Free
JAOA/AACOM Medical Education  |   March 2018
Increasing Self-Awareness of Medical Students Through the Use of Ultrasonography
Author Notes
  • From the Department of Family Medicine, Preventive Medicine, and Community Health (Dr Kondrashova) at the A.T. Still University Kirksville College of Osteopathic Medicine in Missouri (Student Doctor Sandefur). 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Tatyana Kondrashova, MD, PhD, A.T. Still University Kirksville College of Osteopathic Medicine, 800 W Jefferson St, Kirksville, MO, 63501-1443. Email: tkondrashova@atsu.edu
     
Article Information
Imaging / Medical Education
JAOA/AACOM Medical Education   |   March 2018
Increasing Self-Awareness of Medical Students Through the Use of Ultrasonography
The Journal of the American Osteopathic Association, March 2018, Vol. 118, 190-198. doi:10.7556/jaoa.2018.038
The Journal of the American Osteopathic Association, March 2018, Vol. 118, 190-198. doi:10.7556/jaoa.2018.038
Web of Science® Times Cited: 1
Abstract

Context: Self-awareness is vital for the health and development of medical students, but few reported modalities successfully increase medical student self-awareness.

Objective: To assess the effect of ultrasonography on medical student self-awareness and health status.

Methods: In 2016, first- and second-year osteopathic medical students completed a 9-item survey, created specifically for the current study, which included questions about the use of ultrasonography, health status, and self-awareness after completing at least 1 ultrasonography course. Differences between student responses by class were analyzed using χ2 analysis for items assessing experience with ultrasonography and t tests for items assessing self-awareness.

Results: Of the 329 students surveyed, 192 (58.4%) reported using ultrasonography to explore or monitor their own health or body. Forty-nine students (14.9%) found out something about their health that they did not know before their exposure to ultrasonography. Significant differences were found in the use of ultrasonography between first-year and second-year students; more second-year students reported using ultrasonography outside of laboratory hours (P<.05) and discovering incidental findings (P<.05). The largest portions of students reported average health status for exercise (106 of 325 [32.6%]), stress management (174 of 324 [53.7%]), and sleep (137 of 326 [42.0%]). The largest portions of students reported very good health status for tobacco use (282 of 322 [87.6%]), alcohol use (138 of 323 [42.7%]), and healthy relationships (118 of 326 [36.2%]). Statistically significant differences existed in responses between first- and second-year students regarding exercise (P=.007) and alcohol use (P=.001). The majority of students agreed or strongly agreed (182 of 326 [55.8%]) that access to ultrasonography equipment and ultrasonography training during the first and second years of medical school increased their self-awareness.

Conclusions: The results suggest that the incorporation of ultrasonography into medical education could potentially increase medical student health status and self-awareness.

Self-awareness is the conscious knowledge of one's own character, which allows individuals to be aware of their emotions, behaviors, and capabilities.1 In medical education, self-awareness is considered a core competency and has been widely investigated.1-7 For medical students, self-awareness can affect their health and development of clinical skills,8 both of which can affect future patient care. Studies have investigated ways to increase self-awareness in students. Novack et al3 suggested goals and objectives for medical education to promote student self-awareness and encourage humanistic medicine and physician healers. One suggested goal was that students should learn to address their physical and emotional needs and pursue activities that increase self-awareness and personal growth.3 In a study by Benbassat and Baumal,1 techniques were suggested to improve medical student self-awareness through direct and indirect approaches. Direct approaches used small group discussions and individual student counseling focused on students’ feelings in response to clinical situations, and indirect approaches focused on teaching clinical skills with the expectation that self-awareness would be increased.1 The authors concluded that both approaches should be considered; however, the indirect approaches were thought to be more feasible.1 
Saunders et al5 investigated direct approaches to promote self-awareness in first-year medical students using an 11-week mind-body skills course. The authors used open-ended questions about student experiences during the course to assess self-awareness and concluded that students could achieve self-awareness by engaging in self-care and gaining exposure to mind-body medicine in medical school. In a Malaysian study of third-year medical students,6 the authors analyzed the use of reflective writing to raise self-awareness and reflective skills, and they concluded that the exercise increased reflective skills but not self-awareness. Despite the recognized importance of self-awareness in medical students, few modalities to promote it have been investigated. 
Ultrasonography is an increasingly used imaging tool used in medical practice. It is a noninvasive imaging modality that allows rapid, affordable, and portable evaluation and interventional management. Research suggests that ultrasonography improves the personal and professional development of training physicians.9 Studies that have examined ultrasonography use in medical education have shown positive feedback from students and resulted in improved examination skills, as well as anatomical and physiological knowledge.10-14 Although ultrasonography is a tool that can be used for training physicians, its inclusion in undergraduate medical school curricula varies across schools. 
Ultrasonography may be useful as an indirect approach to improve medical student self-awareness. In 2010, clinical ultrasonography courses were implemented into the curriculum at the A.T. Still University Kirksville College of Osteopathic Medicine and have received positive feedback from students and clinical faculty. The courses provide students with knowledge, clinical skills, problem-solving abilities, and interpersonal skills to use point-of-care ultrasonography in future practice. Given the results of previous studies investigating self-awareness in medical school,1-7 there seems to be support for the incorporation of promoting self-awareness in students and the use of ultrasonography into the medical school curriculum. In the current study, we assessed the effect of the use of ultrasonography on medical student self-awareness and their health status. We hypothesized that the incorporation of ultrasonography into medical education would increase medical students’ self-awareness and improve their health status. 
