ULTRASOUND EXPOSURE DURING GROSS ANATOMY

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1 The Journal of Emergency Medicine, Vol. 46, No. 2, pp , 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved /$ - see front matter Education ULTRASOUND EXPOSURE DURING GROSS ANATOMY Stephanie M. Dreher, MD,* Robert DePhilip, PHD, and David Bahner, MD, RDMS *Emergency Medicine Resident, PGY-1, Medical College of Wisconsin, Milwaukee, Wisconsin, Division of Anatomy, The Ohio State University, Columbus, Ohio, and Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, Ohio Reprint Address: Stephanie M. Dreher, MD, Emergency Medicine Resident, PGY-1, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, Abstract Background: As medical schools seek to standardize ultrasound training and incorporate clinical correlations into the basic science years, we proposed that ultrasonography should have a greater role in the anatomy curriculum. Objectives: To describe the introduction of ultrasound into the curriculum of a first-year medical student anatomy course and evaluate the utility of this introduction. Methods: First-year medical students attended two ultrasound lectures and three small-group hands-on sessions that focused on selected aspects of musculoskeletal, thoracic, abdominal, and neck anatomy. Pre and post surveys were administered to assess student perception of their ability to obtain and interpret ultrasound images and the utility of ultrasound in the anatomy course. Understanding of basic ultrasound techniques and imaging was tested in the practical examinations. Results: Of the 269 first-year medical students who completed the course, 144 students completed both surveys entirely, with a response rate of 53%. Students interest and self-perceived experience, comfort, and confidence in ultrasound skills significantly increased (p < 0.001) as a result of this early introduction to ultrasonography. Objective evidence, provided by practical examination scores on ultrasound images, is consistent with this selfperceived confidence reported by students. Conclusions: Ultrasound can be effectively incorporated into an anatomy course for first-year medical students by utilizing didactics and hands-on exposure. Medical students found the addition of ultrasound training to be valuable, not only in enhancing their understanding of anatomy, but also in increasing their interest and experience in ultrasound imaging. Ó 2014 Elsevier Inc., Keywords ultrasound; anatomy; curriculum; education INTRODUCTION Though traditionally performed by sonography technicians and radiologists, ultrasound is becoming more widely used by physicians in over 20 specialties who are using ultrasound for procedural guidance, diagnostic assessment, and screening (1). Procedural guidance ultrasound can include central and peripheral vascular access, thoracentesis, paracentesis, arthrocentesis, regional anesthesia, incision and drainage of abscesses, localization and removal of foreign bodies, lumbar puncture, biopsies, and nerve blocks (2). If a wide range of clinicians can rely on this noninvasive, accurate, and user-dependent tool, the question arises whether the necessary instruction to use ultrasonography is embedded into medical education appropriately. The technology of ultrasound traditionally outpaced the education of the operators. As usage of ultrasonography diffuses across many medical specialties, there is a need to ensure competence, and to define the benefits of appropriate use (3 6). The challenge lies in determining the training and assessment of that training that will be required to ensure competent use of the technology (1). In 2000, the Residency Review Committee for Emergency Medicine announced it would require ultrasound RECEIVED: 21 November 2012; FINAL SUBMISSION RECEIVED: 25 April 2013; ACCEPTED: 14 August

2 232 S. M. Dreher et al. training in emergency medicine residency programs, and subsequently, ultrasound questions began to appear on board certification and in-service examinations (7,8). Some within emergency medicine saw that focused ultrasound could be a part of a longer-term training paradigm in undergraduate medical education and could have a lasting effect by the time students enter their residency program. Students could carry this knowledge into whichever residency of choice. Currently, exposure to ultrasound in medical school is nonuniform and limited during clinical clerkships, with the majority of training in bedside ultrasound occurring during residency (9). However, one medical education study demonstrated that medical schools cannot rely on the clerkship model of education alone to provide adequate training and practice to students in all of the basic clinical skills and procedures (10). Ultrasound may be one of these skills that require additional instruction outside