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Review

Medical Student Ultrasound Education, a WFUMB Position Paper, Part II. A consensus statement by ultrasound societies

Beatrice Hoffmann

1

, Michael Blaivas

2

, Jacques S. Abramowicz

3

, Michael Bachmann Nielsen

4

, Radu Badea

5

, Barbara Braden

6

, Vito Cantisani

7

, Maria C. Chammas

8

, Xin-Wu Cui

9

,

Yi Dong

10

, Odd Helge Gilja

11

, Roman Hari

12

, Hein Lamprecht

13

, Harvey Nisenbaum

14

; Christian Pállson Nolsøe

15

, Dieter Nürnberg

16

, Helmut Prosch

17

, Maija Radzina

18

,

Florian Recker

19

, Alexander Sachs

20

, Adrian Saftoiu

21

, Andreas Serra

22

, Sudhir Vinayak

23

, Sue Westerway

24

, Yi-Hong Chou

25

, Christoph F. Dietrich

26,27

1Harvard Medical School, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, USA,

2University of South Carolina School of Medicine, Department of Emergency Medicine, St Francis Hospital, Columbus Georgia, USA, 3Ultrasound Services, Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois, USA, 4Department of Radiology, Rigshospitalet, University of Copenhagen, Denmark, 5Imaging Desk and Ultrasound Department, School of Medicine, University of Medicine and Pharmacy “Iuliu Hatieganu” and Institute of Gastroenterology and Hepatology “Octavian Fodor”, Cluj Napoca, Romania, 6Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK, 7Department of Imaging Diagnostics, Policlinico Umberto I, University Sapienza, Rome, Italy, 8Department of Radiology, Hospital das Clinicas, School of Medicine. University of São Paulo, Brazil,

9Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, 10Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China,

11National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen and Department of Clinical Medicine, University of Bergen, Norway, 12Institute of Primary Health Care (BIHAM), University of Bern, Switzerland,13Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa,14Department of Medical Imaging, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA, 15Centre for Surgical Ultra- sound, Dep of Surgery, Zealand University Hospital, Køge Asc Prof, Copenhagen Academy for Medical Education and Simulation (CAMES) University of Copenhagen Denmark, 16Brandenburg Medical School Theodor Fontane.

Department of Internal Medicine and Gastroenterology, Neuruppin, Germany,17Dept. of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna General Hospital, Vienna, Austria,18Diagnostic Radiology Institute, Paula Stradina clinical university hospital, Riga, Latvia; University of Latvia, Radiology Research Laboratory, Riga Stradins University,19Department of Obstetrics and Gynecology, University hospital Bonn, Germany. Sono Education Academy, University Hospital Bonn, Germany, 20Department of Biomedical Imaging and Image-guided Therapy. Medical University of Vienna, Vienna, Austria, 21Diagnostic and Therapeutic Techniques in Gastroenterology.

Research Center of Gastroenterology and Hepatology Craiova, Romania, 22Department of Internal Medicine and Nephrology, EFSUMB Learning Center, Klinik Hirslanden, Zürich, Switzerland, 23Department of Imaging &

Diagnostic Radiology, WFUMB COE, Aga Khan University Hospital, Nairobi, Kenya, 24Ultrasound, Charles Sturt University, NSW, Australia, 25Department of Medical Imaging and Radiological Technology, Yuanpei University of Medical Technology, Hsinchu, Taiwan, Department of Radiology, Taipei Veterans General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan, 26Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland, 27Ultrasound Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China

Received 18.04.2020 Accepted 03.05.2020 Med Ultrason

2020, Vol. 22, No 2, 220-229

Corresponding author: Prof. Dr. med. Christoph F. Dietrich

Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland.

Sino-German Research Center of Ultrasound in Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China

E-mail: [email protected]; Phone: +41764408150; ORCID ID: orcid.org/0000-0001-6015-6347 DOI: 10.11152/mu-2599

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Introduction

The inclusion of ultrasound education into medical school curricula is not a new concept. Some universities have been offering ultrasound education to their medi- cal students for over 20 years, either as part of anatomy or physical diagnosis courses, or during clinical rotation blocks [1,2]. Over the last 2 decades, ultrasound has seen increased clinical use by physicians in many specialties.

