SonoMedStudent: Integrating in Ultrasound into the First year of Med school by Dr Tarina Kang #FOAMed

Dr, Tarina Kang, the Ultrasound Director at USC, wrote to the Editor of Advances in Medical Education and Practice in the Aug 2013 journal . She poses quite a good argument for ultrasound in medical education ( with references ) and also discusses how she found it to be best done in the first year – a great read:

Dear editor,

For over 100 years, medical schools throughout the United States have typically followed a standardized curriculum that clearly delineates the preclinical (basic and clinical sciences) and clinical years (patient encounters and care).1 However, the transfer of learning that is derived from isolated data of basic science to clinically relevant information has been a topic of much debate and study throughout the years.

Recently, educators have attempted to unite the preclinical and bedside principles in an effort to make the basic sciences more relevant to medical practice. Basic, clinical, and social sciences are taught simultaneously to reaffirm “the importance of the relationship between the practitioner and patient. Further, the practitioner should focus [on the patient] as a whole, be informed by evidence, and make use of all appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health and healing.”2 Although implementation of an integrated learning curriculum in medical school poses political, logistical, and financial challenges, its rewards for the student may be profound.

The ideal approach to integrating basic science material with the practice of medicine is complex in that educators often have to incorporate innovative and pertinent student experiences, without compromising the existing curriculum requirements. The sheer amount of information that first year medical students are required to learn makes inclusion of additive curriculum difficult. However, it behooves course directors to constantly test, change, and expand course curriculums to maximize the educational benefit to students.

There are a number of ways to implement clinical practice into the first year courses of medical school, with the theoretically most successful ones being those that can be brought to the student during class, where other students and instructors are present for more in-depth and collaborative discussion. Point-of-care ultrasound was developed by emergency physicians in an effort to better evaluate the patient at the bedside. More recently, ultrasound has become an important educational and clinical tool across all specialties due to its ease of use, portability, and applicability at the bedside. Many institutions have integrated bedside ultrasound teaching into the clinical years of medical school. Several US institutions such as Wayne State, Ohio State, and the University of South Carolina have implemented ultrasound curriculums that span from the first year to the entire 4 years of medical school.35 In 2012 Fox et al6at the University of California (Irvine, CA, USA) implemented a novel medical curriculum which integrated web-based lectures and peer instruction for Year I students. They were successfully able to maximize teaching and practice time and integrate practical medicine into the basic science courses. Given the success of these programs and the potential educational benefit they afford students, a seamless introduction of ultrasound into the first year courses at our affiliated medical school seemed like a natural progression.

The goal of the project was to integrate ultrasound, a practical clinical modality, into the preclinical educational experience, specifically, during the anatomy and histology classes and laboratory sessions. The ultrasound instructors successfully completed a 10-week course which combined anatomy and histology laboratory sessions, small group sessions, and lectures. After a year of planning, we successfully integrated ultrasound into the course in a way which emphasized how teaching in a dynamic and safe manner with the ultrasound can illuminate the structural relativity of human anatomy.

The novelty of this curricular change in a course that has never had this type of teaching before was itself an impediment. I think that, in retrospect, the adage “There is strength in numbers” is a proverb one should follow when attempting to implement a new course at a medical school. The more people you know who represent different specialties and ranks in both the hospital and the medical school, the higher the likelihood for continued success of the course.

When I started this project, I was naive to the accepted conduct and decorum that one is expected to follow when trying to introduce unprecedented ideas into the medical school curriculum. I had an idea worthy of pursuing, I created a plan to implement it, and I spoke to the directors of the course, but I did not attempt to gain crucial allies in the medical school who could have accelerated its acceptance. The legacy of new projects and teaching initiatives at medical schools will constantly be endangered unless there is consistent support at the administrative level. As a result, although I had the full support from the course directors, I did not have the complete acceptance of the laboratory professors and instructors who taught the course. This disconnection manifested in frustration and bewilderment by some students attending our course during their teaching time. In addition, because there was no formal explanation of our pilot to the students, some were unable to fully grasp the concept of an integrated educational forum, and noted on course feedback their lack of understanding as to why, and how, point-of-care ultrasound correlates with anatomy and histology. This problem could have been curtailed, at least in some part, by a formal acknowledgment made by not only the course directors but also the administration. With this knowledge, we reached out to several medical school administrators, and we are in talks with them to gain valuable insight and input for further direction for next year’s course. In addition, we are recruiting physicians from different specialties to broaden the type of expertise in our curriculum.

Although I encountered barriers, the experience was invaluable. It helped me understand, with startling clarity, the political structure of medical education. I have since moved to another academic medical center, and we are scheduled to begin talks to create an integrated curriculum with first year medical students. The next time I introduce myself though, I think I’ll bring my friends.”

