ORIGINAL ARTICLE | Scoping Review of Implementing a Longitudinal Curriculum in Undergraduate Medical Education: The Wake Forest Experience.

INTRODUCTION

The integration of hands-on ultrasound experience has become a highly desirable component for undergraduate medical education (UGME) curricula throughout the United States. Several schools have implemented a student-performed ultrasound experience to a variable degree throughout the formal 4-year medical school program. Other individual medical specialties have incorporated ultrasound into their electives highlighting ultrasound based clinical applications.

Along with the integration of hands-on ultrasound in medical education, programs have described the impact of ultrasound integration in medical education curriculum in helping enhance traditional learning of anatomy, medical physiology, and clinical skills of their medical students.

The purpose of this article was to describe the challenges, successes and impact in integrating ultrasound into UGME pre-clinical and clinical years. The authors are hopeful that this manuscript could help inform future UGME program development for schools exploring ways to improve their undergraduate programs.

METHODS

The electronic database PubMed, MEDLINE and the Cochrane Library in English literature were searched for the words “Ultrasonography”, Ultrasound”, with the Boolean operators AND “Medical education”, “Undergraduate”, “School”, “clerkship” AND “Curriculum”.

This data was supplemented by open internet search through Google search engine for other curricula using the search words: “Ultrasonography”, Ultrasound”, with the Boolean operators AND “Medical education”, “Undergraduate”, “School”, “clerkship” AND “Curriculum”.

Search methods conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews.

RESULTS

This search yielded a total of 9,753 results. The review of titles and abstracts narrowed the results and full texts were reviewed by two independent authors. Design, implementation, and assessment of ultrasound education were described at 18 different institutions.

Most schools incorporated ultrasound into 1–2 years of UGME but few describe a vertical four-year medical school ultrasound curriculum. A majority of undergraduate medical school programs incorporated ultrasound instruction in the pre-clinical years by offering it concurrently with gross anatomy, physical examination, or clinical skills courses or integrating it into similar existing courses in the form of modules.

Consistent training and practice during the clinical years was uncommon. When schools did offer electives or “selectives” in ultrasound, ultrasound education was targeted to a specific specialty that has significant clinical integration of ultrasound (e.g., radiology, obstetrics, emergency ultrasound, etc.) and available to all third- or fourth- year students interested in that specialty.

Instructional formats

The format of information delivery across the various programs varied greatly: hands-on sessions, open-access podcast lectures, didactics, web-based learning modules, video assignments, workshops, scanning demonstrations, large and small group sessions, clinical learning through cases, field hospital visit, and independent scanning.

A universal characteristic of almost all these programs was delivery of instructional material in a multimodal format, usually as a combination of the methods listed above. Other shared components included the use of the “flipped classroom” instructional method and formal introductory modules for ultrasound imaging and application.

Integrated ultrasound curriculum development at wake forest school of medicine

The authors describe at length the Wake Forest School of Medicine (WFOSM), including the pre-clinical structure, as well as ultrasound training integration throughout medical school. In short,

frequency and duration of ultrasound didactic modules and labs was designed to focus on the use of ultrasound as a “clinical tool” to teach pre-clinical students anatomy in Year 1 and physiology in Year 2 with minimum course scheduling changes in existing structure.

In years 1 and 2 of the preclinical curriculum, the ultrasound curriculum was conceptualized in a “flipped classroom” model to include didactic instruction through online modules followed by laboratory component with hands-on ultrasound training labs with greater emphasis on experiential learning.

Year 3 clinical curriculum also followed the «flipped classroom» model with content focused on clinical concepts corresponding to the clinical clerkship. After an online review of lectures reorienting students to relevant ultrasound anatomy and physiology, one-hour sessions are organized by physicians during the clinical clerkships under the guidance of the ultrasound curriculum leadership. The sessions are designed to focus on structured bedside exams commonly used by providers in the patient care environment. In rotations like obstetrics, ultrasound was focused on pregnancy and fetal pig phantoms were used to highlight clinical concepts. Following formal didactic and laboratory sessions, students are encouraged to participate in bedside ultrasound exams as opportunities arise during their clinical clerkship.

The final year of ultrasound curriculum for year 4 was added as a POCUS elective unique to a handful of programs. The focus of this 4-week elective is hands-on experience designed to improve bedside image acquisition and skills in point-of-care examinations. Students rotate in emergency and critical care settings in the first two weeks and subspecialty experiences in the final two weeks to increase the awareness of clinical applications of ultrasound in diagnostic and point-of-care use across various subspecialties. Elective rotation settings include: Emergency Medicine, Neurology, Medical-Critical Care, Neurocritical Care, Cardiology, Obstetrics and Gynecology (OB/GYN), Trauma Surgery, Vascular Surgery, Pediatric Cardiology, Internal Medicine, Community Medicine, and Sports Medicine.

CONCLUSION

The authors concluded that ultrasound integration can be a useful assistive educational method in undergraduate medical education but limited by resource intensive set up and high variability of program integration into UGME curricula.