Mastery of this imaging modality requires the develop- ment of spatial aptitude, sono-anatomy and sono-patho- physiology knowledge, as well as an understanding of the limitations of ultrasound. As such, the acquisition of sonographic skills is considered a longitudinal, if not a life-long, learning process. Hence, diagnostic medical so- nography should be introduced at the beginning of gradu- ate and postgraduate training [3,4]. As medical education varies significantly among different universities across the world, it would be difficult for every medical school to adapt the exact same approach to teaching ultrasound.

As a general approach, teaching ultrasound can be employed during the pre-clinical and/or clinical years, be web-based, classroom or hospital-based, and consist of theoretical and practical exercises [5-10]. Courses can focus on anatomy or physiology, or can be tailored to medical subspecialties. Three of the most common limi- tations to introducing ultrasound into a medical school’s curriculum appear to be lack of trained instructors, avail- ability of ultrasound machines, and educational oppor- tunities in an already tightly packed medical school cur- riculum [11,12].

Despite these barriers, ultrasound teaching has found its way into medical school education and has led to a variety of approaches and curricula, frequently supported by re- gional and national medical societies. In this position paper, we summarize supporting efforts and the current involve- ment of several Federations and Societies for Ultrasound in Medicine and Biology and some of their collaborators.

The World Federation of Ultrasound in Medicine and Biology (WFUMB) Perspective

WFUMB’s overall purpose is to bring the use of med- ical ultrasound to every corner of the world. According to the WHO, two thirds of the world’s population has no access to medical imaging [10]. WFUMB has a rapidly growing global network of Centers of Education (COE) and presently runs 16 centers in five continental regions.

The COEs have two main goals: to focus on the ultra- sound education in underserved areas, and to facilitate the dissemination of ultrasound as an integrated part of clinical specialties in the point-of care setting (Point of Care Ultrasound, POCUS). Currently, the main trainee groups of the COEs are medical doctors and other profes- sional healthcare providers. In the future, the work of the COEs will, most likely, increasingly focus on practical student education and integrate collaborative initiatives with local medical schools.

WFUMB is also focusing on improving students’ ul- trasound education through strengthening collaborations with universities and national student organizations. The goal is to build a curriculum that can be adapted to fit regulations and educational needs in medical schools around the world. One such example is the collaboration between WFUMB and the Society of Ultrasound in Med- ical Education (SUSME).

WFUMB created a Task Force for Student Educa- tion and E-Learning that focuses on the development and distribution of e-learning materials and web-based simulation, as a part of practical training (https://wfumb.

info/portfolio-category/e-learning-task-force/). In addi- tion, WFUMB is increasing its student ultrasound edu- cation programs at WFUMB congresses. For instance, the WFUMB Congress 2021 in Timisoara will offer a platform for an international student meeting with the aim to train students, students’ tutors, discuss different curricula and discuss pathways to integrate e-learning, Abstract

Ultrasound is becoming a fundamental first-line diagnostic tool for most medical specialties and an innovative tool to teach anatomy, physiology and pathophysiology to undergraduate and graduate students. However, availability of structured training programs during medical school is lagging behind and many physicians still acquire all their ultrasound skills during postgraduate training.

There is wide variation in medical student ultrasound education worldwide. Sharing successful educational strategies from early adopter medical schools and learning from leading education programs should advance the integration of ultrasound into the university medical school curricula.

In this overview, we present current approaches and suggestions by ultrasound societies concerning medical student educa- tion throughout the world. Based on these examples, we formulate a consensus statement with suggestions on how to integrate ultrasound teaching into the preclinical and clinical medical curricula.

Keywords: ultrasound; skills; education; WFUMB; position paper

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ultrasound phantoms and simulators into a training curri- culum.

