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National Ultrasound Curriculum For Medical.4
National Ultrasound Curriculum For Medical.4
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Baltarowich et al Ultrasound Quarterly & Volume 30, Number 1, March 2014
weaknesses far better than by passive examination of US Control buttons: freeze, save images, cine loop, measure
images. However, such hands-on experience should not be with calipers
expected to guarantee that students will become adept at
rendering diagnoses from images or become competent at Describe Advantages of Ultrasound
performing complete diagnostic US examinations, because the Real-time dynamic imaging (importance of real-time multiplanar
acquisition of such interpretive and scanning skills requires scanning; advantage of cine clips over static images)
prolonged exposure and dedicated practice. Such skills are Multiplanar imaging (nonstandard imaging planes)
typically acquired during a formal residency or fellowship.9 Portable
The intended audience for this curriculum includes US Lack of ionizing radiation
practitioners, departments of radiology, and deans of medical Lower cost
schools. We recognize that the proposed curriculum is a Improved soft tissue resolution compared with noncontrast
comprehensive one, and teaching all elements may not be computed tomography (CT)
feasible at any given institution. In particular, the inclusion Safe, noninvasive
of the ‘‘hands-on’’ portion is labor intensive. Introducing this
curriculum onto preexisting courses may increase the likeli-
Describe Limitations of Ultrasound
hood of successful implementation. Although it is not our Obese patients (attenuation, scatter, image degradation)
intention to dictate how medical schools may apply the cur- Impedance to transmission of sound waves: air (lung, bowel
riculum, by providing 2 different models (Appendices 1 and gas), bone, metal
2), we hope to stimulate medical school educators to consider Smaller field of view
its implementation. Operator dependence
The proposed curriculum has been organized as follows: Less interexamination reproducibility relative to CT
part 1 deals with content, part 2 with a mechanism for po- Correlate Patient Safety and Ultrasound
tential deployment over a 4-year period, whereas part 3 ad-
dresses how the curriculum meets the Accreditation Council Obstetrics: no ionizing radiation; however, US is not enter-
for Graduate Medical Education (ACGME) competencies, as tainment and thus should not be used to create a ‘‘pre-
modified for medical students. natal family photo album’’
Pediatrics: no sedation, no ionizing radiation
Gynecology: pelvic imaging in women of reproductive age
PART 1: THE NATIONAL ULTRASOUND US and magnetic resonance imaging are methods to reduce
CURRICULUM FOR MEDICAL STUDENTS ionizing radiation exposure
The curriculum is based on the AMSER National Heat deposition, cavitation: Doppler, gray-scale imaging
Medical Student Curriculum in Radiology.10 The following ALARA (as low as reasonably achievable) principle
sections outline goals for both preclinical and clinical years.
Identify Classic Appearances of Normal Structures
Preclinical on Ultrasound
Familiarity With the Basic Principles of the Liver, gallbladder, pancreas, spleen, kidneys, aorta, inferior
Physics of Ultrasound vena cava (IVC)
Analogy to SONAR Urinary bladder, uterus, ovaries, prostate
Image acquisition: sound transmission and reflection, scatter, Obstetrical scan: basic fetal anatomy (head, abdomen, heart-
acoustic window beat, limbs, umbilical cord, placenta, cervix)
Image optimization: depth, focal zone, time-gain compensa- Subxiphoid view of heart for pericardial effusion
tion, gain, field of view Femoropopliteal venous system (with and without compression)
Posterior acoustic properties: posterior enhancement (in- Internal jugular vein, subclavian vein (for venous access)
creased sound transmission), sound attenuation, acous- Carotid artery (relation to internal jugular vein, carotid bifurcation)
tical shadowing Diaphragm (hyperechogenicity and movement)
Artifacts: near field, reverberation, edge refraction, mirror image Normal lung (pleural line, sliding lung sign)
Terminology: echogenic, hyperechoic, hypoechoic, anechoic, Thyroid
isoechoic Musculoskeletal: tendon (principle of anisotrophy), muscle,
Characteristics of simple fluid, complex fluid, soft tissue/solid, surface of bone, joint fluid
air/gas, bone/calcium Note: Hands-on scanning is ideal and should be organized, if at
Imaging modes: B-mode (gray scale), Doppler (spectral, color, all possible. Students can scan each other under supervi-
and power), M-mode sion, which can be arranged with attending physicians,
staff sonographers, local school of sonography, and so on.
