Background: Medical student ultrasound education is sparse. In 2002, we began the first medical student rotation in emergency ultrasound. Objective: To evaluate if medical students can learn and retain sonographic skills during a two- or four-week elective. Methods: We gave students an exam on the first and last days of the rotation. Six months later, students took the exam a third time. A control group was used for comparison. Results: Over a 19-month period, we enrolled 45 students (25 on the two-week and 20 on the four-week elective). The four-week student post-test score was significantly better than the two- week posttest score (81% vs. 72%, p=0.003). On the six-month exam, the four-week student post-test score was significantly better than the two-week post-test score (77% vs 69%, p=0.008). The control group did not statistically improve. Conclusion: Medical students can learn bedside ultrasound interpretation with clinical integration and retain the knowledge six months later

Anderson, Craig L

Barajas, Graciela

Cusick, Seric

Fox, J. Christian

Henson, Travis W.

Langdorf, Mark I.

McDonough, JoAnne

Scruggs, William

Zlidenny, Alexander

English

PubMed

Fox, J Christian

Henson, Travis W

Langdorf, Mark I

eScholarship - University of California

UC IrvineWestern Journal of Emergency Medicine: Integrating Emergency Care with Population HealthTitleEducational Assessment of Medical Student Rotation in Emergency UltrasoundPermalinkhttps://escholarship.org/uc/item/6k99630pJournalWestern Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 8(3)ISSN1936-900XAuthorsFox, J ChristianCusick, SericScruggs, Williamet al.Publication Date2007Copyright InformationCopyright 2007 by the author(s). All rights reserved unless otherwise indicated. Contact the author(s) for any necessary permissions. Learn more at https://escholarship.org/terms Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaWestern Journal of Emergency Medicine                                       84                                               Volume VIII, no. 3  :  August 2007 J. Christian Fox, MD, RDMSSeric Cusick, MD, RDMSWilliam Scruggs, MD, RDMSTravis W. Henson, MD Craig L Anderson, MPH, PhD Graciela Barajas, BSAlexander Zlidenny, MD, RDMS JoAnne McDonough, MD, RDMSMark I. Langdorf, MD, MHPE, RDMSEducational Assessment of Medical Student Rotation in Emergency Ultrasound Department of Emergency Medicine, University of California, IrvineSchool of MedicineSubmission history: Submitted May 8, 2007; Accepted July 9, 2007. Reprints available through open access at www.westjem.orgBackground: Medical	 student	 ultrasound	education	 is	 sparse.	 In	 2002,	we	began	 the	 first	medical	student rotation in emergency ultrasound. Objective: To evaluate if medical students can learn and retain sonographic skills during a two- or four-week elective. Methods: We	gave	students	an	exam	on	the	first	and	last	days	of	the	rotation.	Six	months	later,	students	took the exam a third time. A control group was used for comparison. Results: Over a 19-month period, we enrolled 45 students (25 on the two-week and 20 on the four-week	elective).	The	four-week	student	post-test	score	was	significantly	better	than	the	two-	week	post-test score (81% vs 72%, p=0.003). On the six-month exam, the four-week student post-test score was significantly	better	than	the	two-week	post-test	score	(77%	vs	69%,	p=0.008).	The	control	group	did	not	statistically improve. Conclusion: Medical students can learn bedside ultrasound interpretation with clinical integration and retain the knowledge six months later. [WestJEM. 2007;8:84-87.]BACkgROUND   Emergency physicians (EPs) have used bedside ultrasound for almost two decades1,2 with studies demonstrating its accuracy and utility.3-15 Bedside ultrasound is required for residency training in Emergency Medicine (EM)6 and is used in other specialties, but it is not routinely taught in U.S. medical schools. Several studies have evaluated emergency ultrasound (EU) curricula for resident and practicing physicians,	but	this	is	the	first	study	to	address	medical	student	learning in emergency ultrasound. 16-19			We	established	the	first	Emergency	Department	(ED)-based,	fourth-year medical student rotation for EU in 2002. We offer both two- and four-week rotations. Each week includes two	hours	of	didactics	and	five	hours	of	image	interpretation	review (approximately 100 scans), the content of which varied during the study period according to patient variability and didactic scheduling. Each student spent 40 hours per week in the ED performing bedside ultrasounds with supervision by resident and attending EPs. This EM group consists of several registered	diagnostic	medical	sonographer	(RDMS)	certified-	original researChVolume VIII, no. 3  :  August 2007                                                 85                                      Western Journal of Emergency MedicineTable 1. Primary Applications for Emergency Ultrasound (American College of Emergency Physician guidelines20)Focused Assessment of Sonography in Trauma (FAST)Ultrasound in pregnancy (intra-uterine pregnancy, fetal  movement, cardiac activityAbdominal Aortic AneurysmEmergency echocardiographyBiliary ultrasoundRenal ultrasoundProcedural ultrasoundphysicians and other EPs who hold hospital credentialing in the interpretation of EU. Each student had the opportunity to work with a variety of attending EPs, including the emergency ultrasound fellow and the director of emergency ultrasound. Purposes   We sought to determine if these rotations promote improved image interpretation and clinical integration, and whether these skills were retained six-months later. Furthermore, we hypothesized that students would score better after a four-week than a two-week rotation. METHODS   We prospectively enrolled medical students over a 19-month period at our academic, urban, Level I trauma center ED. Informed consent was obtained from each student. We designed a 35-question exam, covering the primary applications of EU as described in the American College of Emergency Physicians Emergency Ultrasound Guidelines (Table 1).20 In addition, we tested ocular ultrasound, detection of soft-tissue abscess, and deep venous thrombosis (DVT). Of the 35 questions, 13 assessed physics and image-acquisition techniques, 13 involved image interpretation with clinical integration, and nine were purely image interpretation, with the majority of the images demonstrating positive findings.	