Honing clinical skills with ultrasound

In January 2019, Yale School of Medicine (YSM) completed a renovation project that included 14 new clinical training rooms equipped with ultrasound tablet devices. This technology did not exist in the former practice space and its addition has already had positive results for medical education.

These changes are particularly evident in the Clinical Skills Course, which spans the first 18 months for all medical students. In it, students learn how to communicate with and examine patients and develop their clinical reasoning skills.

Jaideep Talwalkar, MD, associate professor of medicine and of pediatrics and director of clinical skills explains, “The Clinical Skills Course has always been hands-on, but what is novel about using ultrasound is the added layer of visualization in real time that ultrasound provides, simultaneous with other learning modalities that we’ve already been using.”

Rachel Liu, MBBCh, assistant professor of emergency medicine and director of point-of-care ultrasound education, is excited about the educational opportunities the renovation makes possible. Liu introduced point-of-care ultrasound into the longitudinal preclerkship curriculum six years ago with a pilot program converted into a preclerkship elective. She believes point-of-care ultrasound’s central mission is to aid students in understanding how to integrate anatomy, physiology, and pathology while learning physical examination skills. This approach is different from ultrasound as a diagnostic tool that may be introduced in fourth-year electives, residency, and fellowship training. “Point-of-care ultrasound holds distinct roles in both education and patient care, but it is not a replacement for imaging performed by radiologists or other medical specialists,” Liu says.

When Liu developed the preclerkship pilot, she combed the YSM curriculum to pair it with ultrasound uses. She then worked with Talwalkar and Joseph Donroe, MD, MPH, assistant professor of medicine and director of physical examination education, to bring ultrasound into the Clinical Skills Course. Donroe, who teaches small groups in Liu’s curriculum, provides examples of how ultrasound is enabling him and his colleagues to better instruct students in the art of physical examination.

In the past, faculty would have students practice palpating the abdomen to look for the liver, but it was often difficult for students to understand exactly what they were touching. Now, by coupling the physical exam with ultrasound, students can literally see the liver, making the experience more concrete and memorable. A similar effect is achieved when students can see heart valves opening and closing in real time using ultrasound as they listen to a heartbeat with a stethoscope.

Elizabeth Woo, a third-year MD/PhD student, is grateful to have been in the ultrasound longitudinal course. She describes how during her preclerkship years, ultrasound “allowed me to better contextualize human anatomy as well as seeing the ‘why’ to different clinical maneuvers.”

Second-year medical student Pablo Delis, who is taking the ultrasound elective, echoes Woo’s praise for the course. “Being able to see a heart beating, bowel peristalsing, and lung pleura sliding in real time has been invaluable in solidifying my understanding of these organs. Knowing I am competent in performing essential ultrasound studies and interpreting the images taken by other medical team members has granted me a level of confidence I believe is rare among first-year medical students.”

With the new space and equipment, students can now practice ultrasound in small groups. This opportunity will make it easier for students to develop their skills and take advantage of peer-to-peer teaching. Such shared learning had not been possible previously when students used vendor-loaned equipment at various locations.

Sixteen first-year students and seven second-year students who participated in the longitudinal ultrasound elective have been certified to help train peers. Michael Schwartz, PhD, associate professor of neuroscience and associate dean for curriculum, believes this peer-to-peer training aids students’ development.

Students and faculty are enthusiastic about integrating ultrasound into the medical education curriculum, does it actually improve learning? Liu, Donroe, and Chris Moore, MD, associate professor of emergency medicine and section chief of emergency ultrasound, are conducting research to find out. Most studies involve tests specific to ultrasound teaching. However, Liu says, “nothing has really looked at the effect of ultrasound teaching to the more general curriculum, and this is the part that is important.”

In her research to date, Liu looked at students’ qualifying examinations and the examinations that all students in every medical school must pass (objective structured clinical examinations or OSCEs, and United States Medical Licensing Examinations or USMLEs). “Overall we found that the area where ultrasound teaching seemed to have a beneficial statistical significance was in the physical examination performance of their OSCE.” These findings are limited by a small sample size. The YSM curriculum changed in 2015, and Liu was able to obtain only two years of data from the old curriculum. She plans to repeat the study, as she will soon have access to up to four years of data from the new YSM curriculum.

Evidence that the ultrasound device is enhancing education is critical. As Schwartz says, “If two years later we are talking about the technology of ultrasound, we have missed the boat. The key is not a technological tour de force; it is how the technology enhances education.”

Liu says that when the Department of Emergency Medicine offers point-of-care ultrasound training courses to faculty, “we routinely have attendees from many different specialties.” Both Talwalkar and Donroe attended these courses. Before his initial training, Talwalkar spent a month-long sabbatical in late 2018 in Santiago, Chile, with Liu’s colleague, Pablo Aguilera, MD, Chief of Emergency Medicine, Pontificia Universidad Católica de Chile. Talwalkar’s main goal was to learn the basics of ultrasound because, as he explains, he has been helping “to build ultrasound into the YSM clinical skills curriculum, but had absolutely no ability to help out with the teaching. I was more novice than the students.”

Like Talwalkar, many YSM doctors and residents are new to point-of-care ultrasound and eager for training because the technology’s widespread use is a fairly recent development. Since returning from Chile, Talwalkar has used ultrasound in clinic and on hospital rounds to highlight its uses with residents and students. He says, “Learners are extremely enthusiastic about using it. They recognize the potential applications, but many residents have had little exposure.”

Ultrasound training is standard in such residencies as emergency medicine, obstetrics, and radiology, but other specialties are just starting to incorporate it into their training. Liu plans to collaborate with YSM’s Teaching and Learning Center to create more faculty development opportunities to train future educators.

Gail D’Onofrio, MD, MS, chair and professor of emergency medicine, reflects on the critical role of ultrasound in emergency medicine and as an educational tool. “Ultrasound has become an essential tool in the ED as we evaluate patients with acute life-threatening illnesses and injuries. Dr. Liu is a remarkable trailblazer in educating students, residents, and faculty in the skill of ultrasound. Her passion, expertise, and creativity are apparent in her teaching. She is world-renowned for helping to create the innovative SonoGames® and SonoSlam™ as pedagogical exercises. We are incredibly fortunate to have her here at Yale.”