Go to this article’s link for a list of the references as well.

To read posts on US in Medical Education done at AIUM and other institutions, and see what others are doing and saying about it, go here.

SonoFellowship: Ultrasound Leadership Academy – apply now! @ultrasoundpod @bedsidesono

The Ultrasound Leadership Academy… the ULA….oh yeah! “What is it?” you ask?  It’s only the most awesome experience anyone who wants to learn ultrasound from all over the world could every have!!!

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It’s a virtual 12-month fellowship in ultrasound and Im excited to join Matt Dawson, Mike Stone, Mike Mallin (of ultrasound podcast), and the other awesome ULA professors to be part of enhancing future leaders’ ultrasound knowledge. The fellow not only gets mentorship, one-on-one sessions, and google hangouts to review their images they get from the Vscan obtained during the fellowship (yup, that’s right, you get a Vscan to use during the fellowship), but you also get to learn what it takes to create, direct, and enhance your ultrasound program as well as learn the ins and outs of bedside ultrasound applications…. from the best of the best! Awesome, right?

How can you apply? Go to the website and see how!


SonoSpot ! Now with SonoBilling info, SonoReferences list, SonoFellowship Curriculum & More! #FOAMed

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Remember when I stated that in August we will be revamping the SonoSpot site to include much more – well it took a little longer than one month, but Im very excited to show you what all that research and time has come to – A SonoSpot site that, well, looks the same, but with so much more exciting content!  - Information that will benefit not only those who want to learn bedside focused ultrasound and review cases and tutorials, but also those who want information on billing for ultrasound procedures, to review a list of references in each ultrasound application, as well as review a monthly fellowship curriculum that takes these references and adds the online sites and podcasts available to supplement that topic for each month!

Each of the headers will have drop down menus for even more content. Many topics on bedside ultrasound are found under SonoSpots when you go to Oh, and those guest posts from others who have so patiently waited to have their awesome cases highlighted on SonoSpot will start this week too! Enjoy the new pages (…and they will keep getting enhanced with lecture videos throughout the year – it just gets better! )

Visit our SonoBilling and Privilege Form page – where you can see an estimate of the charges/wRVUs and LCD information that is all found publicly and incorporated into one excel sheet – scroll through it up/down/right/left to get it all in. Be warned: it is a ton of information that summarizes 1,000 pages of public pages into one sheet. Note the disclaimer. This page also has a sample Hospital Privilege form for those who want to get privileging in bedside ultrasound at their institution which is required at some places in order to bill, in addition to the list of items required for US billing as seen on the SonoBilling page.

Visit our SonoSmartphrases for EMRs – here is a sample of smartphrases that describe the documentation for each bedside limited ultrasound procedure that is being billed. The wording for each smartphrase is specifically stated due to the requirements for SonoBilling

Visit our SonoReferences pages – where we highlight the landmark and hot articles in each bedside focused ultrasound application, along with the link to the pubmed page for each. This is a page that is going to continually get updated as more studies get published. This is separate from our SonoStudies site, that go into further detail and discussion on specific studies that pick to highlight for various reasons.

Visit our SonoFellowship Curriculum pages. This is a sample of a curriculum should anyone want to do an ultrasound fellowship. It is a supplement to other educational opportunities that a fellow will get and describes the fellowship month-by-month on the reading assignments – including viewing online #FOAM resources for each topic (websites, blogs, podcasts, etc).

We will continue to optimize our Sonotutorials and SonoCases sites, which are our most popular sites for all bedside ultrasound believers in the world!

Hope you enjoy and, as always, I love any feedback or suggestions for additions to the site for our future upgrades.

SonoNews! AIUM President on Ultrasound in Medical Education & the US in MedEd portal #FOAMed

When I read this message, a light shined so bright inside my little head, that I had to share it. I got the usual emails from AIUM (American Institute of Ultrasound in Medicine), a multi-specialty organization with thousands of members, who educate/study/encourage/collaborate on issues related to ultrasound in medicine. But, the email that came out today, a message from the new AIUM President, discusses with such ease and obviousness about how ultrasound should be integrated into medical school education.