An	interactive	DVD	with	live	ultrasound	video	clips accompanied the exam (available on journal website at www.insertdvdtesthere.com). The university IRB committee approved the study.   We instructed students in ultrasound physics and instrumentation, and aortic, biliary, pelvic (transabdominal/endovaginal), renal, DVT, trauma, cardiac, soft tissue, and ocular ultrasound. Students also did four hours of DVD self-study in both rotations. Didactic and tape review instructors were	RDMS-certified	EM	faculty	and	fellows.	Finally,	students were encouraged to read a 500-page collection of selected ultrasound textbook chapters and research articles.			On	the	first	day	of	the	elective,	students	were	approached	for	enrollment whether on the two or four week rotation, andTable 2. Exam scores for control, and two and four week rotation students.Pre-test Post-test p=(t-test)Control (n=9) 43% 39% 0.116 (ns)2 week (n=25) 46% 72% < 0.0054 week (n=20) 47% 81% < 0.005* p=0.003 for post-test comparison of two and four week groupsTable 3. Exam scores of subset of two and four week rotation students who completed six-month follow-up, compared with the same students’ pre-test scoresSix-month follow-up scores p=(t-test)2 week (n=19) 69% < 0.00054 week (n=15) 77% < 0.0005* p=0.008 for post-test comparison of two and four week groupsbefore any ultrasound instruction. None refused. We planned to exclude students if they had prior ultrasound instruction or experience. None did. Students took the exam on day one	and	again	on	the	final	day	of	their	rotation.	Six	months	after the completion of the rotation, a follow-up exam with DVD was mailed to the students to be completed at their convenience. The same exam was used each time, but students were blinded to both the correct answers and their previous score. Students who completed the six-month exam received a gift card for a large, multi-national coffee chain. Nine students who did not take the emergency ultrasound rotation (control group) took the same exam on two occasions four weeks apart. We calculated p-values using the Student’s t-test, analysis of variance (ANOVA), and a linear regression model that included the pre-test score and a binary variable for the difference between the two and four week electives. Statistical significance	was	set	at	p	<	0.05.	RESUlTS   Over a 19-month period, we enrolled 45 students (25 on the two-week and 20 on the four-week elective). Their results are summarized in Table 2. Thirty-four of 45 students (76%) completed the six-month follow-up exam. Table 3 shows these results compared to the four-week group’s pre-tests.   There was no difference between pre-test scores in the three groups (p=0.688 by ANOVA). However, there was a statistically	significant	improvement	in	the	post-test	scores	for	the four-week group as compared with the two-week group (p=0.005), as well as six-month follow-up scores between the groups (p=0.008). These two comparisons were made using linear regression controlling for pre-test scores. Therefore, not Fox et al  Assessment of Student Rotation in Emergency UltrasoundWestern Journal of Emergency Medicine                                       86                                               Volume VIII, no. 3  :  August 2007 only did scores improve after the two and four week rotations, but both groups retained this improved performance at the six-month follow up.DISCUSSION			This	study	is	the	first	to	investigate	the	effectiveness	of	a	medical student rotation in bedside ultrasound in the ED. Such education is broadly applicable outside of EM, including obstetrics	and	gynecology,	surgery,	critical	care	and	office-based practices.  Our results demonstrate that students have a	significant	increase	in	their	ability	to	interpret	ultrasound	images and integrate them into clinical decision-making after a short period of training. Although the students on the four-week rotation showed a greater improvement than the two-week students at both the completion of the rotation and the six-month follow up, the two-week students nonetheless showed	a	significant	improvement.	These	results	suggest	that incorporating ultrasound education into medical school curricula is feasible and can be successful in a short rotation.   More than 32,000 emergency physicians practice in the United States, but only a small fraction are ultrasound trained. A recent survey documents that ultrasound equipment is consistently available in only 19% of U.S. EDs.21 The primary reason cited for this limited availability was lack of EP training. Our study of medical students suggests relatively short, focused periods of training are effective and may begin to bridge this training gap. lIMITATIONS   This study tested image interpretation and integration into patient management but did not test actual image acquisition. Therefore, we cannot comment on whether two or four weeks of	bedside	training	is	sufficient	to	develop	and	retain	these	skills. As our exam addressed clinical management of patients based	on	ultrasound	findings,	we	cannot	separate	ultrasound	skills from improved clinical acumen during the rotation. It is possible that students who chose a four-week elective in EU are more motivated to learn EM than those choosing two weeks, and this could account for the improved test performance. Furthermore, an inclusion bias may be present; the 76% that chose to complete the six- month follow-up examination may have been the same students who were more motivated during the rotation and had greater retention of information.    