RESEARCH REPORT
The Role of Ultrasound in Graduate Anatomy Education: Current State of Integration in the United States and Faculty Perceptions Danielle F. Royer* Department of Cell and Developmental Biology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
Ultrasound (US) is increasingly taught in medical schools, where it has been shown to be a valuable adjunct to anatomy training. To determine the extent of US training in nonmedical anatomy programs, and evaluate anatomists’ perceptions on the role of US in anatomy education, an online survey was distributed to faculty in anatomy Master’s and Doctoral programs. Survey results sampled 71% of anatomy graduate degree programs nationally. Of the faculty surveyed, 65% report little to no experience with US. Thirtysix percent of programs surveyed incorporate exposure to US, while only 15% provide hands-on US training. Opportunities for anatomy trainees to teach with US were found in 12% of programs. Likert responses indicated that anatomists hold overwhelmingly positive views on the contributions of US to anatomy education: 91% agreed US reinforces anatomical concepts (average 4.33 6 0.68), 95% agreed it reinforces clinical correlates (average 4.43 6 0.65). Anatomists hold moderately positive views on the value of US to the future careers of anatomy graduates: 69% agreed US increases competitiveness on the job market (average 3.91 6 0.90), 85% agreed US is a useful skill for a medical school teaching career (average 4.24 6 0.75), and 41% agreed that US should be required for a medical education career (average 3.34 6 1.09). With continued improvements in technology and the widespread adoption of US into diverse areas of clinical practice, medical education is on the cusp of a paradigm shift with regards to US. Anatomists must decide whether US is an essential skills for the modern anatomist. Anat Sci Educ 9: C 2016 American Association of Anatomists. 453–467. V
Key words: anatomical sciences education; medical education; graduate education; graduate anatomy programs; masters anatomy programs; anatomy education; radiological anatomy; ultrasound education; human gross anatomy
INTRODUCTION Ultrasound (US) is increasingly integrated into the basic science curriculum in undergraduate medical education (UME). Bahner et al. (2014) recently surveyed allopathic medical schools in the
Additional Supporting Information may be found in the online version of this article. *Correspondence to: Dr. Danielle F. Royer, University of Colorado Anschutz Medical Campus, Mail Stop F435, 13001 East 17th Place, Aurora, CO 80045, USA. E-mail:
[email protected] Received 10 July 2015; Revised 29 December 2015; Accepted 29 December 2015. Published online 28 January 2016 in Wiley (wileyonlinelibrary.com). DOI 10.1002/ase.1598
Online
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United States, and found that 62% of schools have integrated US training into UME. While the type and extent of training varies widely, in nearly 40% of medical schools with US integration, student training in US begins in the first year and is primarily used as tool for teaching basic science topics including but not limited to gross anatomy (Bahner et al., 2014). Data selfreported by medical curriculum directors to the American Institute of Ultrasound in Medicine’s (AIUM) Ultrasound in Medical Education Portal support these findings, while further indicating that US training is integrated into the curricula of both Doctor of Medicine (MD) and Doctor of Osteopathic Medicine (DO) physician training programs (AIUM, 2014). The American Institute of Ultrasound in Medicine recognizes two types of US training: Exposure—defined as passive learning where students view others perform a scan, watch a video or listen to a lecture, and Focused Training—defined as hands-on active learning where the students perform and interpret scans themselves. According Anat Sci Educ 9:453–467 (2016)
to AIUM (2014), while 21% (N 5 37 out of 174) of MD and DO-granting medical schools presently report US integration, only 14% (N 5 24) employ focused training to teach US at the UME level; all the schools that employ focused training begin their US curriculum in the first year. Champions of US predict that in the coming years, medical practice will see a paradigm shift surrounding the educational and clinical applications of US—often referred to as the stethoscope of the future—with expanded training for both practicing physicians and student trainees resulting in improved healthcare (Hoppmann et al., 2011b, 2012). The now routine use of US in many areas of clinical care stems from major improvements in US technology in recent years. Contemporary machines are smaller, with more intuitive user-friendly interfaces, yet they capture high quality images that rival older and larger cart-based models (Moore