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SURF  |   March 2019
Point-of-Care Ultrasonography Integration in Undergraduate Medical Education: A Student-Driven Approach
Author Notes
  • From the Department of Biomedical Sciences (Student Doctors Goodcoff and Bialczak and Dr Hanna), the Department of Clinical Science (Student Doctor Keane), and the Clinical Evaluation Center (Dr Ziner) at the West Virginia School of Osteopathic Medicine in Lewisburg. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Adam Goodcoff, OMS III, 400 Lee St N, Anatomy Department, West Virgnia School of Osteopathic Medicine, Lewisburg, WV 24901-1275. Email: agoodcoff@osteo.wvsom.edu
     
Article Information
Imaging / Medical Education / Curriculum
SURF   |   March 2019
Point-of-Care Ultrasonography Integration in Undergraduate Medical Education: A Student-Driven Approach
The Journal of the American Osteopathic Association, March 2019, Vol. 119, e11-e16. doi:https://doi.org/10.7556/jaoa.2019.033
The Journal of the American Osteopathic Association, March 2019, Vol. 119, e11-e16. doi:https://doi.org/10.7556/jaoa.2019.033
Web of Science® Times Cited: 1
Abstract

Background: The importance of medical ultrasonography (US) is well established, but given an already dense curriculum, integration of US into preclinical training can be difficult. Although there is no clear consensus on the best practice for integrating US into medical school curricula, growing student interest in US training demands investigation of potential solutions.

Objective: To investigate whether US integration through peer-assisted learning (PAL) and extracurricular activities during preclinical training is perceived to be valuable by student participants.

Methods: First- and second-year students at the West Virginia School of Osteopathic Medicine (WVSOM) were invited via email to attend 4 monthly PAL extracurricular US sessions on the following point-of-care US topics: (1) basic lung examination to assess pleural sliding, (2) extended focused assessment with sonography for trauma, (3) right upper quadrant biliary examination, and (4) US-guided central venous catheter placement. A brief survey using Likert-style questions inquired about participants’ level of agreement with whether the given session was appropriately complex, increased comfort with US, was informative and interactive, and improved confidence in identifying anatomic structures (sessions 2 and 3 only). A final question asked participants whether they would attend more extracurricular US sessions.

Results: Fifty-eight students (36 unique students) attended the peer-led sessions. Of the 58 students, 50 responded to the survey for a response rate of 86.2%. Responses were overwhelmingly positive. All respondents strongly agreed or agreed that these sessions improved their confidence in identifying anatomic structures using US, and 49 (98%) strongly agreed or agreed that they would attend more US sessions.

Conclusion: Respondents strongly endorsed the peer-led US sessions, which has facilitated the formal integration of an elective US course at WVSOM. The peer-led sessions introduced at WVSOM could provide the framework and motivation for similar courses at osteopathic medical schools across the country.