Methods
This study was determined to be exempt by the A.T. Still University Kirksville College of Osteopathic Medicine Institutional Review Board. In 2010, a series of clinical ultrasonography courses taught over 4 semesters (1 course per semester) during the first 2 years of medical school was implemented into the curriculum at the A.T. Still University Kirksville College of Osteopathic Medicine. In the first semester of the series, first-year students are taught how to use the ultrasound machine and perform upper and lower limb, musculoskeletal, neck, vascular, and ocular ultrasonography. Semester 2 covers abdominal, echocardiography, upper and lower extremity, vascular, and pelvic ultrasonography. Second-year courses are more clinically oriented, so the third semester focuses on lung, endocrine, obstetrics, gynecology, and breast ultrasonography. During the fourth semester of the series, students are taught nerve imaging, needle-guided procedures, and focused assessment with sonography in trauma examinations. 
In all 4 courses, students used ultrasonography on each other during the laboratories. Each student completed a disclosure form before the first laboratory, which specified that abnormal ultrasonographic findings were an unintended consequence of training and could not replace formal comprehensive examinations. Students with abnormal ultrasonographic findings were instructed to see their primary care physician for further evaluation or follow-up. Because the use of educational ultrasonography is not intended for diagnostic purposes, any missed abnormal findings were not the responsibility of the university. 
At the end of the fall 2016 semester, all first- and second-year students were invited during an ultrasonography laboratory to complete a voluntary, anonymous, 9-question survey, which had no effect on the student's grade in the ultrasonography course. The students were given 5 minutes to complete the survey. First-year medical students had completed 1 ultrasonography course prior to the invitation to complete the survey, and second-year students had completed 3 ultrasonography courses. 
The survey was created specifically for the current study and included questions about the students’ use of ultrasonography, their health status, and their self-awareness. Questions 1 through 4 asked students about their use of ultrasonography on themselves or someone else during or outside of scheduled ultrasonography laboratory hours. Question 5 asked students if they noted incidental findings while examining themselves or others. Dichotomous answer choices (“yes” or “no”) were provided for questions 1 through 5. Students were also given space to provide additional comments in their response. Question 6 asked students to rank their current health status in the categories of nutrition, exercise, tobacco use, alcohol use, stress management, sleep, and healthy relationships. Responses for question 6 were rated on a 5-point Likert scale ranging from 1 (“very poor”) to 5 (“very good”). Questions 7 through 9 asked students to indicate their level of agreement with the following statements related to self-awareness: “I am completely self-aware,” “Access to ultrasound equipment and ultrasonography training during the first and second years of medical school increased my self-awareness,” and “Access to ultrasound equipment and ultrasonography training received during the first and second years of medical school helped me improve my health status.” Responses for questions 7 through 9 were rated on a 5-point Likert scale, ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). 
Incomplete surveys were included in the analysis. The differences between student responses by class were analyzed using χ2 analysis for questions 1 through 5 and t tests for questions 6 through 9. Results were presented by year if responses differed or by combined years if responses lacked evidence of a difference. t tests were used to determine whether the mean student response for survey questions 7 through 9 was different from the neutral middle response (“neither agree nor disagree”). SAS version 9.4 software (SAS Institute, Inc) was used for all analyses. A P≤.05 was considered statistically significant. 
Results
A total of 329 first- and second-year medical students completed the survey (response rate, 96%). Of the 329 students, 171 (52%) were first-year students, and 158 (48%) were second-year students. Responses to survey items 1 through 5 are presented in Table 1. A significantly higher percentage of second-year students replied “yes” to questions 2 (“Have you ever used ultrasound to explore or monitor your own health or body outside of laboratory hours?”), 4 (“Have you ever used ultrasound to explore or monitor the health or body of someone else outside of laboratory hours?”), and 5 (“Have you ever had any incidental findings on yourself or others when using ultrasound during laboratory hours or outside of laboratory hours?”) than first-year students (P=.009, P=.05, and P=.001, respectively). 
Table 1.
First- and Second-Year Osteopathic Medical Student Responses to Survey Questions Assessing Experiences With Ultrasonography
Year in Medical School, No. (%)
Survey Item First Year Second Year Total χ21 P Value
1. Have you ever used ultrasonography to explore or monitor your own health or body during laboratory hours? n=171 n=158 n=329 1.76 .19
 No 120 (70.2) 100 (63.3) 220 (66.9)
 Yes 51 (29.8) 58 (36.7) 109 (33.1)
2. Have you ever used ultrasound to explore or monitor your own health or body outside of laboratory hours? n=171 n=157 n=328 6.82 .009
 No 138 (80.7) 107 (68.2) 245 (74.7)
 Yes 33 (19.3) 50 (31.9) 83 (25.3)
3. Have you ever used ultrasound to explore or monitor the health or body of someone else during laboratory hours? n=171 n=158 N=329 1.42 .23
 No 125 (73.1) 106 (67.1) 231 (70.2)
 Yes 46 (26.9) 52 (32.9) 98 (29.8)
4. Have you ever used ultrasound to explore or monitor the health or body of someone else outside of laboratory hours? n=171 n=158 n=329 3.71 .05
 No 132 (77.2) 107 (67.7) 239 (72.6)
 Yes 39 (22.8) 51 (32.3) 90 (27.4)
5. Have you ever had any incidental findings on yourself or others when using ultrasound during laboratory hours or outside of laboratory hours? n=170 n=158 n=328 10.39 .001
 No 155 (91.2) 124 (78.5) 279 (85.1)
 Yes 15 (8.8) 34 (21.5) 49 (14.9)
Table 1.