Furthermore, the WFUMB Education Committee is working on a WFUMB COE Course Book (e-learning material), which would create and collate special teach- ing material for students’ education.

International Federations of Ultrasound in Medicine and Biology

The Asian Federation of Societies for Ultrasound in Medicine and Biology (AFSUMB) perspective The Asian Federation of Societies for Ultrasound in Medicine and Biology (AFSUMB) does not have its own diploma in diagnostic ultrasound, but has been contribut- ing to educational efforts of affiliated national societies by providing qualified speakers/researchers and teams of faculty to join annual meetings and various sympo- sia/workshops. Early examples are the 2nd Ultrasound Workshop of the AFSUMB in Karachi, Pakistan (Janu- ary 17-19, 2004) and the 3rd Ultrasound Workshop of the AFSUMB in Shanghai, China (April 9-11, 2005), events at which medical students and trainees were in- vited to attend with complimentary registration. More current examples include the 2015 AFSUMB’s Asian Symposium of Advanced US technology held in Taipei, Taiwan, October 17-18, 2015, and the 2016 Ultrasound Workshop of the AFSUMB in Bangkok, Thailand, No- vember 7-8, 2016, and the 2017 Ultrasound Workshop of the AFSUMB in Beijing, China (August 19-20, 2017), the events at which medical students and trainees were invited to attend with complimentary registration.

AFSUMB also provides scholarships for trainees, either through its organizing committee of its scientific assembly (AFSUMB Congress), or with the support from the Japanese Society of Ultrasound in Medicine (JSUM), Korean Society of Ultrasound in Medicine (KSUM), and Chinese Taipei Society of Ultrasound in Medicine (CT- SUM). The CTSUM also provides scholarships for medi- cal students (http://www.sumroc.org.tw/ ).

The American Institute of Ultrasound in Medicine (AIUM) perspective

The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary professional association and has been advocating for the need for ultrasound in medical school education. It has been pursuing a num- ber of initiatives, ranging from focused conferences and forums to partnering with the Society of Ultrasound in Medical Education (SUSME) on educational events and collaborative projects for medical students [13-16].

AIUM has taken an increasing interest in graduate ultra- sound education and has begun holding sessions focused

on medical students at its annual conventions, which resulted in an attendance increase by medical students.

Additionally, AIUM sponsored conventions to educate United States medical school deans on the importance of ultrasound education in medical school curricula, and conducted workshops on implementation strategies and approaches. These sessions have been well attend- ed by medical school educational leaders and led to the initiation of multiple curricula efforts around the United States.

The AIUM website (AIUM.org) offers free e-learn- ing resources including video tutorials, lectures, training guidelines, a CME tracker, and a toolkit for initiating ul- trasound curricula in a medical school setting. These are to assist AIUM members as well as a variety of health professionals in initiating ultrasound curricula in a medi- cal school setting. AIUM also provides connections with mentors in ultrasound education with the goal to help educators dealing with administrative and bureaucratic aspects of introducing ultrasound education into a North American medical school.

The Australasian Society of Ultrasound in Medicine (ASUM) perspective

ASUM is also a multidisciplinary professional or- ganization with the mission is to promote best ultrasound practice standards.

Of the 22 medical schools in Australia and New Zea- land, most have a dedicated radiology / medical imag- ing component where the theory of ultrasound is taught.

The teaching of practical aspects of ultrasound however, is variable among schools. The scope of learning varies from using ultrasound during anatomy classes with ca- davers, to another with four half-day practical sessions per year that utilizes local ultrasound practitioners to as- sist with hands-on instructions for scanning classmates [17,18]. Medical students are exposed to ultrasound im- aging during their hospital rotations through the various specialties such as obstetrics, cardiology and radiology, although the opportunities for practical experience in these situations is limited.

Most Australasian university health jurisdictions are concerned that medical curriculums are at satura- tion stage and require a needs assessment and business case before additions to their curriculum are considered.

However, ultrasound has been introduced into some uni- versities with success [17,18].

