Results
Survey
Overall, 53 questionnaires were returned from 46 universities in 17 European
countries. At most of the universities (40/46 universities,
87%), the theoretical background of ultrasound is taught. However,
ultrasound is integrated into anatomy courses (8/46 universities,
17%) or basic science courses (16/46 universities, 35%)
at only a minority of universities. Practical skills in ultrasound are taught at
56% of the universities (26/46 universities) and tested in a
practical exam at 7 of the responding universities (15%). The number of
lessons in which ultrasound was taught ranged from 1 to 58 (mean: 7). When asked
about obstacles hindering the integration of ultrasound into the curricula, the
most commonly reported obstacle was lack of time (27/44 respondents,
61%), followed by faculty funding (17/39, 43%), and
equipment funding (18/40, 45%) ([Table
1]). When asked about the reasons for ultrasound implementation,
90% of all respondents (37/41) indicated that ultrasound
knowledge is useful for all physicians, and an almost equal number of
respondents (34/39, 87%) were convinced that ultrasound
knowledge was useful to learn later in practice. 60% of all respondents
(23/38) indicated that ultrasound helps students learn anatomy ([Table 2]).
Table. 1 Percieved obstacles hindering the integration of
ultrasound into the curricula
|
Not important
|
Somewhat important
|
Indifferent
|
Important
|
Very important
|
Not answered
|
|
Lack of funding for faculty
|
4
|
6
|
12
|
8
|
9
|
14
|
|
Lack of funding for equipment
|
3
|
8
|
11
|
5
|
13
|
13
|
|
Lack of time in current medical curriculum
|
7
|
8
|
4
|
12
|
15
|
7
|
|
Difficulty with faculty recruitment/training
|
4
|
7
|
11
|
7
|
7
|
17
|
|
Lack of acceptance or understanding of ultrasound political
barriers
|
15
|
3
|
5
|
6
|
5
|
19
|
|
No barriers
|
1
|
1
|
3
|
0
|
3
|
45
|
Table. 2 Reasons for ultrasound implementation
|
Not important
|
Somewhat important
|
Indifferent
|
Important
|
Very important
|
Not answered
|
|
Useful to learn later in practice
|
0
|
4
|
1
|
13
|
21
|
14
|
|
Helps students learn anatomy
|
4
|
1
|
10
|
5
|
18
|
15
|
|
Ultrasound and teaching are fun
|
1
|
7
|
12
|
4
|
13
|
16
|
|
Benefits school’s prestige
|
8
|
3
|
8
|
7
|
11
|
16
|
|
Ultrasound knowledge is useful for all physicians
|
0
|
1
|
3
|
4
|
33
|
12
|
Experience of European Universities
Vienna, Austria
Local structure
At the Medical University of Vienna, 640 students enroll each year. The
whole curriculum takes 6 years with 18 weeks of clerkship and a clinical
internship of 48 weeks.
Content of ultrasound lectures
All students attend lectures on the physical background of ultrasound and
its indications in the first semester and see anatomical as well as
pathological US images in their anatomy classes.
Who is teaching?
Radiologists give the lectures on the physical background, as well as on
ultrasound anatomy and pathology. In the hands-on course, one teacher
trains each group of students, either a radiologist or a specially
trained student tutor. The tutors are trained in an elective course and
must have sufficient tutoring experience in peer teaching before being
accepted as a tutor for the student course.
In every course, two groups of students are trained in one room with one
radiologist and one student tutor teaching. In this manner, it can be
ensured that more challenging questions that might be too difficult for
the student tutor can also be answered.
Hands-on courses
Mandatory hands-on courses take place at the end of the 7th
semester and consist of 3 x 2 hours within three weeks. In this course,
students are trained in groups of 5 students. 6 of the 14 ultrasound
devices used for this course are routine US machines from the department
of radiology, 4 US devices are from the students’ skills lab,
and 4 machines are rented from an ultrasound vendor each year for the
period of the course.
Examinations (learning success, testing)
At the end of the 8th semester, all students have to pass an
objective, structured, clinical examination (OSCE). Of the 12 practical
OSCE stations, one is on ultrasound, where each student has to show one
out of six of the standard views and must answer US anatomy and
pathology questions (i. e., cholecystolithiasis, cholecystitis,
pleural and pericardial effusions, ascites, hydronephrosis).