First- and Second-Year Osteopathic Medical Student Responses to Survey Questions Assessing Experiences With Ultrasonography
Year in Medical School, No. (%)
Survey Item First Year Second Year Total χ21 P Value
1. Have you ever used ultrasonography to explore or monitor your own health or body during laboratory hours? n=171 n=158 n=329 1.76 .19
 No 120 (70.2) 100 (63.3) 220 (66.9)
 Yes 51 (29.8) 58 (36.7) 109 (33.1)
2. Have you ever used ultrasound to explore or monitor your own health or body outside of laboratory hours? n=171 n=157 n=328 6.82 .009
 No 138 (80.7) 107 (68.2) 245 (74.7)
 Yes 33 (19.3) 50 (31.9) 83 (25.3)
3. Have you ever used ultrasound to explore or monitor the health or body of someone else during laboratory hours? n=171 n=158 N=329 1.42 .23
 No 125 (73.1) 106 (67.1) 231 (70.2)
 Yes 46 (26.9) 52 (32.9) 98 (29.8)
4. Have you ever used ultrasound to explore or monitor the health or body of someone else outside of laboratory hours? n=171 n=158 n=329 3.71 .05
 No 132 (77.2) 107 (67.7) 239 (72.6)
 Yes 39 (22.8) 51 (32.3) 90 (27.4)
5. Have you ever had any incidental findings on yourself or others when using ultrasound during laboratory hours or outside of laboratory hours? n=170 n=158 n=328 10.39 .001
 No 155 (91.2) 124 (78.5) 279 (85.1)
 Yes 15 (8.8) 34 (21.5) 49 (14.9)
×
The responses to question 6 are presented in Table 2. The mean (SD) response value (ranging from 1 through 5) of first- and second-year students differed regarding exercise (3.4 [1.1] vs 3.1 [1.1]; t323=2.73, P=.007) and alcohol use (3.8 [1.1] vs 4.1 [1.0]; t321=3.30, P=.001). When combining first- and second-year student responses, the largest portions of students reported average health status in terms of exercise (106 of 325 [32.6%]), stress management (174 of 324 [53.7%]), and sleep (137 of 326 [42.0%]). Regarding exercise, a higher percentage of second-year than first-year students reported above average status (45 of 158 [28.5%] and 41of 167 [24.6%], respectively) or very good (31 of 158 [19.6%] and 18 of 167 [10.8%], respectively). The largest portions of students reported very good health status for tobacco use (282 of 322 [87.6%]), alcohol use (138 of 323 [42.7%]), and healthy relationships (118 of 326 [36.2%]). For alcohol use, the largest portions of first-year students reported a very good status (84 of 165 [50.9%]), and the majority of second-year students reported average status (56 of 158 [35.4%]), followed by a very good status (54 of 158 [34.2%]). 
Table 2.
First- and Second-Year Osteopathic Medical Student Responses to Survey Item 6 Assessing Current Health Status
Year in Medical School, No. (%)
Health Status Category First Year Second Year Total P Value
Nutrition n=168 n=158 n=326 .23
 Very good 13 (7.7) 19 (12.0) 32 (9.8)
 Above average 69 (41.1) 64 (40.5) 133 (40.8)
 Average 68 (40.5) 61 (38.6) 129 (39.6)
 Below average 15 (8.9) 13 (8.2) 28 (8.6)
 Very poor 3 (1.8) 1 (0.6) 4 (1.2)
Exercise n=167 n=158 n=325 .007
 Very good 18 (10.8) 31 (19.6) 49 (15.1)
 Above average 41 (24.6) 45 (28.5) 86 (26.5)
 Average 57 (34.1) 49 (31.0) 106 (32.6)
 Below average 42 (25.2) 27 (17.1) 69 (21.2)
 Very poor 9 (5.4) 6 (3.8) 15 (4.6)
Tobacco Use n=164 n=158 n=322 .54
 Very good 145 (88.4) 137 (86.7) 282 (87.6)
 Above average 6 (3.7) 5 (3.2) 11 (3.4)
 Average 4 (2.4) 3 (1.9) 7 (2.2)
 Below average 1 (0.6) 5 (3.2) 6 (1.9)
 Very poor 8 (4.9) 8 (5.1) 16 (5.0)
Alcohol Use n=165 n=158 n=323 .001
 Very good 84 (50.9) 54 (34.2) 138 (42.7)
 Above average 32 (19.4) 31 (19.6) 63 (19.5)
 Average 40 (24.2) 56 (35.4) 96 (29.7)
 Below average 6 (3.6) 14 (8.9) 20 (6.2)
 Very poor 3 (1.8) 3 (1.9) 6 (1.9)
Stress Management n=168 n=156 n=324 .46
 Very good 17 (10.1) 14 (9.0) 31 (9.6)
 Above average 41 (24.4) 49 (31.4) 90 (27.8)
 Average 94 (56.0) 80 (51.3) 174 (53.7)
 Below average 15 (8.9) 13 (8.3) 28 (8.6)
 Very poor 1 (0.6) 0 1 (0.3)
Sleep n=168 n=158 n=326 .99
 Very good 15 (8.9) 11 (7.0) 26 (8.0)
 Above average 35 (20.8) 37 (23.4) 72 (22.1)
 Average 70 (41.7) 67 (42.4) 137 (42.0)
 Below average 46 (27.4) 41 (25.9) 87 (26.7)
 Very poor 2 (1.2) 2 (1.3) 4 (1.2)
Healthy Relationships n=168 n=158 n=326 .80
 Very good 57 (33.9) 61 (38.6) 118 (36.2)
 Above average 57 (33.9) 55 (34.8) 112 (34.4)
 Average 50 (29.8) 35 (22.2) 85 (26.1)
 Below average 4 (2.4) 7 (4.4) 11 (3.4)
 Very poor 0 0 0
Table 2.
