Educational Value of Ultrasonography Used as a Diagnostic Tool by Medical Students at a Student-Run Free Clinic

Abstract

At A.T. Still University’s Kirksville College of Osteopathic Medicine, Still Caring Health Connection is a student-run organization that hosts free clinic nights for the underserved. The clinics are beneficial for patients and medical students because patients receive needed medical attention and medical students get early clinical exposure. During the clinics, medical students use portable ultrasound machines to guide diagnoses. When surveyed about their use of ultrasound on clinic nights, most students responded positively.

Introduction

Educational Value of Student-Run Free Clinics

Student-run free clinics (SRFCs) are common in medical schools because they allow medical students to take responsibility for management of the clinics while also providing disease-specific treatment to the patients.¹ In general, the goals for SRFCs are to provide medical care to underserved populations and create learning experiences for students because they can apply course content to an actual patient. Currently, more than 75% of U.S. medical schools have SFRCs.^{2, 3} In one study,² students and faculty agreed that these clinics are a valuable part of medical education. Specifically, they allow students to gain valuable clinical experiences during the first two years of medical school,⁴ and those experiences often complement the didactic material they are exposed to in the curriculum.⁵ Another benefit of SRFCs is that they promote interprofessional collaboration. Typically, a variety of health professions students (eg, medical, dental, nursing) participate in the clinics, and such collaboration is critical in real-world patient care. From a medical student perspective, learning to work with healthcare providers from different disciplines is a valuable experience, especially before clinical rotations.

Educational Value of Ultrasonography for Future Primary Care Physicians

Ultrasound is a core skill that is being used with increasing frequency in many clinical specialties because of its utility for point-of-care diagnostics.⁷ Therefore, bedside ultrasonography has become more prominent in patient care, and more medical schools are including ultrasound training earlier in undergraduate medical education.⁸ The inclusion of ultrasound training in the curriculum enhances the anatomical and clinical training of students and increases their preparedness for future practice.^{9, 10} In one study,³ early exposure to ultrasound in a patient-centered curriculum was feasible and seemed to improve the physical examination skills of students. Another study suggested that ultrasound surpassed the abilities of auscultation through a stethoscope, whether performed in an outpatient clinic or a trauma situation, making it the stethoscope of the future.¹¹ Other studies suggested that students using ultrasound imaging had greater diagnostic accuracy than those using physical examination skills alone.^{12, 13} However, a limitation of ultrasound imaging is that it is operator-dependent. Undergraduate medical students should be taught this technology so they are familiar with ultrasound techniques and competent with image interpretation. Further, ultrasound training in basic science courses and clinical clerkships allows medical students to stay informed about developments in medicine while preparing them to apply those developments to future patient care.^{11, 14–16}

Value of Ultrasonography in Rural Areas

In this descriptive study we report preliminary results of the integration of portable ultrasonography in SRFCs. Because of advancements in medical technology, medical ultrasound devices are becoming more portable and affordable, which allows their use in diverse patient populations, such as rural and underserved areas where other diagnostic imaging tools may not be easily accessible.¹⁷ The use of portable ultrasound machines in uninsured and underserved populations can provide much-needed access to diagnostic imaging and could, in some cases, save lives. Further, SRFCs are an ideal clinical setting where portable ultrasound and ultrasound competency are extremely valuable. To our knowledge, there is no published data on the use of ultrasonography as a diagnostic tool in SRFCs, and the educational value of ultrasonography has not been assessed in this context. Therefore, the purpose of the current study was to evaluate medical student perception of the incorporation of ultrasound technology into an SRFC and to determine their level of comfort with using ultrasonography and interpreting ultrasound images. We hypothesized that the educational value of ultrasonography in the SRFC would be beneficial for development of clinical decision-making skills because the ultrasound images would provide greater clinical confidence from immediate visual validation of the diagnosis.

Methods

Student-Run Free Clinic

At A.T. Still University’s Kirksville College of Osteopathic Medicine (ATSU-KCOM), Still Caring Health Connection (SCHC) is a student-run medical and dental school organization that strives to give back to the local community and benefit its underserved population by hosting various healthcare events, such as free clinic nights. During these clinic nights, patients indicate which services provided by the clinic they wish to receive, such as diabetes or lipid panels, osteopathic manipulative treatment, or dental screenings. Supervised by attending physicians, the medical and dental students evaluate, diagnose, and treat the clinic patients. Through these clinic encounters, medical students are able to practice numerous skills learned in the medical school curriculum. Further, students are encouraged to perform more complete, rather than focused, physical examinations as a means of reinforcing and practicing clinical skills. For example, students practiced taking a patient history, performing a physical and ultrasound exams, they tested blood pressure, blood glucose and HA1C, learn how to present a patient to a physician, etc. Clinic nights also provide students with an opportunity to apply ultrasound skills obtained through ATSU-KCOM’s clinical ultrasound curriculum.⁶ Ultrasound education has been part of the curriculum at ATSU-KCOM for 10 years and is fully integrated into the first two years.⁶