ASUM is a proponent that PoCUS has been shown to assist in improving patient outcomes and as such, it would be of benefit to include ultrasound education for all medical students beginning in the first year of their studies. As with all federations of WFUMB, ASUM will assist, if approached, in formulating ultrasound content.

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European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) perspective EFSUMB recommends that ultrasound should be used systematically as an easily accessible and instruc- tive educational tool in the curriculum of medical schools [19]. Medical students should acquire theoretical knowl- edge of the modality, and hands-on training should be implemented adhering to evidence-based principles [9,10,17]. The published EFSUMB position paper on student education [19] summarized these current activi- ties, including published teaching materials, standardized examinations, and the EFSUMB e-learning platform.

EFSUMB has launched the Educational Portal on the society website. A textbook is available, the multidis- ciplinary EFSUMB Course Book (ECB) [20,21]. Each reader is invited and encouraged to improve the ECB, and to optimize the available teaching materials by con- tacting EFSUMB. These efforts are made to complement and advance the educational purposes of EFSUMB. Fur- thermore, EFSUMB published the ECB Student Edition (ECBSE), mainly focusing on anatomy, examination techniques, safety issues with accompanying examina- tion technique videos. Specific lessons on US anatomy have been prepared using hands-on live presentations offering self-assessment by the participants [9]. Plans for a future edition to the EFSUMB course book (ECB) include up-to-date ultrasound knowledge, but also pro- viding learning objectives and pre- and posttests. All this material is free to download from the EFSUMB website.

The EFSUMB cases of the month and the EFSUMB case atlas serve as an online image database. Additionally, the EFSUMB Task Force on Ultrasound Medical Student Education has recently published a review of the present knowledge and experiences in a short [9] and long ver- sion [19]. The aim of the Educational and Professional Standard Committee (EPSC) of EFSUMB is to initiate and monitor international cooperative studies on medical student training in medical ultrasound (mainly in anato- my and physiology) and to provide e-learning resources that can be used for US student education. The key por- tion was proposed as “anatomy and physiology training of students using ultrasound”, with the general objectives of improving anatomy knowledge and the quality of training received by medical school students. The pro- posal includes specific objectives which are to be reached at the end of each year or cycle of study, and are relative to each medical discipline that benefits from diagnostic ultrasound [10].

The EUROSON Annual Congress contains specific sessions designed for medical students including practi- cal education and discussion with experts. The program of the most recent two EUROSON Congresses integrated

training courses in point-of-care ultrasound for students, taught by experienced student tutors reflecting the “near- peer teaching” concept. Interestingly, several European countries conduct annual meetings of these student peer teachers where teaching curricula and need for student teaching are evaluated.

The Federation of Latin American Societies of Ultrasound (FLAUS) perspective

The Federation of Latin American Societies of Ultra- sound (FLAUS) consists of ultrasound societies all over Latin America (13 countries are members of FLAUS), with the goal of knowledge sharing among its members.

Similar to many other countries, in Latin America (LA) ultrasound is performed exclusively by physicians. How- ever, among the members of FLAUS, there is a hetero- geneous approach concerning ultrasound education in medical school.

Currently, Latin America has undergraduate and post- graduate ultrasound training available. Both show con- siderable variability among FLAUS members. Among national universities, there is considerable diversity in the approach to undergraduate ultrasound education.

Many universities incorporate ultrasound to a limited de- gree into the medical student curriculum, frequently in the beginning of medical school. Pathways can take the form of an elective during the second or third year of training and represents a basic introduction to ultrasound.

However, some universities have a more advanced and longitudinal approach.

For instance, in 2000, preliminary courses were conducted in Brazil, initially offering extra-curricular courses at the University of São Paulo (USP), at Federal University of São Paulo State (UNIFESP) and Hospital Municipal Souza Aguiar. Some universities in Argentina and Panama have also introduced extra-curricular sonog- raphy courses for undergraduate students [22].