First- and Second-Year Osteopathic Medical Student Responses to Survey Item 6 Assessing Current Health Status
Year in Medical School, No. (%)
Health Status Category First Year Second Year Total P Value
Nutrition n=168 n=158 n=326 .23
 Very good 13 (7.7) 19 (12.0) 32 (9.8)
 Above average 69 (41.1) 64 (40.5) 133 (40.8)
 Average 68 (40.5) 61 (38.6) 129 (39.6)
 Below average 15 (8.9) 13 (8.2) 28 (8.6)
 Very poor 3 (1.8) 1 (0.6) 4 (1.2)
Exercise n=167 n=158 n=325 .007
 Very good 18 (10.8) 31 (19.6) 49 (15.1)
 Above average 41 (24.6) 45 (28.5) 86 (26.5)
 Average 57 (34.1) 49 (31.0) 106 (32.6)
 Below average 42 (25.2) 27 (17.1) 69 (21.2)
 Very poor 9 (5.4) 6 (3.8) 15 (4.6)
Tobacco Use n=164 n=158 n=322 .54
 Very good 145 (88.4) 137 (86.7) 282 (87.6)
 Above average 6 (3.7) 5 (3.2) 11 (3.4)
 Average 4 (2.4) 3 (1.9) 7 (2.2)
 Below average 1 (0.6) 5 (3.2) 6 (1.9)
 Very poor 8 (4.9) 8 (5.1) 16 (5.0)
Alcohol Use n=165 n=158 n=323 .001
 Very good 84 (50.9) 54 (34.2) 138 (42.7)
 Above average 32 (19.4) 31 (19.6) 63 (19.5)
 Average 40 (24.2) 56 (35.4) 96 (29.7)
 Below average 6 (3.6) 14 (8.9) 20 (6.2)
 Very poor 3 (1.8) 3 (1.9) 6 (1.9)
Stress Management n=168 n=156 n=324 .46
 Very good 17 (10.1) 14 (9.0) 31 (9.6)
 Above average 41 (24.4) 49 (31.4) 90 (27.8)
 Average 94 (56.0) 80 (51.3) 174 (53.7)
 Below average 15 (8.9) 13 (8.3) 28 (8.6)
 Very poor 1 (0.6) 0 1 (0.3)
Sleep n=168 n=158 n=326 .99
 Very good 15 (8.9) 11 (7.0) 26 (8.0)
 Above average 35 (20.8) 37 (23.4) 72 (22.1)
 Average 70 (41.7) 67 (42.4) 137 (42.0)
 Below average 46 (27.4) 41 (25.9) 87 (26.7)
 Very poor 2 (1.2) 2 (1.3) 4 (1.2)
Healthy Relationships n=168 n=158 n=326 .80
 Very good 57 (33.9) 61 (38.6) 118 (36.2)
 Above average 57 (33.9) 55 (34.8) 112 (34.4)
 Average 50 (29.8) 35 (22.2) 85 (26.1)
 Below average 4 (2.4) 7 (4.4) 11 (3.4)
 Very poor 0 0 0
×
There were no significant differences in responses between first- and second-year students to items 7 through 9 (Table 3). For questions 7 and 8, the majority of students agreed or strongly agreed with the statements that they were completely self-aware (282 of 325 [86.8%]) and that access to ultrasonography equipment and training increased their self-awareness (182 of 326 [55.8%]). For question 9, the majority of students (194 of 324 [59.9%]) neither agreed nor disagreed that access to ultrasonography equipment and training improved their health status. 
Table 3.
First- and Second-Year Osteopathic Medical Student Responses to Survey Items Assessing Self-Awareness After Ultrasonography Courses
Year in Medical School, No. (%)
Survey Statement First Year Second Year Total P Value
7. I am completely self-aware n=168 n=157 n=325 .80
 Strongly disagree 1 (0.6) 0 1 (0.3)
 Disagree 3 (1.8) 40 (23.8) 5 (1.5)
 Neither agree nor disagree 14 (8.3) 23 (14.6) 37 (11.4)
 Agree 110 (65.5) 92 (58.6) 202 (62.2)
 Strongly agree 40 (23.8) 40 (25.5) 80 (24.6)
8. Access to ultrasound equipment and ultrasonography training increased my self-awareness n=166 n=158 n=326 .59
 Strongly disagree 2 (1.2) 1 (0.6) 3 (0.9)
 Disagree 9 (5.4) 12 (7.6) 21 (6.4)
 Neither agree nor disagree 64 (38.1) 56 (35.4) 120 (36.8)
 Agree 74 (44) 63 (39.9) 137 (42.0)
 Strongly agree 19 (11.3) 26 (16.5) 45 (13.8)
9. Access to ultrasound equipment and ultrasonography training helped me improve my health status n=166 n=158 n=324 .77
 Strongly disagree 4 (2.4) 1 (0.6) 5 (1.5)
 Disagree 12 (7.2) 14 (8.9) 26 (8.0)
 Neither agree nor disagree 97 (58.4) 97 (61.4) 194 (59.9)
 Agree 45 (27.1) 33 (20.9) 78 (24.1)
 Strongly agree 8 (4.8) 13 (8.2) 21 (6.5)
Table 3.
First- and Second-Year Osteopathic Medical Student Responses to Survey Items Assessing Self-Awareness After Ultrasonography Courses
Year in Medical School, No. (%)
Survey Statement First Year Second Year Total P Value
7. I am completely self-aware n=168 n=157 n=325 .80
 Strongly disagree 1 (0.6) 0 1 (0.3)
 Disagree 3 (1.8) 40 (23.8) 5 (1.5)
 Neither agree nor disagree 14 (8.3) 23 (14.6) 37 (11.4)
 Agree 110 (65.5) 92 (58.6) 202 (62.2)
 Strongly agree 40 (23.8) 40 (25.5) 80 (24.6)
8. Access to ultrasound equipment and ultrasonography training increased my self-awareness n=166 n=158 n=326 .59
 Strongly disagree 2 (1.2) 1 (0.6) 3 (0.9)
 Disagree 9 (5.4) 12 (7.6) 21 (6.4)
 Neither agree nor disagree 64 (38.1) 56 (35.4) 120 (36.8)
 Agree 74 (44) 63 (39.9) 137 (42.0)
 Strongly agree 19 (11.3) 26 (16.5) 45 (13.8)
9. Access to ultrasound equipment and ultrasonography training helped me improve my health status n=166 n=158 n=324 .77
 Strongly disagree 4 (2.4) 1 (0.6) 5 (1.5)
 Disagree 12 (7.2) 14 (8.9) 26 (8.0)
 Neither agree nor disagree 97 (58.4) 97 (61.4) 194 (59.9)
 Agree 45 (27.1) 33 (20.9) 78 (24.1)
 Strongly agree 8 (4.8) 13 (8.2) 21 (6.5)
×
Of the 329 students who completed the survey, 178 (54%) provided additional comments. In those comments, students most commonly reported using ultrasonography to explore the musculoskeletal anatomy of the upper and lower extremities (18 of 178 [10%] and 52 of 178 [29%], respectively), the neck and the thyroid (15 of 178 [8%]), the heart (11 [6%]), the lungs (7 [4%]), and for obstetrical purposes (13 [7%]). 
