Introducing point-of-care ultrasound through structured multifaceted ultrasound module in the undergraduate medical curriculum at the University of Hong Kong

Abstract

Incorporation of point-of-care ultrasound in the undergraduate medical curriculum is of great importance to ensure early exposure and safe use of the modality. We aimed to assess the students' learning experiences following implementing an ultrasound module in the medical curriculum at the University of Hong Kong. Medical students in semester 6 (n = 221) were enrolled in the module in 2018. It consisted of 1 hour of didactic lecture, followed by 3 hours of hands-on session. The students had the opportunity to enroll into a four-week Special Study Module to further practice their skills. The students had access to an e-learning platform to assist in their learning. Outcome measures include task-based performance, quizzes, feedback, and round-table discussion to assess the learning experiences. The module was highly rated by over 90% of students (response rate of 96%). Students practiced on peer subject on upper abdominal scanning. Post-training assessment showed an increment of 16% in their understanding of the modality. Students were motivated to enroll into the Special Study Module, where they were trained and became proficient with Focused Assessment with Sonography with Trauma. More than 86% of the students found the e-learning platform easy to use and assisted the training session. Round-table discussion suggested more simulated clinical cases to be added and expansion of future modules. Ultrasound module was successfully implemented into the undergraduate medical curriculum at the University of Hong Kong through new pedagogical approaches. This integration was highly rated by the medical students with improved awareness and better understanding of point-of-care ultrasound.

Introduction

Since the 1950s, ultrasound has been used as a medical diagnostic tool in multiple specialties. By the 1990s, point-of-care ultrasound (PoCUS) for both diagnostic and therapeutic purposes was introduced. Since 2010, most portable ultrasound machines have been able to match the quality of significantly larger machines, making the use of PoCUS even more popular. It allows physicians to perform ultrasound assessment or ultrasound-guided procedures directly at the bedside and has shown improved patient care in many aspects, including better diagnostic accuracy, better procedural safety, reduced procedural pain, reduced time in receiving emergency interventions, and reduced hospital stays.¹

Incorporation of ultrasound teaching in the undergraduate medical core curriculum is of great importance to ensure early exposure to PoCUS. Considering ultrasonography as a highly user-dependent tool, understanding its use, limitations, and safety will ensure the appropriate use of PoCUS and technical competency of future practicing physicians.

Inclusion of ultrasound as teaching adjunct improves skill acquisition and learner's experience.² Ultrasound has been shown to improve the understanding of anatomical structures and physiological phenomena through the real-time multi-planar cross-sectional visualization of anatomical structures. Medical learners and residents welcomed the integration of ultrasound teaching and its clinical application in the undergraduate curriculum.³ Although 62% of American medical schools had integrated ultrasound into the curricula⁴ through different pedagogical approaches, these reported experiences came from curricula with graduate entrants.^5–7 Most approaches include a combination of didactic lectures supplemented with demonstration and/or hands-on scanning session to teach PoCUS to undergraduate medical students.⁸ It has been shown that graduate entrants had distinct qualities and these affected approaches to studying, attitudes, and outcomes. Therefore, the perceived benefits from introducing PoCUS early in the medical curriculum observed in earlier studies may not be applicable to young school leavers for undergraduate entry.^9,10

At the University of Hong Kong (HKU), the Bachelor of Medicine and Bachelor of Surgery (MBBS) program lasts for 12 semesters spreading over six years. Prior to the introduction of the ultrasound module at HKU, ultrasound was taught as part of didactic lectures covering different imaging modalities and supplemented by a live demonstration.

The education reform in 2012 in HKU brought in restructuring of the medical curriculum. With that, there was an opportunity to introduce the ultrasound module into the undergraduate medical curriculum before the start of clinical attachments, bridging the gap between the pre-clinical and clinical years (MBBS III—semester 6). Ultrasound was taught as a modality and introduced as PoCUS with a taster module. The implementation aimed to allow early exposure of PoCUS among students to ensure good understanding of its use, safety, and limitations. This would pave way for building on competency at post-graduate level in the future.

The aims of this study were to assess the feasibility of implementing ultrasound module in the medical curriculum in an undergraduate entry system and to assess the learning experience and skill improvement following the implementation.

Material and methods

This study was carried out at HKU where it practices undergraduate entry to medical school, straight from secondary schools. The ultrasound module was first introduced in March 2015 and evolved over subsequent three years. The current results reported on the experience of our most recent module in 2018. A total of 221 medical students in their third year of undergraduate medical education (MBBS III—semester 6) were enrolled in the study.