The Federal University of Rio de Janeiro School of Medicine started to combine traditional semiology plus point-of-care ultrasound into its curriculum in 2014. In the same year, the Federal University of Juiz de Fora be- gan a program of elective, sequential courses, addressing a variety of sonographic topics. Campinas State Univer- sity began to offer Emergency Department based courses that included an online Moodle platform and face-to- face, competency-based practices. Starting in 2017, the Estácio de Sá University developed the program of in- tegration of ultrasound to the whole curriculum, start- ing with the disciplines of Propedeutics and Emergency Medicine.

However, the current state of ultrasound teaching in medical school in Latin America as a region is in its be- ginnings, and there is no published data or consensus on

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the topic for this region. FLAUS is currently working to develop pathways and a certificate for physicians who are performing ultrasound, but were not able to attend a formal radiology residency or regulated ultrasound course.

The Mediterranean and African Society of Ultrasound (MASU) perspective

MASU is a Society that has been formed to promote the development of ultrasound in the Mediterranean and African regions. The challenges in Africa are immense;

both in terms of diversity and extent [23]. Other than a handful of relatively developed radiology services, most regions are struggling with the ability to train physicians.

Introduction of simple ultrasound skills to any medi- cal school curriculum would go a long way in ensuring that doctors can perform ultrasound examinations learnt during their undergraduate years, thereby reducing the burden on the scarcely available radiologists [24]. In- troducing ultrasound at an undergraduate level will have multiple advantages, ranging from a practical teaching tool, especially for anatomy, to attaining skills to perform ultrasound independently after graduation. However, the main obstacles that prevent ultrasound training in Africa are the cost to purchase machines, technical skill required to maintain these machines, unavailability of skilled in- structors, and the logistical support to provide formal training programs [25].

Other Stakeholders

Society of Ultrasound in Medical Education (SUSME)

Started more than 9 years ago, SUSME had its first World Congress on Ultrasound in Medical Education in April of 2011. Since that time, SUSME has had multi- ple other congresses and continues to collaborate with an increasing number of institutions and societies. The mission of SUSME is to promote the use of ultrasound in medical education through development of educational experiences, research on implementation and outcomes, and distribution of results. SUSME is a unique academic society as its focus is exclusively on ultrasound in medi- cal education without having a trade organization-like purpose. Its goal is to be the academic umbrella for ultra- sound education and educators throughout the multi-year medical school curriculum. It partners with societies like the American Association of Medical Colleges to achieve ultrasound integration into medical schools, as well as multiple specialty trade organizations. The purpose of the SUSME web site is to:

• provide a forum for the exchange of information about the use of ultrasound in medical education

• facilitate communication and collaboration be- tween educators who are using ultrasound in medi- cal education

• develop a database of information about the use of ultrasound in medical school curricula, and

• provide links to resources, events, and associations related to ultrasound in medicine.

Currently, SUSME is running an international evi- dence-based ultrasound in medical education consensus conference and delivery of the first consensus statement and publication is expected in the next year. The consen- sus conference will result in an expected 3 sets of state- ments over an 18-month period, laying out the best evi- dence and recommendations for teaching ultrasound in a medical education setting. The consensus panel is made up of over 60 experts acting as voting members and has another layer of consultant representatives numbering nearly 150 international experts. Consensus conference members represent ultrasound education experts from around the world and include leading researchers and ed- ucators from nearly all clinical, as well as basic science disciplines. A modified Delphi method is being followed in cooperation with McMaster University in Canada, and is being organized by two expert epidemiologists who have run multiple consensus conferences in the past.

Future Perspective

Medical education methodology, especially in anato- my, pathophysiology, procedural performance and physi- cal examination, is undergoing a true paradigm shift based on the application of ultrasound technology. This shift will likely accelerate and fundamentally change on how medicine is taught and practiced [16,26]. For future physicians, better knowledge and skills in ultrasound techniques will be pivotal.

Future improvements will include the preclinical in- tegration of ultrasound hands-on education to facilitate the understanding of the main aspects of anatomy, physi- ology, pathophysiology and pathology, whilst avoiding overloading the student with excessive information.

