Comparison of ultrasonography learning between distance teaching and traditional methodology. An educational systematic review

ABSTRACT BACKGROUND: Use of the web for radiological education is an obvious application. Many computer-based teaching materials have been developed over recent years, and e-learning is becoming increasingly popular in medical schools. OBJECTIVE: To assess whether the effectiveness of distance-learning and/or e-learning, m-learning and web-based methods are equivalent to traditional methods. DESIGN AND SETTING: Systematic review of comparative studies of teaching techniques guided by Best Evidence Medical Education. METHODS: A search was carried out in the MEDLINE, EMBASE, Cochrane Library, Tripdatabase, CINAHL and LILACS online databases in April 2020, for original publications in all languages. The following MeSH terms were used: Ultrasonography; Teleradiology; Telemedicine; Education, Medical; Teaching; and Simulation Training; along with the terms e-learning, m-learning and web-based. All eligible studies were assessed using the Kirkpatrick model and Buckley's quality indicators. RESULTS: The search in the databases and a manual search resulted in 4549 articles, of which 16 had sufficient methodological quality for their inclusion. From analysis of these data, it was observed that teaching of ultrasonography using telemedicine methods is similar to the traditional method, except for venous access procedures, for which the studies did not show agreement. CONCLUSION: We found that learning via telemedicine methodologies presents great acceptance among students, besides demonstrating quality similar to the traditional method. Thus, at least at the moment, this has the capacity to serve as an important adjunct in the teaching of ultrasonography. REGISTRATION NUMBER: DOI: 10.17605/OSF.IO/CGUPA at the OPENSCIENCE Framework.

and guidelines. 6 The value of lectures within teaching has been challenged historically, and investigations have revealed that they have insufficient influence on short and, notably, long-term retention, particularly with regard to expositions that last for longer than 20 minutes. 7 Just 20% to 30% of the information imparted in any given session can be put into practice by trainees immediately following the exposition. Moreover, over the subsequent two weeks, 90% of the data is wasted. 7 Low-cost telemedicine technologies can enable doctors to access expert support, remote procedure guidance and real-time training opportunities, thereby reducing unnecessary transportation costs and improving patient outcomes. [8][9][10][11] There are studies in the medical literature that have reported that doctors who were trained remotely over the internet had a good degree of satisfaction with the quality of their training and achieved a quality level in evaluating ultrasound images that was similar to that of doctors who underwent in-person training. 5,12

OBJECTIVE
The objective of this systematic review was to assess whether the effectiveness of distance-learning and/or e-learning, m-learning and web-based methods, for ultrasonography training, is equivalent to traditional methods.

Study model
The reference point for this study was the education-oriented systematic review model for Best Evidence Medical Education (https://www.bemecollaboration.org/). The study was registered on the OpenScience Framework platform (https://osf.io/wn762).
This study was considered exempt from formal institutional review by our institutional review board because no human or animal subjects were studied.

Modalities of distance-learning
• Electronic learning (E-learning) is an online educational assistance website that instructs and enables students to enhance specific topics.
• Mobile learning (m-Learning) can be described generically as a modality of e-Learning in which learning takes place through easy-to-handle mobile electronic devices (such as smartphones and tablets, for example).
• A video lesson is a video that presents educational material to a subject.
• A live distance class is an online class at a regularly planned time in which learners work together with their instructor and classmates at the same time on the same days. Homework tasks are then accomplished outside of this dedicated lesson period, just like in in-person lessons.

Search strategy
A systematic search of the literature was carried out on April 16, 2020, in the following online databases: Medline (PubMed); EMBASE; Cochrane Library; LILACS; Tripdatabase; CINAHL; ERIC; and SciELO. Original published articles in any language were sought using the following MeSH terms: Ultrasonography; Distance-learning; Online learning; Teleradiology, Telemedicine; Education, Medical; Medical Education Online; Simulation Training; and Teaching. In addition, the terms e-learning, m-learning and web-based were also used. The reference lists of studies that were included and those of the main reviews on this subject were also evaluated. Manual searches were also carried out in the reference lists. All of these searches are shown in Table 1

Selection of studies and data extraction
The study selection process was carried out by two independent reviewers and any disagreement was resolved by a third reviewer. The selection of studies was carried out in two stages. In the first stage, the titles and abstracts of the references identified through the search strategy were evaluated and the potentially eligible studies were preselected. In the second stage, a full-text evaluation of the preselected studies was carried out to confirm their eligibility. In cases of disagreement, a third author was consulted.
Data extraction was performed using a standardized form. The outcomes analyzed were the score previously established for the training method and the performance of the procedure.