Knowledge of Instrumentation
Clinical
Basic probe and image orientation: sagittal, transverse, coronal
Transducers: frequencies, types (linear, curvilinear, sector, List Appropriate Indications for Common
transvaginal), near field, far field Ultrasound Examinations
Machine settings: transducer frequency, depth, focus, gain, time- (Students should be familiar with the ACR Appropriateness
gain compensation Criteria\ Web site as a general guide for all imaging studies)
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Ultrasound Quarterly & Volume 30, Number 1, March 2014 Ultrasound Curriculum for Medical Students
Characterization of masses (cystic, solid, complex) Fluid accumulations (pleural, ascites, hemoperitoneum, he-
Clinically suspected fluid accumulations (ascites, pleural ef- matoma, abscess)
fusion, pericardial effusion, abscess, hematoma) Gallstones, acute cholecystitis, biliary obstruction, hydronephrosis,
Evaluation of right-upper-quadrant (RUQ) pain abdominal aortic aneurysm, renal calculi, splenomegaly
Obstructive jaundice Overdistended urinary bladder, Foley catheter in urinary blad-
Clinically suspected appendicitis in children, young patients, der, enlarged prostate
or pregnant women Gynecology: uterine fibroid, thickened endometrium; hemor-
Suspected splenomegaly rhagic ovarian cyst, corpus luteum, ovarian cancer
Renal failure, hematuria, flank pain Obstetrics: first-trimester pregnancy complications (subchorionic
Screening (and following) abdominal aortic aneurysms hemorrhage, embryonic demise), ectopic pregnancy, pla-
Pelvic mass, pain, abnormal vaginal bleeding centa previa, incompetent cervix, polyhydramnios,
Obstetrics: abnormal bleeding, dating, heartbeat, fetal anato- oligohydramnios
my, decreased fetal activity, suspected ruptured mem- Acute deep vein thrombosis in femoropopliteal system, in-
branes, premature labor ternal jugular vein
Evaluation of palpable neck/thyroid mass Testicular mass, hydrocele, torsion, epididymitis, varicocele
Evaluation of scrotal pain, mass Thoracic conditions: large pericardial effusion (pericardial
Pediatrics: recurrent urinary tract infections, suspected neo- tamponade), paralyzed hemidiaphragm, pneumothorax
natal brain hemorrhage, abdominal or pelvic mass, ab- Pediatrics: intussusception, hypertrophic pyloric stenosis, in-
normal neonatal hip examination, tethered cord tracranial hemorrhage
Echocardiography: pericardial effusion with or without Note: These pathological conditions should be recognized in
tamponade, right-sided heart strain, valvular dysfunction, still images (lecture format); however, real-time images
cardiac/chamber enlargement, calculate ejection fraction (including cine loops) are encouraged.
Carotid bruit; evaluation of transient ischemic attack
Lower- or upper-extremity swelling or pain (suspected deep Describe Clinical Situations Where Ultrasound Is
vein thrombosis) Used to Guide Interventional Procedures
Evaluation of musculoskeletal pain (muscle, tendon, or other
Paracentesis, thoracentesis
superficial soft tissue origin), effusions, collections
Vascular access: peripherally inserted central catheter line,
Guidance for interventional procedures (see separate listing)
venous or arterial access
Observe the Following Ultrasound Studies Biopsies: liver, renal, transplant, breast, prostate, thyroid, lymph
nodes, masses
RUQ US (liver, gallbladder, bile ducts, right kidney, head of
Localization for aspiration and drainage: abscess, hydronephrosis,
pancreas)
cysts
Upper abdominal US (RUQ plus spleen, left kidney)
Musculoskeletal procedures: injections, aspirations, foreign
Aorta, IVC
body localization, biopsies
Pelvic ultrasound (transabdominal and transvaginal scans):
Amniocentesis, fetal therapeutic procedures
urinary bladder, uterus, ovaries, cul de sac, prostate
Sonohysterography, also known as SIS (saline infusion
First-trimester US (gestational sac, yolk sac, embryo, M-mode sonography)
heartbeat)
Pericardiocentesis (tamponade)
Second/third-trimester fetal US (fetal heart beat, placenta,
amniotic fluid, cervix)
Breast US (cyst vs solid, US-guided cyst aspiration or biopsy PART 2: IMPLEMENTATION
of mass, if possible) Incorporating the above curricular content into a 4-year
Thyroid US medical school curriculum has many challenges, including
Venous US (but certainly not limited to) competing content from multiple
- Upper- or lower-extremity deep vein thrombosis study fields of medicine, variability in the medical school curriculum
- Internal jugular vein and subclavian vein (versus com- structure, and limitations in time and resources for teaching
panion arteries; important distinction) hands-on skills such as US imaging.