Most common and simple medical scenarios will be used to illustrate the diagnostic value of ultrasound. An inter- net-based communication platform (forum) between the teachers and the students should be initiated [9,10].

Ultrasound teaching is largely skill based, therefore it requires hands-on training to achieve competency.

Ultrasound teaching should also be evaluated as a re- search tool to assess new didactic and teaching concepts.

Worldwide, there is a growing enthusiasm for education and debate about peer-to-peer teaching which brings the question of insufficient teacher-force or use of simula-

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tors for medical students. Thus, it is timely to propose a consistent and structured implementation of ultrasound curricula into medical schools. The highest ranked, most efficient, and vetted curricula should serve as the basic starting point for future standardization with main atten- tion to practical skills [26-28].

Based on the experience and the evidence obtained from using different ultrasound programs in different set- tings world-wide, the authors involved in this review pro- pose the following statements to be considered regarding course structure, didactic means, equipment of skills labs and the integration into medical curricula.

Example of course structure

Different examples of a course structures exist, and can be a combination of both online and hands-on learn- ing during a period of 1-3 months. Potential content in- cludes small-group practical training, online tests, forma- tive assessment and case-based discussions

Preparation and pre-course test

Preparation is necessary to optimize the personal educational benefit of the course. Detailed knowledge of anatomy or intensive repetition represents the most important preparation. In postgraduate courses, addition- ally knowledge of common and emergency pathologies is supportive.

Physics of ultrasound, documentation, reporting tech- nique, training of visual skills or dexterity are secondary.

Though supportive, they have to be part of every hands- on ultrasound course.

Pre- and post-tests, in other words continuous assess- ment of sono-anatomy and ultrasound related clinical knowledge, increases learning benefit and performance in professional practice [29].

Apart from synchronous case-based teaching, asyn- chronous E-Learning before, in between, and after helps to prepare, reflect and deepen knowledge. Concerning the efficiency of learning, usage of different learning modalities, such as listening to presentations, reading learning material, watching instructional videos, case- based learning and practical training, allows participants to reach up to 75% efficient teaching. Preparation for course directors is concomitantly important. Participants have to be “caught up” at their level of skills, theoretical and practical, following integration into the participant’s team to spread enthusiasm of teachers amongst the par- ticipants. Preclinical ultrasound courses aim to better un- derstanding of anatomy and physiology. Consequently, precourse questions help to select groups of participants with comparable level of skills, as well as suitable prepa- ration and knowledge to the assigned teacher.

Medical students should have study materials avail- able which best prepares them for hands-on components of the course, including examination techniques, anato- my, and safety issues. A pre-course test is optional, but might motivate students more.

Practical skills, hands-on

1) Hands-on training via ultrasound skills labs is an important part of any course (more than 50 % of time should be allocated for this activity).

2) Outside of formal courses, extra peer teaching by student tutors and self-training should be encouraged for skill development.

3) Additional supervised hands-on practice during clinical rotations should be accessible.

4) Opportunities for periods of 2-3 weeks for con- tinuous hands-on practice in clinical or imaging settings should be made available.

For hands-on ultrasound training in undergraduate education, we have the following recommendations:

a. Students should be introduced to hands-on skill training as early as possible.

b. Students should practice scanning with different equipment and with different patient positions.

c. Students should train in diverse student groups (dif- ferent constitutions, prepared vs. unprepared).

d. Students should have the possibility of continuous assessment of practical teaching.

i. Units of 90 min, max 180 min in one session.

ii. Weekly repetition as continuous as possible.

iii. Enough breaks.

e. Students should practice structured scanning as per adapted guidelines.

f. Students should have access to common and frequent pathologies pertinent to their skill level.

g. Students should master documentation techniques using the US machine (picture vs. video, annota- tions, button presets).

h. Students should practice how to report regular anat- i. In advanced training levels, students should practice omy.

fast vs. slow examinations.

j. In advanced training levels, students should have the possibility to perform supervised patient scanning in clinical settings.

k. After basic practical teaching, students should have the possibility to access non-supervised training set- tings such as a USSL.

