Ultrasound in Medical Education: How Far We’ve Come

Point of care ultrasound was an obscure elective during my medical school years, a poorly-attended vacation elective to fill the free time between the match and the first day of residency. At the time, the 2 Emergency Medicine attendings directing the course volunteered an expertise, which endured widespread disregard; their craft persisted, unappreciated by the department and hospital. These faculty had a unique passion, a vision of a paradigm shift in medicine that would save more lives, make better decisions, and improve overall care.

I was initially skeptical of that vision. When they expressed excitement over our new, $50,000 Micromaxx (considered a bargain at the time), it sounded to me like the typical exorbitant medical expense with marginal benefit, peddled by savvy sales rmorrow_image1eps. Then we caught our first tamponade in cardiac arrest during a pulse check and I was hooked: POCUS didn’t belong as one of those obscure hobbies limited to the especially nerdy, but was a vital diagnostic and procedural tool, to be learned and disseminated. I went through residency clearly enamored with the technology. To my dismay, early in my internship, we lost our ultrasound director. It was then that I found mentors in podcasts and through the Free and Open Access Medical Education (FOAMed) community.

By my final year of residency, nurses and attendings were calling on me to pause my work in my assigned pod to travel to theirs to help with US-guided procedures. Having identified the need, I started teaching residents and nurses US-guided procedures. The barriers to education were high-quality simulation phantoms, machine access, and educational time. Time we could volunteer, and for machines we begged and borrowed, but for phantoms, we hit a wall. I searched for answers in the young community of FOAMed but found few workable alternatives to the hundred-to-thousand-dollar commercial phantoms. It was at this impasse that I found inspiration from Mythbusters’ use of ballistics gel. I experimented with ballistics gel to create my own phantom and found it morrow_dsf8521to be an effective and practical alternative to the commercial phantoms. I was approached by several companies aiming to turn this into a money-making opportunity, but I felt this information needed to be shared. This skill was too critical to keep it locked up behind a patent. Instead, with the whole-hearted spirit of FOAMed, I published guides and answered questions and gave cooking classes.

I’ve continued to follow the vision of bringing bedside ultrasound to widespread use, from residency to fellowship, and now into my role as Emergency Ultrasound Director and Director of Ultrasound Education at the University of South Carolina School of Medicine Greenville. The future is bright: the FOAMed community is large and growing; US technology is being integrated into earlier stages of medical education; and pocket machines are bringing US in closer reach of the busy clinician. Ultrasound is moving into the hands of clinicians at the bedside and becoming an extension of our physical exam, and there is a growing literature base to support this trend. Someday ultrasound will take its rightful place next to the stethoscope, and my job as an “ultrasound director” will seem as foreign a concept as “director of auscultation.” The complementary forces of FOAMed and formal medical education will bring us to this future of safer procedures and greater diagnostic accuracy, and I am excited to be a part of it.

How have you seen ultrasound medical education change? What are your favorite FOAMed resources? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Dustin Stephen Morrow, MD, RDMS, is Ultrasound Director at Greenville Health System Emergency Medicine, as well as Director of Ultrasound Education at University of South Carolina School of Medicine Greenville. He can be found on Twitter: @pocusmaverick.

Why SonoStuff.com?

Three reasons:

As a co-director of technology enabled active learning (TEAL) at the UC Davis school of medicine I incorporate important technologies into the medical curriculum, which has primarily been point of care ultrasound (POCUS). Ultrasound is an incredible medical education tool and curriculum integration tool. It can be used to teach, reinforce, and expand lessons in anatomy, physiology, pathology, physical exam, and the list goes on.

I knew there was a better way to teach medical students thaschick_photo_1n standing in front of the classroom and giving a lecture. Student’s need to learn hands-on, spatial reasoning, and critical thinking skills to become excellent physicians. Teaching clinically relevant topics with ultrasound in small groups with individualized instruction
is the best strategy. I needed to flip the classroom.