Discussion
Results of the current study suggest that the incorporation of ultrasonography into a medical school curriculum could improve the health status and self-awareness of students. Further, because medical school can be psychologically and physically challenging, it can be a difficult environment for developing or nurturing self-awareness as it relates to health status.2 Basic health habits may be neglected. Research has shown that medical students are susceptible to burnout, addiction, and emotional impairment.3 In a 2016 systematic review15 the prevalence of depression or depressive symptoms among medical students was estimated at almost one-third, and the prevalence of suicidal ideation among medical students was estimated at over 10%. 
Exposure to ultrasonography in osteopathic medical education provides students with a unique opportunity to link osteopathic tenets to their everyday life both as a student and as a future physician. The use of ultrasonography to monitor health status supports the osteopathic tenets.16 Improving someone's health status and health awareness directly relates to the first 3 osteopathic tenets, as students discover their own body and realize that it is a self-regulating unit of body, mind, and spirit, whose functions are reciprocally related.16 In addition to improving student health, increased self-awareness in medical students may positively affect future patient care. A physician's level of consciousness, emotions, behaviors, and capabilities can interfere with their abilities to provide appropriate patient care.3 Providing medical students with self-awareness training may help them to more effectively address these psychological issues in their future practice.17 Providing them with courses on ultrasonography may be one way to reach this goal. 
In the current study, more second-year students reported using ultrasonography on themselves or others outside of laboratory hours and discovering incidental findings in themselves or others when using ultrasonography than first-year students. These data are likely the result of second-year students having more exposure to ultrasonography and increased clinical knowledge compared with first-year students. Our results also suggest that students used the clinical skills they learned in the ultrasonography course during the first and second years of medical school to monitor their health. In the comment section of the survey responses, students wrote that they most commonly used ultrasonography to explore musculoskeletal anatomy of the upper and lower extremities, the neck and thyroid gland, the heart and lungs, and for obstetrical purposes; all of these areas are included as part of the first and second-year ultrasonography curriculum. Further, students wrote that they benefited from the ability to confirm a “suspected MCL tear” or to check for “cardiac hypertrophy and carotid flow.” Students also wrote that ultrasonography was a great way to increase self-awareness regarding health status. For instance, they could learn about gallstones in a lecture and also use ultrasonography to check themselves and their friends for them. Students indicated that comparing themselves with normal ultrasonographic images from lectures had implications for both increased health status and self-awareness. 
In the current study, first- and second-year students responded differently regarding their health status for exercise and alcohol use. Second-year students reported lower health status for alcohol use than first-year students but better health status for exercise. Overall, only 8.1% of students from both years reported very poor or below average alcohol use, which was less than that reported for medical students in other studies.2,18 An estimated 10% of physicians have alcohol abuse problems, which can adversely affect their overall well-being, health, and medical practices.19 In a study by Ball and Bax,2 problematic drinking was an issue for approximately 20% of medical students. Another study19 surveyed close to 4200 medical students, and approximately 1400 met diagnostic criteria for alcohol abuse or dependence. This outcome translates to about 30% of respondents, which is double the rate of alcohol abuse or dependence reported in nonmedical students, surgeons, US physicians, or the general public.18 As a result of these findings, wellness curricula were recommended for medical schools that identified and remediated factors that contributed to stress and removed barriers to mental health services within the learning environment.18 Further, research suggests that burnout in medical students is strongly related to alcohol abuse as well as increased debt.18 Both factors may become more acute in second-year students, which would explain the higher incidence of alcohol use in second-year students in the current study. 
More than half of the students agreed or strongly agreed that access to ultrasonography equipment and ultrasonography training during their first and second years of medical school increased their self-awareness. On the other hand, the majority of students neither agreed nor disagreed that access to ultrasonography equipment and training improved their health status. Future multicenter studies should include students in all 4 years of medical school and assess the relationships between self-awareness, health status, and ultrasonography across multiple universities. 
The current study had several limitations. There is inherent bias when using self-reported measures. Future studies should consider using various measurement tools of self-awareness, such as the emotional quotient surveys used by Siraj et al,6 to reduce bias. Another limitation of the current study was that “average” was not defined for any of the terms in question 6. One student's idea of average health status in each of the categories may be different from another's idea of average. Also, “below average” alcohol use could have been interpreted as less than average, while “above average” alcohol use could have been interpreted as more than average, resulting in confusion among students. Additionally, the study population was restricted to a single institution. Therefore, results may not be generalizable to other populations. Also, the 5-minute time limit to complete the survey may have restricted some student responses or added to a potential recall bias. 
Conclusion
Given the existing evidence and the results of the current study, incorporation of ultrasonography into medical school curriculum, in addition to being a valuable clinical training tool, provided a possible means for enhancing student self-awareness and health status. Although seemingly unrelated, our results suggest that self-awareness and ultrasonography training may be relevant for osteopathic medical education and may augment each other. In addition to other benefits of ultrasonography training, the inclusion of this imaging modality in the undergraduate medical school curriculum provides students with a real-time link to osteopathic tenets and may contribute to producing well-rounded and healthy physicians. 