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I have been to a few of the national AIUM conventions and my most recent post about it discusses one of the best days of my life, the course in NY at AIUM2013 about ultrasound integration to medical school curriculums where the experts spoke of their experiences, their advice, their ideas ….followed by a panel of medical students who shared their point of view of how it affected their education. It was amazing! Even now, when i think about it, i am inspired, and continue to be excited about how we are starting to do the same at Stanford School of Medicine. I have posted about the reactions that Ultrafest (a free medical student workshop in California) brought to everyone, including what UC Irvine’s Dean Clayman stated about it all. It was quite honest and encouraging. All of this, brings me to this message that i keep reading over and over again. Is it because 2013 is the Year of Ultrasound? Well, likely so, but for that reason and so many more, I just cant stop reading it – please read it below, especially the end when the link to the Ultrasound in Med Ed portal is introduced.

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July 25, 2013

Dear Colleagues:

I believe there is no more important issue facing ultrasound than its incorporation into undergraduate medical schools’ curricula. Many of you saw the visionary presentation of Dean Richard Hoppmann, MD, at the 2012 AIUM Annual Convention in Phoenix, Arizona. Here at New York University School of Medicine, Uche Blackstock, MD, RDMS, an emergency department physician, is developing a multidisciplinary collaborative integrated preclerkship and clerkship curriculum. Consider the following:

It’s another typically busy day at the medical center. A critical care fellow supervises a senior resident placing ultrasound-guided central vascular access in a hypotensive septic elderly patient in the medical intensive care unit. In the outpatient surgery suite, an anesthesiologist prepares a patient for rotator cuff surgery by performing an ultrasound-guided interscalene brachial plexus block for regional anesthesia. In the echocardiography lab, a cardiologist assesses a patient admitted the night before with a non-ST segment elevation myocardial infarction for wall motion abnormalities and cardiac function. An obstetrics and gynecology attending performs a pelvic ultrasound examination on a young woman being ruled out for an ectopic pregnancy, appreciates an intrauterine pregnancy, and discharges the patient home safely.

Over the last 20 years, ultrasound performed at the bedside, by clinicians, has revolutionized the way medicine is practiced. In these diverse cases, the use of ultrasound was critical in providing patients with effective and quality clinical care. Although currently being used for diagnosis, management, and procedural guidance by physicians in numerous and diverse specialties, a significant gap currently exists between what medical students are being taught and how they are expected to practice on completion of their training. Future physicians will be expected to be familiar with the use of ultrasound in their clinical practice, regardless of specialty. At this time, medical educators have a unique and timely opportunity to use ultrasound at the bedside as an innovative teaching modality in the undergraduate medical curriculum.

Handheld ultrasound will transform how medical students are taught in the preclinical curriculum as well. Students will never experience learning medicine the same way. They will be able to scan a live model and appreciate the gallbladder as its lies within the main lobar fissure of the liver. They will have a deeper understanding of the cardiac cycle by viewing the diastolic and systolic phases of a live beating heart. During clerkships, students will learn how bedside ultrasound can be used to make important diagnoses and to allow them to safely perform critical procedures. Bedside ultrasound as a teaching tool will enhance what students have learned traditionally and help reinforce important concepts.

An integrated ultrasound curriculum will require a multidisciplinary collaborative effort by a medical school faculty. This approach will ensure that students receive comprehensive exposure to ultrasound from all perspectives. Medical educators are responsible for ensuring students are well equipped for future clinical practice. Ultrasound, as I see it, will have a dual role in undergraduate medical education. First, it can and should be incorporated into preclinical learning to teach anatomy, physiology, and pathology. Second, there is almost no clinical clerkship, as outlined by the scenarios above, that does not already or else will soon utilize bedside ultrasound. The future is now.

The AIUM’s Ultrasound in Medical Education Interest Group, chaired by David P. Bahner, MD, RDMS, has developed an outstanding online portal to assist those with an interest in integrating ultrasound into medical school curricula. This one-stop clearinghouse includes a mentor program; educational information from multiple organizations; and a tool kit that features curriculum examples, links to online lectures, sample proficiency assessments, tips on discussions with medical school leadership, instructor pools, equipment, and more. We encourage you to explore the Ultrasound in Medical Education Portal. If you know of additional resources that should be included, e-mail

In closing,

AIUM membership for students, residents, and fellows allows these individuals access to helpful ultrasound-related resources and the opportunity to network with experts in medical ultrasound–an excellent complement to the clinical training they receive. This membership category is $25 and offers students the full array of member benefits. The students of today are the future leaders of the AIUM. I hope you will share this opportunitywith those with whom you are in contact.


