1. Vertical Integration of Ultrasound Teaching into US Medical Education
Karl B. Fields, MD
Professor of Family Medicine and Sports Medicine
University of North Carolina
Director of Sports Medicine Fellowship Cone Health System and Greensboro AHEC
2017

2. US Teaching collaboration
Philosophy: US is merely an extension of the physical examination in the 21st century
Our Belief: US will lead to more rapid and less expensive diagnosis as well as greater patient satisfaction
Our inspiration: Dr. Leonard “Bones” McCoy of Star Trek and his medical tricorder –

3. Case 1

4. Case 1

5. Case 1- 3 week FU

6. Case 1- 3 week FU

7. Calf Tear Healing Process

8. Historical Highlights in US
1700s -Leonardo Spellanzani – blindfolded bats
Christian Doppler – position changes frequency and wavelength
Curie brothers – piezo-electric effect of crystals
1915 – Sonar in WW1
1943 – Dussik – Cranial US
1958 – Donald and Brown (Glasgow) – OB US

9. Medical School US Teaching
In 2014 ~ 28 % (48) of the 173 US medical schools report a formal USMED curriculum.
The average number of years of USMED curriculum integration was 2.8
Mandatory ultrasound curricula had most commonly been implemented into years 1 and 2 of medical school (71.4% and 62.9%, respectively).
62% of schools offered some US education that was either mandatory or optional
The most common areas of formal implementation were the anatomy and physical diagnosis courses

10. Medical Student Experience Day, et al
Medical Student Experience Day, et al. J Ultrasound Med 2015; 34:1253–1257 |
One-fourth (26.3% in 2012 and 23.4% in 2013) of responding interns (n = 150) reported having never done an ultrasound scan at the bedside.
In 2012 and 2013, 55.0% and 55.6% of respondents reported never having done an ultrasound scan in a simulation center
Only ~ 9% of Residents have done 10 clinical scans in medical school
Residents strongly agreed that teaching was most valuable in clinical years and at the bedside

11. Barriers to USMED lack of funding for faculty
Lack of adequate equipment
lack of time in clinics and in current medical curricula
Adequate faculty trained to teach US
Not a priority by medical leadership
Political issues – “turf battles” (>50% of directors)
Dinh, Fu, et al. Ultrasound Med 2016; 35:413–419

12. Wayne State School of Medicine Ultrasound Rao, et al Curriculum J Ultrasound Med 2008; 27:745–749
1. Introduction to Ultrasound Basic ultrasound principles
Ultrasound terminology
Transducer types
Essential keyboard controls
Basic ultrasound scanning techniques
2. Musculoskeletal Ultrasound Demonstrate ultrasound appearance
of muscle, tendon, bone, and nerve
Visualization of forearm muscles
Visualization of biceps tendon
Visualization of midforearm radius and
ulna: transverse and longitudinal
Visualization of median nerve and
carpal tunnel
3. Vascular and Cardiac Ultrasound Demonstrate parasternal 4-chamber
views of the heart
Demonstrate carotid artery/jugular vein
images
Discuss M-mode and pulsed flow
echocardiography
Visualization of carotid artery and
jugular vein
Visualization of aorta and vena cava
Visualization of 4-chamber view
Visualization of parasternal axis
M-mode and pulsed field
4. Ultrasound of the Abdomen Demonstrate ultrasound appearance
of liver, kidney, gallbladder, spleen,
bladder, bowel, and pancreas
Visualization of liver
Visualization of gallbladder
Visualization of spleen
5. Genitourinary Ultrasound Demonstrate ultrasound appearance
of bladder, kidney, and ureters
Visualization of bladder
Visualization of kidney
Visualization of ureters
6. Ultrasound and Procedural Skills Localization of foreign bodies
Visualization of internal jugular vein
Visualization of radial artery
Visualization of needle in vascular
Space

13. Comprehensive Curriculum Review by Students and Faculty
90% + of students felt this helped them better prepare for later training
83% of students agreed or strongly agreed that their US training experience was +
Faculty found stronger physical diagnostic skills among students who had formal USMED
87% proficiency on technical testing after 1 year US training
Research notes better placement of needles and lines

14. Some Educational Innovations
Ultrasound scan competitions
Medical student simulated patient experiences with basic training
Examination/ US correlation OSCE
Diagnostic testing using patients/ faculty with known pathology
US flash drive scanning logs – review
Fantastic resources on internet

15. How is US best taught?
Study questions value of lecture or podcast vs. bedside demonstration and discussion.
No beneficial effect noted with addition of lecture or podcast Florescu, et al. J Ultrasound Med 2015; 34:1873–1882
Hands on self scanning and paired peer scanning both effective
Clinical repetition with experienced scanner
Areas of needed research

16. Primary Residency Training
The first residencies to embrace mandatory training in USA were emergency medicine and obstetrics
Primary Care residencies have lagged behind and estimates are that about 35% of family medicine, 20% of IM and 10% of pediatric programs have equipment and some integration of US into training

17. General Surgery US
Research demonstrates value of US in general surgery practice particularly in trauma and in more remote areas
General surgery residents rate US as a high priority need in their training
Pilot projects have demonstrated improved confidence and skills with focused, fairly short training interventions
Residencies have no consistent requirements

18. Physical Medicine (PM&R) Shows Leadership in US Curricular Training Siddiquie, et al; Am. J. Phys. Med. Rehabil. & Vol. 94, No. 12, December 2015
Mayo Clinic program demonstrates an innovative approach to maximizing resources
They have experienced faculty with high level of expertise who provide periodic supervision
Peer feedback process is utilized with residents sharing and critiquing each other
Self-directed learning modules are expected to be completed at scheduled intervals

19. Training Programs with Well Established US Curriculae
Cardiology
Emergency Medicine
Obstetrics
Educational training heavily focused on the bedside with high clinical volume
Advanced techniques and training are elective and often require additional time out of standard curriculum

20. American College of Rheumatology
They provide testing and certification that is good for 10 years and starting in 2010 stand alone courses
ACR started courses at national meeting in 1999 and USSONAR founded in 2005
Rheumatology fellowships provide US training in past 10 years
Fellowship training is highly variable and clinical training to identify MSK injury is often limited
Procedural skills – injection of small joints expected at most

21. Sports Medicine Fellowships
US training is now mandatory
Demonstration of proficiency has not yet been formalized
Many programs offer a lot of procedural but much less diagnostic experience.
Is competency best suggested by volume or an observed supervision process?
Most programs look at a published curriculum guide as a starting point
Finnoff JT, Lavallee ME, Smith J: Musculoskeletal ultrasound education for sports medicine fellows: A suggested/potential curriculum by the American Medical Society for Sports Medicine. Br J Sports Med 2010;44:1144Y8

22. Conclusions
Dramatic improvements in US technology have made this a key diagnostic and therapeutic tool
Portable US has the potential to become the stethoscope for the 21st century physician
Medical students and residents both feel this should become a stronger part of the medical school curriculum and vertically integrated into residency and fellowship training

23. Educational Approaches to US
Studies suggest that training can be implemented at all levels but needs to be more focused on the clinical setting
Some residencies and fellowships in the USA have well-defined US curriculums
Future research should identify the most effective ways to teach US as well as the scanning skills needed in various specialties