Author Contributions
All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 
Acknowledgments
We thank Deborah Goggin, MA, scientific writer at A.T. Still University, for help with manuscript preparation and Vanessa Pazdernik, MS, senior biostatistician at A.T. Still University, for performing the statistical analyses. 
References
Benbassat J, Baumal R. Enhancing self-awareness in medical students: an overview of teaching approaches. Acad Med. 2005;80(2):156-161. [CrossRef] [PubMed]
Ball S, Bax A. Self-care in medical education: effectiveness of health-habits interventions for first-year medical students. Acad Med. 2002;77(9):911-917. [CrossRef] [PubMed]
Novack DH, Epstein RM, Paulsen RH. Toward creating physician-healers: fostering medical students’ self-awareness, personal growth, and well-being. Acad Med. 1999;74(5):516-520. [CrossRef] [PubMed]
Rasheed SP. Self-awareness as a therapeutic tool for nurse/client relationship. Int J Caring Sci. 2015;8(1):211-216.
Saunders PA, Tractenberg RE, Chaterji R, et al.  . Promoting self-awareness and reflection through an experiential mind-body skills course for first year medical students. Med Teach. 2007;29(8):778-784. [CrossRef] [PubMed]
Siraj HH, Salam A, Hani A, et al.   Self awareness and reflective skills in the promotion of personal and professional development of future medical professionals. Educ Med J. 2013;5(4):e29-e33. doi: 10.5959 /eimj.v5i4.171 [CrossRef]
Kennell JH, Tempio CR, Wile MZ. Self-evaluation by first-year medical students in a clinical science programme. Br J Med Educ. 1973;7(4):230-238. [CrossRef] [PubMed]
Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician: personal awareness and effective patient care. JAMA. 1997;278(6):502-509. [CrossRef] [PubMed]
Bahner DP, Goldman E, Way D, Royall NA, Liu YT. The state of ultrasound education in U.S. medical schools: results of a national survey. Acad Med. 2014;89(12):1681-1686. doi: 10.1097 /ACM.0000000000000414 [CrossRef] [PubMed]
Kondrashov P, Johnson JC, Boehm K, Rice D, Kondrashova T. Impact of the clinical ultrasound elective course on retention of anatomical knowledge by second-year medical students in preparation for board exams. Clin Anat. 2015;28(2):156-163. doi: 10.1002/ca.22494 [CrossRef] [PubMed]
Angtuaco TL, Hopkins RH, DuBose TJ, Bursac Z, Angtuaco MJ, Ferris EJ. Sonographic physical diagnosis 101: teaching senior medical students basic ultrasound scanning skills using a compact ultrasound system. Ultrasound Q. 2007;23(2):157-160. [CrossRef] [PubMed]
Afonso N, Amponsah D, Yang J, et al.  . Adding new tools to the black bag: introduction of ultrasound into the physical diagnosis course. J Gen Intern Med. 2010;25(11):1248-1252. doi: 10.1007 /s11606-010-1451-5 [CrossRef] [PubMed]
Syperda VA, Trivedi PN, Melo LC, et al Ultrasonography in preclinical education: a pilot study. J Am Osteopath Assoc. 2008;108(10):601-605. [PubMed]
Kondrashova T, Sexton W, Baer R, Kondrashov P. Integration of didactic knowledge with procedural skill: learning cardiac electrophysiology and electrocardiography using ultrasound. Med Sci Educ. 2015;25(2):141-147. doi: 10.1007/40670-015-0119-5 [CrossRef]
Rotenstein LS, Ramos MA, Torre M, et al Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA. 2016;316(21):2214-2236. doi:10.1001/jama.2016.17324 [CrossRef] [PubMed]
Tenets of osteopathic medicine. American Osteopathic Association website. http://www.osteopathic.org/inside-aoa/about/leadership/Pages/tenets-of-osteopathic-medicine.aspx. Accessed May 22, 2017.
Gorlin R, Zucker HD. Physicians’ reactions to patients: a key to teaching humanistic medicine. N Engl J Med. 1983;308(18):1059-1063. [CrossRef] [PubMed]
Jackson ER, Shanafelt TD, Hasan O, Satele DV, Dyrbye LN. Burnout and alcohol abuse/dependence among US medical students. Acad Med. 2016;91(9):1251-1256. doi: 10.1097/ACM.0000000000001138 [CrossRef] [PubMed]
Cicala RS. Substance abuse among physicians: what you need to know. Hosp Physician. 2003;39(7):39-46.
Table 1.
First- and Second-Year Osteopathic Medical Student Responses to Survey Questions Assessing Experiences With Ultrasonography
Year in Medical School, No. (%)
Survey Item First Year Second Year Total χ21 P Value
1. Have you ever used ultrasonography to explore or monitor your own health or body during laboratory hours? n=171 n=158 n=329 1.76 .19
 No 120 (70.2) 100 (63.3) 220 (66.9)
 Yes 51 (29.8) 58 (36.7) 109 (33.1)
2. Have you ever used ultrasound to explore or monitor your own health or body outside of laboratory hours? n=171 n=157 n=328 6.82 .009
 No 138 (80.7) 107 (68.2) 245 (74.7)
 Yes 33 (19.3) 50 (31.9) 83 (25.3)
3. Have you ever used ultrasound to explore or monitor the health or body of someone else during laboratory hours? n=171 n=158 N=329 1.42 .23
 No 125 (73.1) 106 (67.1) 231 (70.2)
 Yes 46 (26.9) 52 (32.9) 98 (29.8)
4. Have you ever used ultrasound to explore or monitor the health or body of someone else outside of laboratory hours? n=171 n=158 n=329 3.71 .05
 No 132 (77.2) 107 (67.7) 239 (72.6)
 Yes 39 (22.8) 51 (32.3) 90 (27.4)
5. Have you ever had any incidental findings on yourself or others when using ultrasound during laboratory hours or outside of laboratory hours? n=170 n=158 n=328 10.39 .001
 No 155 (91.2) 124 (78.5) 279 (85.1)
 Yes 15 (8.8) 34 (21.5) 49 (14.9)
Table 1.
