RICHARD HOPPMANN

Overview

Ultrasonography has undergone a transformation in the past 2 decades that is fundamentally changing the way that medicine is taught and practiced. Technologic advances have taken ultrasound to the bedside or point of care in the form of laptop and pocket-sized devices that produce high-quality digital images that can be saved in multiple formats or sent anywhere in the world for review.

Because of the portability of ultrasound today, clinicians have real-time information to make diagnoses and management decisions virtually anywhere that they encounter patients, from traditional medical facilities such as the critical care unit to the site of natural disasters and the battlefield. The newer systems are user-friendly and much less expensive than the larger traditional machines, which makes them accessible to many more health care providers.

Ultrasound is a safe imaging modality and should be considered “first” in many clinical scenarios when imaging is indicated, especially those involving children to avoid the risk for cancer from ionizing radiation (i.e., ultrasound versus computed tomography for the diagnosis of appendicitis).1–3 The cost of ultrasound imaging is also considerably less than that of most other imaging modalities, and it can provide equivalent or better images and thus decrease overall health care cost. When compared with other imaging modalities, ultrasound has the added advantage of providing dynamic examinations, such as evaluation of the shoulder for rotator cuff disease or real-time guidance of procedures such as central line placement and thoracentesis.

If ultrasound has all these advantages, why is it not being used more commonly? A major factor limiting the widespread use of ultrasound is the lack of adequately trained practitioners, for despite the technologic advances and ease of use of the new ultrasound units, there still remains a significant operator-dependent component that requires training and practice. A considerable knowledge base is also needed for accurate interpretation of images and decision-making relative to ultrasound.

In this chapter the argument is made that ultrasound should be considered a basic clinical competency across the spectrum of medical education, including critical care medicine. Ultrasound training should begin in medical school and be continued throughout the professional career of most physicians. The concept of competency-based education for ultrasound will be advanced, as well as recommendations for developing competency-based ultrasound curricula.

Ultrasonography in medical student education

Ultrasound was introduced into medical student education in the 1990s and proved to be a valuable teaching tool in courses such as anatomy, physiology, and physical examination.4–6 Ultrasound education gradually expanded into the clinical years of medical school, especially in the discipline of emergency medicine.⁷ The clinical application of ultrasound being taught is as a focused or point-of-care examination designed to answer a specific clinical question such as “Is there a gallstone in the gallbladder that helps explain this patient’s right upper quadrant abdominal pain?” or “Is there overall normal heart function in this patient with shortness of breath?” This point-of-care ultrasound approach has been highly developed in the emergency department setting, and the American College of Emergency Physicians has led the way in defining the necessary training and competencies in point-of-care ultrasound.⁸

In recent years, ultrasound has been successfully integrated across the entire medical student curriculum. Hoppmann et al reported on 4 years of experience with an integrated ultrasound curriculum.⁹ As part of the curriculum, all students at the end of the anatomy course in the first year of medical school are observed individually and evaluated for their ability to perform ultrasound on standardized patients and capture and identify anatomic structures in a series of specific ultrasound images. Such structures included the kidney, liver, and Morison pouch in the right upper abdominal quadrant; kidney and spleen in the left upper abdominal quadrant; urinary bladder in the pelvis; carotid artery and internal jugular vein in the neck; and parasternal long-axis view of the heart. The mean percentage of correct responses after 3 years of these examinations was 97.1%. In addition, from student surveys of the same ultrasound curriculum, more than 90% of students thought that the curriculum had enhanced their medical education, allowed increased clinical correlation with basic science instruction, and improved their understanding and skills of the physical examination.

These findings of students learning basic ultrasound well and reporting that the addition of ultrasound had enhanced their education are consistent across the vast majority of reports in the literature on medical student ultrasound education.

Ultrasound across multiple specialties

Widely used in radiology, cardiology, and obstetrics and gynecology for several decades, ultrasound is now rapidly expanding across many specialties from pediatrics to critical care medicine and orthopedic surgery.¹⁰ In addition, the list of clinical applications for ultrasound has grown considerably in recent years and will probably continue to grow as more practitioners explore new applications of ultrasound to improve patient care and safety in their particular specialty.

With expanding applications of ultrasound across so many specialties, a persuasive argument can be made that every medical student should learn basic ultrasound similar to learning auscultation, since each student will probably encounter a need to use ultrasound in practice regardless of career choice. One can also make the argument that even if medical graduates do not perform ultrasound themselves, their knowledge of the indications, applications, and limitations of ultrasound will result in more appropriate requests for ultrasound studies and a better understanding of the results of such studies.

