The use of a single instructor teaching 80 medical students during 1 scanning session represents a novel method in osteopathic USMED. Overall, we were successful in saving time and faculty resources, and students enjoyed their exposure to ultrasonography and performed well on written examinations. Compared with a traditional USMED curriculum, which requires an extrapolated 600 instruction hours annually, NUSMED required only 96 hours. Although students reported appreciating exposure to ultrasonography, they expressed desire for smaller group and greater individual instruction. Written test questions performed well, with the first-year class answering 88% correctly and the second-year class answering 90.6% correctly.
Teaching modalities of point-of-care ultrasonography frequently include didactics, web-based modules, live demonstrations, and short videos in addition to hands-on scanning sessions.
10 While didactics, modules, and live demonstrations can effectively introduce ultrasonography principles, hands-on sessions are necessary to gain skill.
12-14 We attempted to incorporate these methods into our curriculum. We feel this method of curriculum design has the potential to be adapted and used in other settings that may lack instructional resources, such as other new medical schools. Live ultrasonography demonstrations could even be done remotely by experienced educators, with peer instructors available to lead small groups in person.
In our review of the literature on assessment of knowledge, the most frequent method of evaluation was self-assessment by the learner, with results showing high satisfaction and an increase in knowledge and technical skills.
10 Our student feedback was corroborative, with most students reporting that they enjoyed their exposure and felt they were learning valuable clinical skills. The second most common method of evaluation involved image acquisition and technical skill observation, which is discussed in detail below. Further direct comparison of our curricular effectiveness to others is difficult because of the wide variety of curricula structure and assessment methods; however, we maintain that our curriculum may be appropriate for other settings lacking limited instructor resources.
We considered a cost analysis to quantify cost savings of an extrapolated annual 600 instruction hours compared with our use of 96 hours, but the regional and institutional variations in salary and reimbursement make this difficult. It can reasonably be inferred that the significant reduction in teaching hours represents our cost analysis and translates into intangible monetary savings. It would be important for individual institutions to take stock of their available technical resources before implementing a program like this. At RVUCOM, we were able to use equipment that had been purchased for our osteopathic manipulative treatment sessions, as a similar curricular modality with flipped classroom, live demonstrations, and hands-on practice is used during those sessions.
However, NUSMED had several limitations and uncovered areas for future research and improvement. First, our course evaluations were limited to commentary rather than being quantitative. This format did not facilitate standardization of feedback, as there were no specific evaluation points. For example, 27.9% of students reported desire for more instructors and 47.5% of students requested shorter laboratory sessions and smaller group sizes. We suspect that a greater proportion of students felt this way, but they did not provide commentary in the write-in section. In the future, ultrasonography sessions will be evaluated using a Likert scale that assesses the instructor, precourse videos, session content, and whether the learning objectives were achieved. Second, we evaluated the efficacy of this educational format on written examinations; however, we were not able to evaluate the students’ ability to acquire and interpret images. Ideally, ultrasonography performance should be evaluated under direct observation of skills. However, this would require significant additional faculty resources. As this NUSMED program expands, we hope to integrate these additional methods of evaluation.
Another significant limitation in the curriculum is students’ desire for individual instruction during scanning sessions. While the instructor could deliver didactic content using the flipped classroom and demonstrate scanning skills to the group, it was difficult for her to provide direct feedback and guidance at each station. To this end, we are developing a peer instructor model for future sessions that allows upper-level students to assist with instruction in the hands-on scanning sessions to produce a smaller instructor-to-student ratio. Peer-assisted course models have been effective in delivering undergraduate ultrasonography education
15 and would allow us to increase available instructors while maintaining a single-instructor model. Other studies have also shown that POCUS skills and understanding did not differ between students taught by faculty or peer instructors.
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Students in the current study also reported that laboratory sessions were too lengthy and there were too many students per group. They felt that downtime allowed for off-task activities like studying for other classes or talking among themselves. One strength of our open commentary method of evaluation was that students felt free to leave constructive criticism and advice about their experience with the curriculum. While approximately 48% of students requested smaller class sizes, 70% of these students directly suggested that along with a smaller class size, ultrasonography laboratories should be reduced to 1 hour rather than 2. They felt that this time would provide (1) a straightforward way of reducing group sizes and increasing time spent using the ultrasonography machines, (2) immediately increase the instructor-to-student ratio, and (3) keep students on task, as class could move more quickly with fewer students needing a turn on the probe. As we move into future curriculum development, smaller class sizes and shorter laboratory periods will be a priority.