Ultrasound core curriculum in medical school: a literature reviewABSTRACT
Introduction: Traditionally, inspection, palpation, percussion, and auscultation constitute the four pillars of bedside medicine. Point-of-care ultrasound (POCUS) has shown to be promising in improving the accuracy of clinical diagnosis.
Objective: To carry out a literature review on ultrasound curricula in medical courses.
Methods: A systematic review was carried out in PubMed, LILACS and SciELO databases, including the descriptors: “ultrasonography”, “curriculum”, “medicine” and “medical school”.
Results: 36 studies were analyzed, focusing on the integration of ultrasound into the medical curriculum. Twelve articles that describe specific ultrasonography curricula in detail were identified. Comparative tables were created, grouped by region of the body or area of knowledge.
Conclusions: Ultrasonography is being integrated into medical curricula, contributing to the teaching of various medical course subjects, as well as supporting bedside diagnosis. For its implementation in medical curricula, one must consider the skills to be acquired from the general practitioner’s training perspective. Investment in quality equipment and teacher training is necessary to achieve learning objectives.
Keywords:
ultrasound; curriculum; medical school; medicine
RESUMO
Introdução: Tradicionalmente, inspeção, palpação, percussão e ausculta constituem os quatro pilares da medicina à beira do leito. A Ultrassonografia no Local do Atendimento (POCUS) tem se destacado em melhorar a acurácia do diagnóstico clínico.
Objetivo: Este estudo teve como objetivo realizar revisão de literatura sobre currículos de ultrassonografia em cursos médicos.
Método: Realizou-se uma revisão narrativa nas bases de dados PubMed, LILACS e SciELO, em que se utilizaram os descritores: “ultrassom”, “ultrassonografia”, “currículo”, “medicina” e “escola médica”.
Resultado: Foram analisados 36 artigos com enfoque na integração da ultrassonografia ao currículo de Medicina. Identificaram-se 12 artigos que detalham currículos específicos, a partir dos quais foram elaborados quadros comparativos, agrupados por região anatômica ou área de conhecimento.
Conclusão: A ultrassonografia está sendo integrada aos currículos médicos, contribuindo para o ensino de várias disciplinas, além de ser utilizada como apoio diagnóstico à beira do leito. Para sua incorporação curricular, é necessário considerar as competências a serem adquiridas dentro da perspectiva da formação do médico generalista. Sua adoção requer investimento em equipamentos e treinamento docente para que se alcancem os objetivos de aprendizagem.
Palavras-chave:
Ultrassom; Ultrassonografia; Currículo; Medicina
INTRODUCTION
Inspection, palpation, percussion, and auscultation have been the four pillars of bedside medicine for more than a century, and clinical examination techniques had virtually no modifications or improvements until 1816 with the invention of the stethoscope by physician Rene Laennec of Quimper, France, of the ophthalmoscope by Hermann Helmholtz in 1845, of the neurological reflex hammer by John Madison Taylor in 1888 and of the otoscope by Guy de Chauliac of Montpellier in 1893.
After the popularization of the stethoscope use, only minimal improvements occurred, such as the inclusion of electronic components that allowed amplification, filtering, and archiving of sounds1.
The traditional clinical examination can often neglect or misinterpret findings, resulting in incorrect or missed diagnoses2, since it has limitations, even when performed by experienced physicians who have undergone training and obtained appropriate certifications in accordance with existing training protocols3.
A technological tool that has shown to be promising in terms of the possibility of improving the clinical diagnosis accuracy is the “POCUS: Point-of-Care Ultrasound”4. “POCUS” can be defined as the use of an ultrasound device for diagnosis, used by the attending physician at the point of care, allowing real-time correlation with the patient’s signs and symptoms5. Ultrasound (US) has long been recognized as an extremely useful diagnostic imaging modality due to the presence of real-time imaging, non-invasiveness, portability, and relatively low cost. Moreover, it does not present the risks associated with the administration of intravenous contrast material or ionizing radiation.
POCUS exams are used to answer specific clinical questions, usually binomial, such as if a patient with pain in the right upper quadrant of the abdomen has a gallbladder stone, a trauma victim has intra-abdominal bleeding, someone with calf edema has deep vein thrombosis, or if dyspnea is being caused by heart or lung diseases6. This trend occurs mainly among emergency and intensive care physicians, whose training, in addition to being focused on performing ultrasound-guided procedures, includes training in performing basic thoracic and abdominal ultrasound exams1.
