Dr. Christine McBeth and Dr. Leigha Winters
One of the best, and most sustainable, ways to improve health is through education. Ultrasound education has its own unique challenges, which are often amplified when the educational program is being performed at an international site or in a limited resource environment. This section covers important points to consider before, during and after an educational program and is specific to provider-performed point of care ultrasound.
- Preparation
- Finding the learners
- Planning and scope
- Putting it into action
- Assessment and competency
- Take Aways
Preparation
Arguably the most important aspects of creating a successful and sustainable ultrasound education project (or any skills-based educational intervention, in fact) occur months in advance of project implementation. When first establishing global collaborations, it is critical that educators start with some version of a needs assessment and goal-setting discussion. As educators, you need to identify the “who, what, where, when, why, and how” of medical education: who are your targeted learners? What is the clinically relevant (ultrasound) knowledge that is needed in this specific setting? How do you plan to impart this knowledge or skill set on these particular learners? Where geographically/logistically will you be teaching these skills? When and how often will you be teaching to reinforce specific concepts? Why is it important these learners gain this specific knowledge/skill set? And how will you assess their knowledge acquisition after (or during) project implementation? The following will break down each of these components.
Finding the learners
A useful place to start when creating a new global ultrasound educational project is identifying your targeted learners. If an institution or administrator reached out to you about creating this project, find out who in their institution are they hoping will gain this knowledge. Who do they feel will benefit most from this new skill set? These learners may vary from nurses to mid-level providers to physicians – and will sometimes not be who you would expect from the outset. For example, as physicians from Western medical education backgrounds, we often imagine that we should be sharing our ultrasound knowledge primarily with other physicians. However, in many limited resource settings, it is nurses and/or mid-level providers who provide most of the clinical care, and therefore would be the learners most likely to utilize the ultrasound skills we plan to share. Another important consideration is educational hierarchy. Although we may not think it poor-form to train a resident doctor before her department chief, this may be frowned upon in other settings.
It is also important to consider how broad a range of learners you will have the capacity to teach. If training physicians, will it be physicians from all specialties, or only specific specialties? Will you be teaching trainees only, or also faculty? It is important that you take the time to try to understand how a particular medical system is set up and functions as well as baseline ultrasound knowledge. This will help you navigate the hospital politics and ultimately make the education more successful. You do not want to prepare a talk on adjusting the focal point and the technicalities of using doppler when you should be starting with “this is where you find the ON button.”
If implementing a large project across multiple geographically distant sites, consider how best to share skills between learners. Two common approaches are a) ultrasound champions and b) “train the trainer” models.
Ultrasound champion
With the ultrasound champion model, an accomplished and engaged learner is identified who then serves in future teaching roles and also as a source of inspiration to co-learners. Champions are usually identified at the end of the group training session, when there is a clear sense of who is most enthusiastic and competent in their ultrasound skills. The champion should be formally acknowledged so the group at large knows that they are a local expert and will look to them for additional guidance and support. This approach works well to keep learners engaged in ultrasound learning after the external educators have left. Often the champion is a non-traditional teacher, such as a resident physician or nurse, and it will encourage and motivate other learners to have a champion from within their own ranks.
Train-the-trainers
The train-the-trainers model is a more formalized system of teaching skills to individuals who will continue education after expert educators have left. In this model, expert educators focus on teaching a pre-defined small group of ‘trainers’ who will then go on to teach these skills to others. Unlike the champion model, these individuals are usually targeted before the training has begun and may not have the same aptitude or enthusiasm as a champion. This model works well if the total group size is going to be too large to teach in one sitting. However, it does require ongoing evaluation of the trainers (to ensure they are training others correctly) and can lead to some complications if the trainers (often mid-levels) are lower in the hospital hierarchy than those they go on to teach. Discussion with local administrators to identify who best to designate as trainers before training begins is a good solution to this problem.