Steven R. Goldstein, MD
AIUM President

SonoNews: Radiologists should guide point-of-care ultrasound training? …lets think about this…

In an insert of Diagnostic Imaging, Dr. Michael Blaivas (an emergency physician, past president of ACEP US Section, Section Chair of Emergency/Critical Care for AIUM, and basically about 3 or 4 more titles that would take a few more lines in this post to mention because he is that amazing) spoke about how radiologists have historically been threatened by and become obstructionists in its use by non-radiologists, then became less so as it was apparent that radiologists didnt have the time to do it  - possibly due to radiologist shortages and becoming focused on CT and MRI (according to Dr. John Cronan – chair of Radiology at Brown Univ), and now are not involved or part of the team with point-of-care ultrasound training – but they should be, according to Blaivas in this article by Sara Michael. However, this article concludes the wrong thing – in my opinion – and has misunderstood Blaivas’s point. Instead they reaffirm the angst felt by radiologists today and fail to explore why. Radiologists have submitted a “National Curriculum” for medical student education in ultrasound as well, that has come to add to further controversy as there are no other specialties involved in the discussion…. But, of all the medical student US curriculums out there, most, if not all, are coordinated by non-radiologists.

“Point-of-care ultrasound has become ubiquitous in medicine, from emergency departments to OB and trauma surgery. But that doesn’t mean it’s taking the modality away from radiologists.In fact, radiologists should be the ones guiding its training and promotion – not bemoaning and pushing back on the trend. “Radiologists are not involved in ultrasound education and promoting its use in point of care or elsewhere, but it would be nice to have more involvement,” Michael Blaivas, MD, an emergency medicine physician and past chair of the American College of Emergency Physicians ultrasound section, said during a presentation at RSNA 2012 this week. “It’s better to be seen as proponents of an application, guide it, and help with it, especially an application that is seen as critical at the bedside.” Radiologists are the ultrasound imaging experts, Blaivas said, and should be the first to share their expertise. The specialties shouldn’t be fighting each other, he said, but working to make sure the modality thrives for all clinicians. If radiologists were more involved in teaching, they could ensure quality in its use. “There really is a need for ultrasound education, and this is somewhere we can meet,” he said.”…”Today, [Dr Cronan] said, radiologists are “working feverishly to protect our income,” and the profession faces threats of commoditization with the rise of teleradiology and service-live imaging. Although ultrasound is likened to the stethoscope in its extension of the physical exam, Cronan noted, it’s used by many, understood by few.”

Ive been thinking a lot about it recently, and trying to understand radiologists’ continued angst about non-radiologists performing point-of-care ultrasound. I’ll start with these few points: radiologists do perform ultrasound studies – both limited and complete – and that hasn’t and shouldn’t change, they ARE imaging specialists. I do rely on them when my point-of-care ultrasound shows that a complete ultrasound study or a CT scan is needed. Many radiologists do not see the ultrasound studies that non-radiologists perform or how they are quality assured, and the fear of the unknown can drive quite a few political decisions. They have not been involved in point-of-care ultrasound training either, and this, in combination with the above, will give even more angst. I do agree, they SHOULD be a part of the education (and I know some will disagree with me) – this will have those who perform point-of-care ultrasound learn more techniques (with the applications that are also performed by radiology) and the radiologists will learn/see what we do, how we do it, and why it’s so important for us (and our patients) at the bedside. They will see that our images are actually quite good and that our QA and training direction is strict enough through our ACEP guidelines. Should they be in charge of it’s training? I dont think so. Is it an extension of the physical exam? No, it’s so much more than that. Here’s what keeps coming into my head:

1. The AMA passed a resolution that states ultrasound does not belong to any one specialty, but it can be incorporated into any specialty as defined by that particular specialty – later to also have a resolution that ultrasound is safe, effective, and efficient when used under the direction of an appropriately trained physician and should be supported in its educational efforts when integrating into medical education.

2. Many of the point-of-care ultrasound applications are not ordered/performed through radiology. Before emergency medicine and critical care docs started performing bedside ultrasound, they did not order an orbital ultrasound, an IVC ultrasound, a musculoskeletal ultrasound, a soft tissue ultrasound, an Aorta ultrasound, a cardiac ultrasound, a thoracic ultrasound, a procedural guided central or peripheral venous ultrasound…. through radiology. And, cardiologists did their echoes, OBGYN docs did their pelvic ultrasound over the last 15-20+ years, and, for the most part, trauma teams performed their own FAST scans.

3. Time matters. When there is a patient in shock, a crashing (or stable) trauma patient, and a patient who is acutely short of breath or with acute chest pain or acute abdominal pain or acute pelvic pain or with acute vision loss… and any procedure where ultrasound is needed…. we rule emergent conditions in and out and get that procedure done, quickly.

We need to have this conversation with our radiologists, let them know of our QA process, educate them on the way and the reasons we perform bedside ultrasound, and alleviate their (and all of our consultants’) angst about our ultrasound studies. The team approach to ultrasound training for medical students is very important, and they should be a part of that.