Introducing ultrasound into medical student education is an efficient and effective way to train a large number of individuals who will be not only the next generation of practitioners but also the ultrasound educators of the future. Medical education is generally slow to change, and adding something new to an already crowded medical student curriculum requires strong justification.

Competency-based medical education

If ultrasonography is to be a basic clinical competency, it is essential that educational programs be developed that result in competent users of this technology. In its most basic definition, competency would be the ability of an individual to do a job properly.¹¹ There has been increasing pressure in recent years in medical education globally to move from a time- and process-based system of training to a competency-based training framework.¹²

Frank et al outlined six stages in planning competency-based medical education.¹³ Step 1 calls for identification of the abilities needed by graduates to provide a high standard of patient care based on evidence and expert consensus. Starting with the abilities needed by the practitioner and then working backward to develop the appropriate educational program constitute the essence of competency-based education. Step 2 calls for well-defined competency components that fit together to define a competent practitioner. In step 3, milestones are determined along the developmental path to competency. These milestones are sequenced in a logical fashion to form a foundation of skills and knowledge on which to build to the desired level of competency. In step 4, the educational activities, experiences, and instructional methods are determined to reach these milestones. Step 5 calls for assessment tools to measure student progress, and finally, step 6 requires that a method be in place to evaluate the educational program as a whole.

Ultrasound competency is well suited for this educational approach because it has objective and measureable components and much has been defined with respect to the knowledge and skills that are needed in the clinical arena. Emergency medicine has defined many of these necessary skills with respect to point-of-care ultrasound. Various specialties and subspecialties throughout medicine are defining the core ultrasound knowledge and skills needed within their fields. Since the various specialties better define the abilities needed in their respective fields, medical student educators can use these competencies to develop curricula that will form a foundation to prepare students for further ultrasound training in residency regardless of the career specialty chosen. Having students enter residency with a solid foundation of knowledge and skills in ultrasound will allow them to more easily and quickly develop more sophisticated ultrasound abilities for their particular specialty.

Critical care ultrasound

Dozens of applications of ultrasound have been identified in critical care medicine.¹⁴ It has also been shown that ultrasound examination reveals significant unsuspected clinical abnormalities in patients admitted to the intensive care unit.^15,16

A review of intensive care medicine in 2011 highlighted a number of applications and trends of ultrasound use in critical care medicine, among which were the rapidly evolving use of ultrasound to detect pneumothorax, intracranial hypertension by measuring the diameter of the optic nerve sheath, and gastric fluid with the potential to reduce the risk for aspiration during endotracheal intubation.¹⁷

There is little doubt that ultrasound should be a competency of critical care practitioners; in fact, there was 100% agreement among a panel of international experts in critical care ultrasonography that “general critical ultrasound and basic critical care echocardiography should be mandatory in the curriculum of intensive care unit physicians.”¹⁸ The expert panel defined clinical competencies in the field, and these are serving as a practical guide for physicians seeking training and those who train physicians in critical care ultrasonography.¹⁹

Electronic portfolio

Determining a student’s competency formatively during medical school and then at the end of a course or medical school could be done and documented by way of a student ultrasound electronic portfolio. There are numerous advantages of an electronic portfolio for undergraduate medical education.²⁰ Students can document their activities and provide evidence to demonstrate their development of competencies. Portfolios also provide reflective practice and are an excellent platform for dialogue and mentoring with faculty.

To address the spectrum of knowledge, skills, and behavior that pertain to ultrasound competency, one might consider a four-component learner portfolio. The four components would include web-based interactive ultrasound learning and assessment modules, an archive of images saved over a web portal and evaluated for quality and interpretation, ultrasound simulation results, and video-recorded, objectively structured clinical ultrasound examinations. This last component would have the added advantage of allowing evaluation of the interactive and professional behavior between the learner and patient. Such a four-component portfolio would enable identification of milestones and progress along the path to competency.

Conclusion

Ultrasound has the potential to transform medical education and the practice of medicine for the benefit of patient and learner alike. Ultrasound is a safe and valuable teaching and clinical practice tool. Its expanding role in clinical applications, multiple medical specialties, and clinical settings speaks to its value for a wide variety of practitioners. Ultrasonography should be given serious consideration as a basic clinical competency for all physicians and many other health care providers. Ultrasound instruction should begin in medical school with a competency-based curriculum and continue throughout the professional career of the practitioner. There is strong support for ultrasound as an essential critical care medicine competency. An electronic ultrasound portfolio could prove to be an effective way to manage ultrasound curricula and postgraduate training and document ultrasound competency in practitioners over time.

Pearls and highlights

References