find soft tissue/abscess assessments more useful (27% vs. 9%, p = 0.01).

Conclusion

The most significant barriers to POCUS use were time constraints for physicians and a lack of training for non-physician employees. Our study provides valuable insights into the perceptions of multiple ED professionals, serving as a foundation for promoting POCUS use in the ED.

Septic pulmonary embolism arising from a small temporal boil in a patient with diabetes mellitus type 2: A rare case report

Septic pulmonary embolism (SPE) can originate from unusual sources like small boils, warranting consideration of diverse etiologies in respiratory distress. Prompt diagnosis, tailored antibiotics, and vigilant complication management optimize outcomes. Early recognition and treatment of minor infections, especially in diabetes are crucial.

Removing Barriers to Emergency Medicine Point-of-Care Ultrasound: Illustrated by a Roadmap for Emergency Medicine Point-of-Care Ultrasound Expansion in India

Point-of-care ultrasound (PoCUS) has a potentially vital role to play in emergency medicine (EM), whether it be in high-, medium-, or low-resourced settings. However, numerous barriers are present which impede EM PoCUS implementation nationally and globally: (i) lack of a national practice guideline or scope of practice for EM PoCUS, (ii) resistance from non-PoCUS users of ultrasound imaging (USI) and lack of awareness from those who undertake parallel or post-EM patient care, and (iii) heterogeneous pattern of resources available in different institutes and settings. When combined with the Indian Preconception and Prenatal Diagnostic Techniques (PCPNDT) Act, this has led to the majority of India's 1.4 billion citizens being unable to access EM PoCUS. In order to address these barriers (globally as well as with specific application to India), this article outlines the three core principles of EM PoCUS: (i) the remit of the EM PoCUS USI must be well defined a priori, (ii) the standard of EM PoCUS USI must be the same as that of non-PoCUS users of USI, and (iii) the imaging performed should align with subsequent clinical decision-making and resource availability. These principles are contextualized using an integrated PoCUS framework approach which is designed to provide a robust foundation for consolidation and expansion across different PoCUS specialisms and health-care settings. Thus, a range of mechanisms (from optimization of clinical practice through to PoCUS educational reform) are presented to address such barriers. For India, these are combined with specific mechanisms to address the PCPNDT Act, to provide the basis for influencing national legislation and instigating an addendum to the Act. By mapping to the recent Lancet Commission publication on transforming access to diagnostics, this provides a global and cross-discipline perspective for the recommendations.

Point of Care Ultrasound (POCUS) Utilization and Barriers by Senior Emergency Medicine and Critical Care Residents at Two Teaching Referral Hospitals, Addis Ababa, Ethiopia

Background. POCUS has become an integral part of the practice of emergency medicine. POCUS is a highly focused, limited, goal-directed exam with the expressed purpose of answering selected questions used at the bedside for critically ill patients who are not stable. We aimed to assess POCUS utilization and barriers by senior-year emergency medicine and critical care residents at two tertiary academic and referral hospitals in Addis Ababa, Ethiopia. Methodology. A cross-sectional study was conducted from June 1 to August 30, 2022 in St Paul’s Hospital Millennium Medical College and Tikur Anbessa Specialized Hospital using an electronic survey of senior-year (second and third years) emergency medicine and critical care residents. Data were collected using Goggle form, exported to SPSS version 24, and then analyzed. Result. Seventy-six residents out of 78 (97.4%) responded to the online survey. The mean age was 29.9 years with an SD of 2.87. Fifty-six residents (73.7%) were male and 45 (59.2%) were year 2 residents. Sixty-one (76.3%) had previous POCUS training. Fifty residents (82.0%) received training from the classroom. Twenty-seven residents (35.5%) rated their current level of knowledge as good for sterile transducer techniques, 28 (36.8%) rated fair for their knobology, and 27 (35.5%) rated very good for their transducer selection knowledge. Thirty-two (42.1%) rated very good about their ability to interpret IVC. 26 (34.2%) responded that they had good ability to interpret FAST/EFAST. Forty-nine (64.5%) residents claimed lack of an ultrasound machine followed by 33 (43.4%) lack of organized curriculum were the main barriers to POCUS utilization. Forty-two (55.3%) residents preferred to complete face-to-face teaching, while 33 (43.4%) preferred blended learning both face-to-face and online. Conclusion. POCUS is performed by the majority of EMCC residents. The most frequent scans performed by residents were FAST, IVC, and lung scans. Lack of ultrasound machine and organized curriculum was the main barrier to US utilization. Availability of equipment, face-to-face training, and having an organized curriculum are recommended by residents to improve their skills in the future.

Emergency medicine trainees' perceived barriers to training and credentialing in point-of-care ultrasound: A cross-sectional study

Introduction

Point-of-care ultrasound (POCUS) is an important tool in emergency medicine (EM), with the Australasian College for Emergency Medicine (ACEM) recommending core modalities as part of fellowship training. In Australia, acquisition of these skills is certified via credentialing but is currently poorly undertaken by EM trainees.

Methods

We performed a cross-sectional survey of EM trainees across two academic teaching hospitals in Gold Coast, Queensland, between December 2018 and January 2019, to determine the current state of training and perceived barriers to credentialing in POCUS.

Results

Fifty-two (59%) eligible EM trainees participated. Although credentialing rates (15%) were low amongst respondents, the majority agreed that it was necessary (69%) and should form part of ACEM training (88%). Amongst these trainees, we identified the desire for increased POCUS training and several barriers including time constraints and the credentialing process itself.