The examination focused on detection of  “positive” ultrasound	findings	suggestive	of	pathology.	To	most	accurately assess image-interpretation skills, a more thorough exam would have consisted of multiple normal, abnormal and indeterminate examples for each indication; however, the investigators were concerned that a lengthier exam could have decreased the completion rate. Given that the pre- and post-test were identical, we cannot exclude improvement in scores based simply on taking the same test twice. However, our control group, with no ultrasound training did not improve their test scores, making this confounder unlikely. Due to the variable nature of the ED patient population, the bedside ultrasounds performed by the students and the images available for review during the image interpretation sessions were not controlled for and may have affected individual student performance on questions evaluating certain applications.    We also did not control for the number of scans that either group performed, the random variability in the proportion of each type of scan performed by each student, or any ultrasound experience following the post-test but preceding the six-month follow-up examination. Finally, this educational study was performed at only one site, and therefore generalizability is limited.CONClUSION   This study demonstrates that medical students are able to acquire skills necessary for image interpretation of fundamental emergency ultrasound applications and integrate this into clinical scenarios. A four-week rotation is superior to a	two-week	rotation.	Students	are	able	to	retain	a	significant	amount of their training six months after the rotation. Address for correspondence: J. Christian Fox, M.D. Department of Emergency Medicine, University of California, Irvine, 101 The City Drive, Orange, California 92868. Email: jchristianfox@gmail.comREFERENCES1.   Jehle D, Davis E, Evans T, Harchelroad F, Martin M, Zaiser K and Lucid J. Emergency department sonography by emergency physicians. Am J Emerg Med. 1989; 7:605-611.2.   Heller M and Melanson SW. Applications for ultrasonography in the emergency department. Emerg Med Clin North Am. 1997; 15:735-744.3.   Blaivas M, Lyon M and Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med. 2005; 12:844-849.4.   Squire BT, Fox JC and Anderson CL. Abscess: applied bedside sonography	for	convenient	evaluation	of	superficial	soft	tissue	infections. Acad Emerg Med. 2005; 12:601-606.5.   Ma OJ, Mateer JR, Ogata M, Kefer MP, Wittmann D. and Aprahamian. Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma. 1995; 38:879-885.6.   Schlager D, Lazzareschi G, Whitten D and Sanders AB. A prospective study of ultrasonography in the ED by emergency physicians. Am J Emerg Med. 1994; 12:185-189.7.   Miller AH, Roth BA, Mills TJ, Woody JR, Longmoor CE. and Foster B.  Assessment of Student Rotation in Emergency Ultrasound Fox et alVolume VIII, no. 3  :  August 2007                                                 87                                      Western Journal of Emergency MedicineUltrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med. 2002; 9:800-805.8.   Kuhn M, Bonnin RL, Davey MJ, Rowland JL and Langlois SL. Emergency department ultrasound scanning for abdominal aortic aneurysm: accessible, accurate, and advantageous. Ann Emerg Med. 2000; 36:219-223.9.  Rodgerson JD, Heegaard WG, Plummer D, Hicks J, Clinton J and Sterner S. Emergency department right upper quadrant ultrasound is associated with a reduced time to diagnosis and treatment of ruptured ectopic pregnancies. Acad Emerg Med. 2001; 8:331-336.10. Costantino TG, Bruno EC, Handly N and Dean AJ. Accuracy of emergency medicine ultrasound in the evaluation of abdominal aortic aneurysm. J Emerg Med. 2005; 29: 455-460.11. Costantino TG, Parikh AK, Satz WA and Fojtik JP. Ultrasonography-guided peripheral intravenous access versus traditional approaches in	patients	with	difficult	intravenous	access.	Ann Emerg Med. 2005; 46:456-461.12. Frazee BW, Snoey ER and Levitt A. Emergency Department compression ultrasound to diagnose proximal deep vein thrombosis.  J Emerg Med. 2001; 20:107-112.13. Mandavia DP, Hoffner RJ, Mahaney K and Henderson SO. Bedside echocardiography by emergency physicians. Ann Emerg Med. 2001;38: 377-382.14. Kendall JL and Shimp RJ. Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians. J Emerg Med. 2001, 21: 7-13.15. Blaivas M. Incidence of pericardial effusion in patients presenting to the emergency department with unexplained dyspnea. Acad Emerg Med. 2001; 8:1143-1146.16. Jang T, Aubin C and Naunheim R. Minimum training for right upper quadrant ultrasonography. Am J Emerg Med. 2004; 22:439-443.17. Jang T, Sineff S, Naunheim R and Aubin C. Residents should not  independently perform focused abdominal sonography for trauma after 10 training examinations. J Ultrasound Med. 2004; 23:793-797.18. Jang T, Docherty M, Aubin C and Polites G. Resident-performed compression ultrasonography for the detection of proximal deep vein thrombosis: fast and accurate. Acad Emerg Med. 2004; 11:319-322.19. Blaivas M and Theodoro D. Comparison of perceived and actual times spent by residents performing ultrasound examinations on patients.  Acad Emerg Med. 2003; 10:397-399.20. American College of Emergency Physicians. ACEP emergency ultrasound guidelines-2001. Ann Emerg Med. 2001; 38:470-481.21. Moore CL, Molina AA and Lin H. Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography. Ann Emerg Med. 2006; 47:147-153.Fox et al  Assessment of Student Rotation in Emergency Ultrasound