Planning and scope
As important as identifying the appropriate learners for your project is identifying the appropriate. This is where a formal needs assessment can be incredibly helpful. A needs assessment is a systematic process for determining and addressing needs or “gaps” between current conditions and desired conditions or “wants”. In global ultrasound education projects, the needs assessments range from large- to small-scale issues. Large scale issues include identifying pre-existing imaging resources – do they have CT? MRI? Radiology-based ultrasound? Sonographers or other technicians on site? Also, what are the most common diagnoses seen in the clinical setting? For example, HIV-TB coinfections, rheumatic heart disease and inguinal hernias are much more common in Africa than anywhere in the U.S. – so being able to teach ultrasound skills related to those diagnoses would be very useful. Finally, what interventional treatment options do they have for common or emergent diagnoses? Smaller-scale issues that are important to know for teaching include: the reliability of electricity/utilities, internet access, computer access, and other projection equipment (see Chapter 3). It will also focus on your target students: do they have any prior ultrasound experience? Is it limited to OB? How often will they use the ultrasound? What resources are available to change clinical management?
Conducting a needs assessment on the large-scale issues will help you select the most appropriate content and scope. Understanding the epidemiology of disease in the clinical setting of your ultrasound education project will help you choose the most effective ultrasound exams to teach (i.e. RUQ for liver abscesses, FAST for trauma patients, ECHO for heart failure patients, etc.). For example, it would be beneficial for learners in areas of high HIV and TB prevalence to be taught the Focused Assessment with Sonography for HIV-associated Tuberculosis exam (FASH). In addition, many developing countries have high birth rates with minimal access to prenatal care. So, while obstetric ultrasound may exist in the geographic area where you are implementing your project, it may still be valuable to teach pertinent obstetric POCUS – such as estimating gestational age, identifying placental location, evaluating fetal lie, etc. – to learners who are working in emergency settings.
Clarifying the individual, institutional and community assets will also help you select content that will be most beneficial for their clinical setting. These assets may include provider scope of practice, imaging modalities and availability of medical interventions. Firstly, it is important to identify the individual providers’ scope of practice when selecting the ultrasound skills to teach, as you want the skills to be pertinent to their medical practice. For example, teaching ultrasound-guided procedure skills such as thoracentesis will likely be much more valuable to surgical than obstetric teams. Secondly, knowing what other imaging options (CT, MRI, interventional radiology, etc.) are available in the project setting will help you select ultrasound skills that may be used as substitutes for other, more expensive (or unavailable) imaging modalities. For example, teaching the optic nerve sheath diameter (ONSD) exam to evaluate for increased intracranial pressure in settings where CT is not available will be incredibly beneficial to those learners. Finally, understanding treatment options available in the specific clinical setting will help you select ultrasound skills that will identify diagnoses that can actually be intervened upon. For example, teaching the ultrasound aorta exam in a clinical setting where no interventions are available for aortic aneurysms or aortic dissections is a waste of resources and will ultimately be frustrating for the learners.
Putting it into action
Once your needs assessment is completed and you have identified your target learners, you can start planning for the implementation phase. The implementation can be split into phases including introductory, experience/skill building, competency assessment and ongoing education. There is no consensus for the minimum time needed to complete each of these phases, although many successful studies have shown six months to a year is enough time for proper education and retention for point of care ultrasound.
The introductory phase should be a more intensive time period for training as this will be brand-new information for many clinicians, as well as an important time for instructors to adapt to the educational environment. The time for this phase will vary with how many hours learners will be available each day. In some instances, this educational time might be structured around other required duties. One model for a short introductory course would be a five to ten day program. Mornings might include classroom learning and formal didactics. This would leave the afternoon available for practical skills and hands-on scanning. As ultrasound education is an iterative process, performing the scans and interpreting them over and over is important for knowledge acquisition and retention. If there are only a few hours available for education each day, the introductory time frame might need to be extended over a few weeks. The introductory course would need to include formal lectures, hands-on and interactive demonstrations, practice scanning on volunteers and patients. It may also include homework with both passive and active web- and/or textbook- based learning.
The next experience and skills phase will likely be the longest depending on time available with instructors, learner aptitude and availability. This phase can be from three to nine months, although the optimal and/or shortest time period necessary has not been identified. In order to gain experience, learners will need to work on obtaining proper images, interpret these images and incorporate their findings into their clinical decision making. The length of time for this phase will depend on whether the expert educators will be present during this time, if there are local radiologist or sonographers that can proctor exams or if there will be remote quality assurance during this time, including both live scanning sessions via live video chat, or via assigned review.
