The Journal of Emergency Medicine, Vol. 43, No. 6, pp. 1098–1102, 2012Copyright � 2012 Elsevier Inc.

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doi:10.1016/j.jemermed.2012.01.041

This work wasademic EmergenJune 2010.

RECEIVED: 18 AACCEPTED: 22 Ja

Education

INTRODUCTION OF ULTRASOUND INTO GROSS ANATOMY CURRICULUM:PERCEPTIONS OF MEDICAL STUDENTS

Bart Brown, MD,* Srikar Adhikari, MD, MS, RDMS,† JaredMarx, MD,‡ Lina Lander, SCD,§ andGordon L. Todd, PHDjj*Department of Emergency Medicine, St. Mary’s Medical Center, Evansville, Indiana, †Department of Emergency Medicine,

University of Arizona Health Sciences Center, Tucson, Arizona, ‡Department of Emergency Medicine, University of Kansas Medical Center,Kansas City, Kansas, §Department of Epidemiology, University of Nebraska Medical Center, Omaha, Nebraska,and jjDepartment of Genetics, Cell Biology & Anatomy, University of Nebraska Medical Center, Omaha, Nebraska

Reprint Address: Srikar Adhikari, MD, MS, RDMS, Department of Emergency Medicine, University of Arizona Health Sciences Center,PO Box 245057, Tucson, AZ 85724-5057

, Abstract—Background: The exposure to ultrasoundtechnology during medical school education is highly vari-able across institutions. Objectives: The objectives of thisstudy were to assess medical students’ perceptions of ultra-sound use to teach Gross Anatomy along with traditionalteaching methods, and determine their ability to identifysonographic anatomy after focused didactic sessions.Methods: Prospective observational study. Phase I of thestudy included three focused ultrasound didactic sessions in-tegrated into Gross Anatomy curriculum. During Phase II,first-year medical students completed a questionnaire.Results: One hundred nine subjects participated in thisstudy; 96% (95% confidence interval [CI] 92–99%) agreedthat ultrasound-based teaching increased students’ knowl-edge of anatomy acquired through traditional teachingmethods. Ninety-two percent (95% CI 87–97%) indicatedthat ultrasound-based teaching increases confidence to per-form invasive procedures in the future. Ninety-one percent(95% CI 85–96%) believed that it is feasible to integrate ul-trasound into the current Anatomy curriculum.Ninety-eightpercent (95% CI 95–100%) of medical students accuratelyidentified vascular structures on ultrasound images ofnormal anatomy of the neck. On a scale of 1 to 10, the aver-age confidence level reported in interpreting the images was7.4 (95% CI 7.1–7.7). Overall, 94% (95% CI 91–99%)

presented as an Abstract at the Society of Ac-cy Medicine annual meeting, Phoenix, AZ,

pril 2011; FINAL SUBMISSION RECEIVED: 26 July 2nuary 2012

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accurately answered questions about ultrasound funda-mentals and sonographic anatomy. Conclusions: The major-ity of medical students believed that it is feasible andbeneficial to use ultrasound in conjunction with traditionalteaching methods to teach Gross Anatomy. Medical studentswere very accurate in identifying sonographic vascularanatomy of the neck after brief didactic sessions. � 2012Elsevier Inc.

, Keywords—Gross Anatomy; ultrasound; medical stu-dents; sonographic anatomy

INTRODUCTION

The use of bedside ultrasound by clinicians has greatlyexpanded across medical specialties over the past few de-cades. This rapid, non-invasive imaging tool is increas-ingly being used for both diagnostic purposes andprocedural guidance. Recent advances in technologyhave resulted in a dramatic decrease in size of the ultra-sound machines. The portability of compact ultrasoundsystems has made the technology readily accessible forbedside use in both inpatient and outpatient settings.The utilization of bedside ultrasound by an increasingnumber of medical specialties creates the need for moreultrasound exposure and teaching at the medical studentlevel. However, medical students typically have minimalto no formal teaching in the use of ultrasound.

011;

Figure 1. B-mode image of internal jugular vein (IJV) and ca-rotid artery (CA) in sternocleidomastoid (SCM) muscle trian-gle (transverse view).