Thus, many medical and surgical subspecialties are increasingly adopting the use of ultrasonography, as they consider it a complement or extension of the physical examination7. One of the facilitators of this process is the fact that the equipment and ultrasonography have become, in recent decades, of better quality, less expensive and more compact4, and can be easily transported and used both in medical offices and in hospital visits2.
Authors have referred to the portable point-of-care ultrasound as the “stethoscope of the future”8, “sonoscope”9 or as the “visual stethoscope of the 21st century”10.
Would it be the time to add insonation as a fifth pillar to the physical examination, making POCUS this new element of the bedside examination? 3. If so, how to train medical students for this new reality? What would be the ideal ultrasound curriculum from the perspective of the general practitioner’s training?
Publications have shown the incorporation of ultrasonography in specific disciplines such as anatomy11),(12),(13),(14),(15),(16),(17),(18),(19),(20),(21, physiology20),(22),(23),(24, semiology25),(26),(27),(28),(29),(30),(31),(32),(33),(34),(35),(36),(37),(38),(39).(40), emergencies41),(42) and guided procedures43),(44, as well as curricula with longitudinal axes implemented over several years or even all years of the medical course7),(45),(46),(47),(48),(49),(50),(51),(52),(53),(54),(55, with most publications showing gains in learning and student satisfaction.
OBJECTIVE
The objective of this study is to review the literature regarding the existing ultrasonography curricula in undergraduate medical courses, preparing a summary of the current state of the art in the teaching of this technique.
METHOD
A narrative review of the literature was carried out, including the PubMed, LILACS and SciELO databases, using the following descriptors in Portuguese: “ultrassom”, “ultrassonografia”, “currículo”, “medicina” and “escola médica”, as well as their corresponding terms in English: “ultrasound”, “curriculum”, “medicine” and “medical school”.
A total of 36 studies were evaluated, all of which were submitted to qualitative analysis and with different approaches regarding the incorporation of ultrasonography into the medical curriculum. Of these, 12 articles were identified that describe ultrasonography curricula in undergraduate medical courses and tables were prepared according to the body regions evaluated or area of knowledge, containing the elements analyzed in each one, grouping the information by similarity and comparing the authors’ proposals with each other.
RESULTS
Curricula with distinct characteristics were identified related to the focus on the incorporation of ultrasonography, such as for teaching anatomy, physiology, semiology, emergencies, guided procedures, as well as in a virtual learning environment (e-learning). The respective studies are described in Table 1.
The term “living anatomy” was introduced in 1996 at the University of Hannover, in Germany11, related to the dynamic characteristics of the use of ultrasonography in living beings for the teaching of anatomy.
An article written at Durham University in the United Kingdom describes twelve tips for teaching ultrasound in the undergraduate curriculum: 1. Identify a session in which ultrasound can be integrated with the other basic clinical sciences, to help achieve the learning objectives; 2. Choose a suitable physical environment to maximize the students’ learning experience, promoting interaction and optimizing opportunities for observation of the patient, the image and the equipment; 3. Ensure that students are familiar with the ultrasound equipment, its buttons and controls, as well as the appropriate configuration before the start of classes, so that classes run smoothly regarding this point. (Knobology: study of the handling of buttons and controls of the ultrasound device); 4. Ensure that properly trained staff are available to conduct the exam, guide students on relevant anatomy, and integrate the lesson into the curriculum and learning objectives. 5. Obtain informed consent from the volunteers submitted to ultrasonography and perform an ultrasound scan of the area to be demonstrated before class, in case there is any incidental finding; 6. Have an established protocol for situations that require further investigation if an incidental pathology is identified in an asymptomatic volunteer; 7. Conduct an introductory lecture to set the scene, signal the key points of the required anatomy, and guide students on the ultrasound images that will be studied; 8. Consider patient dignity, positioning, and ergonomics before and throughout the training session; 9. When conducting the training class, permit the initial “wow-factor” and then consistently reinforce key learning objectives, transducer orientation, and anatomy, explaining clinical relevance; 10. Allow students supervised play time, as they learn significantly when handle the transducer and correlate the transducer orientation and organ anatomy on their own; 11. The evaluation of the class is essential to further develop the pedagogical axis of ultrasound; 12. Incorporate the application of ultrasound into formal course evaluations20.