I started by creating online lectures for an introduction to ultrasound lecture, thoracic anatomy, and abdominal anatomy:

Introduction to Ultrasound, POCUS

FAST Focused Assessment of Sonography in Trauma Part 1

FAST Focused Assessment of Sonography in Trauma Part 2

Aorta Exam AAA POCUS

Introduction in Cardiac Ultrasound POCUS

Topics quickly grew in scope and depth. I initially housed my lectures on YouTube and emailed them out to students before the ultrasound laboratory sessions. However, I wanted a platform that allowed for improved organization and showcasing. I needed a single oschick_photo_2nline resource they could go to to find those materials I was making specific to their medical curriculum.

https://www.youtube.com/channel/UCOhSjAZJnKpo8pP7ypvKDsw

Around the same time, during a weekly ultrasound quality assurance session in my emergency department I realized we were reviewing hundreds of scans each month and the reviewers were the only ones benefiting educationally from the process. Many cases were unique and important for education and patient care.

We began providing more feedback to our emergency sonographers and I decided I could use the same software I was using to develop material for the school of schick_photo_3medicine to highlight the most significant contributions to POCUS in our department every week. I quickly realized I needed a resource to house all these videos, one that anyone in my department could refer to when needed. The most efficient and creative method was to start a blog. I was discussing the project and possible names for the blog with colleagues and Dr. Sarah Medeiros said, “sounds like it’s a bunch of ultrasound stuff”. https://sonostuff.com was born.

I owe a great deal to free and open access to medical education or FOAMed. I was hungry for more POCUS education in residency and the ultrasoundpodcast.com came to the rescue. I became a local expert as a resident and even traveled to Tanzania to teach POCUS.

schick_photo_4I primarily began www.SonoStuff.com to organize and share with my department of emergency medicine and school of medicine, but it grew into a contribution to the growing body of amazing education resources that is FOAMed. I now use it as a resource in my global development work along with the many other FOAMed resources.

The work we all do in FOAMed, including AIUM’s the Scan, are an incredible and necessary resource. I have read the textbooks and attended the lectures, but I would not be where I am without FOAMed. I know all or most of those contributing to FOAMed do it out of love for education and patient care, without reimbursement or time off. Thank you to the many high-quality contributors and I am proud to play a small part in the FOAMed movement.schick_photo_5

Michael Schick, DO, MA, is Assistant Professor of Emergency Medicine at UC Davis Medical Center and Co-Director of Technology Enabled Active Learning, UC Davis School of Medicine. He is creator of www.sonostuff.com and can be reached on Twitter: ultrasoundstuff.

FOAMed Made Me A Better Lecturer

My glossy, relentless smile slowly began to sag. My enthusiasm waned. I asked myself, “Why are you even here?

Although that was the first time I actually asked the question, truth be told, it had been germinating in my brain for the past few months.FullSizeRender

It was during one particularly bland and unprepared lecture in my first year of medical school when I found it nearly impossible to read the deluge of text on the PowerPoint slide and listen to the speaker. Not only was I quickly losing interest, but the speaker appeared to be caught off guard by the content of his own slides.  The phrase “Why did I put that in this slide?” was uttered over and over again. Unfortunately, my despair was not limited to this one professor or this one lecture. In fact, getting a good lecture was more outlier than standard.

It was at that moment I decided to stop attending lectures. I figured since the speakers gave me access to their slides and all they were doing in class was reading the slides, I could stay at home and do just as well. As validation for this theory, my grades improved.

Shortly after graduating medical school, I was asked to give my first lecture as an intern. What did I do? I created a PowerPoint with bullets. That lecture went over about as well as those medical school lectures did: horribly.

While the content was acceptable, the presentation wasn’t engaging, and worst of all, it was boring. I found myself perpetuating the cycle and becoming a part of the problem rather than a solution.

For my next lecture, instead of focusing on the required content, I focused on my audience. Luckily I had a group of mentors who had grappled with this so I began to study not only the content of their lectures but also how they lectured.

Soon after, I discovered podcasts and the #FOAMed (Free Open Access Medical Education) movement. Inexplicably, I found I could watch an entire 20-minute talk online without checking my phone. For someone with the attention span of a small bird, this was no small feat.

I tried to emulate what I had been learning and observing for my next talk, and when I gave my next lecture to the residents, I found they were spending less time on their phones and computers and more time engaged in my lecture. After that experience, I immediately asked for more opportunities to lecture because I knew the only way to improve was to do more of them. While the residency was very accommodating, they were only able to give me a lecture every couple of months, and I needed more.