For the current study, first-year and second-year medical students participated in the free SCHC clinic nights. All clinics had at least three faculty physicians on site, and they supervised students during the patient encounters. During physical examinations, students identified whether the use of ultrasonography could guide and confirm the initial diagnosis. The following portable ultrasound machines were available for student use: a Vscan with dual probe handheld portable ultrasound (GE Healthcare) and a Mindray 7 (Shenzhen Mindray Bio-Medical Electronics Co., Ltd.) (Figure 1). A Vscan with dual probe has two transducers in one probe and is hand-sized. A Mindray 7 is the size of a laptop.

Figure 1.

Portable ultrasound units used in the student-run free clinics.

Students participating in the clinics had a working knowledge of ultrasound techniques and applications from their clinical ultrasound coursework. At ATSU-KCOM, the Clinical Ultrasound course is taught in four semesters during the first two years.⁶ During SCHC clinics, students filled out an ultrasound patient log to record the areas and the type of ultrasound scan performed. The log also indicated whether the student’s initial diagnosis was confirmed or not confirmed by the volunteer radiologist on site. Recorded scanning regions included the abdomen, the neck for thyroid gland and carotid arteries, echocardiography, obstetrical ultrasound, and musculoskeletal ultrasound imaging of the wrist and ankle.

Survey

To evaluate medical student perception of the incorporation of ultrasound technology into an SRFC and to determine their level of comfort with using ultrasonography and interpreting ultrasound images, a 12-item paper survey was created specifically for the current study. Students who performed ultrasound examination during patient encounters at the SCHC clinics completed the survey. It contained seven Likert scale questions and five open-ended questions. The Likert scale questions included in the survey were the following: (1) I felt confident using portable ultrasound units to guide my diagnosis; (2) I felt prepared to use the portable ultrasound unit as a diagnostic tool for my patient; (3) The portable ultrasound unit was helpful in guiding my diagnosis; (4) It was easy to identify structures using a portable ultrasound unit; (5) I enjoyed using ultrasound as a diagnostic tool for my patient encounter; (6) Using the portable ultrasound unit improved my clinical reasoning skills; and (7) I received enough training before using the portable ultrasound unit. A standard Likert scale (strongly disagree, disagree, neither agree nor disagree, agree, and strongly agree) was used to evaluate agreement or disagreement. The openended survey questions asked about benefits of using portable ultrasonography, patient response to the use of portable ultrasonography, and possible curricular implications. The open-ended questions included in the survey were the following: (1) What were your thoughts regarding the use of a portable ultrasound unit to guide your diagnosis? (2) How do you feel the use of portable ultrasound impacted your patient encounter? Positively? Negatively? (3) How did your patient respond to your use of a portable ultrasound unit? (4) What components of the Clinical Ultrasound course were most relevant to your patient encounters at the free clinic? (5) What would you like to see added to the Clinical Ultrasound course that would have been helpful for your patient encounters at the free clinic?

The A.T. Still University-Kirksville Institutional Review Board considered the current study exempt. Students were informed that they provided their consent by completing the survey. All data were collected anonymously, and participation in the survey did not affect student grades in any way.

Results

Student Perception of Incorporation of Ultrasonography into SRFC

Because the COVID-19 pandemic caused our SCHC clinics to close to meet social distancing guidelines and stay-at-home orders, data from only seven students were collected. Therefore, here we present those preliminary results and hope to complete the study at a future date.

For the Likert survey responses, 71% (5/7) of students felt confident using portable ultrasound units to guide diagnosis, 43% (3/7) felt prepared to use the portable ultrasound unit as a diagnostic tool for the patient, and 100% (7/7) indicated the portable ultrasound unit was helpful in guiding diagnosis. The majority of students (86%, 6/7) thought it was easy to identify structures using a portable ultrasound unit, 100% (7/7) enjoyed using ultrasound as a diagnostic tool for the patient encounters, and 100% (7/7) indicated using the portable ultrasound unit improved their clinical reasoning skills. All (100%, 7/7) indicated they received enough ultrasound training before using the portable ultrasound unit.

Educational Value of Ultrasonography During SRFC

The open-ended question responses supported the Likert scale responses. For the question about the use of portable ultrasound to guide diagnosis, one student wrote, “It was helpful to rule out an obvious fracture and also, to give my patient’s father more satisfaction in our treatment and diagnosis.” Other students wrote, “It was really helpful to rule out some differential diagnosis,” and “It helped us come to a conclusive diagnosis.”