Ultrasound skills lab (USSL) example

Skills labs provide special practical training aimed at developing the students’ hands-on skills in a com- fortable learning atmosphere. These utilize special fa- cilities to improve practical skills in examination (e.g.

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physical examination, blood drawing, auscultation of heart and lung, etc.). The Centre for Medical Skills and Simulation should incorporate an Ultrasound Skills Lab (USSL). USSL areas should have special equipment for US hands-on training and US e-learning. In the USSL, different US machines (3-4 traditional and POCUS ma- chines), as well as simulators and phantoms are ideally available for hands-on experience. The students’ optimal ratio could be 2-3 at one training station if resources al- low. These modules are taught by faculty trainers (profes- sors), student tutors (peer teaching), and by themselves via self-study. Furthermore, the USSL is equipped with anatomical material, US books, charts/posters, e-learn- ing material and access to resources for image review.

Hands-on training in the USSL should follow a well-de- fined schedule based on the main curriculum. Coordina- tion of the USSL should be performed interdisciplinary by enthusiastic clinicians with fundamental knowledge of practical ultrasound in their medical specialty and ad- vanced teaching skills.

Near-peer teaching in US education

Lack of teaching capacity is a major barrier to the implementation of ultrasound in undergraduate curricula [28]. Near-peer teaching has been evaluated in multiple intervention studies and has shown to be non-inferior to faculty-led teaching e.g. in musculoskeletal [30] or ab- dominal [31] ultrasound. Near-peer teaching may even have advantages over faculty-led teaching, e.g. the small distance between students and teachers both socially and intellectually that might foster learning because of cogni- tive and social congruence [32]. Based on the available evidence and the experience from different ultrasound societies, we generally encourage the involvement of near-peer teachers in undergraduate ultrasound training and highlight the importance of a high-quality and con- tinuous teaching for near-peer tutors.

Post Course Test

Skills taught in ultrasound courses should be subject to a post course examination. Tests can be administered as an Objective Structured Clinical Examination (OSCE), examples include the Objective Structured Assessment of Ultrasound Skills (OSAUS) scale [33] and the OSCE sta- tions validated by Hofer et al [34]. Furthermore, e-learn- ing pathway exams may help for continuous reevaluation of students’ knowledge. Due to flexibility and location independent usage, e-learning assessment should be in- tegrated adapted to curriculum milestones. During the study the collection of all passed tools, trainings, courses and lectures in US education in a US students logbook is useful. Evaluation of different US education tools is necessary and helpful implementation of US curricula.

Several simulators contain modules that allow evaluation

of the student’s progress and proficiency in obtaining correct images, either by direct, real-time feedback, or by comparing the student’s image with images from an image Library.

The use of guidelines in teaching ultrasound Over the last decade WFUMB and its federation of societies produced a series of guidelines and recommen- dations regarding different ultrasound applications for improved medical education It is imperative for medi- cal ultrasound education to ensure that the teaching is introduced and conducted appropriately based on the best available evidence. Experiences among institutions engaged in ultrasound education should be shared and guidelines and basic recommendations for ultrasound in medical student curricula should be established based on well-designed outcome studies, expert recommenda- tions, and adult learning principles [26].

Potential equipment and resources Ultrasound equipment

Technological advancements have made equipment accessible and affordable, with hand-held ultrasound de- vices as small as a smartphone [35-37]. Moreover, hand- held ultrasound has the potential to enhance the outcome of the physical examination, validating the practitioner’s initial clinical findings [10]. It is suggested that the qual- ity of the ultrasound image determines the result of the examination, but for teaching students, the small, inex- pensive portable ultrasound devices seem to be suffi- cient. For demonstration and training in more advanced clinical concepts such as contrast enhanced ultrasound (CEUS) or elastography, a high-quality unit will give a clearer demonstration. In order to understand the full bandwidth of scanning possibilities, US machines with all kinds of probes are mandatory in undergraduate edu- cation. Modern solutions with integrated technique in US probes as well as different solutions of image acquisi- tion (piezo crystal vs. semiconductor based) are available in undergraduate US education and introduce early the technical creativity of ultrasound equipment, clinicians will have to work with.