In order to track progress, a log-book for learners is useful to record the number and quality of scans. Logged scans should note the type of scan performed and the learner’s interpretation. The expert educator can then provide feedback on these scans and assess them for quality. Ideally, a certain portion of these should be directly observed by a proctor (in person or remotely) for guidance and to ensure proper skills. Video-chat is a novel method to participate in in-person review when the expert is no longer in country.
During the experience and skills phase, there should also be continued reinforcement of topics previously covered with lectures and study resources. According to the American College of Emergency Physicians (ACEP) ultrasound guidelines for achieving competency in a practice-based approach, doing 25-50 supervised scans in each practice area is the minimum recommended with at least 150-250 total scans, so length of training can be adjusted for learners to achieve these minimum recommended guidelines. There have been studies that have shown six months for the experiential be successful within an approximately one year long training schedule.
The next phase is competency assessment, which is covered more thoroughly in the next section. After initial competency has been shown, it is important to re-validate competency periodically to ensure retention. This often will be another three months to one year, depending on the ultimate goal and timeline for a project. Whatever type of competency assessment was chosen for initial evaluation should be performed again after an additional three and six months to ensure retention of skills and knowledge. For many projects, this time period can be facilitated by an ultrasound champion or local trainer (see above).
The final phase, ongoing education and validation, ensures that skills that have been acquired are maintained. It is helpful for learners to continually log activity and interpretations with periodic expert review. This can be done on-site if available, or remotely (see Chapter 6) and eventually via a local ultrasound champion or expert. In addition, ongoing continued education is important. The International Federation for Emergency Medicine (IFEM) recommends 2.5-5 hours per year in specific ultrasound education and 5-10 hours of CME for instructors or local ultrasound champion. Free or discounted CME may be available for those living in low-resource countries (see below).
Assessment and competency
For a skill such as point of care ultrasound, it is important to have both theoretical knowledge as well as practical skills. During the experience and skills phase of education, this will be observed directly by instructors through bedside scanning and quality assurance review. During the competency assessment phase, this can be done via multiple modalities to assess both knowledge and hands-on skills.
To start, students should be evaluated by a knowledge assessment. Traditional written testing is well-adapted to test theoretical knowledge. This may be structured as a multiple choice exam to cover topics such as physics, artifacts and fundamental knowledge. Written testing can also include image-based questions that evaluate learners’ ability to recognize normal and abnormal anatomy and pathology. If relevant to the learner’s training level, questions may also include “next best step” stems to assess the ability to incorporate these images into clinical care and decision making.
In addition to knowledge assessment, it is important to assess learners’ skills. The most common means to assess practical skills is via direct observation with an objective structured clinical exam (OSCE). This can be done on simulators, volunteers or actual patients with their permission. This is most commonly done with a bedside instructor using a scoring sheet. This scoring sheet should be standardized for each exam-type being performed and includes both a checklist and a global rating scale of skills. Examples of OSCE’s for POCUS can easily be found online and can be adjusted as needed. If this could not be done in person, it could be videotaped and transmitted with acquired images, or performed via video conference. Ideally the same instructor would perform all OSCE’s to ensure some standardization although this is not always possible.
Both knowledge and skills assessments are taken into consideration to determine a student’s competency. This may be with a number of quality scans or achieving a certain score on written tests. Options for re-mediation can also be included if a student is not able to pass a portion of the exams but other requirements have been met. Ideally, the practical and written exams can be repeated in 3-6 months to ensure retention of skills.
Students enrolled in the curriculum or who have completed exams can also be tasked to give lectures or lead hands-on scanning rounds with new learners and/or instructors as an additional way to observe knowledge and identify gaps in comprehension. It is also important to ensure that learners are still logging scans and interpretations after completing formal training process and undergoing quality assurance review to ensure comprehension. (see Chapter 6).
Take Aways
- Educational programs should begin with a needs assessment and be appropriate to local context.
- Ultrasound teaching is developed over phases with knowledge, experience and skills building, competency assessment and ongoing education.
- Educational programs take many months with constant evaluation and feedback.
Ultrasound CME:
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