For the questions about how the use of portable ultrasound impacted the patient encounters and how the patients responded to the use of portable ultrasound, students wrote comments like, “[it] helped us discover it was likely a fibrous cyst,” and “It was nice to show them what we’re seeing and showed them we can rule out some bad diagnoses.” Other students wrote, “The patient seemed to appreciate getting results right then and there,” and “The patient’s father seemed happy to have a diagnostic test done when no x-ray was available.” The students’ written comments suggested that most patients responded to the use of ultrasonography very positively. Students wrote, “He seemed to like getting results rapidly,” “The patients loved it and loved being explained what’s on the screen,” and “They liked that we were able to perform an ultrasound exam.” One student suggested a possible negative patient outcome from portable ultrasound in the following comment: “the patient abdominal exam prompted the identification of an unknown U.S. abnormality. Might result in additional imaging the patient cannot afford.”

The following are examples of what students wrote in response to the question about the most relevant components of the Clinical Ultrasound course at the free clinic: “Knowing how to use an ultrasound, what to look for”; “How to orient probe. How to get oriented to structures on screen”; “The repeated practice of identifying normal anatomy and where to look”; “Recognizing the different components of a joint and evaluating for any abnormalities”; and “The shoulder, ankle, and uterus/ovary components were most useful.” Students also indicated that cardiac and gynecological ultrasound laboratories were very helpful in preparing them for the patient encounters.

A common comment from students in response to the question about what they would like to see added to the Clinical Ultrasound course to make it more helpful for patient encounters at the free clinic was that they wanted to “use portable ultrasound machines in lab. This will get us more accustomed to new/different machines.” The most frequent comment to this survey question was related to their desire to have “more practice on ID of pathology within each organ system.”

Discussion

The purpose of the current study was to evaluate medical student perception of the incorporation of ultrasound technology into an SRFC and to determine their level of comfort with using ultrasonography and interpreting ultrasound images. Survey results suggested medical students were receptive to incorporating portable ultrasound into the SRFC and that portable ultrasound units were helpful in guiding diagnoses. Most students felt confident using the portable ultrasound units, which suggested they were competent at obtaining and interpreting ultrasound images. Because it can impact physician competence and patient safety, the ability to accurately identify and interpret ultrasound images is an important aspect of medical training, and medical students need to feel comfortable with these skills.

All students agreed that the use of ultrasonography was beneficial to the development of their clinical reasoning skills and agreed that the portable ultrasound units had a positive impact on their patient encounters. Further, reported student confidence using portable ultrasound units and their comfort identifying anatomical structures suggested the students had been well prepared by their ultrasound curriculum to apply their knowledge in a clinical setting. Taken together, these findings suggested that SRFCs can be a valuable educational tool for medical students to fill the gap between formal training and real-world experience.

Student responses to the open-ended survey questions indicated that they were overwhelmingly positive about the incorporation of ultrasonography as a diagnostic tool into SRFCs and into ATSU-KCOM’s curriculum overall. The use of ultrasound technology during the free clinic encounters helped patients better understand their health status and improve their overall experience. These results suggest that ultrasound technology should be incorporated to a greater extent in rural medicine given that this clinical setting typically has limited access to other forms of imaging and a larger proportion of uninsured patients.

In general, SRFCs can be a valuable and distinct aspect of medical education, especially considering they provide valuable opportunities for students interested in primary care. Further, first-year students can benefit from the unique learning environment of SRFCs as they are mentored by second-year students and attending physician volunteers about aspects of patient presentation, physical examination, and ultrasonography skills. These clinics are also vital for creating academic/community partnerships between the medical school and the local community by providing free medical services. Using ultrasonography as a diagnostic tool at SRFCs is also beneficial because it improves student proficiency and level of comfort in their diagnoses while providing care to underserved populations.

The current study had several limitations. Because the COVID-19 pandemic caused our SCHC clinics to close to meet social distancing guidelines and stay-at-home orders, data from only 7 students were collected. Therefore, our findings are preliminary and should be interpreted with caution.

Conclusion

Results of the current preliminary study suggested beneficial outcomes for patients from a rural and underserved area and for medical students from the use of ultrasonography at SRFCs. Patients received needed medical care, and medical students received clinical exposure early in their medical education. Our results suggested the first-year and second-year medical students were able to apply the skills they had learned through the ultrasound curriculum at ATSU-KCOM and could use these skills to scan actual patients in a clinical setting. Further, using portable bedside ultrasound equipment helped students adapt to changing medical technologies, improved their clinical reasoning skills, and enabled them to become well-rounded and knowledgeable physicians of the future.