Ultrasonography: A basic clinical competency

Overview

Ultrasonography has undergone a transformation in the past 2 decades that is fundamentally changing the way that medicine is taught and practiced. Technologic advances have taken ultrasound to the bedside or point of care in the form of laptop and pocket-sized devices that produce high-quality digital images that can be saved in multiple formats or sent anywhere in the world for review.

Because of the portability of ultrasound today, clinicians have real-time information to make diagnoses and management decisions virtually anywhere that they encounter patients, from traditional medical facilities such as the critical care unit to the site of natural disasters and the battlefield. The newer systems are user-friendly and much less expensive than the larger traditional machines, which makes them accessible to many more health care providers.

Ultrasound is a safe imaging modality and should be considered “first” in many clinical scenarios when imaging is indicated, especially those involving children to avoid the risk for cancer from ionizing radiation (i.e., ultrasound versus computed tomography for the diagnosis of appendicitis).1–3 The cost of ultrasound imaging is also considerably less than that of most other imaging modalities, and it can provide equivalent or better images and thus decrease overall health care cost. When compared with other imaging modalities, ultrasound has the added advantage of providing dynamic examinations, such as evaluation of the shoulder for rotator cuff disease or real-time guidance of procedures such as central line placement and thoracentesis.

If ultrasound has all these advantages, why is it not being used more commonly? A major factor limiting the widespread use of ultrasound is the lack of adequately trained practitioners, for despite the technologic advances and ease of use of the new ultrasound units, there still remains a significant operator-dependent component that requires training and practice. A considerable knowledge base is also needed for accurate interpretation of images and decision-making relative to ultrasound.

In this chapter the argument is made that ultrasound should be considered a basic clinical competency across the spectrum of medical education, including critical care medicine. Ultrasound training should begin in medical school and be continued throughout the professional career of most physicians. The concept of competency-based education for ultrasound will be advanced, as well as recommendations for developing competency-based ultrasound curricula.

Ultrasonography in medical student education

Ultrasound was introduced into medical student education in the 1990s and proved to be a valuable teaching tool in courses such as anatomy, physiology, and physical examination.4–6 Ultrasound education gradually expanded into the clinical years of medical school, especially in the discipline of emergency medicine.⁷ The clinical application of ultrasound being taught is as a focused or point-of-care examination designed to answer a specific clinical question such as “Is there a gallstone in the gallbladder that helps explain this patient’s right upper quadrant abdominal pain?” or “Is there overall normal heart function in this patient with shortness of breath?” This point-of-care ultrasound approach has been highly developed in the emergency department setting, and the American College of Emergency Physicians has led the way in defining the necessary training and competencies in point-of-care ultrasound.⁸

In recent years, ultrasound has been successfully integrated across the entire medical student curriculum. Hoppmann et al reported on 4 years of experience with an integrated ultrasound curriculum.⁹ As part of the curriculum, all students at the end of the anatomy course in the first year of medical school are observed individually and evaluated for their ability to perform ultrasound on standardized patients and capture and identify anatomic structures in a series of specific ultrasound images. Such structures included the kidney, liver, and Morison pouch in the right upper abdominal quadrant; kidney and spleen in the left upper abdominal quadrant; urinary bladder in the pelvis; carotid artery and internal jugular vein in the neck; and parasternal long-axis view of the heart. The mean percentage of correct responses after 3 years of these examinations was 97.1%. In addition, from student surveys of the same ultrasound curriculum, more than 90% of students thought that the curriculum had enhanced their medical education, allowed increased clinical correlation with basic science instruction, and improved their understanding and skills of the physical examination.

These findings of students learning basic ultrasound well and reporting that the addition of ultrasound had enhanced their education are consistent across the vast majority of reports in the literature on medical student ultrasound education.