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Teaching medical ultrasound has increased in popularity in medical schools with hands-on workshops as an essential part of teaching. However, the lockdown due to COVID-19 kept medical schools from conducting these workshops.
The aim of this paper is to describe an alternative method used by our medical school to allow our students to acquire the essential psychomotor skills to produce ultrasound images.
Our students took online ultrasound courses. Consequently, they had to practice ultrasound exercises on a virtual simulator, using the mouse of their computer to control a simulated transducer. Our team measured the precision reached at the completion of simulation exercises. Before and after completion of the courses and simulator’s exercises, students had to complete a questionnaire dedicated to psychomotor skills. A general evaluation questionnaire was also submitted.
A total of 193 students returned the precourse questionnaire. A total of 184 performed all the simulator exercises and 181 answered the postcourse questionnaire. Of the 180 general evaluation questionnaires that were sent out, 136 (76%) were returned. The average precourse score was 4.23 (SD 2.14). After exercising, the average postcourse score was 6.36 (SD 1.82), with a significant improvement (
The integration of an online simulator for the practical learning of ultrasound in remote learning situations has allowed for substantial acquisitions in the psychomotor field of ultrasound diagnosis. Despite the absence of workshops, the students were able to learn and practice how to handle an ultrasound probe to reproduce standard images. This study enhances the value of online programs in medical education, even for practical skills.
Ultrasound in medical education is gaining more and more interest due to the motivation of medical students on one hand [
Ultrasound teaching is classically divided into two mains parts: theoretical lectures focused on physics, image acquisition, indications, limitations and hygiene, and practical exercises focusing on the acquisition of psychomotor skills necessary to get diagnostic ultrasound images [
In 2020, the COVID-19 pandemic abruptly disrupted the habitual working/learning practices of many medical entities. The impact was felt from emergency departments [
This method of teaching ultrasound has been structured into two parts. First, to make a detailed presentation of the ultrasound exploration of the different systems and to complete the theoretical teaching of the bachelor’s years, we directed the students to the “Blended learning” site of the Institute of General Medicine of the University of Bern [
The aim of this paper is to describe and evaluate this alternate online method we used to train our medical students in the acquisition of the visuospatial and visuomotor skills required to manipulate an ultrasound transducer and produce images of diagnostic quality without live workshop attendance.
The online simulator was provided by an Israeli start-up (Innoging, Tel Aviv;
View of the simulator interface, with the generated ultrasound slice on the left and the probe on the mannequin on the right. As the probe is drawn closer to the reference position, it becomes green. At the same time, the counter (at the top, on the left) increases up to 100 (perfect matching).
Bases of probe manipulation
Liver and right kidney
Bladder and uterus
Heart
Pregnancy
Right kidney
Liver and gallbladder
Large vessels, spleen, thorax
Aorta
Aorta
Aorta and inferior vena cava (IVC)
Aorta and IVC
IVC
Spleen
Spleen
Spleen
Spleen
Thorax
Thorax
Thorax
Thorax
Liver, pancreas, gallbladder, bile ducts
Liver
Liver
Liver
Liver and gallbladder
Liver
Liver and main biliary duct
Liver and main biliary duct
Gallbladder
Gallbladder
Gallbladder
Left liver
Pancreas
Pancreas
Pancreas
Kidneys, urinary tract, bladder, uterus
Right kidney
Right kidney
Left kidney
Left kidney
Left kidney
Right kidney
Bladder
Uterus
Bladder and uterus
Bladder and uterus
Bladder and uterus
Musculoskeletal system, neck, lymph nodes
Achilles’ tendon
Achilles’ tendon
Thyroid
Thyroid
Thyroid
Cervical lymph nodes
Cervical lymph nodes
Thyroid
Thyroid
Cervical lymph nodes
Groin
Groin
Every student in the first year of master’s studies in the medical school of the University of Lausanne, Switzerland received a personal code to access the simulator. They had to carry out the various exercises proposed, with the recommendation of practicing the exercises only after studying the corresponding chapter of the “Blended learning” course. Access was open from mid-May to the end of August 2020.
The completion of exercises was monitored. The precision obtained by the trainee during the simulator exercises, where a typical image had to be reproduced, was measured as a percentage of the reference position given at the beginning of each exercise.
A questionnaire targeting the manipulation of an ultrasound probe had to be completed by each participant at the beginning and at the end of the training (pre- and postcourse, 20 questions, maximum score 10;
Example of a question of the pre-posttest: I have just got the previous images (images 2a and 2b). To get the image 2c during the same run, I have to make the following movement with my probe: (a) translation to the left, (b) anticlockwise rotation, (c) inclination to the right, (d) I don't know. Answer b: anticlockwise rotation.