A total of 15 comparative tables were prepared among 12 published ultrasonography curricula, grouping items by similarity. Table 2 describes competencies related to the use of the ultrasound device. From Table 3 to Table 13, competencies are included according to the body region or type of anatomical element analyzed. Table 14 includes the area of pediatrics. Table 15 describes the curricular elements related to the use of ultrasonography for guided procedures and Table 16 describes specific ultrasound protocols.
DISCUSSION
Point of Care Ultrasound
Radiographic images have been used in the understanding of macroscopic anatomy since the beginning of the last century. From the 1990s onwards, when better performance and relatively less expensive equipment started to emerge, several experts in the field of education foresaw the enormous resource that ultrasound could become in the field of medicine15.
Many clinical and surgical subspecialties are increasingly adopting the use of ultrasonography, as they consider it a complement or extension of the physical examination7. The integration of ultrasound into traditional clinical examination can be a safe tool to improve diagnostic accuracy and immediately confirm suspicious findings at a reasonable cost46 and can be easily repeated if the patient’s condition changes4. Its use can improve patient safety and satisfaction, making medical care faster and more economical56. One of the facilitators of this process is the fact that the ultrasound equipment has become of better quality, less expensive and more compact in recent decades4, and can be comfortably transported and used both in medical offices and in hospital visits2. Probably its main limitation is its dependence on the operator, and there are several levels of competence that need to be acquired57. A study carried out with 196 hospitalized patients, where cardiac and abdominal ultrasonography was performed using a portable device, showed a significant change in the main diagnosis and management in 36 (18.4%) patients, confirmation of the diagnosis in 38 (19.4%) and an important additional diagnosis in 18 (9.2%) of the cases58. The use of the point of care as an initial evaluation method in the selection of patients to undergo more detailed examinations has also been mentioned59.
There is a greater trend toward the use of POCUS among emergency and intensive care physicians, that includes training in the performance of basic thoracic and abdominal ultrasound examinations1, as well as guided procedures, with better accuracy and reduction of complications when compared to unguided tests4),(43.
Ultrasonography in medical undergraduate school
The remarkable incorporation of ultrasound imaging in medical practice has spread to training in fellowships and residencies, and now also involves undergraduate medical education34. Should the physical examination include, in addition to inspection, palpation, percussion, and auscultation, the element of insonation?3 What would be the ideal ultrasonography curriculum from the perspective of the training of the general practitioner and what is the ideal way to carry out this practice?
For physicians to be able to perform the exams, it is necessary that medical schools have incorporated the teaching of ultrasonography into their undergraduate curricula. “Ultrasonography in medical education: listening to the echoes of the past to form a vision for the future”, is the title of an article carried out at the University of Irvine in California. POCUS in medical education is growing. Subspecialties should recognize each other’s expertise and come together as a cohesive unit to keep up with the educational needs of future generations of physicians60.
Regardless of at which point in the curriculum ultrasound teaching is incorporated, skills in using the equipment buttons (“basic knobology”), must be acquired before practical classes, as they may represent an excessive cognitive load for students32.
Ultrasonography, especially when introduced at the beginning of the curriculum, can allow the student to better understand the importance of teaching basic sciences. As future physicians, students must learn to interpret the results of clinical investigations from the early stage of their learning, and the integration of methods such as ultrasonography since the beginning of the medical school provides students with a significant foundation20.
The American Academy of Emergency Medicine and the American Institute of Ultrasound in Medicine advocate for the integration of US training into the core curriculum of medical schools. In 2013, at the 2nd World Congress on Ultrasonography in Medical Education, more than 85 medical schools met to discuss the topic. The implementation of US in the curriculum improves the learning of basic concepts, improves the understanding of the physical examination, involves students in active learning, and is seen as useful and enjoyable by students31.
Similarly, the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) recommends that ultrasound be used as an educational tool in the curriculum of modern medical schools62.
Ultrasound imaging is used in preclinical education at most medical schools in the United States (76%) and students are trained to perform practical ultrasonography exams at half of the colleges (49%). However, only a minority of institutions offer an elective internship in POCUS (14%) (63). The learning objectives vary according to the curricular year. The highest workload occurs in the third (penultimate) medical year56.