Since I couldn’t give lectures to our residents as frequently as I desired, I thought maybe I could practice on my computer. Initially, I figured I could record a few lectures and put them on YouTube. But the more I thought about it, the more I wasn’t sure this is how I wanted to distribute my content. I always got distracted when I went on YouTube. I would start looking for ultrasound videos and then somehow end up watching an hour of compilations of cats falling asleep and rollerbladers falling.

That’s when I thought about creating a website. I wanted a place where I could upload all of my lectures in an easy-to-navigate format, with minimal distractions. I remember reading somewhere that the average student attention span was approximately 10 minutes, so decided I was going to try and make my videos 5 minutes long to increase the likelihood that people would actually watch the whole video. That’s where 5-minute sono was born.

Eventually I purchased a USB microphone and paid for good screen capture software and began recording. Initially I wanted to focus on purely instructional videos without any mention of the evidence or current literature. This made it much easier to keep my content as short as possible, with the long-term plan to create a podcast where I could talk about literature as much as I wanted. Setting up a website to look good and work seamlessly is very difficult. Thankfully the ultrasound director where I went to residency is kind of a genius on that front. There have definitely been a few hiccups along the way, but overall the experience of been pretty amazing. This has taken a tremendous amount of work, but viewership has been steadily increasing, which is encouraging.  I still have a large amount of instructional 5-minute sono videos to create, but decided to start introducing more literature reviews in the form of a blog and podcasts. Soon I’ll begin my faculty position at the University of Tennessee in Chattanooga, Tennessee, Department of Emergency Medicine, and anticipate I’ll be able to lecture to the residents to my heart’s content. But that won’t stop me from continuing the steady stream of ultrasound instructional videos and supporting the FOAMed movement.

How do you make your talks more engaging? What are your favorite FOAMed resources? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jacob Avila, MD, is Co-fellowship and Ultrasound Director, Clinical Assistant Professor at the University of Tennessee in Chattanooga, Tennessee. To check out some of his FOAMed material, visit 5 Min Sono.

Kindred Spirits

The Peter H. Arger, MD, Excellence in Medical Student Education Award honors an AIUM member whose outstanding contributions to the development of medical ultrasound education warrant special merit. At the 2016 AIUM Annual Convention, John Christian Fox, MD, RDMS, FACEP, FAAEM, FAIUM, was presented with this award. Here’s what he had to say about this honor and the future of medical ultrasound education.

J Christian Fox 1

What does it mean to you to be named the recipient of the Peter H. Arger Excellence in Medical Student Education Award winner?

After I did some research about Dr Arger and spoke with others who know him well, I began to realize that he and I are kindred spirits. Even though we are from different generations and different specialties, we are actually very much aligned. His work in the 1990s, while disruptive at the time, paved the way for multi-specialty performance of quality ultrasound examinations through practice accreditation. Furthermore, he initiated the Endowment for Education and Research (EER) which had a tremendous impact on ultrasound in medical education. From this fund, the AIUM was able to finance the highly successful 2nd Annual Dean’s Forum on Ultrasound in Medical Education held at UC Irvine in June 2015. Specifically, EER provided support to bring deans from more than 40 medical schools to my campus where we broke into small groups and developed a 4-year curriculum of ultrasound in medical education.

Why have you volunteered so much of your time to the AIUM?

When I was a fellow in emergency ultrasound in 2001, I first heard about the AIUM and flew down to Orlando to check out the annual meeting. We kicked off the emergency ultrasound section with a small group of people and from that early experience I was struck by how people from various specialties would do their best to check their politics at the door and get to work on what our combined passion was: Ultrasound. The point-of-care ultrasound revolution that ensued would never have happened in my opinion if it wasn’t for the multi-specialty collaboration that AIUM so vehemently catalyzes. While we may be facing local battles, once we put that AIUM badge around our necks, everyone is great at collaborating in the name of research and education rather than engaging in politics. Maybe that sounds a bit rosy for some reading this but it’s my honest assessment of what brings me back to the AIUM year after year! Where else can I go to see world-class multi-specialty ultrasound research? So many cool projects have come from ideas that were created during these sessions. Where else can I learn from international masters teaching me the nuances of the art of ultrasound?

What do you see as the biggest barrier(s) to having ultrasound integrated into the medical education curriculum?