Course model

The ultrasound module was designed to introduce the modality to the students and improve their understanding of PoCUS and to build the foundation on technical competency in the future.

The ultrasound module took place during semester 6 of MBBS III program through the use of a “flipped classroom” approach and consisted of 1 hour of lecture on ultrasound imaging, followed by 3 hours of hands-on training session with radiologists or sonographers. The students had access to an e-learning platform to build on knowledge before the training session, so as to maximize the time spent on hands-on ultrasound practice. They also had full access to the e-learning platform after the training session to consolidate their new skills. As the ultrasound module evolved, the interactive ultrasound e-learning platform was developed and accessible to every student in order to enhance their learning experience through illustrations, videos, and short pertinent summaries. An interactive questions and answers section was designed to evaluate and consolidate their knowledge in ultrasound.

The “flipped classroom” approach allowed transition from traditional lectures to assigned tasks and paved the way for more face-to-face interactive learning during class. This would allow more student-led learning and open up new opportunities for teachers.¹¹ Hands-on training on the other hand has been associated with increased knowledge retention, learning engagement, opportunities for real-time feedback, and adaption of different learning styles.

In addition, students were given the opportunity to enroll into a four-week Special Study Module (SSM) with the Department of Diagnostic Radiology to further practice and become more confident with their skills in ultrasound imaging.

The different components of the ultrasound module are described in details in the following sections.

Lecture

The didactic lecture gave an overview of the ultrasound principal clinical utility with emphasis on its advantages and pitfalls as compared to other imaging modalities.

Ultrasound training session

The class was divided into four groups with approximately 54 to 56 students in each group, and the hands-on training sessions were conducted four times in the academic year (Figure 1). The training session started with a 30-minute introduction covering the basic ultrasound physics, ultrasound safety, scanning modes, basic image interpretation, and sonographic findings for normal anatomy of the hepatobiliary system. The students were then divided into subgroups of 13 to 14 to practice on each other by applying ultrasound scanning on the upper abdomen, under the tutor's guidance over 2.5 hours. Skilled tutors were sonographers or radiologists invited from different institutions in Hong Kong.

Table 1.

Sections on the e-learning platform.

Section	Content
I. Overview	(A) What is ultrasound? (B) How does ultrasound work?  - Ultrasound physics  - Common ultrasound terminology  - Ultrasound imaging artefacts (C) How are ultrasound scans performed?  - Considerations before scan  - Professional considerations  - Key concepts  - Scanning techniques  - Generic knobology
II. Normal anatomy and pathology	(A) Neck  - Cervical region: normal anatomy and pathologies (B) Torso  - Breast and axilla: normal anatomy and pathologies  - Thorax: pathologies (C) Abdomen  - Liver: normal anatomy and pathologies  - Gallbladder: normal anatomy and pathologies  - Pancreas and spleen: normal anatomy and pathologies  - Kidney: normal anatomy and pathologies (D) Pelvis  - Urinary bladder: normal anatomy and pathologies  - Pelvis: normal anatomy and pathologies (E) Miscellaneous  - Miscellaneous: normal anatomy and pathologies
III. Interventional procedures	(A) Drainage (B) Biopsy (C) Ultrasound contrast
IV. Assessment	(A) Assessment overview (B) Assessment anatomy (C) Assessment pathology

The learning outcomes were set out before the start of the training sessions and were as follows:

1. To understand the important considerations before and during scanning and

2. To be able to recognize the normal abdominal anatomy.

Guidance notes were provided for tutors to ensure conformity of teaching delivery. Tutors first ensured that each student was competent in the safe application of ultrasound before starting the scanning. They were then instructed to demonstrate and explain the imaging planes and knobology, followed by demonstration of the use of the ultrasound apparatus on a volunteer student, to provide hands-on tips, and to explain how to recognize the different appearances of normal abdominal anatomy on ultrasound by using the correct ultrasound terminology.

Before the start of the hands-on training, students were briefed on the guidelines of participating as healthy volunteers.¹² In the event of incidental findings, the module coordinator will initiate referral to the University Health Service if deemed appropriate after consultation with the student volunteer. Each student had the opportunity to practice on each other under tutor's supervision and to receive constructive advice on the skills demonstrated. Each practice lasted approximately 10 to 15 minutes to avoid inappropriate exposure. At the end of the training session, they were evaluated individually by the tutor on their capability to identify the liver and the kidney on peer subject. Immediate feedback was given by the tutors before conclusion of the session.