Physicians who participated in training during undergraduate school seek more hours of training and perform more exams after graduation, reporting greater proficiency in the use of ultrasound for clinical decision-making, in emergency scenarios, and use of new techniques64. The most commonly used environments for teaching ultrasound are anatomy laboratories and simulation laboratories, being guided by non-radiologists with experience in point-of-care ultrasound, at an instructor:student ratio of 1:465. It has also been proposed 1 instructor for every 8 students, and, in this other study, most of the teachers who dedicated time to this activity had training in the area of medical emergencies, followed by family medicine and radiology66.
Limiting factors for the implementation of an undergraduate ultrasound curriculum include the lack of people with adequate training of knowledge related to the diagnostic accuracy of ultrasonography in the hands of undergraduates, and relative absence of legal frameworks on the subject. The duration of the learning process for image acquisition competence, as well as its interpretation are also variable, extending from only the assessment of the normal to integration within a clinical context6),(67. Other challenges encountered in the practice of ultrasound teaching include the need for people to be examined, with the possibility of finding a pathology about which a volunteer was unaware20, as well as the development of instruments to assess ultrasound, as it includes not only the interpretation of the image, but also its acquisition, which requires manual skills with the use of the transducer68, lack of space in the curriculum and low financial support56. Nonetheless, although the current curricula have little space for additional content, classes, and teaching, it seems important to include the basics of ultrasonography in the undergraduate medical curriculum7.
Care must be taken to avoid assigning a workload below the minimum necessary for learning. An increase in confidence reported by students regarding anatomical knowledge has already been observed, but without significant impact on assessments, making the risk associated with limited exposure questionable, which increases confidence without increasing skills, showing the possibility that the in vivo imaging may not be effective when used as a short auxiliary teaching tool19.
More focused learning objectives demonstrate good learning among first-year medical students, correlated to normal anatomy and physiology: 1. basic physics of ultrasound, instrumentation, and equipment use; 2. Focused cardiac ultrasonography, including anatomy, assessment of global contractility and pericardial effusion; 3. focused thoracic ultrasonography, including anatomy, normal ultrasonographic artifacts, and evaluation of the pleura (for pulmonary edema) and diaphragm (for pleural effusion); 4. focused abdominal ultrasonography, including gallbladder anatomy, appearance of stones, and ultrasonographic evaluation of Murphy’s sign, as well as aortic anatomy and abdominal aortic aneurysm evaluation35.
Regarding the technical aspects, the teaching of ultrasonography can be performed with real equipment (which allows both live models and phantoms to be insonated) or through computerized simulators, equipped with transducers similar to the real ones, which show images recorded from the movement that the student makes with the transducer in relation to the body of the simulator (69). Students rate the instructor-led teaching and practice on live volunteers (including transducer selection, knobology, and image adjustment) as superior to teaching by ultrasound simulator (notebooks with simulated ultrasound transducers, which allow the student to manipulate images on the screen in real time).69
Studies with remote teaching of ultrasonography have also been published, such as an e-learning program for lung ultrasound. The students in the e-learning group scored similarly to the classroom training in relation to knowledge gain and retention70, but despite this, the e-learning does not allow the training of the manual skill of handling the device and the patient’s insonation for image acquisition. The face-to-face practical moment seems to be the most important for learning, and it has already been demonstrated that there is no significant difference between groups that had previous theoretical classes and those that went directly to the practical class with the ultrasound device. (71.
Ultrasonography is able to integrate form and function dynamically, as well as highlight to students future clinical applications of the basic sciences. This clinical contextualization is important because students can understand why anatomy, physiology, or pathology are important20. The prevailing opinion among anatomists, as well as among physicians assisting in the teaching of anatomy and semiology, is that ultrasonography has significant potential to improve anatomical understanding, increase physical examination, and provide a necessary link between the teaching of anatomy during the preclinical years and actual application of clinical anatomy in patients, subsequently in medical education, for diagnosis and treatment of the disease34.