and Copel, 2011), while offering the full diagnostic capabilities of larger units such as spectral pulsed and continuous wave Doppler (Royse et al., 2012). The reduction in size has coincided with an impressive reduction in cost. In the mid-1990s, a fully capable cart-based machine cost approximately $250,000 – about the price of a family home – while today an equally powerful yet portable machine costs less than $60,000, and hand-held devices with more limited functions are available for significantly less (Royse et al., 2012). The portability and diversity of US machines available today, from handheld devices to fully functioning laptop-based systems, make them easy to maneuver and adaptable across a diversity of care settings ranging from hospital wards, rural clinics, developing nations, prehospital emergency response units, and even active battlefields and in outer space (Moore and Copel, 2011). Point-of-care ultrasound (POCUS) performed at the bedside, focused US evaluations to answer specific clinical questions (e.g., FAST – focused assessment with sonography for trauma), and US-guided procedures are now commonplace in numerous specialties (Moore and Copel, 2011; Royse et al., 2012; Bahner et al., 2013; Solomon and Saldana, 2014). Indeed, the American Medical Association deems US within the scope of practice of appropriately trained physicians (AMA, 1999), and the Accreditation Council for Graduate Medical Education (ACGME) now requires US training as part of residency programs in Emergency Medicine and Internal Medicine, specialties outside of those which have traditional utilized US such as Radiology and Obstetrics and Gynecology (ACGME, 2015a,b). There are clear clinical advantages to US, and training in this modality is already required for select residencies, but worldwide there remains concerns over the adequacy of training standards and governance for nonspecialists utilizing US in clinic or in education (Pascual et al., 2011; Solomon and Saldana, 2014; Wittenberg, 2014), as well as uncertainty regarding the optimal time to introduce US training, what essentials should be covered, and the lack of outcome-based evidence demonstrating the educational benefits of US for preclinical training (Hoppmann et al., 2011b; Pascual et al., 2011; Wong et al., 2011; Bahner et al., 2014; Baltarowich et al., 2014). Medical or diagnostic imaging, for example X-ray, computerized tomography (CT), magnetic resonance (MR), as well as US, has been used as a tool to help teach medical basic sciences such as gross anatomy for several decades (Erkonen et al., 1990; Miles, 2005; Ganske et al., 2006; Phillips et al., 2012). Despite a reduction in gross anatomy teaching hours and major improvements in imaging technologies during the 454
first part of the 21st century, medical schools have not abandoned cadaver laboratories for gross anatomy education (Drake et al., 2002, 2014; see McLachlan et al., 2004 for an exception). Rather, many educators worldwide view medical imaging as complementary to more traditional means of learning gross anatomy such as dissection (Lufler et al., 2010; Sugand et al., 2010; Pascual et al., 2011; Stringer et al., 2012; Baltarowich et al., 2014; Benninger et al., 2014; Moscova et al., 2014; Grignon et al., 2016). Using radiology to teach gross anatomy can help students in basic science courses better meet the core competencies outlined by the ACGME (Gregory et al., 2009). Additionally, studies suggest that the incorporation of radiological images, either as a formal part of the course or as optional self-study modules, improves the acquisition of anatomical knowledge and facilitates its long-term retention in medical students (Erkonen et al., 1992; Feigin et al., 2007; Lufler et al., 2010; Phillips et al., 2012; Kondrashov et al., 2015). For example, Lufler et al. (2010) showed that the study of cadaver CT scans in tandem with a dissection-based course significantly improved academic performance in the gross anatomy in general, and on examination questions relating to spatial relationships specifically. However, not all imaging modalities offer the same potential for educational value. Ultrasound, unlike other imaging modalities, poses no risk of ionizing radiation (Moore and Copel, 2011), allowing for applications in an educational setting where students can safely perform peer or self-scanning, and volunteer models can be recruited without health risks (Miles, 2005). Moreover, US can be performed and interpreted by learners themselves in real time, which makes this modality especially useful for educational purposes as it harnesses cognitive principles such as anchored or contextualized learning, and active learning, which are known to promote deep understanding in adults (Bransford et al., 2000; Zumwalt et al., 2010; Cuttings and Saks, 2012; Griksaitis