Students were also rotated to an ultrasound simulation system in which pathological conditions were demonstrated.

In addition to this practical evaluation, the students were asked to complete a pre-workshop and a post-workshop questionnaire through the e-learning platform. The pre-workshop questionnaire contained five questions on basic ultrasound utility and aimed to estimate the students' initial knowledge. The post-workshop questionnaire consisted of the same five pre-workshop questions in order to assess the knowledge improvement and five additional questions on normal abdominal anatomy, intended to evaluate the acquired ultrasound skills.

Special Study Module

This module offered opportunity to interested students to be further trained in using ultrasound to make important bedside diagnosis. The learning objectives of this module were to understand ultrasound acquisition techniques and to master Focused Assessment with Sonography with Trauma (FAST) scan and upper abdominal ultrasound imaging. During the four-week module, the students attended ultrasound clinics, shadowed various radiologists around the teaching hospital, and experienced first-hand in observing the clinical application of ultrasound. Students were scheduled to practice on each other in the clinical skill laboratory every morning, followed by clinic visits in the afternoon. Once a week, students would receive tutorial from experienced sonographer. At the end of the module, each student was assessed by both sonographer and radiologist on the ability of performing FAST scan, to differentiate between inferior vena cava (IVC) and aorta, and to follow the aorta to look for abdominal aortic aneurysms on peer subject.

E-learning platform

To complement the ultrasound module, an innovative and interactive e-learning platform was developed and funded by the Teaching Development Grant of HKU. It was developed over a 30-month period aiming to deliver an e-learning platform suitable and relevant to undergraduates.

Before, during, and after the hands-on training session, the students could access the e-learning platform to consolidate their skills and looking for scanning tips. Ultrasound physics and considerations before scan including patient safety were covered in the first section. The potential benefits and risks of ultrasound, the ALARA Principle (As Low As Reasonably Achievable) which should be observed when adjusting controls prior the exam, were detailed. It also contained a database of sonographic images of normal anatomy, commonly encountered pathologies and video clips of ultrasound-guided interventional procedures. The platform was fully developed at the beginning of 2018 and integrated into the ultrasound module (Table 1 and Figure 2).

Figure 1.

Training sessions' organization in 2018.

Figure 2.

Example of the abdomen section of the ultrasound e-learning platform. IVC: inferior vena cava.

Healthy volunteers were recruited as normal subjects in the video series and normal sonographic images. The clinical cases were a collection of pathological conditions retrospectively retrieved from the local database and collaborative institutions. Ethics compliance was observed, and approval was sought from the local institutional review board prior to the commencement of the project. No personal identifiable data were presented on the sonographic images or videos captured. A team of experienced radiologists, sonographers, and the team at the Teaching and Learning Unit of the university contributed to the e-learning platform.

Feedback

At the end of the training session, feedback forms were distributed to the students to work on the improvement and sustainability of the ultrasound module. Similarly, feedback was assimilated from students who enrolled to the SSM program.

The students evaluated the impact of the module on their learning and self-reflection with a 5-point Likert-type scale (strongly agree = 5, agree = 4, neutral = 3, disagree = 2 and strongly disagree = 1).

Kirkpatrick 4-level model was used as a framework of categorizing outcome measures of the student's feedback and performance. In summary, level 1 was correlated with increased learner satisfaction or confidence; level 2 was defined as increased knowledge and competency of ultrasound; level 3 showed improved skills in other tasks; and level 4 was correlated with improvement in clinical practice and improved patient's care.^8,13,14

A round-table discussion was conducted with project investigator and tutors to discuss the successes and improvements that could enhance the ultrasound module.

Results

Lecture

The whole-class lecture was delivered before the hands-on training session. The importance of the indications, applications, advantages, and pitfalls of the modality were stressed to ensure PoCUS was appropriately used, as non-selective and indiscriminate application of the modality could result in harm than benefit to patients.¹

Ultrasound training session

Among the 221 students enrolled into the module, 83% of them participated in the ultrasound training session, leading to a 1:12 tutor to student ratio. Funds were secured to purchase portable ultrasound units specifically for the purpose of teaching and learning, with these being housed in the clinical skills laboratory. All the students were able to identify the liver and the kidney during the practical evaluation.