The study was designed as a quality control for ultrasound teaching. As such, our ethical review board determined that the project did not fall within the scope of the Law on Human research (Req-2021-00589), and informed consent was waived. The data was anonymized to guarantee the privacy of participants.
The statistical analyses were carried out with
A total of 193 students finished the precourse training during the allotted period. A total of 184 students performed all the simulator exercises and 181 performed the postcourse test. The faculty sent 180 evaluation questionnaires, of which 136 (76%) were returned.
Analysis of the target questionnaires determined that the scores had increased significantly after the completion of the simulator exercises (
Differences between the posttest score and pretest score. The mean difference was 2.12 (SD 2.13), with a maximum of 8.5 and a minimum of –3. The comparison of the two tests showed a significant difference, with an improvement in performance after the simulation exercises (Wilcoxon rank sum test;
Relation between the simulator score (precision of the execution of the simulation exercises) and the posttest score (understanding of probe manipulation) for each student (Spearman rho 0.2664;
A total of 20 students performed better during the precourse (mean score 6.75, SD 1.93) than during the postcourse (mean score 5.32, SD 1.97;
Nearly two-thirds (n=84, 62.6%) of the students said they enjoyed working on the simulator. A total of 79 (58.0%) students felt that they had achieved the course’s objective of reproducing ultrasound images. A total of 115 (84.5%) estimated that, after that course, they were able to recognize the abdominal organs by ultrasound. A total of 83 (61.9%) students found that the exercises were adapted to their previous knowledge, and 68.6% (n=92) felt that they had progressed in understanding ultrasound anatomy. Inadequate connection speed had been a problem for 40.2% (n=54) of students.
Among the negative comments, difficulty in manipulation of the simulator probe and the mannequin from the computer mouse or trackpad were frequently cited. Another recurring remark was related to the “Blended learning” courses being in the German language.
Our study has demonstrated that the integration of an alternative teaching model during the pandemic lockdown for the practical learning of ultrasound with an online mode has allowed substantial psychomotor skill acquisitions for ultrasound diagnosis.
The COVID-19 pandemic has impacted medical education everywhere. Universities were forced to switch to online teaching [
Despite the limitations related to the urgency of its implementation (course of “Blended learning” in a foreign language, difficulties in manipulating the probe of the simulator with a mouse or trackpad, difficulties in orienting the mannequin, simulation with slow internet connection) nearly two-thirds of students were satisfied with the experience.
Simulation is a popular teaching method in health care education [
Whatever the technology and the price of the ultrasound simulator, many reservations are expressed about the real place of simulation in ultrasound teaching [
For 20 students, the posttest score was lower than the pretest score. However, their score on the simulator was the same as that of all the students.
Some students had already received an introduction to ultrasound before the project was launched. We did not specifically ask the question of previous training to the participants. Nevertheless, a closer look at this group of “negative” performers revealed that it consisted of many pupils repeating the grade and young sonographers and students in higher grades from other universities; in other words, students with previous exposure to ultrasound training.
Students had free access to the new learning method during the 3.5 months. They received the initial instructions and then they were free to proceed to the activities at their own pace and convenience. As for other medical students worldwide, lockdown did not mean enforced idleness. They were committed to different health care initiatives against COVID-19 [
Difficulties with manipulations of the simulator probe and the mannequin from the computer mouse or trackpad were mentioned as a problem in the simulation’s experience. Gunabushanam et al [
Unfortunately in our study, we could not evaluate the impact of online simulation training on real practical skills. Because of the completely virtual setup of the study, only simulator-based analysis and subjective feedback were available for analysis. A future part of the study will compare the ultrasound scanning performance of different groups of students: the young sonographers’ tutors, the medical students exposed to the simulator without additional supervised training, and the young sonographers’ students with traditional training. This later group is still in training with hands-on workshops. As soon as the present lockdown will be lifted, we will proceed with this additional study. Another limitation was related to the foreign language of the “Blended learning” course. This course is a part of the official program of medical students’ ultrasound teaching from the SSUM-SGUM. The translation in the other official Swiss languages has been planned, but as with many other projects this year, it has been delayed because of the pandemic.
We have observed that exposition of medical students to a completely virtual ultrasound simulation experience has enabled them to acquire substantial visuospatial and visuomotor ultrasound skills. Until today, these competencies were only acquired through practical work on site with tutors. With this study, we demonstrated the value of a dedicated online method to remotely teach practical ultrasound. Self-learning has the potential of substantially reducing the barriers to use ultrasound simulation and its potential costs.
Swiss Society of Ultrasound in Medicine
None declared.