et al., 2012). In an early documented use of US to supplement a dissection-based medical gross anatomy course, Teichgr€aber et al. (1996) from Germany highlighted the many potential benefits of this approach to basic science training: linking dynamic topography of a living patient with the static topography of a cadaver; comparing anatomy of younger patients (i.e., peers) with that of a predominantly elderly cadaver population; accurately determining organ size; comparing crosssectional US images with cadaver cross-sections and improving 3D orientation; depicting in real time the positional or structural changes in anatomy that result from normal physiological processes such as respiration; increasing motivation to study anatomy due to more clinically oriented teaching. Since the work of Teichgr€aber et al. (1996), numerous studies have reported on the successful integration of US training in medical gross anatomy courses in the United States and abroad, and scholars have begun to rigorously evaluate the potential benefits that US training can contribution to anatomy education. In a few instances, the US training initiated in gross anatomy during the first year of medical school sets the stage for a comprehensive vertical US curriculum that spans the full four years of UME. Beginning nearly a decade ago, the University of South Carolina School of Medicine implemented this type of innovative US training program (Hoppmann et al., 2006). Using a multimodal approach, they developed a curriculum focused on hands-on training in POCUS; in year one, US training was coordinated with the content covered in Royer
gross anatomy lectures and dissections. Surveys averaged across four years of the pilot curriculum indicated that this innovation was very well received by first year students: 95% felt US enhanced their medical education; 91% believed US allowed for increased clinical correlations in basic sciences; 92% reported US enhanced their physical exam skills; 81% stated US enhanced their ability to learn basic anatomy; and students performed very well on US assessments, with a class average of 97% demonstrating the feasibility of training first year medical students to utilize this imaging modality (Hoppmann et al., 2011b). At Wayne State University School of Medicine, Rao et al. (2008) developed a similar verticallyintegrated US curriculum spanning UME. The Wayne State students also reported that US enhanced their ability to learn human anatomy (74%), and the majority (91%) believed that they would benefit from continued US education throughout medical school. The Ohio State University College of Medicine has also implemented a four-year US curriculum with many of the same features noted above (Bahner et al., 2013), as well as an innovative strategy—The Ultrasound Challenge—a friendly competition to promote US and showcase student skills (Bahner et al., 2012). The efforts of Bahner et al. (2012) demonstrate the feasibility of developing and implementing a vertical US curriculum even with limited faculty who are experienced in POCUS. While at present vertical four-year US curricula are far from common in American medical schools (Bahner et al., 2014), this may change as the technology continues to improve, established training programs mature and continue to share their successes and lessons learned, and clinical applications of POCUS continue to proliferate. In anticipation of more widespread adoption by medical schools, Baltarowich et al. (2014) presented a national curriculum for US in medical education based on the National Medical Student Curriculum in Radiology created by the Alliance of Medical Student Educators in Radiology. The model curriculum is divided into preclinical and clinical training phases, allowing for US integration throughout UME. It identifies the primary goal of a preclinical US curriculum as enhancing the understanding of anatomy, physiology, and pathology, which Baltarowich and coworkers suggest is best achieved via direct hands-on practice with US starting early on in medical training. Specifically, students successfully completing the preclinical US curriculum would be able to identify the classic appearances of normal anatomical structures on US. More commonly, US has been incorporated into preclinical training via the addition of targeted sessions corresponding to the schedule of gross anatomy and other basic sciences. A wide variety of strategies have been successfully employed, ranging from simple exposure to US via multiple short didactic sessions covering different topics in sonography (Brown et al., 2012), lectures complemented by live scanning demonstrations projected for a large audience (Griksaitis et al., 2012; Stringer et al., 2012) or shown in a small group setting (Ivanusic et al., 2010), to focused US training via short didactic presentations or online modules preceding live demonstrations and hands-on scanning of various anatomical regions performed by students themselves (Heilo et al., 1997; Wittich et al., 2002; Tshibwabwa and Groves, 2005; Swamy and Searle, 2012; Hammoudi et al., 2013; Sweetman et al., 2013; Dreher et al., 2014; Jurjus et al., 2014; Patten, 2014), and self-contained US electives offered during preclinical training (Wicke et al., 2003; Kondrashov et al., 2015). Across these studies, students expressed overwhelmingly positive Anatomical Sciences Education