We received a good response rate of 96% from the distributed questionnaires immediately after the session, with 177 responded out of 184 students who attended the session. Of the received feedback, over 95% of the students thought the session was practical and useful (Kirkpatrick level 1) (Table 2). Students also commented on the increase in self-assurance in using ultrasound (Kirkpatrick level 2). The training session was particularly well evaluated by the students, with 91% of “good” or “excellent” rating and motivated them to apply for the SSM for further knowledge and skill consolidation. All the students attempted the pre-workshop questionnaire and 83% attempted the post-workshop questionnaire. Among the 184 students who participated in the session, 138 of them submitted both pre- and post-workshop questionnaires (Figure 3). There was an average 16% positive increment in student's knowledge following the session.

Table 2.

Students' feedback on the ultrasound training session.

Students found	Strongly agree and agree (%)
The workshop met my expectations	93
I enjoyed the ultrasound training session	93
The training session was practical and useful	95
The training session was innovative in supporting learning	89
I feel more confident using ultrasound machine and probes	86
Time allocation of the workshop was sufficient	90

Figure 3.

Percentage of right answers of the pre- and post-workshop quiz among the 138 pairs.

SSM

The intake of SSM students had tripled from 4 students per year previously to 12 students per year after the initiation of the ultrasound module. All the students who participated in the SSM passed the end-of-module formative practical assessment by demonstrating the skills in performing FAST scan and identifying the aorta and IVC on peer subjects confidently (Kirkpatrick levels 2 and 3).

E-learning platform

The platform was used during the ultrasound training session based on the “flipped-classroom” model, where students were asked to access specific sections of the e-learning platform before the training session. Students were also given free access to other sections before, during, and after the session.

A prototype of the e-learning platform was first introduced to the students of the SSM program in 2016 and then during the training session in 2017. Feedback collected through a questionnaire showed that students requested scanning videos, more pathology-related images, and multiple-choice questions in an assessment section. Those comments were taken into consideration, and the final version of the e-learning platform was made available online in early 2018.

A total of 664 sessions were opened on the platform during the 2018 ultrasound module. Following the hands-on session, more than 82% of the students rated the platform “good” and “excellent.” Most of them found the platform and material easy to use and aligned with the learning outcomes (Kirkpatrick 1). Results of the students' experience were summarized in Table 3.

Table 3.

Students' feedback on the e-learning platform.

Students found	Strongly agree and agree (%)
The platform was easy to use	86
It increased my interest in ultrasound	76
The platform has been well designed to help me learn	89
The content was aligned with the learning outcomes	94
Assessment features were useful	85
The platform helped to consolidate what were taught	94
With a greater access to the learning process and time saving	93

Round-table discussion with tutors

The project investigator and tutors from the past training sessions had the opportunity to discuss and feedback on the project effectiveness, the successes, and challenges during implementation of the ultrasound module and to bring suggestions of strategic improvement in integrating ultrasonography into undergraduate medical education.

They found the ultrasound training session as an effective means in exposing student to the modality and the information on the e-learning platform appropriate and aligned with students' knowledge. The importance of maintaining a high tutor to student ratio was also stressed. Involved tutors had suggested more modules to be developed in the future with incorporation of simulated clinical scenarios to make ultrasound learning more “realistic” and “practical” in the classroom and expanding the current SSM to involve other radiology departments in Hong Kong.

Discussion

With PoCUS becoming increasingly applied across different medical specialties and ultrasound equipment becoming more portable and affordable,^1,15,16 the delivery of ultrasound teaching in the undergraduate medical curriculum becomes paramount and strategic to effectively use this technology to aid clinical management. Ultrasound is operator-dependent, and PoCUS requires appropriate training to achieve competency.

Although successes have been reported in universities with graduate entrants, there were concerns of introducing ultrasound teaching to the undergraduates given the voluminous curricula.⁴ Hoppmann et al. highlighted concerns with incorporating ultrasound teaching too early on in the medical curriculum, which may overwhelm students who are still trying to acclimatize to the heavy workload of medical school.² This effect could potentially be more pronounced among medical students who join the undergraduate curriculum straight after secondary schools. We have shown in our project that the integration was feasible in a system with undergraduate entry, and the experience was as beneficial as those shown in graduate entrants. Furthermore, we have strategically selected to introduce the ultrasound module in semester 6 of MBBS III during the transition period from pre-clinical to clinical years, when our students would have acquired the necessary knowledge in anatomy and physiology, at the stage of preparing themselves to clinical exposure; timely for introduction of a technique that would be useful in clinical practice and to bridge the gap between knowledge and clinical application.

