Simulators Role in Ultrasound Training

I believe the future of health care will involve the expanded use of diagnostic ultrasound, which will be accomplished through the use of an enhanced version of today’s handheld ultrasound scanner. I envision this “sono-scope” to be a wireless, lightweight, handheld imaging device with a long battery life and high-quality image capture that will expand the capabilities of the stethoscope.

The compact, portable ultrasoundpedersen_image scanners began entering the medical imaging marketplace around year 2000. Since then the market has grown dramatically, and the portable scanners have bifurcated into two broad groups: (i) The pocket-sized or handheld scanners (HHUS) and (ii) the larger, full-featured point-of-care ultrasound systems (POCUS).

These devices provide doctors with an extension of their senses and augment existing tools. But to be truly transformational, users need to receive ultrasound training from the beginning of their medical career, which will allow them quickly to “rule in” and “rule out” possible diagnoses and lead to earlier treatment decisions and/or more relevant further tests.

I maintain that the main barrier for making the HHUS (and POCUS) every clinician’s examination tool of choice, is not the technology, but rather the lack of opportunity to acquire and develop the needed scanning skills.

Thus, finding training strategies that enable the integration of ultrasound into medical schools is an essential step in overcoming this barrier. If the next generation of doctors had ultrasound for diagnosis and guided procedures as a vital part of their training, they would quickly develop a natural comfort with this tool and, with time, increasing sophistication. A parallel can be drawn regarding the attitude toward acquiring computer skills. As recent as 40 years ago, the operation of computers was thought to be limited to a select, carefully trained group of specialists. Today, nearly everyone is able to operate computers at some level.

Effective training in medical ultrasound requires both clinical knowledge (understanding of anatomy, physiology, and pathology) and scanning skills (psycho-motor skills, which are the integration of motion and the mental processes of recognizing anatomic structures in 3D from the 2D images). While both clinical knowledge and scanning skills are essential, the former is often emphasized at the expense of the latter because clinical knowledge can be delivered cost effectively and in flexible formats through online courses (including MOOCs), self-study, and in traditional classroom courses. Scanning skills, on the other hand, are acquired through hands-on experience, by examining patients, preferably both healthy and with symptoms, under the guidance of an experienced sonographer. Here, the medical educational enterprise does not currently have the capacity to meet this training need. There are too few scanners available for learners to use. There are too few patients or human subjects in general available for scanning. Last but not least, there are too few qualified instructors who can guide the learning.

There exists a potentially effective approach to overcoming this limitation in delivering scanning skills training: The use of ultrasound training simulators. Simulation provides a controlled and safe practice environment to promote learning. The efficacy of the simulator-based training is well-established. For example, human errors related to airline accidents have decreased in large part due to flight simulator training. Likewise, high-fidelity medical simulations have been shown to be educationally effective, as evidenced by the strong correlation between surgical simulator training and improved outcomes. Several studies have demonstrated the learning value of simulator-based training in diagnostic ultrasound.

Just as HHUS and POCUS have proliferated over the last 15 years, so have ultrasound simulator products. Some training simulators cover multiple clinical specialties, while others are designed for a specific application. Typically, the learner scans a physical manikin with a realistic-looking sham transducer, which produces an image on the display corresponding to the position and orientation of the sham transducer on the manikin, along with an anatomy display of the location of the image plane through the body.

An important component of the simulator design is the degree to which the simulator provides structured learning with guidance, interaction, and assessment. While all simulators include educational modules, only a few offer self-paced learning and competence verification. All in all, today’s ultrasound simulators are sophisticated devices that are capable of meeting training needs on basic and even intermediate levels. However, because the purchase price is sufficiently high (from $10K to more than $100K) sonography programs and simulation centers at larger hospitals are typically the only facilities able to acquire this technology.

When the medical community is ready to embrace ultrasound as an imaging modality of first choice for doctors from all specialties, I am convinced that technological innovation will lead to affordable, yet customizable and realistic training simulators. In particular, what is needed are portable and lightweight simulators that run on ordinary, modern PC/laptops, making personal ownership of a simulator possible as well as allowing medical schools to purchase such simulators in large quantities. For individualized training, it is essential that the simulator be task-based and able to verify the acquired skills level. To deliver the best realism, the image material should preferably be acquired directly from human subjects, and to provide the optimal development and assessment of psychomotor skills, the scanning practice on the simulator should resemble actual patient scanning as closely as possible. Such low-cost training simulators can lay the groundwork for building up such ultrasound skills both among practicing specialists and students enrolled in medical schools.

Have you/do you use simulators in your ultrasound training? What are the advantages or disadvantages? What would make simulation training better? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Peder C. Pedersen is Professor of Electrical and Computer Engineering at Worcester Polytechnic Institute.

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.