SonoNews: Chest ultrasound for acute dyspnea used by internal medicine…yes!

In a recent publication through Medscape, they site a research article and presentation at the American College of Chest Physicians – in Chest Oct 2012  - stating “With minimal training, internal medicine house staff can successfully use hand-held ultrasound devices in the diagnosis of acute dyspnea.” This is huge! Why? Well, where do I begin? First off, lung ultrasound is advancing like never before – not that it wasn’t already known it was awesome for pneumothorax, pleural effusion, and pulmonary edema, but now the evaluation for pneumonia has gotten a lot of press. Secondly, you have more studies coming out that with minimal training, lung ultrasound can be used by physicians to help diagnose the cause for shortness of breath, which is great and helps get the fear of looking out of the conversation. FInally, and more exciting to me than anything above, is that bedside ultrasound is spreading!!! – to internal medicine (in this posting), but also to involve surgical clinics, sports medicine, pediatrics, and ophthalmologists  - – using bedside ultrasound to aid in their evaluation of their patients.

The article describes: “Ravindra Rajmane, MD, from the New York University Langone Medical Center in New York City, and colleagues reported the study findings in a poster presentation here at CHEST 2012: American College of Chest Physicians Annual Meeting. “The technology of sonography has improved markedly over the past few years,” Dr. Rajmane told Medscape Medical News. “Our study underscores the ease of transporting and effectively applying this technology with minimal training,” she said. “Our residents were able to successfully learn the basics of lung ultrasonography with a 1-hour didactic lecture followed by 1 hour of hands-on training. Unstructured training was also provided during ICU [intensive care unit] rounds.” According to the researchers, acute dyspnea is normally assessed with a combination of history taking, physical examination, electrocardiography, chest x-ray, and lab work. Lung ultrasound is increasingly being used to assess acute respiratory conditions because it is faster, less invasive, and more sensitive.” – Hallelujiah!!!

Keep it spreadin….

Even the OBGYN doctors are learning to use lung ultrasound in evaluating shortness of breath in pregnant patients!

A prior case that evaluated a patient who came in with shock and shortness of breath illustrates a way lung ultrasound can be used to help evaluate, diagnose, and work up your patient and can be find here.

SonoNews: Medicare adds Iatrogenic Pneumothorax to list of hospital acquired conditions!

What does that mean? If a pneumothorax results from that central line attempt or that thoracentesis and any other procedures with this complication, Medicare will not reimburse for it. In the new issue of SonoSite news, it discusses this and how the tool that could prevent pneumothorax from occurring, if used during your procedures, is the exact tool that is best to diagnose at bedside. How ironic is that?!

“Effective October 1, 2012: If, during the performance of a venous catheterization procedure, the clinician accidentally causes a pneumothorax, Medicare will no longer reimburse the hospital for the extra costs of a resulting pneumothorax (collapsed lung) complication. Continue reading

SonoNews: American Institute of Ultrasound in Medicine (AIUM) Practice Guidelines released

AIUM  - an organization that truly is an “institute” that is all about ultrasound – it used to be a community of only radiologists, but over the last few years, as bedside ultrasound has become part of many other specialties, there are now more sections for those specialties to become their own ‘community within a community’ – so to speak. Emergency physicians who are ultrasound enthusiasts, of course, are a growing section within AIUM – and if you ever want to meet every single leader in bedside ultrasound, this is the conference to go to! They also have AIUM and ACEP joint workshops in bedside US and promote research among all specialties. AIUM has been releasing their Practice Guidelines of each application and has recently completed quite a few. Each specialty define their own use of bedside ultrasound, and there are “complete” and “limited” (or “focused”, which may not include every detail listed under the AIUM guideline) scans, but its always nice to see what AIUM considers as their guideline to others. Continue reading

SonoInterview by Medscape: A Radiologist’s perspective of Appendix US…replacing CT? Yes!

This comes in great timing as a prior SonoSpot post describing recent studies evaluating CT findings in appendicitis rule-outs show that the majority ( 80-90% ) are negative…. US, clinical judgement, and a possible observation period can go a long way in radiation reduction.

Expert Interview: Stephanie Wilson, MD, on the Value of Ultrasonography for Imaging Appendicitis

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SonoInterview by Medscape: A Radiologist’s perspective on the topic of point-of-care Ultrasound

In case anyone out in the Sono world was wondering what friends we have out there in Radiology, include this guy on the list… someone who understands what is best for patient care, how bedside US can save lives, and how every specialty has the capability and patient population to help their patients through this tool.

Handheld Units Shift Ultrasonography From a Diagnostic to a Clinical Evaluation Tool, Broadening Its Appeal

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