It’s funny because these barriers are not static. Initially I saw a lot of people struggling to justify ultrasound’s role in the curriculum. It takes a few deep discussions, and even some hands-on scanning, to get the Deans to reframe their concept of ultrasound. Well, now that’s ancient history (like 2 years ago) and now we face other burdens. I get the sense the Deans are frothing now to not be the last school to incorporate this, and now they need to find the cash and prizes. They need the funding to support the curriculum administratively and they need to get machines and simulation all dialed in. That’s no simple task as you can imagine, but they are Deans and that’s their job – to fund initiatives that have the most impact on the curriculum.

Tell us a little about your TED talk experience.

Oh it was intense. Hardest thing I’ve ever done for sure. As much as I’m kind of a ham and love public speaking, this was very difficult for me. I had to really get out of my comfort zone and become a perfectionist. Lots of rules, which required weekly meetings with my two coaches. One was helping me perfect the content while the other was working on my performance. Every sentence has to land perfectly. Too much pressure to put on someone who is more of a big picture kinda person than a detail-oriented person. But all that being said, it stands as my proudest speaking moment.

Who is your mentor and why?

I’ve had so many mentors over the years it’s really hard to answer this question because I firmly believe that mentorship relationships should really form organically, and not be assigned or they lack authenticity. I’ll start with my residency director who later became my Chair, Mark Langdorf. He single-handedly taught me emergency medicine and then gave me the idea to do an ultrasound fellowship. I remember packing my moving truck, and wondering to myself exactly why I was moving from Laguna Beach to Chicago but his guidance proved critical. Then my fellowship director Mike Lambert is the guy who I really sync’d up with and spent a ton of time emulating his laid back approach to life and work. To this day, every time I’m around him, my blood pressure drops. But what he taught me was the importance of image quality and instilled in me a love, or an obsession really, for all things piezoelectric. The other mentor that really helped shape my approach to edutainment and social media is not one person but a duo. It’s the ultrasoundpodcast.com guys Mike Mallin and Matt Dawson. I really look up to them and what they’ve done for point-of-care and their tenacity to keep all their content (books and media) Free and Open Access Medical Education (FOAM).

I’m Tired of Falling Asleep During Lectures

I remember the first test I failed. It was an immunology exam that I took about halfway through my first year of medical school. Seeking some solace, I asked a classmate for advice. His snarky response was, “Why don’t you try NOT sleeping through the class?”

sleeping in classHe did have a point, but I couldn’t help it. The professor was so incredibly boring. I couldn’t understand why he would spend so long talking about a study performed decades ago involving injecting mice with bacteria. How would this make me a good doctor?

I quickly found the solution to my problem: I had to stop going to class. Imagine that? The best way for me to get a medical education was NOT attending the courses–at least this particular course. It turns out I learned a lot better reading by the pool in sunny Southern California than in that big lecture hall. I soon discovered that many of my classmates were doing the same thing. Some read the textbooks at home or at a coffee shop. Some bought entirely different textbooks on the same subject. Some bought audio tapes for a particular subject. Of course some did prefer the classroom. In the end, we all passed.

Spending 4 years in college and 4 more in medical school makes you extremely sensitive to the lecturer’s delivery of the material. We spend years sitting in large groups in dark rooms quietly listening to someone on some stage talking at us. These days, most lecturers are reading off slides and within the first minute, you know what you’ve got yourself into.

Why do we subject our learners to someone standing behind a podium reading slides for an hour? Why do we think this works? Most likely it’s because very few people know there is a better way of doing things.

Our ultrasound instructor in medical school, Dr Chris Fox, likes to talk about “flipping the classroom.” Prior to our ultrasound didactics, he would give us access to an online podcast for the scanning technique of the day. We could watch it in pieces or all at once and we could watch it at any time and however many times we wanted. Best of all, we could pause, rewind and fast forward. We would then show up for a brief lecture consisting of a 5- to 10-minute review of the podcast where we could ask questions. Then we split up into groups to practice scanning.

That’s what I call efficient. And fun.