First- and Second-Year Osteopathic Medical Student Responses to Survey Questions Assessing Experiences With Ultrasonography
Year in Medical School, No. (%)
Survey Item First Year Second Year Total χ21 P Value
1. Have you ever used ultrasonography to explore or monitor your own health or body during laboratory hours? n=171 n=158 n=329 1.76 .19
 No 120 (70.2) 100 (63.3) 220 (66.9)
 Yes 51 (29.8) 58 (36.7) 109 (33.1)
2. Have you ever used ultrasound to explore or monitor your own health or body outside of laboratory hours? n=171 n=157 n=328 6.82 .009
 No 138 (80.7) 107 (68.2) 245 (74.7)
 Yes 33 (19.3) 50 (31.9) 83 (25.3)
3. Have you ever used ultrasound to explore or monitor the health or body of someone else during laboratory hours? n=171 n=158 N=329 1.42 .23
 No 125 (73.1) 106 (67.1) 231 (70.2)
 Yes 46 (26.9) 52 (32.9) 98 (29.8)
4. Have you ever used ultrasound to explore or monitor the health or body of someone else outside of laboratory hours? n=171 n=158 n=329 3.71 .05
 No 132 (77.2) 107 (67.7) 239 (72.6)
 Yes 39 (22.8) 51 (32.3) 90 (27.4)
5. Have you ever had any incidental findings on yourself or others when using ultrasound during laboratory hours or outside of laboratory hours? n=170 n=158 n=328 10.39 .001
 No 155 (91.2) 124 (78.5) 279 (85.1)
 Yes 15 (8.8) 34 (21.5) 49 (14.9)
×
Table 2.
First- and Second-Year Osteopathic Medical Student Responses to Survey Item 6 Assessing Current Health Status
Year in Medical School, No. (%)
Health Status Category First Year Second Year Total P Value
Nutrition n=168 n=158 n=326 .23
 Very good 13 (7.7) 19 (12.0) 32 (9.8)
 Above average 69 (41.1) 64 (40.5) 133 (40.8)
 Average 68 (40.5) 61 (38.6) 129 (39.6)
 Below average 15 (8.9) 13 (8.2) 28 (8.6)
 Very poor 3 (1.8) 1 (0.6) 4 (1.2)
Exercise n=167 n=158 n=325 .007
 Very good 18 (10.8) 31 (19.6) 49 (15.1)
 Above average 41 (24.6) 45 (28.5) 86 (26.5)
 Average 57 (34.1) 49 (31.0) 106 (32.6)
 Below average 42 (25.2) 27 (17.1) 69 (21.2)
 Very poor 9 (5.4) 6 (3.8) 15 (4.6)
Tobacco Use n=164 n=158 n=322 .54
 Very good 145 (88.4) 137 (86.7) 282 (87.6)
 Above average 6 (3.7) 5 (3.2) 11 (3.4)
 Average 4 (2.4) 3 (1.9) 7 (2.2)
 Below average 1 (0.6) 5 (3.2) 6 (1.9)
 Very poor 8 (4.9) 8 (5.1) 16 (5.0)
Alcohol Use n=165 n=158 n=323 .001
 Very good 84 (50.9) 54 (34.2) 138 (42.7)
 Above average 32 (19.4) 31 (19.6) 63 (19.5)
 Average 40 (24.2) 56 (35.4) 96 (29.7)
 Below average 6 (3.6) 14 (8.9) 20 (6.2)
 Very poor 3 (1.8) 3 (1.9) 6 (1.9)
Stress Management n=168 n=156 n=324 .46
 Very good 17 (10.1) 14 (9.0) 31 (9.6)
 Above average 41 (24.4) 49 (31.4) 90 (27.8)
 Average 94 (56.0) 80 (51.3) 174 (53.7)
 Below average 15 (8.9) 13 (8.3) 28 (8.6)
 Very poor 1 (0.6) 0 1 (0.3)
Sleep n=168 n=158 n=326 .99
 Very good 15 (8.9) 11 (7.0) 26 (8.0)
 Above average 35 (20.8) 37 (23.4) 72 (22.1)
 Average 70 (41.7) 67 (42.4) 137 (42.0)
 Below average 46 (27.4) 41 (25.9) 87 (26.7)
 Very poor 2 (1.2) 2 (1.3) 4 (1.2)
Healthy Relationships n=168 n=158 n=326 .80
 Very good 57 (33.9) 61 (38.6) 118 (36.2)
 Above average 57 (33.9) 55 (34.8) 112 (34.4)
 Average 50 (29.8) 35 (22.2) 85 (26.1)
 Below average 4 (2.4) 7 (4.4) 11 (3.4)
 Very poor 0 0 0
Table 2.