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views of US, its benefits to learning anatomy specifically, benefits to their medical education generally, and have typically requested more US training opportunities. For example, when investigating the impact of a single two-hour long abdominal US training session with hands-on practice, Sweetman et al. (2013) found that students perceived US to benefit anatomy in the following ways: improved their confidence in abdominal anatomy knowledge (71%), helped them link surface and internal anatomy (80%), provided more clinical relevant anatomical knowledge than cadaver anatomy (87%), and gained additional information on abdominal anatomy (90%), echoing many of the benefits postulated nearly two decades ago by Teichgr€aber and coworkers. Dreher et al. (2014) also found positive medical student views of the hands-on US training sessions coordinated with their regional gross anatomy curriculum, while also reporting a significant increase in student self-reported confidence across a range of US skills such as basic physics, knobology, and identifying anatomical structures. The benefits of US to medical anatomy education are not limited to curricula that employ hands-on focused training, but are also apparent in curricula utilizing demonstrations or didactic teaching only. Ivanusic et al. (2010) found that undergraduate medical students who viewed a one-hour transthoracic echocardiography live scanning session reported that US effectively demonstrated important cardiac anatomy (90%), reinforced lecture material (83%), and stimulated interest in cardiac anatomy (86%). Free text comments by the same students highlighted how US facilitates the study of living anatomy in a way that is not possible with cadaver dissection. Such positive student views of the advantages of US to teach anatomy are remarkable given that about 20% of students also reported difficulty with image orientation, not surprising after a single one-hour demonstration. Similar positive outcomes were found by Brown et al. (2012) following their addition of three short didactic presentations on US in a first year medical gross anatomy course. At Kirksville College of Osteopathic Medicine, a new clinical elective in US offered to the second year students proved so popular that no control group was available to compare the impact of the elective on gross anatomy examination scores in the second year the elective was offered (Kondrashov et al., 2015). While enthusiasm from students is important, student perceptions alone do not demonstrate that this strategy has a real positive impact on anatomy education. Educators have begun the task of rigorously assessing the contributions of US to learning human anatomy and other basic sciences. Griksaitis et al. (2012) compared the effectiveness of ultrasound versus cadaveric prosections for teaching normal cardiac anatomy. They found that both classroom strategies significantly improved anatomy test scores, providing evidence that both approaches are educationally beneficial. Another study (Kondrashov et al., 2015) found that students who completed an elective course in US had significantly greater improvements in anatomy examination scores. More studies are needed to fully appreciate the pedagogical potential of this strategy for anatomy education. At the UME level, US not only enhances coursework in the basic sciences, but has also begun contributing to clinical skills training. One proposed advantage to using US to teach physical examination is that this modality allows immediate validation of physical findings determined by palpation, percussion, and auscultation, by providing immediate visual feedback, which may help the learner refine their skill with 455