Ultrasound to Teach Gross Anatomy 1099

Currently, a majority of medical schools rely onclerkship experiences to teach ultrasound skills to medi-cal students (1). The integration of ultrasound educationinto the medical school curriculum is slowly evolving.At present, the exposure to ultrasound technology duringmedical school training is highly variable across theinstitutions. Some institutions have begun to integratea vertical ultrasound curriculum into their medical schoolcurriculum that includes both didactics and hands-ontraining sessions (2–4). In many institutions the curri-culum is usually limited to review of a few ultrasoundimages during their anatomy course. We believe thatultrasonography is a useful adjunct to the traditionalteaching methods, such as cadaver laboratories, inteaching Gross Anatomy. The objectives of this studywere to assess medical students’ perceptions ofultrasound use to teach Gross Anatomy along withtraditional teaching methods, and determine medicalstudents’ ability to identify sonographic neck anatomyafter focused didactic sessions.

METHODS

Study Design and Population

This prospective observational study was conducted at anacademic medical center between September and De-cember 2009. The study was approved by the InstitutionalReview Board (IRB). IRB-approved verbal consent pro-cess was followed to enroll subjects. All first-year medi-cal students enrolled in Gross Anatomy class wereeligible to participate in this study.

Study Protocol

The study was conducted in two phases. Phase I includedthree focused ultrasound didactic sessions integrated into

Gross Anatomy curriculum. The three 20-min didacticsessions were delivered over a 2-month period for thefirst-year medical students by three of the investigatorswith expertise in ultrasound. The PowerPoint (MicrosoftCorporation, Redmond, WA) presentations were madeavailable to medical students via the BlackboardAcademic Suite (Blackboard Inc., Washington, DC).The educational elements included ultrasound fundamen-tals, sonographic anatomy of the neck, anatomical varia-tions, and ultrasound-guided procedural skills. Theultrasound didactic sessions were coordinated with ca-daver laboratories during the course section devoted toneck anatomy. Ultrasound images (Figure 1) and videoclips were reviewed in the didactic sessions to familiarizemedical students with the ultrasound system, exposethem to sonographic anatomy, and provide a foundationfor performing ultrasound-guided procedures in futureclinical practice.

During Phase II of the study, medical students wereasked to complete a questionnaire. The questionnairewas developed based on current literature using standardsurvey methods. Three emergency physicians with exper-tise in ultrasound reviewed the questionnaire for facevalidity, relevance, and clarity. A five-point Likert scalewas used to assess agreement with statements regardingthe learning experience. Fourteen specific questionsaddressing medical student’s perceptions of the integra-tion of ultrasound teaching into their Gross Anatomycurriculum were included in the questionnaire. The ques-tionnaire also contained questions to assess the student’scomprehension of the ultrasound fundamentals and abil-ity to accurately interpret ultrasound images of vascularstructures in the neck.

Participation in this study was voluntary and had nobearing on a student’s standing in the course. A verbalconsent was obtained from the medical students beforeadministering the questionnaires. The questionnaireswere administered and collected anonymously to protectstudents’ confidentiality. The percentage of question-naires returned was tracked. One research assistantblinded to the study hypothesis entered all questionnairedata into an Excel database (Microsoft). To assess theaccuracy of data entry, a randomly sampled 20% ofquestionnaires were reentered by one of the investigators.

Measures

The primary outcomes were medical students’ percep-tions of ultrasound use for Gross Anatomy teaching.The secondary outcomes were accuracy of medicalstudents in interpreting ultrasound images of vascularstructures in the neck and answering questions relatedto ultrasound principles and sonographic anatomy. Theaccuracy was determined based on the responses

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provided to questions in the questionnaire. Ultrasoundimage acquisition skills were not evaluated in this study.

Data Analysis

Descriptive analyses were performed using SAS software(SAS Institute Inc., Cary, NC). Questionnaire responseswere reported as percentage of total respondents, alongwith 95% confidence intervals (CI). Continuous datawere presented as means with SDs.

