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Vertical Curriculum

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  • 1. Using Hand-Held Ultrasound to Enhance Pre-Clinical Medical School Curricula Mary Beth Poston, MD, MSCR University of South Carolina School of Medicine Columbia, SC
  • 2. Workshop Outline • Background – Ultrasound in medical education • integrated UltraSound Curriculum (iUSC) – Ultrasound Vertical Curriculum • Ultrasound in the Pre-Clinical Years – Curriculum Content – Evaluation – Resources
  • 3. Learning Objectives • To discuss the new role of hands-on learning in medical education • To demonstrate how one medical school has implemented a vertical curriculum in ultrasound technology • To demonstrate specifically how this complements learning in the Pre-Clinical curriculum • To demonstrate the ease with which these techniques can be taught and learned
  • 4. Why Ultrasound?
  • 5. Ultrasound in Medical Education • Expansion of hands-on learning, simulation in education • Using ultrasound as an adjunct to physical exam skills has been shown to be an acquirable skill for medical students – Identification of cardiac pathology – Abdominal ultrasound • Ultrasound technology as part of some residency training programs – FAST exam in Emergency Medicine training
  • 6. Comparison of Hand-Carried Ultrasound to Bedside Cardiovascular Physical Examination Kopal SL, et al. Am J Cardiol 2005 • Two first year medical students • 4 hrs of lecture and 14 hrs of hands-on experience • Students outperformed 5 board-certified cardiologists in identifying cardiac pathology in 61 cardiac patients • Students identified 75% of the pathologies and cardiologists identified 49%
  • 7. British Medical Journal May 2008 – Feature Article on Ultrasound Education Dr Giles Maskell, radiologist at the Royal Cornwall Hospital in Truro, believes ultrasonography should be taught to everyone in medical school: "It is a fantastic tool and every medical student should be taught to use ultrasound like they are taught to use a stethoscope”. “This is already happening at one medical school in the United States. The University of South Carolina is pioneering a project to train all medical students in ultrasonography.”
  • 8. iUSC • Class of 2010, first fully trained in ultrasound vertical curriculum • In 2006, USCSM introduced the ultrasound curriculum in the basic science years • In 2007, this was expanded to the clinical years
  • 9. USC-SOM Vertical Curricula • Ethics and Professionalism • Genetics • Geriatrics • Nutrition • Substance Abuse • Ultrasound
  • 10. Vertical Curriculum • Defined as “the interdepartmental integration, in basic science courses and clinical rotations over the course of the four-year curriculum, of topical subject matters that transcend the purview of an individual USC-SOM department” • Distinguishable from “horizontal integration” in that the latter attempts to teach similar preclinical topics simultaneously even if in different required courses
  • 11. Vertical Curriculum - Oversight • Overseen by individual VC directors • Also overseen by the Interdepartmental/ Interdisciplinary Integration Subcommittee of the Curriculum Committee, which – Conducts periodic reviews and updates of vertical curricula – Ensures the integration of interdepartmental and interdisciplinary educational efforts – Oversees initiation and maintenance of a curricular tracking system
  • 12. Vertical Curriculum - Tracking • Mapping within curriculum data base helps with oversight • Overarching and course specific objectives for each of the vertical curricula are included in the curriculum data base • Methods of assessment are outlined in the curriculum data base
  • 13. Vertical Curriculum - Ultrasound • M1 – taught in conjunction with Gross Anatomy and Physiology • M2 – expansion of M1 curriculum, coordinated with lecture topics in Pathology/Pathophysiology and Physical Diagnosis • M3 – most core clerkships have an ultrasound learning component and OSCE – IM – thyroid, central line placement – OB/Gyn – pregnancy with bleeding – Surgery – FAST exam – Family Medicine – AAA – Pediatrics - HOCM, situs inversus, dehydration • M4 – Review of essential skills – Elective in emergency bedside ultrasound – Capstone workshop
  • 14. Ultrasound in the Pre-Clinical Curriculum
  • 15. M1 Curriculum • Fall Semester – Gross Anatomy – Introductory lecture during Orientation – “Knobology” – Cardiac ultrasound – Neck ultrasound (carotid artery, internal jugular vein, thyroid) – Pelvic ultrasound (urinary bladder) – Abdominal (hepatic, spleen, renal) ultrasound • Evaluated with Objective Structured Clinical Examination (OSCE)
  • 16. M1 Curriculum • Spring Semester – Physiology – Vascular hemodynamics (introduces concepts of color flow and doppler to demonstrate direction of flow and measurement of velocity, recognition of arterial and venous wave forms) – Cardiac hemodynamics (normal function) Wall and valve motion, flow through cardiac chambers – Evaluating for cardiogenic shock: gross LV/RV function and size, gross valve function • Evaluated with the addition of case-based multiple choice test questions to standard Physiology quizzes and tests