Riga, Latvia
Local structure
There are two medical faculties in Latvia: The Riga Stradins University
(RSU) medical faculty enrolls 250 students each year and the University
of Latvia (LU) enrolls 70 students annually. Both universities provide
mandatory formal teaching in medical ultrasound over the six years at
RSU and over two years at LU.
Content of lectures
Students attend lectures about the basics of ultrasound, which are also
available in student e-platform studies. Starting in 2013, RSU began to
use the ultrasound simulator, ULTRASIM, in the field of abdominal, neck
ultrasound, obstetrics, and gynecology. Students attend lectures about
the basics of ultrasound for two hours, which are also available in
student e-platform studies. Ultrasound is integrated into the basic
studies for 15 hours at RSU. LU has integrated medical ultrasound into
the diagnostic imaging course with lectures and practical sessions for
up to six hours of training. There is one more optional practical and
theoretical class about the basics of ultrasound held at the RSU
Department of Radiology, with 12 students per one supervisor
radiologist. Following the demonstration lesson, students can practice
on the ultrasound simulator for 32 hours. Following the demonstration
lesson, students can spend free time practicing on the ultrasound
simulator.
Who is teaching?
The ultrasound lectures at RSU and LU are conducted by members of the
interdisciplinary team, which consists of radiologists, cardiologists,
anesthesiologists, and certified ultrasound specialists from various
specialties, all with experience in the use of ultrasound and who have
board certification. Radiology trainees supervise the practical courses.
These trainees had successfully applied for a practical ultrasound
teaching program at the University Hospitalʼs ultrasound unit that
lasted at least two years, in which they acquired deeper knowledge
through the examination of patients on a daily basis and had proven
their skills and knowledge after the exam.
Hands-on courses
At the beginning of the clinical section, all students in the fifth, or,
optionally, the sixth semester, are offered a place in this elective,
parallel to the clinical examination courses. The practical course of LU
includes two two-hour sessions with groups consisting of ten students.
The participants perform all the exercises on each other under the
supervision of the tutor. Current high-end ultrasound equipment or a
dedicated portable ultrasound machine from the university
hospital’s ultrasound unit for point-of-care ultrasound (POCUS)
are used for training. The ULTRASIM simulator allows students to
practice the performance of ultrasound examination on a mannequin while
viewing real-time ultrasound images. Students fill out evaluation forms
at the end of the ultrasound course. The second-level ultrasound program
is implemented in the 5th year radiology program, with one class
dedicated to ultrasound pathology. Students have one hour of supervised
hands-on training.
Examinations
At the end of the lecture series, there is a written multiple-choice
test. The practical course finishes with a practical and oral
examination based on a standardized assessment process. Successful
attendance is obligatory for all students and is a prerequisite for
further courses.
Ulm, Germany
Local structure
Currently, a total of 325 students begin their studies every year at the
medical faculty of the University in Ulm. The entire curriculum requires
six years and is divided into two years of preclinical studies and
another four years of clinical education, including several clinical
internships and three trimesters of a practical year. Ultrasound has
been a mandatory component of the human medicine degree curriculum since
the winter term of 2016/17.
Content of lectures
The Ulm ultrasound course consists of lectures and a practical course
conducted in small groups. The lecture-based part regularly includes an
interdisciplinary approach (including cardiology, hepatology,
gastroenterology, endocrinology, radiology, pediatrics, anesthesiology,
and others). It conveys the theoretical content, basic principles, and
potential application areas of ultrasound. The practical course imparts
the basic handling of the equipment, as well as a fundamental
understanding of anatomic structures. The course also includes
instructions for examinations of the liver, gallbladder and bile ducts,
kidneys and adrenal glands, spleen, pancreas, abdominal vessels, and
lymph nodes.
Who is teaching?
The ultrasound lectures are conducted by members of the interdisciplinary
ultrasound team, which consists of internists, cardiologists,
radiologists, pediatricians, and anesthesiologists, all with experience
in the use of ultrasound. The practical course is supervised by tutors
who are medical students. All of them have attended the course
themselves. They subsequently successfully applied for a practical
ultrasound course that lasts at least four weeks at the university
hospitalsʼ interdisciplinary ultrasound unit, in which they acquired
deeper knowledge through the examination of patients on a daily
basis.
