#AIUM13 for an EM doc: Part 1- All about Ultrasound in Medical Education- by the experts & EBM review #FOAMed

The American Institute of Ultrasound in Medicine (AIUM) 2013 conference in New York City was the best AIUM I have ever been to, and it continues to open up my mind (having my ideas run wild!)  to so many things that ultrasound will do for medicine, while reminding me of the up-to-date studies that clarify many ultrasound-related topics in medicine. It is true that Ultrasound should be considered first with many conditions, and as an emergency physician, point-of-care bedside ultrasound is definitely an example of that. It absolutely should also be implemented into medical school education to have a head-start at becoming an excellent physician. AIUM has an emergency and critical care section too and I have taken full advantage of the information there, as should you. (Jason Nomura has gathered all AIUM13 tweets for your reading pleasure for all AIUM13 topics)

IMG_1144 YOU = Year of Ultrasound!

This post is a one part of a 4-Part Series where I discuss all the lectures, panel discussions, and events that i attended there, and what every emergency doctor should get out of it, and the literature that backs it up or discusses the controversy – all through my and other’s twitter feed with the addition of some links to relevant material.

The first day was one of my favorites! It was the Ultrasound in Medical Education panel discussion from the experts, coordinated by Dr David Bahner, who has recently published study after study after study after study with regard to how he incorporated ultrasound into medical education and how to standardize ultrasound education. You can even listen to and view the whole course if you have an AIUM membership, by going here. Dr. Richard Hoppman, the Dean of University of South Carolina, who has also published study after study after study after study on this topic, also gave his pearls and wisdom from the Dean’s perspective. (Hear/View his interview with UltrasoundPodcast by going here.) Other experts also gave their expertise in this hot topic, as they have also published and highlighted study after study after study after study as shown below in the tweet and panels’ pearls from the course (as well @SonoMedED tweets who provided more highlights for the course): Ultrasound in Medical Education (I posted on the comparison of Ultrasound to physical exam previously – but there is so much I need to add to it now!)

AIUM’s Ultrasound First Declaration- Integration of US into Medical School Curricula

a. Provide clinicians with resources to guide medical student training in clinical ultrasound to better provide care for their patients

b. Provide educators with the resources and tools to coordinate clinical ultrasound in medical curricula

c. Provide researchers with evidence based resources to create and validate new knowledge through innovative and rigorous academic pursuits

d. Provide administrators with data and contact personnel at respective medical institutions who are applying novel ultrasound education across the medical spectra

e. Provide medical students with a one-stop portal to navigate current United States medical student ultrasound education and opportunities to get in school

1. David Bahner – This would involve changing curricula, training faculty, acquiring equipment, support staffing, quality assurance, OSCE or SDOT, establish “best-practices.” In 2004, the medical organizations differentiated & defined ultrasound into four categories: Comprehensive, Focused, Procedural, Physical exam aid

2. D. Lichtenstein – “They call me Dr. Lung, but I do more.” There are exciting ways to show medical students the importance of ultrasound….New territories of ultrasound: mesenteric ischemia (“a bowel that doesn’t move is a dead bowel”), pneumoperitoneum, increased ocular use. Took 15 publications in order to publish the BLUE protocol that reviews 10 signs of lung US. Respiratory failure: BLUE http://crashingpatient.com/wp-content/uploads/2011/07/Lichtenstein-Slides.pdf … ; Circulatory failure: FALLS (if no B lines then good systolic fxn; if B lines then bad systolic function); Cardiac Arrest: SESAME protocol (lung sliding (if pneumothorax- immed interv), echo, then IVC and AAA at your discretion: http://www.slideshare.net/nswhems/the-arrested-patient … Lung Ultrasound in Critically Ill for Limiting Radiographs (LUCIFLR) project  – to decrease CT and chest Xrays (but not to eradicate Xrays “or LUCIFLR will = LUCIFER”). Lung ultrasound can limit the need for chest X-rays in the ICU and the ED.

3. Creagh Boulger – speaking on literature review of ultrasound curriculum for medical students. MT “@SonoMedED: Medical students effectively use ultrasound in just 5 min in some situations.” [Even beating clinicians in diagnosis! See: this study.] . Study after study has shown that medical students benefit from ultrasound in medical education. How to fit it into the schedule? what they did – online didactics (like Fox’s iTunes series), then 16 weeks of hands-on, concluded with a checklist based assessment. Why teach it? Increases Anatomy Learning, increases diagnostic ability in radiology, assists in spatial relationships, and they see “live anatomy” with better ability to learn physiology in real-time.

4. Social Media and Ultrasound Learning – MT “@SonoMedED@EDUltrasound and @EDUltrasoundQA Uses Twitter with daily tweets to teach ultrasound with social media.” …In addition to little ole me (@SonoSpot), @SonoTron, @TheSonoCave, @bedsidesono, @Ultrasoundpod, @westernsono, @sinaiemus, @UTS_Australia, @USEDCDN … and many others who are in emergency medicine/critical care and highlight ultrasound with their own pearls.