of the clinical setting. With appropriate well-designed training, preclinical medical students can attain a sufficient degree of ultrasound proficiency and can apply these skills successfully (9). A group of first-year medical students have been successfully taught cardiac ultrasound and anatomy using hand-held ultrasound devices (11). Likewise, real-time ultrasound has been used by second-year medical students to improve their diagnostic accuracy of measuring the liver (12). Another study compared the ability of first-year medical students using ultrasonography after 18 h of ultrasound training with board-certified cardiologists using stethoscopes to accurately diagnose various presentations of cardiac disease (8,13). In this comparison, the students using ultrasonography were more accurate. Clearly, ultrasound is a skill that even junior medical students can learn with appropriate training. Recently, novel curricular adjustments have been made in several U.S. medical schools to include a 4-year vertical curriculum in clinical ultrasound (8,14). As medical schools seek to incorporate more clinical correlations into the basic science years, it has also been proposed that diagnostic imaging should have a greater role in the anatomy curriculum (15). In addition to the donorcadaver, the anatomy atlas, and computer-assisted instruction, ultrasound could contribute to anatomy education by combining surface anatomy with sectional anatomy. The dynamic ultrasound imaging of live models provides reference for students that conventional radiographs and computed tomography images cannot. The impact of hands-on active learning of ultrasound anatomy cannot be overemphasized because this will be the same task needed at the clinical bedside. Convinced that ultrasound imaging will be an important skill for future physicians in a wide range of medical specialties, we looked for the best ways to incorporate an introduction of ultrasound into the medical curriculum at this College of Medicine. Beginning in 2006, we introduced a clinical correlation of a case of cholecystitis that included ultrasound imaging as part of the patient work-up. In subsequent years, we added optional hands-on laboratory experience using the device. Students learned to image the extremities, torso, and neck anatomy on a live model as part of a curriculum that paralleled their dissections in the cadaver laboratory. Based on student feedback, ultrasound remained part of the anatomy curriculum as an introductory exposure to ultrasound in medical school. The study describes and evaluates the current version of our introduction of ultrasound into the anatomy course of first-year medical students. Currently, students receive instruction on basic elements of ultrasound imaging, on how to use the ultrasound device, and how to obtain ultrasound images of targeted areas of musculoskeletal, trunk, and neck anatomy, all in parallel with their dissections. The objectives of this study were 1) to demonstrate the utility of incorporating ultrasound into preclinical medical students anatomy education; and 2) to determine if ultrasound imaging enhances first-year medical students understanding of anatomy. Study Design METHODS This cohort study was approved by the hospital Institutional Review Board. Study Setting and Population The study population consisted of 269 first-year medical students enrolled in Gross Anatomy during August through November After the successful incorporation of abdominal ultrasound imaging into first-year medical students study of anatomy during the academic year, the Anatomy Division at this College of Medicine modified the curriculum to also include ultrasound imaging of the musculoskeletal system and neck in The curriculum was further refined with student and faculty feedback through pre- and postexperience surveys in , culminating in a complete and defined curriculum design for the academic year. Study Protocol Students attended two 1-h ultrasound instructional didactic sessions during their scheduled anatomy lecture time. One of the authors (D.P.B.) is the Director of Ultrasound and presented the lectures. During the first didactic and