Echocardiogram (basic views) The following examples for implementation of a US
Neonatal brain US (if possible) curriculum (offered as Appendices 1 and 2) provide a few op-
Carotid US (if possible) tions that have been developed at specific institutions and need
Biopsy guidance/fluid aspiration or drainage (if possible) not be used in their entirety, but serve as models that can be
Note: These studies may be observed on live patients, models, adapted and applied as deemed appropriate for each institution.
students scanning each other under supervision, recorded The majority of medical schools begin with a 2-year
examples, videos, and so on. didactic preclinical curriculum followed by 2 years of clinical
experience, as proposed by Flexner11 over 100 years ago.
Recognize or at Least See Classic Examples of Acknowledging this, the authors have divided the curricular
Common Pathological Conditions on Ultrasound content into ‘‘preclinical’’ and ‘‘clinical’’ sections, which assists
Cyst versus complex cyst versus solid mass (could be within in differentiating essential ‘‘preclinical’’ material best suited for
liver, spleen, kidney, ovary, breast, testis, thyroid) didactic presentations and the occasional workshop/laboratory
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Baltarowich et al Ultrasound Quarterly & Volume 30, Number 1, March 2014
versus the ‘‘clinical’’ material with ‘‘hands-on’’skills best suited Y pros and cons of US imaging to assess clinical problems
for clinical clerkships.12 Y accuracy of US for diagnosis of common diseases
Preclinical 2. Patient care: ‘‘Medical students should provide care that is
In the preclinical years, the US curriculum can be inte- safe, compassionate, and effective in diagnosis and man-
grated into the overall curriculum to supplement general un- agement of common health problems.’’
derstanding of anatomy, physiology, and pathology.13,14 This a. Diagnostic management skills
horizontal incorporation of a US curriculum is likely best Y how to choose the appropriate imaging examination
organized and implemented by a multidisciplinary group in- (ACR Appropriateness Criteria\).
cluding radiologists and other US specialists with the course Y importance of proper clinical information to interpret
directors of the anatomy, physiology, and pathophysiology US findings
preclinical courses. Hands-on sessions can also be incorpo- Y influence of patient variables on the US image: body
rated into a physical diagnosis course. Appendix 1 describes habitus, sex, age
such a course taken from a 4-year curriculum being piloted at Y difference between preliminary and final report
Harvard Medical School, Boston, Mass. b. Visual interpretation skills
Ideally, the curricular content would be taught in di- Y basic US anatomy: neck/abdomen/pelvis/vessels
dactic lectures and small-group sessions, enriched by the ex- Y recognize poor US technique
perience and contribution of US imaging experts. This would Y importance of prior images/correlative examinations
include 1 or 2 introductory lectures in US physics, image acqui- Y recognize classic critical findings
sition, indications, and limitations. Alternatively, some medical c. Image acquisition skills
schools may choose a more vertical approach, assigning spe- Y demonstrates the ability to image select normal anat-
cific hours to ultrasound imaging for didactics and workshops to omy in standard views, as outlined in the curriculum
cover the complete preclinical curriculum. By applying the con- d. Knowledge of US interventional procedures
structivist theory of learning,15 the content can be separated into Y biopsies; fluid drainages
several sessions over the 2 preclinical years to allow building on e. Patient safety and US exposure
prior content to improve understanding and retention. Y Doppler and potential for cavitation
Clinical Y appropriate use: US is not entertainment
Two models are outlined in Appendix 2. The first one f. Knowledge of new developments in US
offers graduated levels of exposure and imaging experience Y contrast enhanced US: potential uses
for medical students during third-year clerkships (Harvard g. Interacting compassionately with a patient
Medical School, Boston, Mass).16 A second model is more Y answering questions, explaining the examination
compact, organized as a dedicated 3-day program (Thomas Y how to give bad results
Jefferson University Hospital, Philadelphia, Pa). We offer both
examples but realize that ongoing graduate medical educa- 3. Practice-based learning and improvement: ‘‘Medical stu-
tion in US imaging will be necessary before competency is dent should continually seek to improve their knowledge
reached.17 With the current wide variability in clinical clerk- and skills by multiple means, be able to self-evaluate, and
ship requirements, it is conceivable that a student could apply new knowledge to his/her practice.’’