5. John Pellerito –  how to incorporate US into med school: buy in from Dean, faculty training, facility space, US equipment, MULTI-specialty involvement (emergency medicine, radiology, critical care, obstetrics, medicine, surgery). US in med school: online didactics, most time must be spent with hands-on: knobology, anatomy, physiology, pathology (- partner with pathology /radiology dept to show how ultrasound correlates with histology/specimens and CT/MRI [they will learn to read those better too by learning ultrasound!]). Society of US in Med Ed (SUSME) website to see sample curriculum. The Challenges of incorporating US into Medical Education: maintenance of longitudinal curriculum, keep faculty enthusiastic, budget for new equipment, space needs. MT“@SonoMedED: Challenges with med stud ultrasound educ 4yr curriculum, keep faculty interested.  pic.twitter.com/UnRSCGs0vk”. Who to Train them? First will be faculty, then the seniors can teach the juniors. Essentials im developing an US curriculum: didactics and hands-on training, integration into anatomy, physiology, physical exam and diagnosis skills, clinical clerkships, and requires student assessment and image archiving and review. Faculty/Facility needs: classroom, bedside, anatomy lab, stretchers, gel, towels, monitors, models (students or patients), faculty from multiple specialties

6. Amponsah/Jackson – from Wayne State : how they incorporate US in med stud curriculum: didactics, 2nd yr competency test, multi-specialty involvement. Where US helps med stud in anatomy learning: spatial relations, pathology, live anatomy pic.twitter.com/MCI972lryO . Need high faculty:student ratio. LCME requirements are key to getting ultrasound into medical school:

LCME requirements are a great way to advocate for ultrasound education as part of active learning for medical students …..The following LCME requirements can be satisfied with ultrasound: ED-5-A: A medical education program must include instructional opportunities for active learning and independent study to foster the skills necessary for life-long learning; ED-12: The curriculum of a medical education program should include laboratory or other practical opportunities for the direct application for the scientific method, accurate observation of biomedical phenomena, and critical analysis of data; ED-28:A medical education program must include ongoing assessment of medical student’s problem solving, clinical reasoning, decision making, and communication skills.

7. J. Christian Fox – From UC Irvine.  pic.twitter.com/znUAea1wew . Bridging the gap between pre-clinical and clinical students with simulations: How to do it: transitioning from pre-clinical to clinical medical students: podcast, then hands-on with healthy volunteer, then task trainer, then recognize pathology on simulator, then standardized patient with pathology, then clinical rotation utilization by way of an OSCE  pic.twitter.com/ix4Rl2X4WS “Sono-genic” models great to use- models with great US anatomy. Issues in real patients: obesity, COPD, pain- all limit scan ability but great for later training. Great models: Sono-Studs… Or, not so good: Sono-Mess MT“@SonoMedED: Terms for good sonographic models…Sonogenic…Sonolicious.” (Ah, I digress…). Solve issue of assessing pathology: simulation! Various simulators are on the market: http://Sonosim.com , http://bluephantom.com  ,http://Vimedix.com http://www.medaphor.com/  , http://www.medsim.com/ultrasim.html . MT “@SonoMedED: Dr. Fox signs up pts for modeling with various pathologies. Model pts with pathology compensated $80 for 4 hour session. Often challenging to schedule patients though.” Great way to get models who have pathology! Studies show increasing ultrasound performed in ED when increased medical student ultrasound learning, also that liver span size better when use ultrasound. Medical students are better with ultrasound in diagnosing cardiac disease when compared to cardiologists’ physical exam.

8. Michael Blaivas - The role of specialty organizations- AIUM, SUSME, WINFOCUS, and specialty specific: ACEP, SAEM, ACS, ACOG, ACCP, SCCM, Card, Rads. http://SUSME.org  primary purpose is integrating US into med educ. http://WINFOCUS.org  primary purpose to help proliferation of Ultrasound education, is worldwide, has detailed US educ curriculum, policy making depending on region/country. Summary- issues and specialty organization – how they help  pic.twitter.com/ZsO9BKWa6B