Quality assessment
All eligible studies were assessed using Buckley's quality indicators 14 and the Kirkpatrick training assessment model described   15 These tools are based on instruments that cover a wide range of methodological issues in studies on evaluation of teaching methodologies.

RESULTS
The search in the databases yielded 5,090 articles. Additionally, seven articles were found through a manual search. After excluding duplicates, 5,048 articles were screened, out of which 61 were evaluated in their entirety; from these, 16 presented sufficient methodological quality for their inclusion (Figure 1). The study by Socransky et al. 16 was excluded due to loss to follow-up of over 50% of the initial participants. Hempel et al. 17 was not included because its results from the study phase that were compatible with our inclusion criteria had already been published previously. 7 Eleven studies evaluated teaching among doctors and/or residents and/or medical school students; 7,18-27 one study conducted in England evaluated teaching among nurses, 28 and four studies carried out in Spain evaluated physical therapy students. 4,[29][30][31] Regarding methodology, one study was a cross-sectional, randomized study, 28 one was a prospective pseudorandomized study, 25 one was a prospective cohort 19 and three were randomized controlled trials. 4,7,18,[20][21][22][23][24]26,27,[29][30][31] In ten studies, a questionnaire was administered both before and after each teaching technique was applied. 7  Furthermore, in the prospective cohort study by Cuca et al.,19 no assessment of ultrasonography practice was conducted. There were only assessments via questionnaires regarding thoracic structures in ultrasonography, including two post-tests. That study evaluated 75 doctors and medical students and it was found that teaching via e-learning showed results that were similar to those of the traditional method, including through a survey conducted two weeks after the teaching, which evaluated the retention of information.
In a randomized clinical trial by Edrich et al., 20 138 anesthesiologists were assessed. They were divided into three groups: a group without instruction, a group with classroom instruction and a group that received instruction through telemedicine. It was concluded that teaching via telemedicine provided results that were similar to those through the traditional methodology, including in a questionnaire administered four weeks after the teaching, to evaluate the retention of information.
Fernández-Lao et al. 29  They concluded that the m-learning group achieved better patient positioning, transducer management and image adjustment than the traditional method group. However, less time was required for performing the examination through the traditional method.
In a randomized clinical trial by Maloney et al., 23 theoretical teaching of musculoskeletal ultrasonography was evaluated among 33 radiology residents, without any practical evaluation. It was concluded that the group with the traditional teaching methodology presented a result that was slightly better than that of the e-learning group (less than 5% difference).
Platz et al. carried out two studies analyzing FAST, but without evaluation of ultrasound practice. One was a prospective pseudorandomized trial 25 among 55 doctors and residents of different specialties divided into three groups: traditional method, telemedicine method and no previous instruction. From this, it was concluded that telemedicine teaching presented results similar to those of the traditional method. The other was a randomized clinical trial 24 among 44 emergency and surgery residents, in which it was found that computer-based classes were not inferior to classroom classes among individuals without previous training, for teaching about FAST ultrasound.
Soon et al. 27 carried out a randomized clinical trial on pointof-care ultrasound for pleural effusion and pneumothorax, among 45 pediatric physicians without experience of ultrasound. These subjects were divided into two groups: web classroom and in-person classroom, followed by practice on living models. They concluded that teaching via the web was at least as effective as the usual teaching method, including with regard to evaluation of information retention, among 39 of the study participants, conducted two months later.
A summary of all the studies is presented in Table 2. 4,7,18-31