Resources

The funding of ultrasound education programs re- mains a crucial aspect of implementation and sustain- ability, and will depend on the economic resources of the region in which the program is to be implemented. Under resourced medical schools may be extremely challenged to implement such courses, but may qualify for inter- national grants that could support an ultrasound train-

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ing program or might attract sponsorship from industry [26]. Other schools may find avenues to fund programs via gifts or donations, or an increase in student fees to fund the relevant program. Establishing an enthusiastic team of students, clinicians and professors dedicated to US teaching in an appropriate learning atmosphere, e.g.

USSL, may be just as important as financial aspects.

Approaches to Data Storage and Reporting Documentation tools in medical education have been suboptimal for some time [38]. Data storage and report- ing are of utmost importance for quality control and con- structive feedback [12,16]. This can be achieved by using static images obtained by a video printer, stored images or preferably recorded cine loops. Documentation and re- porting should be prepared according to standard termi- nology. Reporting can be done onsite or remotely by tel- eradiology. Teleradiology requires adequate bandwidth as stored images are large even when compressed and the appropriate software and communication infrastructure.

Third party systems are also available and are often spe- cifically designed for education allowing easy video and image review, feedback and annotation through a remote web interface. There are various types of file compres- sion, but all are either lossy or lossless. Using lossy com- pression, the original images are not recovered exactly, whereas lossless compression techniques recover exact images of the original images. Various compression al- gorithm like Lossless JPEG, JPEG-LS, JPEG 2000, PNG and CALIC are in use but JPEG-LS has been found to be the best algorithm based on compression speed and compression ratio for medical image sequences [39].

Future developments in ultrasound image transfer and case discussion could include ultrasound real-time direct live communication and real time ultrasound im- age transfer. However, privacy and online security of protected health information data will be an important factor in the development of such online and real-time teaching and training options.

Video recording and archiving of entire ultrasound examinations requires huge data storage capacity, but has become possible. This is a valuable tool in teaching, as it allows offline reading and detailed feedback on quality standards and image improvement away from a potential hectic clinical environment [40].

Students should learn and practice precise and ac- curate reporting using correct terminology. Reports and worksheets should guide the student through a structured approach and use of ultrasound reporting software sys- tems may provide this learning experience. These clini-

cal picture archiving and communication databases are searchable and may provide additional educational op- tions for topic-related, case-based group teaching. How- ever, these databases require a high initial expense and constant expensive maintenance, and are not universally available.

Perspectives for postgraduate ultrasound training Further training can be determined by the (sub-) spe- cialty the student/physician will be working in. Prac- ticing ultrasound is a life-long learning process and constant refinement of techniques, adaptation to novel technologies/applications as well as advancing clinical knowledge. Regional, national and international net- works and tutorships should support further individual progress and learning under the umbrella of the ultra- sound societies. Establishing quality indicators in report- ing, image documentation and procedure outcomes and defining minimum activity numbers might help raise the general standard of ultrasound performance and to make it progressively comparable.

Summary

We have discussed current knowledge of ultrasound teaching in medical education including various meth- odologies and various educational systems. The authors, representing multiple societies and specialties through- out the world, summarize that medical student education and teaching efforts vary greatly among federations. It would be an unrealistic expectation that every medical school adapts the exact same approach to teaching ultra- sound.

We encourage the following concepts.

1) To introduce medical student ultrasound education as early as possible in the curriculum, e.g. during preclinical anatomy teaching.

2) To foster acquisition of practical ultrasound skills in an early stage of training (at least 40 hours during early years of medical school training).

3) Skills taught in ultrasound courses should be subject to a post-course examination.

4) The basic teaching content should be examina- tion technique, anatomy (normal findings) and safety issues.

5) To teach standardized medical sonography ter- minology.

6) To teach so-called “very important pathologies (VIP) is motivating but should be optional.

Conflict of interst: none

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