3 Early Ultrasound Exposure for First-Year Medical Students during Gross Anatomy 233 scanning sessions, basic ultrasound physics, knobology, and terminology were also emphasized. After discussing proper probe selection, each didactic session then compared atlas depictions of anatomy to ultrasound images that the students will obtain during the scanning sessions. All first-year medical students were assigned to a small group consisting of first-year medical students and one senior medical student proctor. Senior medical students, residents, and faculty proctored the ultrasound laboratory sessions that focused on the use of ultrasound to study selected aspects of musculoskeletal anatomy, thoracic and abdominal anatomy, and neck anatomy. Firstyear medical students received a list of objectives prior to each scanning session and proctors received specific hands-on training and scanning guidelines prior to each session. Several resident and attending physicians circulated in the laboratory during each session to provide overall guidance. During Block 1 Musculoskeletal, at which time students were participating in cadaveric extremity dissections, first-year medical students viewed a proctor demonstration of ultrasound imaging of the shoulder, wrist, and elbow. Each student was then provided the opportunity to scan one of the three joints during individual scanning time while observing others as they imaged the other joints noted above. Focal anatomy during shoulder imaging included the humeral head, the biceps tendon within the bicipital groove, the subscapularis tendon inserting onto the lesser tuberosity of the humerus, and the supraspinatus tendon inserting onto the greater tuberosity of the humerus. Elbow imaging included the biceps brachii tendon, brachial artery, median nerve, and humerus, radius, and ulna in the anticubital fossa. Wrist imaging included the components of the carpal tunnel, as well as the radial artery, radius, and ulna. During Block 2 Abdomen/Thorax, when students were completing their abdominal cadaveric dissections, first-year medical students viewed a proctor demonstration of ultrasound imaging of the liver, great vessels, and kidneys. Each student was then given the opportunity to perform this imaging on a live model with proctor guidance. Specific liver anatomy included the portal triad, differentiating portal from hepatic veins, hepatic veins draining into the inferior vena cava (IVC), and the effect of deep respiration on liver imaging. Focal kidney imaging included the liver kidney interface and the psoas muscle. Abdominal vessel imaging focused on locating the aorta anterior to the vertebral bodies, scanning the aorta distally to image the aortic bifurcation, and proximally to identify the inferior mesenteric artery, the superior mesenteric artery, and the celiac trunk branching from the aorta, and drainage of the IVC into the right atrium. Finally, during Block 3 Head/Neck, when students were completing cadaveric neck dissections, first-year medical students viewed a proctor demonstration of ultrasound imaging of neck anatomy, focusing on the tracheal rings, the thyroid gland, the carotid arteries, and internal jugular vein. Each student then performed the imaging individually on a live model. In summary, the 2011 anatomy curriculum included a total of 2 h for didactic lecture and a total of 3.5 h for hands-on proctoring and scanning time. Each student was allotted 1 h each for the musculoskeletal (MSK) and neck scans, and 1½ h for the thoracic/abdominal scanning session. Students that desired more ultrasound exposure were encouraged to seek out more ultrasound opportunities via the College of Medicine s Ultrasound Interest Group. Measures Outcomes of interest in this study were both subjective and objective. Students perceptions of interest and confidence in ultrasound were evaluated using pre- and postultrasound experience surveys. The presurvey was distributed, completed, and collected in the lecture hall prior to the first didactic lecture. The postsurvey was distributed, completed, and collected after the final hands-on scanning session. Students understanding of ultrasound analysis and interpretation were also evaluated using test questions in the anatomy practical examinations for each block. Data Analysis Prior to the first ultrasound didactic lecture, a survey was distributed to all students attending the lecture. The survey utilized a five-point Likert scale intended to assess prior experience with and interest in ultrasound. Additional questions regarding confidence with ultrasound skills were asked using a seven-point Likert scale. Confidence was measured on an expanded, more discretionary scale because these questions came from another overall meta-research project on ultrasound application in the medical center. After completion of the last ultrasound scanning session, students were again asked to complete a survey to assess gain in knowledge and experience with ultrasound after the ultrasound in anatomy intervention. Mean scores of each question in the presurvey and postsurvey were compared using a paired-sample t-test. Students perceived benefit of having ultrasound incorporated into their study of anatomy was also questioned. The anatomy laboratory practical examinations for each block included one to two questions that included an ultrasound image and a question asking students to identify structures on the image or testing concepts taught during the ultrasound imaging sessions.