Conclusion

Although there is general agreement amongst EM trainees for POCUS credentialing, barriers such as time limitations and technical difficulties were prohibitive for many. We propose the development of an internal structured POCUS training programme within mandatory training time to address these issues.

Making Artificial Intelligence Lemonade Out of Data Lemons: Adaptation of a Public Apical Echo Database for Creation of a Subxiphoid Visual Estimation Automatic Ejection Fraction Machine Learning Algorithm

OBJECTIVES

A paucity of point-of-care ultrasound (POCUS) databases limits machine learning (ML). Assess feasibility of training ML algorithms to visually estimate left ventricular ejection fraction (EF) from a subxiphoid (SX) window using only apical 4-chamber (A4C) images.

METHODS

Researchers used a long-short-term-memory algorithm for image analysis. Using the Stanford EchoNet-Dynamic database of 10,036 A4C videos with calculated exact EF, researchers tested 3 ML training permeations. First, training on unaltered Stanford A4C videos, then unaltered and 90° clockwise (CW) rotated videos and finally unaltered, 90° rotated and horizontally flipped videos. As a real-world test, we obtained 615 SX videos from Harbor-UCLA (HUCLA) with EF calculations in 5% ranges. Researchers performed 1000 randomizations of EF point estimation within HUCLA EF ranges to compensate for ML and HUCLA EF mismatch, obtaining a mean value for absolute error (MAE) comparison and performed Bland-Altman analyses.

RESULTS

The ML algorithm EF mean MAE was estimated at 23.0, with a range of 22.8-23.3 using unaltered A4C video, mean MAE was 16.7, with a range of 16.5-16.9 using unaltered and 90° CW rotated video, mean MAE was 16.6, with a range of 16.3-16.8 using unaltered, 90° CW rotated and horizontally flipped video training. Bland-Altman showed weakest agreement at 40-45% EF.

CONCLUSIONS

Researchers successfully adapted unrelated ultrasound window data to train a POCUS ML algorithm with fair MAE using data manipulation to simulate a different ultrasound examination. This may be important for future POCUS algorithm design to help overcome a paucity of POCUS databases.

Design and implementation of a basic and global point of care ultrasound (POCUS) certification curriculum for emergency medicine faculty

Point of care ultrasound (POCUS) use in the emergency department is associated with improved patient outcomes and increased patient satisfaction. When used for procedural guidance, it has been shown to increase first pass success and decrease complications. As of 2012, ultrasound has been identified as a core skill required for graduating emergency medicine (EM) residents. Despite this, only a minority of EM faculty who trained prior to 2008 are credentialed in POCUS. Half of all EM training programs in the United States have less than 50% of their faculty credentialed to perform and teach POCUS to learners. As the use of POCUS continues to grow in medicine, it is especially important to have a pathway for faculty to attain competence and become credentialed in POCUS. The goal of this paper was to outline an implementation process of a curriculum designed to credential EM faculty in POCUS.

Impact of Insurance Benefits and Education on Point-of-Care Ultrasound Use in a Single Emergency Department: An Interrupted Time Series Analysis

Background and Objectives: Point-of-care ultrasound (POCUS) is a useful tool that helps clinicians properly treat patients in emergency department (ED). This study aimed to evaluate the impact of specific interventions on the use of POCUS in the ED. Materials and Methods: This retrospective study used an interrupted time series analysis to assess how interventions changed the use of POCUS in the emergency department of a tertiary medical institute in South Korea from October 2016 to February 2021. We chose two main interventions—expansion of benefit coverage of the National Health Insurance (NHI) for emergency ultrasound (EUS) and annual ultrasound educational workshops. The primary variable was the EUS rate, defined as the number of EUS scans per 1000 eligible patients per month. We compared the level and slope of EUS rates before and after interventions. Results: A total of 5188 scanned records were included. Before interventions, the EUS rate had increased gradually. After interventions, except for the first workshop, the EUS rate immediately increased significantly (p < 0.05). The difference in the EUS rate according to the expansion of the NHI was estimated to be the largest (p < 0.001). However, the change in slope significantly decreased after the third workshop during the coronavirus disease 2019 pandemic (p = 0.004). The EUS rate increased significantly in the presence of physicians participating in intensive POCUS training (p < 0.001). Conclusion: This study found that expansion of insurance coverage for EUS and ultrasound education led to a significant and immediate increase in the use of POCUS, suggesting that POCUS use can be increased by improving education and insurance benefits.

Development and Remodeling of Point-of-Care Ultrasound Education for Emergency Medicine Residents in Resource Limited Countries during the COVID-19 Pandemic

The administration of an accurate and effective POCUS course is a crucial tool in improving health education and thus the health care system in low- to middle-income countries. The development of the ultrasound curriculum in these countries during the pandemic era is a major challenge for medical educators. Therefore, this study aims to survey the learner experience after implementing the POCUS curriculum for first-year emergency medicine residents. All learners responded to the survey. Our results demonstrated that the ultrasound rotation and our ultra-sound learning materials were useful tools which showed a positive impact on POCUS knowledge for our learners. However, some obstacles of POCUS learning were identified to assist in closing faculty development gaps, including the availability of handheld devices, as well as the re-modeling of the ultrasound rotation course, which should be managed according to the feedback we received. This study demonstrated a clear need for constant updates in higher education, medical program development, accuracy of local learning materials, and the explosion of virtual and online learning platforms during this decade.