Through the use of the “flipped classroom” approach with access to the e-learning platform, students had the opportunity to improve their knowledge before the training session, so as to maximize the time spent on hands-on ultrasound practice. They also had full access to the e-learning platform after the training session to consolidate their new skills. Although free online resources are widely accessible by students, the e-learning platform in our module was tailored to medical students and kept the essential physics with simple explanations and illustrative examples for easy understanding. Functionality of the modality and technical considerations were also highlighted.

Herein, we demonstrated the students enjoyed the ultrasound module with objective improvement in their knowledge following the training provided in the module, achieveing Kirkpatrick levels 1 and 2 education. The hands-on experiential learning enhanced students' understanding of the abdominal anatomy and allowed interactive active learning with continuous feedback from tutors. Furthermore, it motivated them to explore more about this modality, evident by the increment in SSM enrollment. The SSM students were efficiently trained in specific tasks, namely, the FAST scan and identification of the aorta and IVC, thus reaching the Kirkpatrick level 3 education, in addition to a well-rounded experience of ultrasound learning with clinics exposure.

This study had several limitations. First, we used peer subjects during the 3-hour hands-on training session instead of normal or patient volunteers. However, we feel that this model would allow students to experience first-hand being the subjects under investigation to improve learning engagement, not to mention this being more cost-effective and allowing better logistic arrangement. Furthermore, we adhered to the guidelines set out by the British Medical Ultrasound Society (BMUS) in using healthy volunteers for ultrasound training.¹² Nevertheless, opportunities for bed-side training in the wards will be important, and there is on-going plan to collaborate with the clinical departments, such as Emergency Medicine and Surgery, to further promote the use of PoCUS, its teaching, and clinical exposure. Second, no competency-based assessment was included at the end of the training session at this stage. The training session was initially set out as an experiential learning experience, however we are gradually introducing a competency-based assessment to assess the performance of the training. Third, the low tutor to student ratio in ultrasound training session was suboptimal. As with the challenges of introducing new pegadogical module, we are working continuously with other radiology departments to recruit more experienced ultrasound tutors and have initiated the first pilot project involving senior students as adjunct tutors through the Student in Medical Education program.

With these encouring experiences and feedbacks, there will be possible extention of the module in other areas of medicine and at earlier stage of the medical curriculum. There will be potential for sharing our experiences with other medical institutions in the region and ultimately forming a standardized PoCUS curriculum across the region.

In conclusion, ultrasound module was successfully implemented into the undergraduate medical curriculum, through a mixture of traditional and new pedagogical approaches. This integration improved the students' learning experience and awareness of this increasingly important bedside technique with opportunity to gain proficiency in PoCUS at the post-graduate level.

Ethics approval

Ethics approval was sought and granted by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW 15-570 and UW 17-387).

Guarantor

Elaine Yuen Phin Lee

Contributors

Conception and design: Elaine Yuen Phin Lee, Varut Vardhanabhuti and Pek Lan Khong. Acquisition of data: Elaine Yuen Phin Lee, Teresa Sui Ping Kwong, Alta Yee Tak Lai, Esther Man Fung Wong, Keith Wan Hang Chiu, Varut Vardhanabhuti, Pek Lan Khong. Analysis and interpretation of data: Pascale Chung Hang Shen, Benedicte Coiffier, Elaine Yuen Phin Lee, Teresa Sui Ping Kwong, Alta Yee Tak Lai, Esther Man Fung Wong, Keith Wan Hang Chiu, Varut Vardhanabhuti, Pek Lan Khong. Drafting the manuscript: Pascale Chung Hang Shen, Benedicte Coiffier, Elaine Yuen Phin Lee. Revising critically the manuscript: Teresa Sui Ping Kwong, Alta Yee Tak Lai, Esther Man Fung Wong, Keith Wan Hang Chiu, Varut Vardhanabhuti, Pek Lan Khong. Final approval of the version to be published: Pascale Chung Hang Shen, Benedicte Coiffier, Elaine Yuen Phin Lee, Teresa Sui Ping Kwong, Alta Yee Tak Lai, Esther Man Fung Wong, Keith Wan Hang Chiu, Varut Vardhanabhuti, Pek Lan Khong.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The e-learning platform of this study was funded by the Teaching Development Grant, University of Hong Kong.