9. Dean Richard Hoppman – from University of South Carolina:  pic.twitter.com/hAx4Iqv9rR . US in medical education- A Dean’s Perspective, how to get them on your side: how to get US in medical education- get medical students on your side, show US enhances medical education, satisfies LCME requirements, fits all types curriculum. When ultrasound becomes part of Step 2 exams is when you know we’ve arrived… [Wow! Can u imagine?!]….Ultrasound competency could be an advantage to residency application. Even if they don’t use US in residency, can order/ interpret/understand ultrasound and other radiology studies better, they’ll think Ultrasound First! How ultrasound adds value to institution  pic.twitter.com/dzJt0VAaNE . Hopefully one day ultrasound training will be a requirement for medical school graduation. How to fund ultrasound for your institution  pic.twitter.com/uItTHJj2Jb . MT“@SonoMedED: Universities increasing focus on entrepreneurship. patent ultrasound ideas or devices. Help fund program” Great idea by Hoppmann -> MT “@SonoMedED: Advocate option for donors to contribute to medical school ultrasound programs.”The new stethoscope? MT“@SonoMedED: Grants supply equipment for med studs, even handheld units.  pic.twitter.com/5t9wbOtsef” medical students love it, medical students become alumni, alumni become donors. Great way to advocate for it pic.twitter.com/TnxBLjhsJn. Dean’s summary message to all: Get it. Learn it. Do it. Teach it. For your patients & healthcare  pic.twitter.com/LfUQv2SbJK . Yes!!-> “@SonoMedED: Great insight from Dean Hoppmann. pic.twitter.com/VcW1BUmbRl

10. Teresa Liu – from GW  (the one who is putting it all together for med studs at AIUM/SAEM/ACEP). White paper on ultrasound in medical student education is in progress. ACGME now incorporates ultrasound into EMed and RRC doing same for rheumatology. Medical students can get involved in specialty organizations/journals focused in ultrasound: JUM, Acad Med, SUSME/SAEM/AIUM/ACEP. Lower cost-Increased use! -> MT“@SonoMedED: Liu- need for making US tech more affordable to better penetrate into all specialties.”

11. Alex Levitov- curriculum and competency assessments: challenges & opportunities. Driving force for ultrasound are many clinical cases where it’s relevant & when time matters: its a busy day or patient critical.When people ask why – tell them this:  pic.twitter.com/CUth7L3Vxj . US allows immediate diagnosis, immeidate data in patient care, & allow reassessment after intervention (CVC placement, chest tube, foley…). Competency in US- image acquistion in years 1/2 ; Simulators, clinical cases & they decide what to do next for years 3/4. US in meded-cardiac physiology usually rated low by medical students, but rated high after ultrasound used to enhance education. Best way to incorporate US in medical education- staged approach -& use clinical cases early, ask about interventions in clinical years

12. Vicki Noble- from Mass General – discusses Ultrasound Competency -NEJM article -Point of Care Ultrasonography shows how many use it . “Numbers” for image acquisition competency- should it exist? Arguments for & against exist. Outcome need to be different? “Consensus is great, paralysis is bad”-concept of plateau-do more of same if literature show numbers don’t matter may mean we should change. US competency numbers may be different for different ultrasound applications; numbers may not matter for some applications- testing image interpretation requires clinical integration & “next step” questions. Online ACEP US test: http://www.emsono.com/acep/exam.html 

13. James Palma- from Georgetown – web based & organizational considerations in ultrasound in med ed – organ based approach – online didactics; hands on. web based US curriculum pic.twitter.com/l9fuWycluk

14. Last but not least – MEDICAL STUDENT PANEL !! Medical students panel discussing how #ultrasound helps them -going into different specialties pic.twitter.com/4B8IjKjtTQ . Ultrasound helps spatial relations in anatomy, great for MSK in real time (ie. rotator cuff movement), heart great to match with physiology (“it’s hard to understand heart physiology by reading a book, and so much better when you see the valves opening and closing and how the heart pumps”) . Great to see kidney ultrasound because anatomy dissection takes all abdominal organs out & can’t appreciate spatial relations. “@SonoMedED: Med Student Panel-Ultrasound physiology best demonstrated for IVC collapsibility and ejection fraction.” When asking medical student their preference: separate course versus full integration in different classes with regard to ultrasound into medical education: all wanted the latter – unanimously! . Story by a medical student: Psychiatric ward patient w/ abdominal pain got hand-held ultrasound by medical student showing cholecystitis- comprehensive ultrasound confirmed; OR that day. MT“@SonoMedED: Med Stud Panel-key to making integration of ultrasound successful: make it clinically relevant in 1st/2nd year.”  “Ultrasound makes me feel that I can contribute to the team.” 

15. Prior advances in Ultrasound in Medical Education has been highlighted by others: I have posted about how ACEP, AAMC, and AIUM last year has started speaking about ultrasound in medical education; UltrasoundPodcast have a great podcast about it and how to incorporate it here and here; WesternSono posted about this from the Canadian perspective with an amazing and fun talk pitching ultrasound training in medical education here;  the world is advancing this goal as well!

Some of the great slides that grabbed my attention from the AIUM13 course: (apologies for the blurry iPhone images)

IMG_1158IMG_1159IMG_1161 IMG_1163IMG_1164IMG_1168

The Medical Student Panel:

IMG_1169

The Course’s Faculty: aka – the All-Stars!

IMG_1170

And, to conclude with great insight and words of wisdom for why ultrasound should be in medical education:

And what he has done to spread the gospel of ‘sound! – go here to read more and hear a speech done by the Dean of UC Irvine Medical School on why its so important to incorporate ultrasound into medical education for our patients.

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