Hands-on courses
At the beginning of the clinical section, all students in the fifth or,
optionally, the sixth semester are offered a place in an elective,
parallel to the clinical examination courses. The lecture series
consists of 13 units of 45-minute sessions. The practical course
includes four two-hour sessions with groups that consist of four
students. Within this group, the participants perform all the exercises
on each other under the supervision of the tutor. All groups use
current, high-end ultrasound equipment from the university hospitalʼs
interdisciplinary ultrasound unit. Both parts of the course require
compulsory attendance.
Examinations
At the end of the lecture series, there is a written, multiple-choice
test. The practical course finishes with a practical and oral
examination based on a standardized assessment process. Successful
attendance is obligatory for all students and is a prerequisite for
further courses.
Chieti, Italy
Local structure
About 220 students begin each first year of the six-year course of
medical school at “G. D’Annunzio” University of
Chieti. Participation in this ultrasound course is mandatory.
Content of lectures
The university offers ultrasound training for 3rd and
4th year students. The theoretical part regularly
involves multiple disciplines. It includes a review of basic principles
and application areas of ultrasound. The practical course imparts the
basic handling of the equipment, as well as a fundamental understanding
of the anatomic structures on the organ systems of the abdomen, thorax,
heart, lymphatic system, thyroid, and blood vessels.
Who is teaching?
The ultrasound courses are held by internists (professors, medical
doctors, PhD students, and residents) with many years of ultrasound
experience according to the guidelines of the Italian Society for
Ultrasound in Medicine and Biology (SIUMB) and of EFSUMB. The sessions
consist of a theoretical part on the basics of ultrasound and a more
important practical section, which includes live demonstrations and
hands-on training. During the lessons, there are often presentations of
images and videos that demonstrate physiological and pathological
ultrasound findings.
Hands-on courses
The courses are organized over four weeks, with practical training of two
hours/week. The students are divided into groups of 5–10
students for each teacher and ultrasound machine for better
understanding of ultrasound technique and to have a real possibility to
experience “hands-on” ultrasound. The students are
usually also the models for hands-on sessions.
Examinations (learning success, testing)
There is no written or multiple-choice test, but ultrasound skills are
evaluated in a practical test at the end of the training period. All
participants fill in a questionnaire to assess the satisfaction with the
course. Medical students with a special interest in medical ultrasound
are invited to participate in advanced lessons and courses organized by
university or scientific societies.
Gdansk, Poland
Local structure
At the Medical University of Gdańsk, 300 students are accepted
each year. The whole curriculum requires six years. Currently, there are
no obligatory US courses. Interested students, however, are invited to
participate in an optional abdominal and chest ultrasound course
and/or join an ultrasound student scientific circle (about 350
members in 2019). There are plans to incorporate an ultrasound course
into the curriculum in the future.
Content of lectures
The objectives of the voluntary ultrasound course are to obtain skills in
handling ultrasound devices and to visualize abdominal organs and detect
possible abnormalities. The course is divided into the following
sections: 1. Ultrasound handling; 2. Gallbladder and biliary ducts; 3.
Vessels of the liver; 4. Liver segments; 5. Pancreas and spleen; 6.
Kidneys and the urinary system; and 7. Big vessels of the abdomen. Each
section starts with a 20-minute demonstration for groups of
15–20 students led by experienced doctors. Afterward, the
students have about two to four weeks to master each section by
themselves. No simulators are used. Students practice on each other or
on volunteers. Students practice at the Workshop of Diagnostic
Ultrasound at the pediatric, hematologic, and oncologic wards at the
Medical University of Gdansk, where well-trained doctors are available
from Monday to Friday for six hours a day. In addition, students can
repeat and deepen their knowledge using a Polish education website
platform (www.eduson.pl), where each section is explained in an easy and
simple way, with images and movies that can be used as a reference
(mainly while practicing on a machine).
On average, students spend 42 h and 24 min (minimal 16 h and maximal 70
h) practicing by themselves during the whole course.
The ultrasound scientific club has no predefined content. There are a few
theoretical and practical events every year with unlimited access to the
ultrasound machines throughout the academic year and during the
holidays.
Who is teaching?