Ultrasonography (US) is an efficient and inexpensive tool to assist physicians in diagnosing conditions and treating patients.1 Point-of-care US appeared in emergency medicine in 19882 and has since expanded into many fields of medicine today.3 While certain fields use particular US examinations, such as the focused assessment with sonography for trauma (FAST), multiple specialties use the same skill sets and examinations, increasing the importance of student familiarity regardless of students’ specialty aspirations. 
Medical practice innovations take time to integrate into medical school culture, but with the prevalence of point-of-care US in clinical medicine, the need to integrate is overdue. Ultrasonography has been likened to the stethoscope in terms of utility and ease of use,4 and it is known to increase diagnostic accuracy in the cardiovascular system, as illustrated by Kobal et al.5 Currently, US training is commonly incorporated into graduate medical education,6 but the addition of US training in undergraduate medical education (UME), particularly preclinical training, improves students’ understanding of anatomy and physical diagnosis.4 
Recent studies have shown that students want to acquire the skills for using such a vital tool during their medical school training.7 One study of peer-instructed US found that 100% of the 105 medical student respondents felt that their emerging clinical skills improved after an 8-month US course.8 In a similar study, researchers concluded that students’ perceptions of peer instructors’ teaching competency was equivalent to their perceived competence of faculty instructors.9 These data offer a possible solution to one of the more prevalent limitations in medical school education: the limited availability of skilled instructors.9 Additional limitations in US education include limited funding and faculty resources,10 as well as difficulty in finding time within already dense courses and limited understanding where such training fits best.6 
Ultrasonography training is divided into 2 categories: exposure and focused training.4 Exposure to US occurs through passive learning, such as observation and lecture-based teaching. Exposure takes less curricular time but may not provide long-term understanding.11 Focused training is hands-on scanning and interpreting images.4 Such active learning may be better suited for long-term retention; however, application-type activities are time intensive, thus negatively affecting curricular time constraints. These issues are further complicated by student and faculty perceptions of “cramming” information when new content is added to already dense curricula. 
One method of integrating new content into UME and achieving favorable student responses is through peer teaching.12 Peer teaching, or peer-assisted learning (PAL), in which students help each other learn and learn by teaching, is commonplace in medical schools.13 Problem-based learning and team-based learning sessions or formal methods of peer teaching are often included in curricula. Students who provide peer teaching and receive peer learning through these types of activities often score higher and show fewer shortfalls in learning compared with faculty-led instruction methods.13 Benè and Bergus13 reported a statistically significant improvement in the grades of students who were peer teaching musculoskeletal US. They also discussed a problem-based learning study in which students who were peer taught scored higher than those instructed by faculty.13 Additionally, student satisfaction with these peer activities is often high.12-14 However, data are lacking for PAL related to US in the UME curriculum. One report described an anatomy-US dissection course planned by faculty, which included a PAL component.15 Results indicated that students were very accepting of the peer teachers and valued the inclusion of US education. 
We found very few publications on PAL as a method of formal curricula integration. In recent years, several medical schools have hosted single-day US symposiums, which are organized by students and use both physicians and upper-level students to teach US techniques. These “UltraFest” events provide structured PAL with guidance from physician faculty in a hands-on setting.10,16 These sessions use student volunteers as scanning models for US practice in addition to simulators and offer an affordable opportunity for hands-on US learning at all skill levels. In 2016, students at the West Virginia School of Osteopathic Medicine (WVSOM) coordinated a US course similar to “UltraFest” opportunities offered by other medical schools.10,16 This course had high student interest and led to the design of the PAL US case series at WVSOM. In this article, we discuss the experiences with PAL US sessions and student responses to these sessions to emphasize PAL as a feasible and effective method to facilitate US integration into UME. 
Methods
The institutional review board at WVSOM examined this quality improvement project and determined that it did not constitute human participants research. This project was carried out at WVSOM from October 1, 2017, to February 1, 2018. First- and second-year WVSOM students were recruited through an email that explained what would occur in each of the 4 monthly, extracurricular sessions. Each session was taught by peers and lasted approximately 1.5 hours, including 1 hour of scanning practice for participants (ie, students who attended the sessions but did not teach). Participants were asked but not required to attend all sessions. The sessions were as follows: (1) basic lung examination to assess pleural sliding, (2) extended FAST, (3) right upper quadrant biliary examination, and (4) US-guided central venous catheter placement. 
Each session began with a clinical scenario and a differential diagnosis, discussion of the clinical utility of the specific technique, and an overview of how to perform the technique. Student participants carried out peer-guided practice on each other using portable US units (Sonosite MicroMaxx; FujiFilm SonoSite Inc) and handheld V-scan devices (GE Healthcare) for the initial 3 sessions. For the fourth session, participants used US-capable central venous catheter task trainers (Blue Phantom, CAE Healthcare) and an additional peer-scanning practice for anatomy identification in situ with the V-scan devices. Training and manual skills occurred through SonoSim modules (SonoSim, Inc), and clinical faculty provided feedback and instruction, if requested, before the sessions. The clinical faculty also reviewed the didactic portion of the presentations. 
All students signed in to the sessions. A brief optional survey was distributed at the end of each session for quality improvement purposes. The statements included in the survey were as follows: 
  • 1. The complexity of this session was appropriate for my level of training.
  • 2. After this session, I feel more comfortable using ultrasound for instructed chief complaint.
  • 3. The session was informative and interactive.
  • 4. I felt that this session improved my confidence in identifying anatomical structures on US (sessions 2 and 3 only).
  • 5. If given the opportunity, I would attend more of these sessions.
Likert-style response options were provided using a 5-point scale, with 1 representing “strongly disagree” and 5 representing “strongly agree.” No instructor was assigned to monitor students’ survey completion during or after the session. The survey was handed out in paper format and completed by hand, then scanned into our digital records. Data from these sessions were manually entered into Microsoft Excel spreadsheets (Microsoft Corporation) for further analysis. 