  • 17. M2 Curriculum • Coordinated with Introduction to Clinical Medicine (ICM) • Fall Semester: Physical Diagnosis – All standard cardiac views – General abdominal ultrasound • Pathophysiology – Abdominal aorta (AAA screen) – Lower extremity vascular (DVT screen) • Evaluating based on Web-based modules with multiple choice questions, “open book” multiple choice quiz
  • 18. M2 Curriculum (ICM) • Spring Semester – Pathophysiology – Pelvic ultrasound (female gynecology) – Vascular ultrasound (inferior vena cava for volume status estimation) – Cardiogenic shock – Ultrasound guided procedures – (uses ultrasound phantoms) • Evaluated with OSCE
  • 19. Delivery of Course Content Ultrasound Labs • Primarily hands-on labs: 1 hour groups – May have brief (max 30 minutes, usually less than 10 minutes) pre-lab lecture/demonstration – Occasional (usually no more than 1/semester) longer classroom lecture for complex topics – Group size of ~ 20 students, 4 faculty preceptors, 4-5 standardized patients – 2-4 “open lab sessions”/semester, 2 hours each, staffed by iUSC faculty (1 or 2 faculty per session)
  • 20. Web-based Modules • Cover a wide range of topics from ultrasound physics to specific clinical indications • Demonstrate relevant technique plus discuss evidence based guidelines for use of ultrasound in the clinical setting • Include ultrasound images and loops • Generally 12-15 minutes in length
  • 21. Web-based Module: Demonstration • http://media.med.sc.edu/ultrasound_institute /M2/11B/player.html
  • 22. Pre-Clinical Ultrasound Curriculum Assessment of Skills • OSCE is standard testing format with standardized patients, M1-M4 • Must demonstrate – Understanding of technology (M1-M4) – Ability to acquire images (M1-M4) – Ability to interpret findings in context of patient history and physical exam (M3-M4) – Ability to use findings appropriately in planning patient care (M3-M4)
  • 23. Additional Measures in Pre-clinical Curriculum: Standard Multiple Choice Questions • May be incorporated into quizzes and tests for the course with which the curriculum is paired • Can create “stand-alone” quizzes • Can incorporate questions with other learning materials (web-based modules) • Questions usually include cases and/or images
  • 24. Pre-Clinical Ultrasound Curriculum Assessment of Impact • Student surveys/Focus Groups • Controlled studies
  • 25. Survey/Focus Group Questions: % Strongly Agree/Agree M1 M2 Year 07 08 09 Year 07 08 09 US enhanced my ability to learn basic Gross Anatomy (M1)/allowed for increased clinical correlation with basic science instruction (M2) 94 88 61 81 94 90 US faculty is knowledgeable 98 100 95 95 99 100 I found the hands on lab sessions with standardized patients helpful in learning US 97 97 88 91 100 87 I found the open lab sessions (practicing scanning each other) helpful in learning US 96 100 83 58 55 88 I found the overall educational experience in US enhanced my medical education 100 95 90 85 97 96 I would like to see more US in the curriculum 92 76 50 70 84 64 Able to achieve a basic skill level (M1)/improve my US scanning skills (M2) 100 100 97 87 96 94 M2 ONLY: Found online learning modules helpful US enhanced skill/understanding of the physical exam 40 51 38 78 92 90
  • 26. Controlled Study of Comparative Performance on Gross Anatomy Multiple Choice Quiz • 3 predefined dissection groups: – Group A: Anterior wall – Group B: Viscera – Group C: Posterior wall • Half of each group randomly assigned to additional abdominal ultrasound exposure during abdominal dissection
  • 27. Controlled Study of Comparative Performance on Gross Anatomy Multiple Choice Quiz • Performance on 25 question quiz compared – Questions from pre-existing test bank utilized in the usual fashion – Prior to test administration, Ultrasound and Gross Anatomy faculty reviewed quiz and identified 6 questions thought to be related to Ultrasound Concepts
  • 28. Controlled Study of Comparative Performance on Gross Anatomy Multiple Choice Quiz: Results – Intervention group (n=53) – Control group (n=50) – Multiple comparisons explored (US vs no US within and across dissection groups) without a clear pattern of significant differences (though in most comparisons US scores slightly higher) – Additional comparisons planned controlling for overall Gross Anatomy grade Mean difference (+/- SD) Significance All 25 questions 0.786(+/-1.597) ns 19 “non US” questions 0.397(+/- 0.96) ns 6 “US” questions 0.355(+/-1.79) P<0.1
  • 29. Resources: Faculty Recruitment and Development • Faculty are across many clinical specialties: – Emergency Medicine – Internal Medicine and related subspecialties – Family Medicine – Pediatrics – Radiology • Recruited on the basis of interest • Offered brief course in basic US (via our EM department or iUSC), additional training sessions occur sporadically • Most learning is “on the job”
  • 30. Learning Objectives - Revisited • You should now – Understand the new role of hands-on learning in medical education – Know how one medical school has implemented a vertical curriculum in ultrasound technology • And have the confidence to consider such at your own institution – See the ease with which these techniques can be taught and learned
  • 31. Thank You! Ultrasound Demonstration Available Many thanks to Victor Rao, Lance Paulman, Erika Blanck, Duncan Howe, Stanley Fowler and Richard Hoppmann