DISCUSSION
Out of the 16 studies analyzed, nine 7,18-21,24,25,27,28 showed similar results between the traditional and telemedicine groups. It should be noted that in four of these studies 18,19,24,25 there was no practical evaluation; in these, assessments were only made through questionnaires that were administered before and after the teaching intervention.
In five studies, 4,26,[29][30][31] it was demonstrated that distance-learning was superior. Moreover, among these five studies, four 4,29-31 evaluated physical therapy students; in two of these studies, m-learning technology was used, 4,29 while e-learning technology was used in the other two. 30,31 Two studies 22,23 showed that the traditional education group had slightly better results than the telemedicine group that used e-learning technology. We need to contextualize that all these studies were carried out before the COVID-19 pandemic. Although the study by Lozano-Lozano et al. 4 was published in 2020, it was carried out in 2014-2015.
In the present-day world, people acquire information daily through computers and, especially, smartphones. The current generation of students uses electronic media regularly, such that this is an essential part of their daily lives and modifies their brain structures in relation to learning. Thus, 37% of healthcare students have already used an application to develop their professional skills. 32 Therefore, there is a need to adapt teaching methods. In this regard, the use of traditional teaching tools is now out of context. 4 A study by Gul et  to the clarity of procedures, the ability to ask questions and the quality of time spent learning, even in relation to surgical procedures. 28,33 The most evident advantage of telemedicine teaching was the better positioning of the patient and handling of the transducer. 4,29 Weber et al. 34 also reported that there was a marked improvement in performance in the early stages of teaching; however, in their study, only the telemedicine group used augmented reality together with telementoring, which could be characterized as a form of bias.
Regarding studies on ultrasound-guided procedures, there was no agreement among the results. Bertran et al. 26  The benefits of learning from computers are numerous and include interactivity, novelty, flexible programming, teachers' relief from the need to give repetitive lectures and greater consistency in quality. 16,35,36 The disadvantages of computer-based instruction include the lack of human interaction and guidance, the material presented in a format that is less pleasant to read than in a textbook and the possibility for a student to have unanswered questions. 7,23,35 Use of the web for radiological education is an obvious application. [37][38][39] Many computer-based teaching materials have been developed over recent years. M-learning, which is defined as "the ability to access educational resources, tools and materials anywhere, using a mobile device (smartphone)", 4,29,40 along with e-learning, is becoming increasingly popular in medical schools. Guides on the implementation of e-learning have been appearing. 6,18,22,30,31,35,[41][42][43][44] This method of learning has many organizational advantages over classroom lessons, as follows: 5,7,17,19,20,25,27,30,31,41 • Environment free from stressful factors and without judgment.
• Easy and uniform dissemination of teaching resources for teachers.
• Temporal and spatial flexibility for students.
The monetary savings that accrue through use of these new teaching methods should also be taken into account. Professionals in rural areas need to travel to major centers to receive medical education and training; 28,45 alternatively, trained professionals from the main centers need to travel to teach in remote areas. 8,28,46 Both of these situations are time-consuming and expensive. 8,28,46 Telemedicine education offers an economical alternative for teaching skills in remote environments or for situations in which resources are limited. 8,28,45,47 One limitation of this systematic review was that it seemed that many types of ultrasound examinations have not been evaluated in primary studies on distance-learning techniques in the medical literature, such as examinations on the thyroid, neck, breasts and prostate. In addition, because of the variability of outcomes between studies, performing a meta-analysis was not possible.
Regarding the implications for research, distance-learning techniques can be expanded to other areas of healthcare, such as biomedicine and nutrition, among others. Evaluations among medical specialties that remain little explored also need to be undertaken.
It should be noted that none of the studies presented level 4 of the Kirkpatrick model (changes in system/organizational practice and changes among participants, students, residents or colleagues).
Studies at level 4 could confirm the good results that were shown by the studies at levels 2B and 3 that were found. Another possibility that needs to be better explored is to combine these technologies with augmented reality and virtual reality, which would facilitate teaching in relation to areas that are difficult to access.
Such combinations have already been successfully demonstrated with regard to obstetric examinations, in a study published by Zimmermann et al., 48 and this should be extended to other ultrasound examinations. Therefore, we can state that teaching of ultrasound by means of telemedicine is a novelty that is being implemented in the 21 st century. It presents possibilities such as videos and texts on computers or cell phones, with use of the internet and applications and/or programs, in addition to the possibility of augmented reality, which has already been analyzed in some studies. Thus, a new teaching technique is presented here, which is available to teachers for implementation, with the possibility of recording classes and making them available for repeated student viewing. This is something that is often impossible with classroom lessons. It should be noted that not all the studies evaluated here included practical analyses on ultrasound. However, with regard to the theoretical part of teaching, distance-learning presents results similar to traditional methods in the classroom.

CONCLUSION
In this systematic review, we found that learning by means of telemedicine methodologies is widely accepted by students.
Distance-learning can have quality similar to the traditional method and, at least at present, it can serve as an important adjunct in the teaching of ultrasonography, especially in relation to places that are difficult to access, where there are no schools/ universities where this teaching could take place.
However, instructors need to pay attention to each student's particularities. Some students might not adapt to or appreciate the techniques of online teaching because of low levels of interaction between people or the need to study using a textbook rather than a screen. The need for internet access in order to have live video classes may be a problem for some locations. Studies conducted using this technology during the COVID-19 pandemic will provide new data on this technology. In addition, studies are still needed to assess the practical part of teaching ultrasonography at a distance.