physical examinations (Shapiro et al., 2002; Butter et al., 2007). Medical students with limited instruction and practice were successful in using US to measure vertical liver span, reporting more accurate and less variable measurements than experienced board-certified physicians using traditional physical examination techniques (Mouratev et al., 2013). In a small pilot study using US to teach physical examination, medical student competency performing US examinations of normal (control) patients and clinical (pathological) patients improved significantly, and students indicated that the US training improved their physical examination skills (Shapiro et al., 2002). When comparing clinical skill in performing a physical examination of the abdomen, Butter and coworkers (2007) found that the cohort which received a hands-on focused training session in US later during the course showed significantly greater improvement in competence, yet all students reported significant improvements in self-confidence with the physical examination following US training. Their results suggest that while US training can enhance physical examination skills, a minimum level of competency may be needed before students can benefit from the visual feedback offered by US. However, a study by Sweetman et al. (2013) found no improvement in clinical examination skills in the cohort that had completed a hands-on session on abdominal US, despite overwhelmingly positive student views on using US to learn the examination and anatomy of the abdomen. Beyond the physical examination, US can serve as an adjunct to training in other clinical skills. Following a short hands-on focused US training course on the clinical evaluation of the abdominal aorta, Wong et al. (2011) found that 62% of medical students could achieve the competency standard set by the United Kingdom’s College of Emergency Medicine, and that the measurements of the abdominal aorta recorded from US scans by these competent students did not differ significantly from those of experts. At the University of South Carolina School of Medicine, first year students were trained to perform longitudinal suprapatellar US scans of the knee to diagnose effusions (Hoppmann et al., 2011a). After a one-hour hands-on workshop, they found that students had 100% success rates in anatomical structure identifications, diagnoses of knee effusions, and diagnoses of the severity of the condition, which emphasizes the manner in which US can complements clinical skills training during UME. While most studies suggest the potential for US to benefit student learning of a myriad of clinical skills, Sweetman et al. (2013) caution of the potential risks associated with increasing learner confidence without increasing their actual competence. There is undoubtedly a learning curve to performing US. It is reasonable to ask whether the learning curve itself may interfere with the contributions of US to basic sciences education or clinical skills training. Jamniczky et al. (2015) showed that the additional cognitive load imposed by utilizing US as a learning strategy did not hinder the study of anatomy itself, although it did adversely impact learning more complex tasks such as the physical examination. Specifically, they found that knobology was inversely associated with student perceptions of the utility of US for learning physical examination, possibly because learning this clinical skill already imposes a higher cognitive demand on novice students (Jamniczky et al., 2015). This work suggests that more thorough training in US machine usage is needed before US can be successfully employed as a strategy to teach physical examination skills in medical students (Jamniczky et al., 2015). 456
In general, medical students hold overwhelmingly positive views on the benefits of using US to learn gross anatomy, and several studies highlight the feasibility of training junior medical students to translate their basic science knowledge into performing high quality US evaluations. The studies noted above suggest that US as a learning strategy can measurably improve the acquisition and retention of knowledge in anatomy and other basic sciences, potentially improving clinical skills as well, while also providing an opportunity for students to apply basic anatomical knowledge to clinical situations. However, as noted by Hoppmann et al. (2011b), there remains a need to demonstrate the long-term impact of early US training via well-designed outcome studies, to ensure that US curricula are grounded in the best available evidence. Overall, it is clear that US has the potential to make significant beneficial contributions to the study of gross anatomy, at least in a medical education setting. Despite the advantages of US to supplement and enhance the study of gross anatomy and other preclinical basic sciences, and its increasing incorporation in medical school curricula in the United States and abroad, the degree to which US training has been integrated into the curricula of nonmedical graduate programs in anatomical sciences remains unknown. The goals of this study are (1) to determine the current state of US integration in nonmedical graduate programs in anatomical sciences in the United States, and (2) to gauge anatomy faculty views on the potential role of US in anatomy graduate education outside of medical schools.
