Chapter 5: Learning Tools

Dr. Michael Schick

Developing curricula for low resource settings has unique challenges, particularly when teaching novice learners the complex motor and cognitive skill of point-of-care ultrasound.  The following section outlines suggestions for effective learning tools and curriculum strategies as well as common pitfalls to avoid.  

Invest before you teach

A focused ultrasound training course or longitudinal curriculum should be approached like any other rigorous educational program.  It is important that the program be well thought-out. Set specific goals, expectations, and engage local experts in the planning process. Do not just show up without a plan in mind.

The context of the curriculum is important as well. Is your program stand-alone or part of a larger educational effort?  Creating a successful educational program will be more likely if you can integrate local resources into the plan.  Think big and think long term.  Select material that is essential and material that can be covered in the future.  Use the essential material to develop objectives and a curriculum plan that specifically addresses the knowledge, skills and behaviors that your learners need to be effective. 

Part of understanding your learners and local context is through a needs assessment and is an important step that should not be skipped (see Chapter 4). It is often challenging to complete a needs assessment across oceans or country lines.  A local leader or contact is critical.  As mentioned above, the curriculum should be local and learner-focused. It is important to know what the needs are regarding: EquipmentLearners (educational level and practice setting)Health system (resources available), The learning environment (wifi, projector, electricity, etc)Language, Culture (are there things you should or should not teach, such as gender identification).

The needs assessment can also help you identify what learners want to know. It is a common pitfall to either use ‘canned’ materials that you do not edit or adapt or teach content that is not interesting or relevant to your learners. It can be hazardous using educational materials from high resource health settings in low resourced health settings.  Resources and practice patterns will be different.  Medical knowledge, language mastery, and experience with ultrasound will be different.  Analogies and examples you may use at your home institution may not translate well.  Try to use locally relevant examples.  For example, chapati rather than chocolate chip cookies as a description for ovaries.  

Along these same lines, do not teach modalities learners won’t need.  For example, many low resourced health settings cannot intervene on abdominal aortic aneurysms and some will not perform pelvic exams or do certain procedures (think: transvaginal ultrasound).  It will be critical to understand the local scope of practice and resources available. 

Above all, come prepared to teach.  Be ready with extra material and always have a backup teaching plan in case there is no electricity, your computer fails or have other unforeseen challenges. Make your photocopies ahead of time and bring as many of your own supplies as you can.

Teaching strategies

Although lectures are often our default and what first comes to mind, using standard lecture-based learning is not always the best, and may in fact be the least effective way to teach.  It may not be completely unavoidable but think creatively on how you can “flip the classroom.”  There are innumerable resources for online material and you can also bring materials with you.  

If and when you do give lectures, create them for an audience that may not have the same knowledge and language mastery as you. Lectures should be short and sweet and use simple and clear language. It is important to avoid medical jargon and other common idioms or slang. Similarly, case based learning should be relevant and appropriate to the  local setting to make it applicable to participants. Lectures can become interactive as well by  building in slides to force participation and interaction.

When arranging for times to teach, we recommend creating a schedule with local leaders and attempting to hold your learners to it; however, we acknowledge that often plans can go awry.  Be flexible and understand that learners have many competing obligations.  What is important is for you to accomplish your goals and objectives, rather than sticking to a specific schedule. 

Flipped classroom and active Learning

Active learning is the most effective and enjoyable way for most adults to learn.  There are innumerable methods, but we have found the following strategies most effective: modified team based learning, problem based learning and use of case based learning and gamification such as using laser pointers, drawing with white boards, and other competition-based games. Gamification may also serve as an ongoing assessment tool as described below.

Ultrasound is a hands-on skill.  Therefore, image acquisition using hands-on practice is paramount.  This can occur in many forms, but we often begin with scanning fellow learners and quickly transition to “ultrasound rounds” in emergency departments, wards, clinics or anywhere else deemed appropriate by local practitioners.  At times patients can be brought into the learning environment to scan as a group.  It is important to limit the learner group size so that hands-on time is maximized and to gain patient consent.  Simulation cases can also be used to grow hands-on skills and learn to apply ultrasound skills clinically. 

Active Assessment

Assessment is often the most challenging aspect of the educational process when doing global work but is also the most important.  It is critical to know if your teaching is effective and what knowledge gaps exist in your learners. Active assessment should occur throughout the learning process, not just at the beginning or end of the curriculum (and differs from the formalized written and practical assessment described in Chapter 4).

Active assessment can take many forms, but one strategy we utilize is gamification using a jeopardy board or something similar.  This strategy engages learners, creates a more equitable form for learner participation, and will accomplish the goal of identifying learner gaps and allow the instructor to immediately correct knowledge deficits. Learners will have different backgrounds, expertise, and learning challenges.  Using interactive strategies such as games also serves to develop an instructor-learning relationship and make learners more comfortable participating as well as asking questions. This is important both for the expert educators and the ultrasound champions or trainers. Knowledge gaps can also be identified in more formalized ways such as with direct-observation or written tests (see Chapter 4).

Make it all about the learner

More than one group has fallen prey to presenting the same POCUS educational content they teach in their home country to a group in a low-resource setting. This is problematic in a number of ways, as mentioned above. The solution is to create a locally-focused curriculum. Care should be taken to understand local disease processes, available resources and local medical capacity. Within lectures, use local examples of diseases and scenarios that are relevant to the learners.  There are often infectious diseases and ultrasound algorithms such as FASH, ABUE, SOTL may be relevant in the learners clinical setting.  Similarly, avoid discussing technologies and other resources that are unavailable to them. 

Beyond making it relevant to learners, instructors should make the curriculum leaner-focused by developing clear objectives and expectations for learners.  Be open and honest about what they need to know and the time required to become proficient in POCUS.  Leaners should understand that ultrasound is not a skilled mastered after a 40 minute lecture and requires ongoing practice.

Delegating responsibility

As early as it is appropriate, identify one or more ultrasound champions who can grow into local leaders.  Be clear what their responsibilities will be and how you can support them. (see Chapter 4). In addition, it is important to have an active role for learners in teaching.  Learners can prepare short lectures or lead discussions.  Teaching is an effective way to master a topic. 

Part of having learner expectations is keeping track of learner progress and giving them feedback.  Take attendance and monitor who participates.  Give feedback regularly throughout the educational process that is both formative and summative.  Small incentives such as food, learning tools like books or swag from your home institution can also improve the experience of learners. 

Develop a post-trip plan

Although different groups will have different periods of time they are able to be on site, eventually the teachers will have to return home. It is important to develop a plan with local leaders and prospective ultrasound champions for when you leave.  We recommend learners keep scan logs, log interesting or impactful cases, track and any continuing education. Other questions to consider prior to departure are: How will education continue? How will quality assurance and improvement occur? Will remote or tele-ultrasound QA be part of your program?  (see Chapter 6) Who will be in charge of the program? How will competence be measured? How will credentialing occur?

Take aways

  1. Make the curriculum locally relevant and appropriate.
  2. Focus on the learners and actively engage them in their own education.
  3. Develop a plan for continued learning once you have gone home.

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