RESULTS

One hundred nine first-year medical students participatedin this study. The questionnaire response rate was 91%.Data reentry by a second investigator showed 100%agree-ment. The majority of medical students (96%, 95%CI 92–99%) agreed that ultrasound-based teaching in-creased students’ knowledge of anatomy acquiredthrough traditional teaching methods. Ninety-six percent(95% CI 92–99%) felt that ultrasound is a useful adjunctin effectively demonstrating anatomical variations. Anoverwhelming number of medical students (99%, 95%CI 97–100%) agreed that it was beneficial to learnultrasound-based anatomy in addition to the traditionalmethods of teaching. Ninety-two percent (95% CI 87–97%) indicated that ultrasound-based teaching increasesconfidence to perform invasive procedures in the future.Ninety-one percent (95% CI 85–96%) felt it is feasibleto integrate ultrasound into the current Anatomy curricu-lum. Ninety-eight percent (95% CI 95–100%) expressedinterest in learning focused scanning if the ultrasoundequipment and expertise were available. The most com-mon barriers reported for the use of ultrasound to teachGross Anatomy were inadequate allocation of time forultrasound-based teaching in the Anatomy curriculum(68%, 95%CI 59–76%) and lack of ultrasound equipmentin the Anatomy department (87%, 95% CI 80–93%).

Ninety-eight percent (95% CI 95–100%) of medicalstudents accurately identified vascular structures onsonographic images of normal anatomy of the neck. Ona scale of 1 to 10, the average confidence level reportedin interpreting the images was 7.4 (95% CI 7.1–7.7).Approximately three-fourths (76%, 95% CI 70–84%) ofthe medical students reported no difficulty recognizingvascular structures. Overall, 94% (95% CI 91–99%)accurately answered questions about ultrasound funda-mentals and sonographic anatomy.

DISCUSSION

The cost-effectiveness and portability of ultrasound makeit an ideal tool to supplement traditional methods of GrossAnatomy instruction in medical school. Demonstration of

anatomy with ultrasound can augment the student’sknowledge of anatomy acquired through traditionalteaching methods while improving understanding of theclinical relevance of anatomical principles. Ultrasound-based anatomy instruction can also potentially increasethe student’s confidence in their ability to perform inva-sive procedures during residency training.

Prior studies have shown that basic ultrasound con-cepts can be effectively taught to medical students usingshort training courses (5). The use of ultrasound as an ad-junct to traditional teaching methods has been shown toimprove medical students’ physical examination skills(6,7). Decara and colleagues demonstrated that it wasfeasible for medical students to use hand-carried ultra-sound devices, and their use led to significantly more ac-curate bedside diagnoses (8). In a study done byTeichgraber et al., hands-on ultrasound workshops per-formed by medical students were successfully integratedinto an Anatomy course (9).

In our study, the majority of first-year medical studentsfound ultrasound didactic sessions to be very effective inteaching Gross Anatomy. There was a strong agreementamong medical students with the statement that it is bene-ficial to supplement traditional teaching methods with ul-trasound. The medical students have indicated that theywould like to gain experience in focused hands-on scan-ning and suggested that they were very interested in learn-ing more about ultrasound skills. Additionally, medicalstudents performed exceedingly well in ultrasound imageinterpretation and answering questions covering basic ul-trasound principles. This suggests that they can satisfacto-rily comprehend and apply ultrasound principles aftershort focused training sessions. Our questionnaire re-sponses indicated that students were enthusiastic about ul-trasound technology andbelieved that theywere benefitingfrom participating in the ultrasound didactic sessions.

The real-time and dynamic anatomic evaluation withultrasonography appeals to the current generation ofmedical students because it is technologically advancedcompared to traditional static teaching methods (10).Our study findings indicated that students were receptiveto establishing an ultrasound-based adjunct curriculum,and believed it will aid in their confidence to perform in-vasive procedures in the future. Our study also providedinsights into medical students’ perception of barriers toultrasound-based anatomy teaching, which can be usedto integrate ultrasound into medical school curriculum.Our results strongly support the integration of ultrasonog-raphy into the medical school curriculum.