4 234 S. M. Dreher et al. RESULTS Of the 269 first-year students that completed the anatomy course, 218 first-year medical students completed the presurvey that was handed out to every student that attended the first ultrasound didactic lecture (the total number of students who attended the lecture is unknown). Of these, 144 students completed both the presurvey and postsurvey entirely, for a response rate of 66% (or 53% if including the entire first-year class). Analysis of pre- and postsurvey data indicates that students interest in ultrasound significantly increased (p < 0.001) after the Ultrasound in Anatomy experience. Whereas the mean interest of presurvey responders in ultrasound was 2.99 on a fivepoint Likert scale, the mean interest of postsurvey responders in ultrasound was 3.44 after the Ultrasound in Anatomy intervention. Of the 144 first-year medical students, 141 had never conducted an ultrasound scan. In the presurvey, firstyear students rated their current level of experience in ultrasound as a mean of 1.07 on a five-point Likert scale. The mean level of experience of postsurvey responders in ultrasound was 2.35 after the Ultrasound in Anatomy intervention, a significant improvement (p < 0.001). Similarly, first-year students were also asked to grade their individual ultrasound skills in each survey on a five-point Likert scale. The mean grade in the presurvey increased from 1.30 to 3.31 in the postsurvey (p < 0.001). Table 1 demonstrates first-year students self- perceived confidence in basic ultrasound knobology skills and concepts in ultrasound physics in the pre- and postsurveys. First-year medical students self-perceived confidence in imaging and identifying specific anatomical structures using ultrasound was also assessed using a five-point Likert scale. The specific structures that were imaged, identified, and measured were consistent with the stated objectives of the Gross Anatomy course and ultrasound curriculum. Table 2 demonstrates first-year students self-perceived confidence in ultrasound imaging of structures in the musculoskeletal system, abdomen, and neck on live models. The final part of each pre- and postsurvey assessed firstyear students confidence and comfort with ultrasound technical skills using a seven-point Likert scale for further discrepancy in student self-reporting. Table 3 depicts the students self-reports in the pre- and postsurveys for these questions. Overall, students self-perceived comfort and confidence in ultrasound skills increased substantially and significantly after the Ultrasound in Anatomy intervention (Figure 1). After viewing images in a didactics lecture and then obtaining images during the hands-on scanning session for each block, students were tested on equivalent images in their anatomy practical examination for each block (Figure 2). Validity and reliability of multiple measures, including discrimination index, suggests that the questions used in each examination are reliable measures of knowledge. The Block 1 MSK practical examination included one ultrasound question in which 73% of the class correctly matched the tendon of the long head of biceps brachii muscle tagged on the cadaver with its image on ultrasound (Figure 3). The Block 2 Abdomen & Thorax practical examination included two ultrasound questions. Only 42% of students correctly identified the hepatic vein on an ultrasound image and stated its function to carry venous blood from the portal system to the Table 1. Self-Perceived Confidence in Basic Ultrasound Skills Ultrasound Skill Presurvey Mean Rating Postsurvey Mean Rating Rating Difference Significance Knobology Turning on the machine p < Entering patient information p < Adjusting gain p < Adjusting depth p < Adjusting focus p < Labeling an image with comments p < Labeling an image with body marker p < Using Color flow mode p < Measuring a linear structure p < Measuring diameter p < Saving an image p < Explaining probe selection and differences p < Ultrasound physics Understanding ultrasound wave formation p < Understanding frequency/resolution p < Understanding basics of ultrasound physics p < First-year students were asked to reflect each skill and provide an honest assessment of his or her own level of ability at that time point by selecting the rating that fits best. 1 = Very unskilled (Novice), 2 = Unskilled (Beginning proficiency), 3 = Intermediate performer, 4 = Skilled (Advanced), 5 = Very skilled (Expert).