Results
In total, 58 students attended the PAL sessions. Attendance ranged from 8 to 28 students at each of the 4 sessions, with 36 unique students attending at least 1 session and 1 student attending all 4 sessions. Of 58 students, 50 responded to the surveys, for a response rate of 86.2%. Student interest was highest in the fourth session on central venous catheter placement, which incorporated task trainers and peer scanning. Overall, student responses were overwhelmingly positive, with 46 (96%) strongly agreeing or agreeing that the sessions were presented at an appropriate level of complexity for their current level of knowledge. Additionally, students felt more comfortable and confident in using US as assessed by the postsession survey. Forty-nine participants (98%) strongly agreed or agreed that the sessions were informative and interactive, and 49 of 50 students (98%) indicated they strongly agreed or agreed that they would attend another session if available (Figure). One student strongly disagreed that he or she would attend another session. Given that there was no free text area, we cannot determine whether this response was genuine or an error. 
Figure.
Overall survey responses from osteopathic medical students regarding peer-assisted learning ultrasonography (US) sessions (N=50). Most students strongly agreed with each of the statements. aStatement was applicable to sessions 2 and 3 only.
Figure.
Overall survey responses from osteopathic medical students regarding peer-assisted learning ultrasonography (US) sessions (N=50). Most students strongly agreed with each of the statements. aStatement was applicable to sessions 2 and 3 only.
Discussion
Most medical schools state that US education should be a part of UME6; however, the 2 most commonly reported barriers to integration are the inability to find time in an already dense curriculum and limited funding. Our institution also struggles with these issues, and adding content into already dense courses can be viewed negatively by both faculty and students. The overwhelmingly positive response to our PAL sessions suggests students would welcome more integration of these topics in formal UME, especially through hands-on US practice and educational methods that include PAL. Osteopathic medical education presents an ideal setting for this hands-on skill training. Osteopathic medical schools are already fitted with large osteopathic manipulative medicine training laboratories, and osteopathic teaching emphasizes hands-on practice as early as the first week of medical school. 
It is important to recognize that the PAL US sessions at WVSOM were completely designed and implemented by students. The ability of students at WVSOM to create these sessions illustrates the feasibility of such a method at other medical schools. These PAL sessions could relieve many of the limitations of graduate medical education US integration while providing satisfactory skill training. Given the positive reception to PAL sessions and UltraFest events, and given the relative ease of creation of these sessions, we are hopeful that other medical schools would have similar levels of success at integrating this content into their curriculum. 
In addition to our PAL sessions, we informally targeted specific faculty and requested more US discussion in their didactics. Faculty responded positively to requests, and some anatomy faculty added brief discussions regarding US into some didactic sessions. Examples include lectures on imaging in anatomy content, increased support for further US integration into clinical skills laboratories in the future, increased contributions to extracurricular instruction on US through student clubs, and the initiation of a 5-week summer elective for first-year medical students led by faculty. 
Our use of the PAL model to initiate hands-on US was well received by the students (Figure), with 98% of students agreeing that they would like more opportunities to use US. We believe an elective introductory hands-on US course administered to students before starting their third-year curriculum would greatly benefit them as they become immersed in the clinical setting. Moreover, our hope is for all medical students to achieve minimum competency with US and to be able to supplement their understanding of hands-on learning during their clinical rotations in years 3 and 4. This early minimal competency will allow students to become proficient in US before entering residency, where they will need US skills regardless of their chosen specialty. 
Limitations
This project has some limitations. It is important to acknowledge that student responses do not constitute proficiency in US skills but rather convey student interest. In future studies, we plan to examine student ability to successfully obtain certain competencies or milestones as outlined by Dinh et al.18 Despite this limitation, previous work suggests that learning through peer teaching in a medical school setting is as effective as faculty-driven learning.12,13 Hands-on training has shown improved US competence in anesthesiology residents17; further investigation could determine whether hands-on PAL shows the same result for medical students. Regardless of this limitation, student interest in certain topics helps with approval when new or additional topics are added into curricula. An additional limitation of this report is whether students would be as interested or satisfied in the PAL sessions for US skills if it were part of the formal curriculum. Formal curricula often include graded assessments, and it has been reported that grading scales can undermine PAL because students focus on the grade rather than the learning.19 Additionally, it would be worthwhile to know how many schools use team-based learning or simulation as an option for integrating US learning through PAL. 
Conclusion
Growth in clinical use of US necessitates the integration of point-of-care US into a medical school curriculum. At WVSOM, PAL helped raise awareness of the prevalence and importance of US in clinical medicine and helped increase overall interest in further curricular integration. Since the inception of this study, a summer elective for first-year students and a second-year elective course have been designed and implemented into the WVSOM curriculum. If given the opportunity, 98% of the students who participated in the PAL US sessions agreed that they would attend similar sessions. Although other universities are at varying stages of integration, many schools do not have any US integration at all.20 Universal integration of US is ideal to ensure that medical students trained across the country are receiving education on this vital tool. As the use of US continues to expand, physicians will increasingly be expected to operate them competently to enhance care. Dinh et al18 identified 90 core clinical US milestones graduating medical students should obtain before graduation. We believe curricular integration of such content can be facilitated by faculty and students working together to identify and discuss best practices for integration at their institution. 
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Figure.
Overall survey responses from osteopathic medical students regarding peer-assisted learning ultrasonography (US) sessions (N=50). Most students strongly agreed with each of the statements. aStatement was applicable to sessions 2 and 3 only.
Figure.
Overall survey responses from osteopathic medical students regarding peer-assisted learning ultrasonography (US) sessions (N=50). Most students strongly agreed with each of the statements. aStatement was applicable to sessions 2 and 3 only.