METHODS Survey Design and Distribution An anonymous, voluntary 24-question online survey was developed and administered via SurveyMonkeyV (SurveyMonkey Inc., Palo Alto, CA) to collect data to elucidate the current state of US training in anatomical sciences graduate programs in the United States, and evaluate the perceptions of anatomy faculty on the potential role of US in graduate anatomy education outside of the medical school setting. To achieve these dual goals, the survey instrument contained questions divided into four main content areas (Table 1): (1) respondent and program information, included to provide context for the responses, (2) medical imaging training (including US) incorporated into the program, (3) respondent familiarity with US, and (4) faculty perceptions. Questions in the latter content area captured faculty attitudes for three major themes: value of US to anatomy education, value of US for anatomy graduates’ future careers, and US training. Each survey question was accompanied by an optional comment box, allowing respondents to further explain their responses as needed. A copy of the survey is available in Supplementary Materials. Participants could skip a question or cease the survey at any point. No incentive was provided for voluntary survey participation. Prior to distribution, the survey was reviewed by two medical school teaching faculty members (one PhD-trained anatomist with no experience in US, one MD-trained clinician with experience in US); their suggestions were incorporated into the final survey instrument to enhance question clarity, content validity, and face validity. The study protocol was approved for exemption by the Colorado Multiple Institutional Review Board. In June 2014 an invitation to participate, comprising a short description of the purpose of the study and a link to the voluntary survey, was circulated to the membership of C
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Table 1. Number and Type of Questions in Each Survey Content Area Number of Questions
Survey Content Areas
Types of Question
Respondent and graduate program information (for context)
6
Forced-response Free text response
Current imaging training, including ultrasound, integrated in program
10
Forced-response
Respondent familiarity with ultrasound
1
Forced-responsea
Perceptions Theme 1: Theme 2: Theme 3:
7
Likert scale (symmetric five-point Likert scale: 1 5 strongly disagree, 5 5 strongly agree)
on role of ultrasound in anatomy Value of ultrasound to anatomy education Value of ultrasound for future career Ultrasound training
a
The following response categories were available: No experience; Novice user (e.g., scanned a few times at workshops or demonstrations; viewed some educational modules); Intermediate user (e.g., some formal or informal training; infrequent use in clinical, research or educational setting); Expert user (e.g., formal training; credentials; regular use in clinical, research or educational setting).
the American Association of Anatomists (AAA)—via the Anatomy Connected online forum, and the American Association of Clinical Anatomists (AACA)—via the education listserv, with a reminder posted two weeks later. To further solicit participation, additional survey requests were distributed directly by the author to faculty affiliated with graduate programs in anatomical sciences in the United States. For purposes of survey distribution, a national inventory of accredited programs in anatomical sciences broadly defined was compiled by the author from two sources: (1) the list of graduate programs available in the Career and Professional Resources section of the American Association of Anatomists website (AAA, 2014), which identified 53 programs (32 master’s, 21 doctoral), and (2) supplemental program information obtained from online searches, which revealed an additional 13 programs (7 master’s, 6 doctoral). From these sources combined, at least 66 graduate degree programs in anatomical sciences (39 master’s and 27 doctoral) housed at 43 separate post-secondary institutions are believed to be currently operating in the United States. In July 2014, targeted survey requests were distributed to core faculty at 35 institutions that offer graduate degree programs in anatomical sciences. Faculty affiliations and contact details were determined by the author based on public information displayed on program websites. The survey closed in December 2014.
Survey Analysis R
All analyses were completed using SASV statistical package, version 9.4 (SAS Institute Inc., Cary NC). Two tests, Cronbach’s alpha and Kendall’s tau-b, were employed to assess reliability and validity respectively. Cronbach’s alpha is a reliability coefficient that ranges from zero to one; as the coefficient approaches one, it indicates greater internal consistency between items on a Likert scale, with values at or above 0.70 considered an acceptable threshold for reliability (Peterson, 1994; Santos, 1999). A standardized alpha coefficient was computed for all seven Likert items evaluating faculty perceptions, and separate coefficients were computed for items attributed to two subscales representing different perception Anatomical Sciences Education
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themes—value of US to anatomy education (2 items), value of US to future careers (3 items)—as an individual’s response to items on each subscale were predicted to be positively correlated because they measure different aspects of the same concept. The remaining two items, although grouped together for purposes of discussion, measure different concepts. Since Cronbach’s alpha cannot provide estimates of reliability for single items (Santos, 1999), no separate coefficient was reported for these items. Kendall’s tau-b is a nonparametric rank correlation coefficient which measures the strength of the association between sets of paired values, making adjustments for ties, and is appropriate for smaller sample sizes where the assumption of normality may not be satisfied (Sokal and Rohlf, 1995). As with other correlation coefficients, the tau statistic ranges from 21 to 11, with a positive coefficient indicating that both values increase together. Significance testing of the tau coefficient is used as an indication of the construct validity of the survey instrument. Descriptive summary statistics were computed for all questions. The Wilcoxon rank sum test was employed to compare perception responses between two groups: faculty participants with a low level of experience with US (no experience or novice user responses) versus those with a high level of experience (intermediate or expert user responses). The Wilcoxon rank sum test (also called the Wilcoxon two-sample or the Mann-Whitney U test), is a nonparametric alternative to the two sample t-test suitable for comparing measures between groups in cases of smaller sample size and data which may depart from a normal distribution, such as responses to a Likert rating scale (Sokal and Rohlf, 1995).