I’m now in charge of teaching my co-residents the same ultrasound skills I learned in medical school. Problem is, I don’t have a podcast series of lectures. In fact, I started with no lectures at all. Truth is, I could have devoted hours creating engaging, interesting, and effective PowerPoint slides. But, why should I reinvent the wheel when colleagues of mine from around the world have already developed these presentations? If I could use those, then I could focus on what I do best, which is teach the hands-on components.

Thank goodness for FOAM (Free Online Access Meducation). The term was coined in 2012 in the emergency medicine community and Life in the Fastlane has a whole page dedicated to its history and explanation.

Essentially, FOAM is a growing movement to provide high-quality and FREE medical education materials online for anyone to use. It’s a dream come true for any educator. Time to give a lecture? You could spend hours throwing together 60 slides for a lecture, but somebody else has already done it, and they’re REALLY good at it. Let them teach the lecture so you can use your time to practice and reinforce. Whether it’s an ultrasound technique or reviewing how to work up and treat chest pain, the principle is the same.

For me, using FOAM to teach residents is a lifesaver. Walking a learner through the machine and the exam technique comes natural to those with experience. Putting together a presentation to introduce it all to a big group requires time that I don’t always have. Plus, my proficiency in PowerPoint is limited and producing high-quality videos and images with overlaid anatomy takes considerable time, assuming you know how to do it.

Many of us know about FOAM resources already, probably just not the name. The Ultrasound Podcast is a fantastic resource with educational videos and challenges. There is also a smartphone app called One Minute Ultrasound for Apple and Android phones, which is a great on-the-go resource. The American Academy of Emergency Medicine (ACEP) runs Sonoguide.com with a whole host of resources. Another great resource is Sonomojo.org, which is a collection of FOAM resources for ultrasound. AIUM offers free resources and practice guidelines as well as teaching tools for members.

So let’s stop putting our students to sleep and start engaging them on their own terms. Give them the resources then use your time more effectively to get practical and work on procedural skills or problem solving. FOAM is there to guide the way.

How do you make your presentations engaging? Do you use any FOAM resources with teaching? If so, have you found it useful? Have questions about the future of FOAM? Comment below or let us know on Twitter: @AIUM_Ultrasound.

David Flick is a 3rd year family medicine resident at Tripler Army Medical Center. He received 4 years of ultrasound training at the University of California, Irvine School of Medicine. He currently runs the resident ultrasound curriculum and is an outspoken proponent for ultrasound training in the primary care specialties.

 

It’s All About The Students

A relatively new AIUM award, the Peter H. Arger, MD, Excellence in Medical Student Education Award honors an AIUM member whose outstanding contributions to the development of medical ultrasound education warrant special merit. At the 2015 AIUM Annual Convention, David Bahner, MD, RDMS, was presented with this award. Here’s what he had to say about this honor and the future of medical ultrasound education.David Bahner

What does it mean to you to be named only the second recipient of the Peter H. Arger Excellence in Medical Student Education Award winner?
I am very honored to be recognized by the AIUM and feel it is an honor to receive this award named after a pioneer in imaging, Dr Peter H. Arger.  Dr Arger’s passion for medical education and his commitment to ultrasound is well known.  It is my hope to continue those activities in medical education that Dr Arger pioneered in his work with the AIUM. Watching the first award winner, Dr Richard Hoppmann, receive this award last year was a thrill because it meant that the AIUM was recognizing the importance of medical ultrasound education. I am grateful for this great honor and hope to live up to the substantial role model Dr Peter Arger has been for this important area in ultrasound.

Why is ultrasound in medical education so important?
In the past, the feeling that ultrasound is operator dependent has been a drag on its impact within medicine. However, since medical education has been changing at many institutions because of electronic medical records, changes in curricula, and changes in technology, opportunities for point-of-care ultrasound now abound. Add to that the fact that ultrasound has become portable and affordable, and we see more operators embracing this modality. Unfortunately, the training for this device many times doesn’t starts until residency or even after clinicians have completed their medical training. By that time, however, the technology has outpaced the education. If the future can be planned to prepare 21st century clinicians to use this ultrasound tool, implementing this within medical school allows “pluripotent” students the ability to learn the foundations of ultrasound before entering residency.