5 Early Ultrasound Exposure for First-Year Medical Students during Gross Anatomy 235 Table 2. Self-Perceived Confidence in Ultrasound Imaging of Anatomical Structures in Live Models Ultrasound Skill Presurvey Mean Rating Postsurvey Mean Rating Rating Difference Significance Musculoskeletal system Using ultrasound to image MSK anatomy p < Using ultrasound to evaluate joints p < Using ultrasound to evaluate for effusion p < Using ultrasound to evaluate the rotator cuff tendons p < Thorax and abdomen Performing a right upper quadrant ultrasound p < Using ultrasound to distinguish hepatic vs. portal veins p < Detecting free fluid in the right upper quadrant p < Imaging and measuring the kidney p < Using ultrasound to assess volume status via the IVC p < Using ultrasound to identify the aorta and its branches p < Using ultrasound to identify the portal triad p < Head and neck Using ultrasound to identify the carotid arteries p < Using ultrasound to identify the internal jugular vein p < Using ultrasound to identify & evaluate the thyroid p < Using ultrasound to identify tracheal rings p < MSK = musculoskeletal; IVC = inferior vena cava. First-year students were asked to reflect each skill and provide an honest assessment of his or her own level of ability at that time point by selecting the rating that fits best. 1 = Very unskilled (Novice), 2 = Unskilled (Beginning proficiency), 3 = Intermediate performer, 4 = Skilled (Advanced), 5 = Very skilled (Expert). inferior vena cava. However, 79% of students were able to correctly describe the position of the ultrasound probe given an unlabeled image of the aortic bifurcation (Figure 4). The Block 3 Head & Neck Practical examination also included two ultrasound questions. Ninety-five percent of students correctly identified the internal jugular vein on an ultrasound image; 90% of students correctly identified an ultrasound image of a tracheal ring and described its responsibility for structural integrity of the trachea. DISCUSSION The incorporation of ultrasound imaging into first-year medical students instruction in Gross Anatomy is achieved successfully with a combination of didactics and hands-on practice. Pre- and postsurvey data clearly indicate that first-year medical students feel the curriculum changes incorporating ultrasound imaging into the study of Gross Anatomy are valuable, not only in enhancing their understanding of anatomy, but also in increasing their interest in and experience with ultrasound. Incorporation of ultrasound techniques during Gross Anatomy not only increases interest in ultrasound, but also increases medical student skills with ultrasound imaging. Medical students self-report significantly increased confidence in basic ultrasound physics and knobology, as well as increased confidence in identifying anatomical structures. Interestingly, there is a trend in the survey responses that confidence in ultrasound increases with each consecutive block. Students feel more confident in identifying specific anatomical structures as the course progresses. This could be due to students increased familiarity with anatomy, with ultrasound, or both. This could also be due to the natural maturation of the students as they Table 3. Self-Perceived Confidence Using Ultrasound Statement Presurvey Mean Rating Postsurvey Mean Rating Rating Difference Significance I feel very comfortable adjusting hand pressure to create a clear image p < I am comfortable distinguishing arteries vs. veins vs. nerves on an p < ultrasound device. I am comfortable distinguishing solid structures vs. fluid on an p < ultrasound device. I am confident I can obtain various ultrasound views p < I am confident I can use ultrasound to identify anatomical pathology p < First-year students were asked to rate his or her agreement with the following statements about ultrasound skill and uses, using the following scale: 1 = strongly disagree, 3 = slightly disagree, 4 = neutral, 5 = slightly agree, 7 = strongly agree.

6 236 S. M. Dreher et al. Figure 1. Students self-perceived skill and confidence using ultrasound (US) a sample of the survey questions asked and resulting responses. transition from an undergraduate to medical school mindset. However, it is also the authors opinion that the musculoskeletal ultrasound skill set in Block 1 is more difficult than the abdominal examination in Block 2, which is subsequently more difficult than the neck examination in Block 3 for the general user. For the purposes of this study, ultrasound was integrated into the current Anatomy course structure. Conversely, from the perspective of ultrasound education, the reverse order of examinations would be preferable. This would allow students to begin with the simple neck examination, followed by the more robust abdominal examination, and then finishing with the most conceptually difficult musculoskeletal examination. It is unclear if the trend of increased confidence as the year Figure 2. Percentage of students who correctly and incorrectly answered anatomy practical examination questions regarding ultrasound knowledge. US = ultrasound; IJV = internal jugular vein.