Experienced doctors and a professor are available for the course, all of
whom are pediatricians who perform ultrasound exclusively in everyday
practice.
The same experienced specialists are available for the ultrasound
scientific club, where older and more experienced students
(‘leaders’) also help younger students when appointed by
the professor and after passing an exam.
Hands-on courses
One machine is available for interested students (course or ultrasound
scientific club) for practice by themselves all day (7:00–22:00,
seven days/week), two in the afternoon (14:00–22:00) and
another two all day or in the afternoon only, depending on availability
(may be used for patient examination if needed).
Examinations (learning success, testing)
After each chapter, there is a practical test, where each student is
asked to visualize particular organs or anatomical structures, to
perform particular tasks (measurements, different sections of organs,
Doppler examinations), and to answer a few theoretical questions. No
examinations are mandatory for the ultrasound scientific club, except
for the ‘leaders,’ similar to the examinations in the
course. The required knowledge includes ultrasound examinations of the
whole abdomen, thyroid, and lungs.
Timișoara, Romania
Local structure
Approximately 600 students begin the courses at the "Victor
Babeș" University of Medicine and Pharmacy Timișoara each year.
The curriculum for general medicine requires six years, two years of
pre-clinical and four years of clinical courses.
Content of lectures
Currently, the university curriculum offers a basic course in abdominal
ultrasound for all students in the 3rd year and an optional
course in echocardiography and abdominal ultrasound for the students
from the 4th year (this one is attended by around 100
students every year), both structured as one hour/week courses
and one hour/week practical sessions for 14 weeks (one
semester). These courses include lectures on basic principles and
ultrasound examination technique, normal abdominal ultrasound anatomy,
and primary indications for abdominal ultrasound and ultrasound
pathology related to the abdominal organs. There is also, on the
university website, an e-Book of Ultrasound for Students in Romanian,
English, and French, with text and pictures available for all students
and also for external use
(http://www.umft.ro/data_files/documente-atasate-sectiuni/2213/curs_20eco_20eng.pdf).
Who is teaching?
Gastroenterologists, professors, associate professors and lecturers, who
are experts (level III) in ultrasound of the Romanian Society of
Ultrasound in Medicine and Biology (SRUMB) and EFSUMB hold the
ultrasound courses. The practical sessions are based on live
demonstrations, hands-on training, and video presentations, and are also
held by gastroenterologists, assistant professors, and PhD students.
Usually, one teacher trains two groups. A gallery of images and short
movies of pathological conditions for students in training are under
development. Sometimes, at the student’s request, a two-day
additional ultrasound course for students is arranged during the
weekend, with short theoretical lectures (approximately two hours) and
mainly hands-on activities with portable ultrasound machines. Postdoc
and PhD students are primarily involved in these types of activities,
but with the strong support of the professors and associate
professors.
Hands-on courses
The courses are organized during one semester (14 weeks in length), with
lectures for one hour/week and practical training for one
hour/week. During the practical sessions, the students are
divided into groups of 7–10 students, each group usually using
one ultrasound machine (five machines are prepared for this purpose).
The hands-on sessions are based on learning normal ultrasound anatomy
using students as models. Teachers demonstrate pathological
conditions.
Examinations (learning success, testing)
The evaluation period is at the end of the semester and consists of a
theoretical multiple-choice test and a practical exam, in which students
must recognize and describe frequent ultrasound pathologies from video
cases. A questionnaire about their satisfaction regarding the ultrasound
course is offered to students at the end of their activity and the
results are evaluated at the university level. The best students from
the ultrasound courses are invited to participate in advanced ultrasound
training to become tutors for future ultrasound courses.
Uppsala, Sweden
Local structure
At the Medical School of Uppsala University, 250 students begin each
year. The whole curriculum requires 5.5 years: 2 years pre-clinical
courses and 3.5 years clinical courses. After graduation, a two-year
internship (Foundations Years) follows, which leads to board
certification.
Content of lectures
During the 3rd year of the medical program, the students begin
to learn the basic principles of ultrasound. Ultrasound is integrated
into the curriculum, and the FATE (Focused Assessed Transthoracic
Echocardiography) protocol is used. As preparation for a half day (four
hours) of knobology and practicing ultrasound, students go through
e-learning
(https://sonosim.ttlms.com/signon/).