What do you see as the biggest barrier to having ultrasound integrated into the medical education curriculum?
The lack of trained faculty either funded or supported in this process of training medical students is the biggest barrier to implementing ultrasound training in medical school. This lack of faculty is coupled with a “crowded’ curriculum where medical educators don’t see the benefit of adding ultrasound at the expense of removing other parts of the curriculum. The true insight is that ultrasound can be integrated into many parts of the medical student curriculum when both teachers and students embrace learning how to use ultrasound.  For example, anatomists learning how to scan or family practitioners working with ultrasound to guide procedures are possible solutions to these barriers.

You are a born and bred Ohioan. Why are people from Ohio so proud of Ohio?
It probably has something to do with the history of the state and how that has played into innovation, politics and competitiveness. Ohio is best known for the Wright Brothers who hailed from Dayton and used their hard work and innovation to change the 20th century with the discovery of lift and flight. Politically it has been an influential state in most presidential elections. Plus, 6 presidents are from Ohio. Ohioans are fierce competitors and extremely proud of the 16 national football championships earned by The Ohio State University. Oh, and the Pro Football Hall of Fame and Rock and Roll Hall of Fame are located within Ohio. We have a lot to be proud of.

Personally, my family grew up in Ohio and I feel a bond with the change of seasons, the geography, the history, the people, and the culture of hard work and helping others. I am an American, an Ohioan, a doctor, an educator, an innovator, and a Buckeye.

What role does or should ultrasound play in medical education? What are you proud of? Where did you learn your ultrasound skills? Comment below or let us know on Twitter: @AIUM_Ultrasound.

David Bahner, MD, RDMS, is Professor and Director of Ultrasound in the Department of Emergency Medicine at The Ohio State University College of Medicine.

Because Adults Need to Play

One of my favorite TedMed 2014 talks is by Jill Vialet, CEO and Founder of Playworks titled “The Power of Play”.  In it Jill describes how people and circumstances are transformed through play. There is actually a physical and mental function which play serves in our daily lives. When I first began educating health care providers in ultrasound internationally, I noticed this. Amidst directing and organizing courses–alternating lectures first, then lectures last; hands-on stations first with flipped classroom pre-class; a half-day course; a two-day course; or even a three-day course. The combination matrix never really mattered and the post-course evaluations never varied.

SonoGames 3However, one key piece of each course always ensured a winning recipe for sealing the learners’ knowledge and ending on a greatly positive note.

That was the final day’s game of Jeopardy®.

Yes, splitting the adult course attendants in two competing teams and having them play a game. Despite the relatively benign prize of candy, having them play promised a room full of noise, laughter, positive feelings, and raving post-course evaluations.

From India, Ireland, Sri Lanka, and Ghana, it didn’t matter the country. It didn’t even matter if they knew the rules of the game. What mattered, and what made the course, was play. This was true for the learners as well as the educators.

As the president of the Academy of Emergency Ultrasound (AEUS) of the Society for Academic Emergency Medicine (SAEM) in 2011, I was allotted 4 hours of conference time to plan as I wished. I immediately saw this as an opportunity to create and innovate. I envisioned a 4-hour game event of fun, focused ultrasound education, and resident competition. My friend Y. Teresa Liu, M.D. (Harbor-UCLA Medical Center) had told me about running an ultrasound game event with our mutual good friend David Bahner, MD. (the Ohio State University Medical Center).  I conferred with my education officer Andrew Liteplo, MD. (Massachusetts General Hospital).  He loved the idea.

The SonoGames® was born.

Since that first year, we have increased the aspects and the intensity of play. This past year, the organizing committee dressed in costume commensurate with the conference city. There was a best team costume competition, a best team name award, and the teams competed for medals and for the opportunity to bring the SonoCup to their home institution.

I am convinced that the success of this event is due to its focus on play and fun. We are now planning for the 2016 SonoGames® and I suspect there will be even more play, fun, laughter, and learning.  If you want to learn more about the details of how we structured the games, check out the article that appeared in the Journal of Ultrasound in Medicine. And, if you think you are up to the challenge, get your 3-member ultrasound-savvy team ready to compete!

How do you play? What other ideas do you have to incorporate play and ultrasound? Have you ever competed in an ultrasound event? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Resa E. Lewiss (@ultrasoundREL) is the Director of Point-of-Care Ultrasound at the University of Colorado. She has published on medical education and Point-of-Care Ultrasound. Check out her TedMed2014 talk.