First- and Second-Year Osteopathic Medical Student Responses to Survey Item 6 Assessing Current Health Status
Year in Medical School, No. (%)
Health Status Category First Year Second Year Total P Value
Nutrition n=168 n=158 n=326 .23
 Very good 13 (7.7) 19 (12.0) 32 (9.8)
 Above average 69 (41.1) 64 (40.5) 133 (40.8)
 Average 68 (40.5) 61 (38.6) 129 (39.6)
 Below average 15 (8.9) 13 (8.2) 28 (8.6)
 Very poor 3 (1.8) 1 (0.6) 4 (1.2)
Exercise n=167 n=158 n=325 .007
 Very good 18 (10.8) 31 (19.6) 49 (15.1)
 Above average 41 (24.6) 45 (28.5) 86 (26.5)
 Average 57 (34.1) 49 (31.0) 106 (32.6)
 Below average 42 (25.2) 27 (17.1) 69 (21.2)
 Very poor 9 (5.4) 6 (3.8) 15 (4.6)
Tobacco Use n=164 n=158 n=322 .54
 Very good 145 (88.4) 137 (86.7) 282 (87.6)
 Above average 6 (3.7) 5 (3.2) 11 (3.4)
 Average 4 (2.4) 3 (1.9) 7 (2.2)
 Below average 1 (0.6) 5 (3.2) 6 (1.9)
 Very poor 8 (4.9) 8 (5.1) 16 (5.0)
Alcohol Use n=165 n=158 n=323 .001
 Very good 84 (50.9) 54 (34.2) 138 (42.7)
 Above average 32 (19.4) 31 (19.6) 63 (19.5)
 Average 40 (24.2) 56 (35.4) 96 (29.7)
 Below average 6 (3.6) 14 (8.9) 20 (6.2)
 Very poor 3 (1.8) 3 (1.9) 6 (1.9)
Stress Management n=168 n=156 n=324 .46
 Very good 17 (10.1) 14 (9.0) 31 (9.6)
 Above average 41 (24.4) 49 (31.4) 90 (27.8)
 Average 94 (56.0) 80 (51.3) 174 (53.7)
 Below average 15 (8.9) 13 (8.3) 28 (8.6)
 Very poor 1 (0.6) 0 1 (0.3)
Sleep n=168 n=158 n=326 .99
 Very good 15 (8.9) 11 (7.0) 26 (8.0)
 Above average 35 (20.8) 37 (23.4) 72 (22.1)
 Average 70 (41.7) 67 (42.4) 137 (42.0)
 Below average 46 (27.4) 41 (25.9) 87 (26.7)
 Very poor 2 (1.2) 2 (1.3) 4 (1.2)
Healthy Relationships n=168 n=158 n=326 .80
 Very good 57 (33.9) 61 (38.6) 118 (36.2)
 Above average 57 (33.9) 55 (34.8) 112 (34.4)
 Average 50 (29.8) 35 (22.2) 85 (26.1)
 Below average 4 (2.4) 7 (4.4) 11 (3.4)
 Very poor 0 0 0
×
Table 3.
First- and Second-Year Osteopathic Medical Student Responses to Survey Items Assessing Self-Awareness After Ultrasonography Courses
Year in Medical School, No. (%)
Survey Statement First Year Second Year Total P Value
7. I am completely self-aware n=168 n=157 n=325 .80
 Strongly disagree 1 (0.6) 0 1 (0.3)
 Disagree 3 (1.8) 40 (23.8) 5 (1.5)
 Neither agree nor disagree 14 (8.3) 23 (14.6) 37 (11.4)
 Agree 110 (65.5) 92 (58.6) 202 (62.2)
 Strongly agree 40 (23.8) 40 (25.5) 80 (24.6)
8. Access to ultrasound equipment and ultrasonography training increased my self-awareness n=166 n=158 n=326 .59
 Strongly disagree 2 (1.2) 1 (0.6) 3 (0.9)
 Disagree 9 (5.4) 12 (7.6) 21 (6.4)
 Neither agree nor disagree 64 (38.1) 56 (35.4) 120 (36.8)
 Agree 74 (44) 63 (39.9) 137 (42.0)
 Strongly agree 19 (11.3) 26 (16.5) 45 (13.8)
9. Access to ultrasound equipment and ultrasonography training helped me improve my health status n=166 n=158 n=324 .77
 Strongly disagree 4 (2.4) 1 (0.6) 5 (1.5)
 Disagree 12 (7.2) 14 (8.9) 26 (8.0)
 Neither agree nor disagree 97 (58.4) 97 (61.4) 194 (59.9)
 Agree 45 (27.1) 33 (20.9) 78 (24.1)
 Strongly agree 8 (4.8) 13 (8.2) 21 (6.5)
Table 3.
First- and Second-Year Osteopathic Medical Student Responses to Survey Items Assessing Self-Awareness After Ultrasonography Courses
Year in Medical School, No. (%)
Survey Statement First Year Second Year Total P Value
7. I am completely self-aware n=168 n=157 n=325 .80
 Strongly disagree 1 (0.6) 0 1 (0.3)
 Disagree 3 (1.8) 40 (23.8) 5 (1.5)
 Neither agree nor disagree 14 (8.3) 23 (14.6) 37 (11.4)
 Agree 110 (65.5) 92 (58.6) 202 (62.2)
 Strongly agree 40 (23.8) 40 (25.5) 80 (24.6)
8. Access to ultrasound equipment and ultrasonography training increased my self-awareness n=166 n=158 n=326 .59
 Strongly disagree 2 (1.2) 1 (0.6) 3 (0.9)
 Disagree 9 (5.4) 12 (7.6) 21 (6.4)
 Neither agree nor disagree 64 (38.1) 56 (35.4) 120 (36.8)
 Agree 74 (44) 63 (39.9) 137 (42.0)
 Strongly agree 19 (11.3) 26 (16.5) 45 (13.8)
9. Access to ultrasound equipment and ultrasonography training helped me improve my health status n=166 n=158 n=324 .77
 Strongly disagree 4 (2.4) 1 (0.6) 5 (1.5)
 Disagree 12 (7.2) 14 (8.9) 26 (8.0)
 Neither agree nor disagree 97 (58.4) 97 (61.4) 194 (59.9)
 Agree 45 (27.1) 33 (20.9) 78 (24.1)
 Strongly agree 8 (4.8) 13 (8.2) 21 (6.5)
×