7 Early Ultrasound Exposure for First-Year Medical Students during Gross Anatomy 237 Figure 3. Example of a question used on the Gross Anatomy practical examination regarding musculoskeletal anatomy and ultrasound. Students were required to match the tendon of the long head of biceps brachii muscle tagged on the cadaver with its image on ultrasound. The correct answer is D. progresses is due to student experience or the general difficulty of the required examination. Objective evidence, from practical examination scores regarding ultrasound images, is consistent with this selfperceived confidence reported by students. These test questions were chosen because they reflected not only material taught during the anatomy course, but also ultrasound skills that should have been developed during the hands-on scanning sessions. Instead of testing students on simple recognition of an anatomical structure on ultrasound, students are required to make a correlation between a structure demonstrated on a cadaveric dissection and its appearance on the ultrasound image. This indirect, two-step question structure is consistent with novel changes in anatomy education. Within the limited parameters, this study suggests that the hands-on teaching in ultrasound had an impact on the positive retention of information that was demonstrated Figure 4. Example of a question used on the Gross Anatomy practical examination regarding abdominal anatomy and ultrasound. This question is an indirect two-step question that required the student to first identify the aortic bifurcation and then use landmark knowledge from the ultrasound scanning session to answer. The correct answer is C.

8 238 S. M. Dreher et al. in the anatomy practical examinations. Given the success of the hands-on sessions, as indicated by high scores on ultrasound-related questions in the practical examination, it is evident that senior medical students can effectively proctor small group sessions and provide helpful instruction in ultrasound imaging. This is consistent with previous studies demonstrating that medical students can be effectively taught ultrasound imaging by their trained medical student peers (16,17). This study demonstrates that students perceive value in early exposure to this clinical tool. As these novice medical students progress onward in their medical education, their improved ability to effectively use ultrasound technology at the bedside as a result of this early intervention will be proven or disavowed. Traditionally, anatomy has started the medical school experience. Ideally, early ultrasound exposure at this time could lay a foundation to build upon opportunities to use ultrasound in subsequent years of training, resulting in competent and confident fourth-year medical students that are not only able to apply bedside ultrasound in practice, but also able to effectively teach others. Students could be prepared to use ultrasound on their first day of residency, in any specialty of their choice. Future directions to follow medical student progress could include saving ultrasound images during scanning sessions to a specific user name for each student, allowing them to develop individual portfolios of ultrasound images throughout the course of medical school. Outside of regularly scheduled ultrasound activities designed by the Ultrasound Interest Group, individuals could be encouraged to perform ultrasound scan independently, with the help of online or audio podcasts. Ideally, clinical ultrasound scanning sessions on real patients with faculty mentors could be incorporated into clinical experience in order for students to visualize pathology. As medical schools across the country begin to develop a 4-year ultrasound curriculum, this study suggests that ultrasound imaging can be effectively and successfully incorporated into the Gross Anatomy curriculum. Limitations First-year medical students begin with a limited base of knowledge that is largely built upon during their medical school training. Given that hardly any students had been exposed to ultrasound prior to Gross Anatomy, any amount of exposure would increase the knowledge and skills within this study population. However, the significance of this study lies in students self-reported perception of increased knowledge and comfort with ultrasound. Actual knowledge, as determined by test scores, was included in this study to demonstrate consistency between knowledge gained and perceived knowledge gained. Several limitations are inherent in this study s design. Although this study s response rate exceeds acceptable parameters and limits nonresponse bias, survey responses were dependent on students motivation, honesty, and memory. This survey relied on a convenience sample of first-year medical students those who attended the first didactic lecture and those who attended the final hands-on session. Undercoverage bias may exist in an