The term “living anatomy” was introduced in 1996 at the University of Hannover, in Germany. The authors observed that ultrasonography can bring benefits to first-year medical students such as: correlation of classical topographic anatomy with the living situation, accurate determination of organ sizes, better understanding of sectional anatomy and three-dimensional reasoning, as well as better visualization of anatomical relationships between vessels and organs taking into account physiological phenomena such as, for example, variations in the caliber of veins during breathing. Moreover, a strict separation between basic and clinical sciences is inadequate today, where students need to process more and more knowledge in less time, and quickly forget most of the information as long as they don’t see the facts applied to clinical problems. Ultrasonography can be a connection between basic and clinical sciences and, in this way, the inclusion of the ultrasonographic method from the beginning of the course also generates the students’ greater motivation due to the possibility of performing clinical correlations11.
Several medical schools have introduced ultrasonography in the teaching of anatomy and physiology36),(37),(39. Ultrasound allows students to understand characteristics of different tissues and anatomy in several planes, something unattainable in a dissection room or physiology theoretical class20. Students consider that anatomy classes using ultrasonography can be used to improve their understanding of anatomy16),(17),(18, stimulate the learning of clinical anatomy, and improve clinical reasoning skills.13) With appropriate and well-planned use, ultrasound can be the key to involving students in the teaching-learning process, promoting the development of deeper approaches to learning through the clinical application of knowledge20),(34.
The use of portable ultrasound equipment in learning cardiac anatomy allows students to contemplate aspects such as the dynamic nature of heart anatomy and physiology in real time,23 such as the opening and closing of heart valves, blood flow through color Doppler, aspects not visible in conventional cadaveric anatomy.12 The dynamic correlation between ultrasound, auscultation, and electrocardiogram is also possible.22).(24
After brief echocardiographic training using a portable ultrasound equipment to detect valvular disease and left ventricular alterations (systolic dysfunction, increased dimensions, and hypertrophy), medical students’ diagnostic accuracy was superior to that of experienced cardiologists performing only clinical cardiological examination.26
The use of ultrasonography has shown to be useful in the teaching of hepatic semiology, improving the accuracy of the examination, especially in the identification of the edges of the liver for the performance of hepatimetry.27),(31 Learning to diagnose liver diseases at the point of care has also been demonstrated.25) Ultrasound examination also had advantages over physical examination in the evaluation of the gallbladder and aorta, but it is emphasized that more training is necessary in cases of patient obesity.27 On the one hand, during the initial phase of learning the clinical abdominal examination, ultrasonography does not provide benefits as an aid method, but for students who have already mastered the basic semiological maneuvers, ultrasonography has proven to be effective in improving the physical examination technique.28
It has also been observed that training related to musculoskeletal, abdominal, and cardiac ultrasonography were more successful in retaining relevant anatomical information when compared to the cervical region and eyeball.21 The use of ultrasonography as a facilitator to understand diseases in rheumatology had good results, despite the small number of students who made up the study group.29 A study on ultrasonography applied to the anatomical evaluation of the shoulder and knee by medical students has also been conducted, but few anatomical structures have been evaluated in each region.38
One of the studies with the largest sample evaluated 307 students after training in semiology, who participated in cardiovascular and abdominal ultrasound activities, initially observing exams and then practicing in standardized patients. The structures most easily identified with ultrasonography by the students were the internal jugular vein and the abdominal aorta. As for the identification of the gallbladder, the heart and structures related to Eco-FAST, it was more challenging, which is related to the different learning curves required for each anatomical structure.30
Ultrasonography influenced the correction of thyroid palpation and pulmonary percussion (lower limit of the lung) in a study conducted with 104 medical students.31
Previous ultrasound training improves the students’ ability to palpate the femoral pulse, but ultrasound had no influence on improving the correct estimation of the anatomical location of the femoral vein.33
Medical students who received POCUS training did not show significant differences in mean scores in theoretical assessments but performed better in clinical ability assessments by OSCE 40.