Educational Assessment of Medical Student Rotation in Emergency Ultrasound

A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med.

A prospective study of ultrasonography in the ED by emergency physicians. Am J Emerg Med.

Abscess: applied bedside sonography infections. Acad Emerg Med.

Accuracy of emergency medicine ultrasound in the evaluation of abdominal aortic aneurysm. J Emerg Med.

American College of Emergency Physicians. ACEP emergency ultrasound guidelines-2001. Ann Emerg Med.

Applications for ultrasonography in the emergency department. Emerg Med Clin North Am.

Assessment of Student Rotation in Emergency Ultrasound Fox et alVolume VIII, n o . 3 :

Bedside echocardiography by emergency physicians. Ann Emerg Med.

Comparison of perceived and actual times spent by residents performing ultrasound examinations on patients. Acad Emerg Med.

Emergency Department compression ultrasound to diagnose proximal deep vein thrombosis. J Emerg Med.

Emergency department right upper quadrant ultrasound is associated with a reduced time to diagnosis and treatment of ruptured ectopic pregnancies. Acad Emerg Med.

Emergency department sonography by emergency physicians. Am J Emerg Med.

Emergency department ultrasound scanning for abdominal aortic aneurysm: accessible, accurate, and advantageous. Ann Emerg Med.

Incidence of pericardial effusion in patients presenting to the emergency department with unexplained dyspnea. Acad Emerg Med.

Minimum training for right upper quadrant ultrasonography. Am J Emerg Med.

Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians. J Emerg Med.

Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma.

Resident-performed compression ultrasonography for the detection of proximal deep vein thrombosis: fast and accurate. Acad Emerg Med.

Residents should not independently perform focused abdominal sonography for trauma after 10 training examinations. J Ultrasound Med.

Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography. Ann Emerg Med.

Ultrasonographyguided peripheral intravenous access versus traditional approaches in Emerg Med.

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Educational Assessment of Medical Student Rotation in Emergency Ultrasound

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