Teaching takes place in groups of four to seven students per
facilitator. The facilitator is a junior doctor trained in ultrasound
and the FATE protocol. During the last year, medical students also learn
the “FAST” (Focused Assessment with Sonography in
Trauma) protocol, with basically the same setup as for the FATE
protocol. Facilitators are residents in emergency medicine at the
Uppsala University Hospital. The FAST protocol is integrated into the
course of emergency medicine, taken just before graduation.
Who is teaching?
Specially trained junior doctors hold lectures on the physical science
basis, as well as on ultrasound anatomy and pathology. In hands-on
courses, a specially trained junior doctor trains each group of
students. The junior doctors are well trained in the clinic and have
sufficient tutoring experience before being accepted as a tutor for the
course. In every course, small groups of students train in one room. In
every room, there is one student tutor teaching.
Hands-on courses
Mandatory hands-on courses take place at the end of the 5th
semester. In this course, students are trained in groups of five
students. 6 of the 14 ultrasound devices used for this course are
hand-held ultrasound devices and the rest of the devices are a mix of
brand new and slightly older, less mobile ultrasound equipment.
Examinations (learning success, testing)
During year 3, all students go through e-learning
(https://sonosim.ttlms.com/signon/).
Teaching and examination are performed in groups of four to seven
students per tutor. Multiple choice questions (MCQs) and OSCE stations
are used for the examination.
Copenhagen, Denmark
Local structure
At the Medical University of Copenhagen, 546 students were accepted in
2018. The curriculum of medicine is scheduled for six years. Thereafter,
one year of practical training as an intern is mandatory to obtain the
right to practice independently as a physician.
Content of lectures
All students receive lectures about the basic physics of ultrasound.
Ultrasound is included in the anatomy classes, in a specific one-day
ultrasound course, in an imaging course, and in classes from other
medical specialties as an adjunct. In the 6th year, an
optional eight-week course in ultrasound is offered that is designed so
that students can obtain the level of expertise of a first-year resident
in radiology (see below).
Who is teaching?
Radiologists, who are associate professors or professors at the
university, are in charge of the lectures. Residents in radiology,
specially trained medical students, associate professors and professors
are involved in the hands-on training.
Hands-on courses
A full-day course is offered in ultrasound in the sixth semester (not
mandatory), which includes four hours of hands-on practice. Furthermore,
one hour is offered later in the semester. Hands-on is also included in
the teaching from several other medical specialties without formal
hands-on training.
Examinations (learning success, testing)
A question regarding ultrasound may or may not be included in the OSCE
exam in the 4th year. For the optional eight-week course, a
test on an abdominal ultrasound simulator (the Copenhagen Test) must be
passed before beginning training in the radiology department. At the end
of the course, students must pass a practical exam demonstrating
abdominal pathology in a patient.
London, UK
Local structure
At Imperial College Medical School London, approximately 350–380
students are accepted each year. The whole curriculum requires six
years, with the first three years of pre-clinical study that includes an
eight-month period of research, which leads to a Bachelor of Science
degree. The following three years are clinical years spent in teaching
and district general hospitals, as well as within primary care, which
leads to a Bachelor of Medicine and Bachelor of Surgery degree. This is
then followed by a two-year internship before interns become fully
registered doctors with the general medical council. The exposure to
ultrasound varies among the 40 medical schools in the UK, but, in
general, there is little exposure to ultrasound during the undergraduate
years.
Content of ultrasound lectures
The teaching of anatomy now includes radiological anatomy in a clinical
context. The lectures and teaching modules, however, usually comprise
the use of cross-sectional modalities, namely, CT or MRI, which are
easier to correlate with anatomical cross-sections. Ultrasound may be
mentioned on occasion but does not feature heavily during the course at
Imperial College London. The 5th year students spend a week
in radiology departments and are exposed to all modalities, including
ultrasound. There are e-learning modules that have some ultrasound
content, but these are taught more in terms of body parts and systems
rather than being modality-based.
Who is teaching?
Radiologists and sonographers hold lectures on the physical background,
as well as on ultrasound anatomy and pathology. During the clinical
years, depending on the specialty, students may be taught some US by
specialists in the particular field, especially if it is performed as
part of point-of-care ultrasound e. g., in the emergency
department and anesthesia department.