RESULTS Survey Participation In total, 62 anatomists completed all or part of the survey; 51 respondents were affiliated with American institutions, and 11 with international institutions. Survey participants sampled a broad range of faculty roles within their graduate programs: teaching faculty (53%, N 5 33), program director 457
Table 2. Survey Responses From Anatomical Sciences Graduate Programs in the United States Number of Accredited Programs (United States)
Number of Survey Responses
Program Response Ratea
Master’s
39
27
69.2%
Doctoral
27
21
77.8%
TOTAL
66
47
71.2%
(at 43 separate institutions)
(at 33 separate institutions)
Degree type
a
Calculated based on 66 anatomical sciences graduate degree programs presently offered in the United States.
and/or department chair (23%, N 5 14), gross anatomy course director (16%, N 5 10), and graduate student advisor (8%, N 5 5).
Institutional Representation in the United States Forty seven complete survey responses were collected from programs in the United States, which represents 71.2% of the 66 nationally accredited graduate programs in anatomical sciences (Table 2). Multiple faculty responses were received for five programs. For these cases, individual responses to questions of program and imaging curriculum were carefully compared; with one exception (discussed below), program and curricular responses were identical, thus the entries were combined, providing a single data point to represent each of the 47 American programs sampled. In the case of one institution, two participants reported differing views on whether student teaching in the cadaver laboratory was a required or optional part of the degree; the answer provided by the respondent self-identified as the gross anatomy course director was employed. As reported in Table 2, 27 responses were received from master’s programs and 21 from doctoral programs. Of the institutions offering both master’s and doctoral degrees in anatomical sciences, responses indicated significant overlap in all aspects of program curriculum measured by this survey. Therefore, responses from master’s and doctoral programs at the same institution were combined into one data point representing a single institutional program. The few instances where curriculum differs between degree programs within the same institution are noted in the relevant sections below. Thus, the data presented in this study reflects the current state of US training in 76.7% (33 out of 43) of institutions in the United States identified as offering graduate programs in anatomical sciences (Table 2). Among the survey responses from institutional programs in the United States, 6 (18%) represent doctoral programs, 13 (39%) are master’s programs, and 14 (43%) offer both master’s and doctoral degrees.
Current State of Ultrasound Training in Anatomical Sciences Graduate Programs in the United States As discussed previously, AIUM (2014) distinguishes two types of learning strategies in US education: focused training and exposure. Focused training utilizes principles of active learn458
ing, where students themselves perform the scan, and/or read and interpret the medical image on their own, whereas exposure is a more passive learning strategy, including activities such as watching a live demonstration performed by someone else, viewing an online module, reading a book chapter, or studying pre-labeled medical images including US scans. Of the 33 institutional programs sampled by the survey, 85% (N 5 28) reported curricula that incorporated exposure to a range of medical imaging modalities such as x-ray, computed tomography (CT), magnetic resonance imaging (MR) as well as US, while 36% (N 5 12) reported providing exposure to US specifically (Fig. 1). In contrast, 45% (N 5 15) of the programs surveyed provided focused training in various medical imaging modalities including US, while only 15% (N 5 5) stated that they utilized focused training in US specifically (Fig. 1). To begin to understand factors that may facilitate the inclusion of US training in anatomical sciences graduate programs, participants were asked to provide information on other aspects of their programs including degree requirements for gross anatomy, cadaver dissection, and teaching experience. Among anatomical sciences programs surveyed, 76% (N 5 25) required that students successfully complete a gross
Figure 1. Prevalence of four types of medical imaging training in anatomy graduate programs in the United States. Prevalence is expressed as the percentage of programs that utilize each type of training out of the 33 programs surveyed (the number of programs is listed at the base of each bar). As described in the text, exposure is defined as passive learning (e.g., watching a video or a live demonstration), while focused training is defined as active learning (e.g., students perform a scan or interpret an image themselves); imaging refers to the range of medical imaging modalities including ultrasound, while ultrasound refers to training in this modality specifically.