complete a medical school curriculum without ever directly a. Use evidence-based methods for selecting when to use
scanning a patient with US. Although not optimal, the authors US and what US criteria to apply to clinical problems.
recognize that US imaging is largely skill based and requires Y ACR Appropriateness Criteria\
significant experience to achieve competency. Y Society of Radiologists in Ultrasound consensus panels
on ovarian cysts, endometrial assessment, thyroid
nodule biopsy, carotid, shoulder, and first trimester
PART 3: ULTRASOUND AND MEDICAL STUDENT b. Research presentation topics appropriately using peer-
COMPETENCIES (ACGME SPECIFIC, MODIFIED, reviewed literature
FOR MEDICAL STUDENTS) Y prepare a PowerPoint presentation on a US topic
The curriculum must follow the ACGME-mandated c. Self-assessment modules
competency-based model of learning. The residency compe-
tencies have been modified for medical students.18 These have 4. Interpersonal and communication skills: ‘‘Medical student
served as a template, which we have subsequently applied to can communicate and interact effectively with patients and
US knowledge and practice. health care providers.’’
1. Medical knowledge: ‘‘The medical student should dem- a. calms anxious patients, obtains adequate history be-
onstrate basic knowledge of normal anatomy, disease fore doing a US examination, answers questions, ex-
processes, and US’’ plains findings, gives results to patients (or, observes a
a. General medical knowledge US specialist’s interactions with a patient in similar
Y normal anatomy circumstances)
Y disease processes b. presents US findings using PACS (picture archiving
b. Ultrasound specific knowledge and communications system) in the context of a clin-
Y outlined in the Ultrasound Curriculum ical conference with peers
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Ultrasound Quarterly & Volume 30, Number 1, March 2014 Ultrasound Curriculum for Medical Students
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Baltarowich et al Ultrasound Quarterly & Volume 30, Number 1, March 2014
9. Hertzberg BS, Kliewer MA, Bowie JD. Physician training requirements aorta/pulmonary relationships, pericardial space, limited
in sonography: how many cases are needed for competence? Doppler, and M-mode introduced.
AJR Am J Roentgenol. 2000;174:1221Y1227.
10. Lewis P, Shaffer K, Donovan A. AMSER National Medical Student b. Scanning time: identify 4-chamber view, A-V valves
Curriculum in Radiology: 2012. Available at: http://www.aur.org/
Secondary-Alliances.aspx?id=141. Updated February 21, 2012.
Accessed December 10, 2013. APPENDIX 2: CLINICAL CURRICULUM MODELS
11. Flexner A. Medical Education in the United States and Canada: A report
to the Carnegie Foundation for the Advancement of Teaching, Bulletin
Number 4 (The Flexner Report). New York, NY: The Carnegie Model for Third-Year Clerkships
Foundation for the Advancement of Teaching; 1910. At the start of the third year, a preparatory fundamentals
12. Bahner DP, Royall NA. Advanced ultrasound training for fourth-year of imaging course, based on clinical clerkships: internal medi-
medical students: a novel training program at the Ohio State University cine, surgery, obstetrics-gynecology/pediatrics, neurology, psy-
College of Medicine. Acad Med. 2013;88(2):206Y213.
13. Swamy M, Searle RF. Anatomy teaching with portable ultrasound to
chiatry, are taught. It consists of four 3-hour modules that
medical students. BMC Med Educ. 2012;12:99. include a short plenary introductory lecture and small-group
14. Dreher SM, Dephilip R, Bahner DP. Ultrasound exposure during gross discussions, organized by clinical symptoms with discussions of
anatomy. J Emerg Med. 2013:1Y10. differential diagnosis and appropriate imaging modalities.
15. Bruner J. Toward a Theory of Instruction. Cambridge, MA: Harvard
University Press; 1966.