Hands-on courses
There is a “hands-on” US afternoon during the one-week
secondment to radiology in year 5 where students get to scan each other,
typically in groups of five to six, with a radiologist or sonographer as
an instructor.
Examinations (learning success, testing)
Ultrasound knowledge is not formally examined but may be part of an
anatomy question or year 3 exam, depending on what specialty is chosen
for the student’s research project. Ultrasound may also be part
of an objective structured clinical examination (OSCE) in year 6.
Discussion
Over the last several years, EFSUMB [1]
[2] and WFUMB [3] as
well as several other publications have addressed the issue of student training in
ultrasound [4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12] and promote ultrasound as an educational tool
that should be used in the modern teaching of medicine.
Due to the fact that ultrasound allows real-time, noninvasive visualization of
anatomic structures and their physiological function in vivo, ultrasound has
been advocated as an auxiliary educational tool, in particular, for anatomy and
physiology teaching (“living anatomy”), as well as for the teaching
of physical examinations and basic clinical skills [13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]. There is already consistent evidence that this
type of teaching is also very well accepted, wanted, and enjoyed by students [3]
[14]
[22], even if the evidence regarding the effect of US
on external outcomes is still limited [14]
[23]
[24].
The present paper indicates that formal ultrasound education is beginning to enter
the curricula of medical schools in Europe. While ultrasound training is already
well established at some universities, responses from other universities indicate
that ultrasound plays no or only a small role. Not surprisingly, most of the
respondents felt that ultrasound knowledge is useful for all physicians. This high
enthusiasm for ultrasound by the respondents is most likely biased to some degree,
as the respondents belonged mainly to universities with already established US
training programs or which were otherwise involved in US education.
Although the respondents acknowledged the importance of US education in medical
universities, the mean hours of US training were reported to be as low as seven
hours.
Interestingly, hands-on skills in ultrasound were taught in only 56% of the
responding universities. One reason for the low proportion of hands-on training may
be explained by the fact that the responses indicated that, although the benefits
of
the integration of ultrasound into the curricula are well understood, lack of time
and limited faculty funding are perceived as major obstacles. Lack of time as well
as a lack of funding are both related to the fact that hands-on ultrasound training
requires small groups of students, which, in turn, requires a high number of
teachers and equipment. Examples from Vienna and Ulm, as well as from other medical
universities around the world, show that trained students can support staff
physicians in curricular training, and thus, reduce personnel time and costs [3]
[13]
[25]
[26]. The added value and the teaching quality of
student tutors in ultrasound education have not been well investigated
scientifically thus far. However, as has been shown for other fields of medical
education [27]
[28], data suggest that results of peer-assisted
ultrasound learning in undergraduate medical education may be equal to that of
traditional faculty teaching [11]
[29]
[30]
[31]
[32]. Teach-the-teacher curricula should be developed,
with the aim of optimizing student tutor-based training. An example of such a
student tutor training curriculum is the “Young Sonographers” of the
Swiss Society of Ultrasound in Medicine (SGUM), which was developed in cooperation
with student groups and the Institute of Primary Health Care in Bern [3]. Other initiatives that used students as mentors in
ultrasound have proved to be successful [26]
[33]
[34], with the students acquiring adequate teaching
skills in a relatively short training period, thus suggesting again that peer
mentoring can facilitate the large-scale implementation of ultrasound teaching in
undergraduate student education.
The financial burdens and demand on teachers indicated as obstacles for the
integration of ultrasound into the curricula can in part be overcome by implementing
e-learning, as practiced in Gdansk, Timisoara and Uppsala [35]
[36]. Other options are ultrasound phantoms and
simulators which are implemented in several ultrasound teaching programs for medical
students, for example, in Riga and Copenhagen. They may help to learn to practice
medical ultrasound in a protected learning environment before practicing the
technique in a clinical setting [37]
[38]
[39]
[40]
[41].
As the response rate of the survey was very low, the results do not give a
comprehensive overview of ultrasound education in Europe. Presumably, the response
rate was higher from universities in which ultrasound was integrated to some degree
into the respective curricula. Furthermore, the selection of the universities to
report on ultrasound activities was not representative but was mainly intended to
give an overview of the different approaches from a variety of universities.