inadequate sampling of first-year medical students who study independently and do not attend lecture or Gross Anatomy laboratory. Finally, first-year students are limited in further usage and application of ultrasound during their remaining preclinical years. Although this medical college offers many opportunities for preclinical medical students to become involved in ultrasound activities, participation is purely voluntary after Gross Anatomy. There is no way to predict solely based on survey responses which students will actually initiate further involvement in ultrasound. Longitudinal involvement in ultrasound-related extracurricular activities and later success in ultrasound application in future practice would require a long-term study, not investigated through the parameters used in this study. CONCLUSIONS Ultrasound imaging can be successfully introduced into a first-year medical anatomy course. Ultrasound imaging enhances first-year medical students understanding of anatomy and can be effectively taught to preclinical medical students by senior-level medical students under physician mentor supervision. This is demonstrated by students subjective impression of their ultrasound experience and correlated with objective evidence based on scores on the practical anatomy examinations. The benefits of this early instruction in producing students who are more prepared to use ultrasound at the bedside in the future needs to be more fully explored. REFERENCES 1. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011;364: Nicolaou S, Talsky A, Khashoggi K, Venu V. Ultrasound-guided interventional radiology in critical care. Crit Care Med 2007; 35(5 Suppl):S Filly RA. Is it time for the sonoscope? If so, then let s do it right!. J Ultrasound Med 2003;22: Adler RS. The use of compact ultra-sound in anesthesia: friend or foe. Anesth Analg 2007;105: Bree RL, Benson CB, Bowie JD, et al. The role of radiology in the era of compact ultrasound systems: SRU Conference, October 14 and 15. Ultrasound Q 2003;2004(20): Greenbaum LD. It is time for the sonoscope. 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9 Early Ultrasound Exposure for First-Year Medical Students during Gross Anatomy Cook T, Hunt P, Hoppman R. Emergency medicine leads the way for training medical students in clinician-based ultrasound: a radical paradigm shift in patient imaging. Acad Emerg Med 2007;14: Syperda VA, Trivedi PN, Melo LC, et al. Ultrasonography in preclinical education: a pilot study. J Am Osteopath Assoc 2008;108: Remmen R, Derese A, Scherpbier A, et al. Can medical schools rely on clerkships to train students in basic clinical skills? Med Educ 1999;33: Wittich CM, Montgomery SC, Neben MA, et al. Teaching cardiovascular anatomy to medical students by using a handheld ultrasound device. JAMA 2002;288: Barloon TJ, Brown BP, Abu-Yousef MM, et al. Teaching physical examination of the adult liver with use of real-time sonography. Acad Radiol 1998;5: Kobal SL, Trento L, Baharami S, et al. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol 2005;96: Rao S, van Holsbeeck L, Musial JL, et al. A pilot study of comprehensive ultrasound education at the Wayne State University School of Medicine. J Ultrasound Med 2008;27: Ganske I, Su T, Loukas M, Shaffer K. Teaching methods in anatomy courses in North American medical schools: the role of radiology. Acad Radiol 2006;13: Knobe M, Munker R, Sellei RM, et al. Peer teaching: a randomized controlled trial using student-teachers to teach musculoskeletal ultrasound. Med Educ 2010;44: Jeppesen KM, Bahner DP. Teaching bedside sonography using peer mentoring: a prospective randomized trial. J Ultrasound Med 2012; 31:455 9.

10 240 S. M. Dreher et al. ARTICLE SUMMARY 1. Why is this topic important? Ultrasonography is an important user-dependent skill set for future physicians in a multitude of specialties. Physicians need to develop competence and confidence using this diagnostic modality early in their medical training. 2. What does this study attempt to show? We suggest a successful and appealing way to incorporate ultrasound experience early into medical training, sparking interest in ultrasound and allowing students to build on their initial exposure throughout their medical training and careers, no matter what field of medicine they decide to pursue. 3. What are the key findings? Students interest and self-perceived experience, comfort, and confidence in ultrasound skills significantly increased. Objective evidence, provided by practical examination scores on ultrasound images, is consistent with this self-perceived confidence reported by students. 4. How is patient care impacted? Early exposure and training on a user-dependent diagnostic modality leads to competent physicians that are comfortable and confident in obtaining and interpreting ultrasound images, ultimately improving the efficiency and accuracy of appropriate patient care.