Ultrasound is introduced, along with all other imaging
16. Di Salvo DN, Clarke P, Cho C, et al. Redesign and implementation of modalities, centered on clinical problems specific for each
the radiology clerkship: from traditional to longitudinal and integrative clerkship (several examples given).
[published online ahead of print August 28, 2013]. J Am Coll Radiol. 1. Imaging for Internal Medicine
2013. doi:pii S1546-1440(13)0031-3.10.1016/j.jacr.2013.05.018. Y chest pain/dyspnea (eg, pulmonary embolus: computed
17. Dubinsky TJ, Garra BS, Reading C, et al. Society of Radiologists in
Ultrasound resident curriculum. Ultrasound Q. 2014;29(4):275Y291. tomography [CT] pulmonary angiogram, lower-extremity
18. Lewis P, Donovan A. Radiology and the medical student competencies: Doppler US)
2012. Available at: http://www.aur.org/Secondary-Alliances.aspx?id=141; Y pleuritic chest pain (eg, pleural effusion: chest CT and
http://www.acgme.org/outcome/comp/compmin.asp. chest US)
Accessed December 10, 2013.
2. Imaging for Surgery
Y Right-upper-quadrant pain (biliary colic: US, abdomen CT)
APPENDIX 1: PRECLINICAL CURRICULUM MODEL Y Right-lower-quadrant pain (appendicitis: abdomen CT, US)
Ultrasound and Physical Diagnosis Course 3. Imaging for Obstetrics-Gynecology/Pediatrics
Y abnormal uterine bleeding (eg, endometrial hyperplasia: US)
‘‘Ultrasound in physical diagnosis’’ course (introducing
Y first trimester bleeding (eg, ectopic pregnancy or mis-
ultrasound [US] into a physical diagnosis course, allowing for
carriage: US)
small-group hands-on sessions). Students scan each other,
Y projectile vomiting (eg, hypertrophic pyloric stenosis: US,
models, or patients under direct supervision of fellows/at-
upper gastrointestinal imaging)
tending physicians/US specialists from pertinent clinical spe-
Y abnormal neonatal hip examination (eg, neonatal hip US,
cialties. These are five 2-hour sessions organized as follows:
plain film)
Session I. Physical Principles of Ultrasound/Intro to Scanning
Y premature neonatal brain hemorrhage (neonatal head US)
a. Short plenary lecture covering basic physics concepts (as
4. Imaging for Neurology/Psychiatry
per curriculum)
Y Transient ischemic attack (eg, head CT, carotid US)
b. Scanning time: students get introduced to the transducer
Y Worst headache (eg, subarachnoid hemorrhage: head CT,
and basic machine controls by scanning the neck and
transcranial Doppler)
identifying structures outlined in the curriculum
Session II. Abdomen US Additional opportunities for US teaching in year 3 for
a. Short plenary introduction to main abdominal organs schools with radiology clerkship or elective
b. Scanning time: students scan models and identify many 1. Students scan each other, under supervision of technolo-
of the structures outlined in the curriculum. Physical gist/radiologist, concentrating on recognizing structures as
findings (liver or spleen tip, aortic pulsation) are corre- outlined in curriculum. For schools with US simulators,
lated with US findings these may be utilized at this time.
Session III. Thyroid US 2. Students spend time observing in the US department,
a. Short plenary introduction by thyroid endocrinologist, under guidance of a staff member, and are brought in on
followed by US specialist all types of scans.
b. Scanning time: students scan patients, if possible 3. Students present cases of US examinations to a different
Session IV. Musculoskeletal US staff member using hospital PACS (picture archiving and
a. Short plenary introduction by musculoskeletal specialist communications system) to illustrate the findings.
b. Scanning time: students scan each other, or patients from 4. Students are matched with colleagues on a clinical clerk-
rheumatology, physical medicine and rehabilitation, or ship (this works best with obstetrics-gynecology or pedi-
sports medicine clinic atric clerkships) and are brought together for a combined
Session V: Cardiac US clinical-radiology conference. Student from clinical clerk-
a. Short plenary introduction by cardiologist, followed by ship presents a case; radiology clerkship/elective student
demonstration, emphasizing chamber and valve recognition, then shows images on PACS; discussion of management or
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Ultrasound Quarterly & Volume 30, Number 1, March 2014 Ultrasound Curriculum for Medical Students
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.