Limitations

There were several methodological limitations, includinga small sample size. As with any survey study, results are

Ultrasound to Teach Gross Anatomy 1101

dependent on the validity of the self-reported data. Themedia resources of theAnatomy department at our institu-tion may not approximate that of their cohorts in other lo-cations. Our study was limited to teaching sonographicneck anatomy, and it will be useful to know if student per-ceptions of the use of ultrasound technology to learn anat-omy of other regions would be as equally positive.Another limitation was the amount of time available forthe ultrasound didactic sessions secondary to many didac-tic requirements of the first-year medical students duringtheir Gross Anatomy course. We did not evaluate long-term retention of ultrasound concepts taught during fo-cused didactic sessions.We also did not look at the overallimpact of early ultrasound exposurewithinmedical schooleducation. Future studies could focus on the long-termbenefits related to patient care from early exposure toultrasound technology during medical school training.

CONCLUSIONS

The majority of medical students felt that it is feasibleand beneficial to use ultrasound in conjunction withtraditional teaching methods to teach Gross Anatomy.Medical students were very accurate in identifying sono-graphic vascular anatomy of the neck after brief didacticsessions.

REFERENCES

1. Fox JC, Cusick S, Scruggs W, et al. Educational assessment ofmedical student rotation in emergency ultrasound. West J EmergMed 2007;8:84–7.

2. Hoppmann R, Cook T, Hunt P, et al. Ultrasound in medical educa-tion: a vertical curriculum at the University of South CarolinaSchool of Medicine. J S C Med Assoc 2006;102:330–4.

3. Cook T, Hunt P, HoppmanR. Emergencymedicine leads theway fortraining medical students in clinician-based ultrasound: a radicalparadigm shift in patient imaging. Acad Emerg Med 2007;14:558–61.

4. Rao S, van Holsbeeck L, Musial JL, et al. A pilot study of com-prehensive ultrasound education at the Wayne State UniversitySchool of Medicine: a pioneer year review. J Ultrasound Med2008;27:745–9.

5. Yoo MC, Villegas L, Jones DB. Basic ultrasound curriculum formedical students: validation of content and phantom. J Laparoen-dosc Adv Surg Tech A 2004;14:374–9.

6. Butter J, Grant TH, Egan M, et al. Does ultrasound training boostYear 1 medical student competence and confidence when learningabdominal examination? Med Educ 2007;41:843–8.

7. Barloon TJ, Brown BP, Abu-Yousef MM, et al. Teaching physicalexamination of the adult liver with use of real-time sonography.Acad Radiol 1998;5:101–3.

8. Decara JM, Kirkpatrick JN, Spencer KT, et al. Use of hand-carriedultrasound devices to augment the accuracy of medical student bed-side cardiac diagnoses. J Am Soc Echocardiogr 2005;18:257–63.

9. Teichgraber UK, Meyer JM. Poulsen Nautrup C, von RautenfeldDB. Ultrasound anatomy: a practical teaching system in humangross anatomy. Med Educ 1996;30:296–8.

10. Ivanusic J, Cowie B, Barrington M. Undergraduate student percep-tions of the use of ultrasonography in the study of ‘‘living anatomy’’Anat Sci Educ 2010;3:318–22.

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ARTICLE SUMMARY

1. Why is this topic important?The increasing use of bedside ultrasound by different

medical specialties creates the need for more ultrasoundeducation at the medical student level. Currently, medicalstudents receive minimal to no formal training in the useof bedside ultrasound.2. What does this study attempt to show?

This study attempts to assess perceptions of the medicalstudents of ultrasound use to teach Gross Anatomy in con-junction with traditional teaching methods, and determinetheir ability to recognize sonographic anatomy after fo-cused didactic sessions.3. What are the key findings?

A majority of medical students (96%) agreed thatultrasound-based teaching increased students’ knowledgeof anatomy acquired through traditional teaching methodsand is a useful adjunct in effectively demonstratinganatomical variations. Most of the medical students(>90%) indicated that it is feasible to integrate ultrasoundinto the current Anatomy curriculum and increases confi-dence to perform invasive procedures in the future. Over-all, a majority (98%) of medical students accuratelyidentified sonographic vascular anatomy of the neck.4. How is patient care impacted?

Medical student ultrasound education will ultimatelyimprove patient care by increasing their confidence andability to use bedside ultrasound in their daily clinicalpractice.