Ultrasound training with tutors and peer instruction provided to 110 students during an emergency medicine internship was very well accepted by the students, with an overwhelming majority stating that they would feel more confident to obtain abdominal ultrasound and FAST visualizations after the course.41
A POCUS ultrasound examination performed by medical students and reviewed by an emergency physician, including 482 patients, resulted in a change in management in 17.3% of the exams performed, detected a new diagnosis in 12.4% and reduced the time to discharge by 33.5%. Due to the tests, the physicians avoided requesting an additional imaging study for 53.0% of patients.42
Regarding invasive procedures, the use of ultrasonography to guide venous punctures did not reduce the number of attempts required to achieve venous access, but it was observed that vein cannulation is easier when ultrasound is used.44
As for the jugular vein, the use of ultrasonography to guide the passage of the jugular central venous catheter by students with little experience in this type of puncture significantly reduced inadvertent arterial puncture, an essential result to improve patient safety.43
Literature review on the teaching of ultrasonography in undergraduate medical courses
Researchers from the University of Toronto, Canada, conducted a literature review on the teaching of ultrasonography in undergraduate medical courses. Initially, 328 articles were obtained, of which 128 remained after the application of the inclusion criteria.72
Authors from the University of Galway, Ireland, conducted a literature review on the teaching of ultrasonography in undergraduate medical courses. After applying the inclusion and exclusion criteria, 128 articles remained. The authors grouped the data into categories according to the part of the curriculum where the teaching of ultrasonography was anchored: in the teaching of anatomy (“living anatomy”), physiology, physical examination, invasive procedures (in cadavers or in simulated models), as a learning stimulator (including events on social media and competitions), simulation (including ultrasound simulators with a simulated transducer and a non-human model with an image bank, which links real-time changes in the image visible on the screen with hand movements, as well as the insonation of phantoms with real ultrasound equipment), e-learning and online teaching, new teaching techniques (role play, patient simulated by the students themselves, podcasts) or peer tutoring by students from later school years.73
In the same year, researchers from the Thomas Jefferson University School of Medicine also conducted a review on the evidence of educational outcomes associated with teaching sonography to medical students. A total of 95 articles were included. The main data observed were that students like and want more training in US. They generally have a positive evaluation, including in the preclinical years, and can learn basic ultrasonography knowledge and skills in relatively short trainings; however, continuous practice is necessary for skill retention. Educators should continue to use expert input to determine the optimal flow and timing for the inclusion of ultrasonography in medical education, as high-quality outcome data remain elusive. The authors suggest that future research should focus less on student perceptions and the ability to learn ultrasonography, but rather on determining where trainings fit best into the undergraduate curriculum to optimize student and patient outcomes.74
A study published by the University of Manitoba, Canada, conducted a review on POCUS in cardiology, including the different approaches adopted by various medical training programs regarding the duration of training, knowledge prerequisites, and teaching methodologies (including e-learning, practical training, and simulation). The authors also described issues related to the need for competency assessment and the limitations of the technology itself, and pointed out the role of cardiac ultrasonography as a tool for teaching other knowledges (such as for teaching anatomy) and as a diagnostic skill are different educational pathways. Considering that evidence, that suggests that there is a decrease in the acquired skills in time, it may be necessary to standardize tools for continuous performance evaluation during undergraduate school.67
A review was also carried out by researchers from the University of Auckland, in New Zealand, on ultrasonography for the teaching of anatomy. From an initial total of 76 results, 20 were selected to be analyzed. The authors highlight the need for medical students to develop skills in the interpretation and use of ultrasonography due to its importance in clinical practice, predicting a future where a good foundation in the use of ultrasound and image interpretation will be needed for physicians from different areas of expertise.75
A group of researchers from the universities of Catania, Milan, Bologna and Parma, in Italy, conducted a literature review with the aim of evaluating whether the integration of ultrasonography classes into the curriculum of medical students improves the learning of the physical examination and improves their skills when performing it. The authors comment that the integration of ultrasound into the undergraduate medical curriculum, whether in a short-term or long-term intervention, seems to improve students’ skills and confidence to perform physical examinations, with significant student satisfaction, probably due to the possibility of immediate feedback with the image, allowing the correlation of the position of internal organs with the body surface in real time, helping the student to know whether they are examining the patient correctly, which improves the accuracy and understanding of the physical examination, especially for palpation and percussion.76
CONCLUSIONS
Ultrasonography has been increasingly incorporated into undergraduate medical curricula. It is a method that can help in the teaching of other disciplines such as anatomy, physiology, and semiology, as well as constitute a method of diagnostic aid at the bedside. For its implementation in medical curricula, it is necessary to consider the competencies to be acquired from the perspective of the training of general practitioners. It is necessary to invest in quality equipment and in the training of teachers to achieve the learning objectives.
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