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requirement exists only for doctoral students and not master’s students at the same institution. In contrast, fewer programs provided opportunities for student trainees to gain teaching experience in anatomy using medical imaging modalities; this type of experience was optional in 18% (N 5 6) of programs, and required by 6% (N 5 2) of programs (Fig. 2). As for teaching experience in US specifically, only two of the programs surveyed (6%) required that students participate in this type of experience, and two other programs (6%) maintained this as an option. One survey participant indicated plans to add an optional US teaching opportunity in the 2015 2 2016 academic year; once this happens, all programs offering focused training in US will also offer opportunities for students to gain teaching experience in US.
Figure 2. Prevalence of four types of teaching opportunities offered by anatomy graduate programs in the United States. Prevalence is expressed as the percentage of programs that provide each type of experience out of the 33 programs surveyed (the number of programs is listed at the base of each bar). Both mandatory and optional teaching experiences are included here.
anatomy course. Those programs reported variation in the composition of the gross course: students enrolled in gross anatomy with medical students in 52% of programs (N 5 17), with allied health students in 3% of programs (N 5 1), and in a stand-alone graduate course in 21% of programs (N 5 7). Respondents from two programs indicated that their students typically enrolled in gross anatomy with medical students, but commented that enrollment with other cohorts was possible if gross anatomy was completed in a different semester, and one respondent noted that medical gross anatomy is later supplemented by a stand-alone graduate gross anatomy course. For the remaining programs that do not require gross anatomy, this course was listed as one of several possible courses for degree completion. Cadaver dissection is required as part of training in gross anatomy at 88% (N 5 28) of schools surveyed. Of the five programs that currently incorporate hands-on focused training in US in their curricula, nearly all programs (N 5 4) provided gross anatomy instruction for graduate students via a mandatory medical gross course, while only one employed a stand-alone graduate course in gross anatomy. A similar trend was seen with the 12 programs that reported exposure to US in their anatomical sciences curricula; of these, eight provided mandatory gross anatomy instruction in a course combined with medical students, while fewer (N 5 3) required completion of a stand-alone graduate course in gross anatomy, and for a single program there was no mandatory gross anatomy degree requirement. In all programs that incorporated either exposure or focused training in US, cadaver dissection was a required part of the gross anatomy curriculum. As Figure 2 shows, many of the programs surveyed offered diverse opportunities for students to gain teaching experience in gross anatomy during their graduate training, and these experiences varied widely. Helping to teach in the cadaver dissection laboratory was the most common teaching experience among surveyed programs, with 53% (N 517) of programs requiring this experience for the degree, and 25% (N 5 8) making it optional. Graduate students had the option to deliver gross anatomy lectures in 25% (N 5 8) of the programs surveyed, and are required to gain lecture experience in 22% (N 5 7) of programs, although in one instance the Anatomical Sciences Education
SEPTEMBER/OCTOBER 2016
Faculty Familiarity with Ultrasound Available responses from anatomy faculty participants affiliated with both national and international schools are reported here. The anatomy faculty surveyed reported a range of familiarity with ultrasound: 36% had no experience (N 5 21), 29% considered themselves novice users (N 5 17), 21% intermediate users (N 5 12), and 14% experts in ultrasound (N 5 8); category definitions can be found in Table 1. Due to the small number of international respondents who completed this question (N 5 9), familiarity with ultrasound was not statistically compared between American and foreign faculty. However, results showed that participants from outside the United States reported US experience ranging from No Experience to Expert User, the same range as respondents affiliated with American universities. Based on these data, anatomy faculty familiarity with US was organized into two groups: (1) Low Experience, combining No Experience plus Novice users (65% of respondents), and (2) High Experience, combining Intermediate plus Expert users (35% of respondents), to compare perceptions on the role of US according between faculty with different levels of familiarity with US. It is worth noting that a domestic participant, self-classified as an intermediate user of US, commented that they are currently completing coursework and clinical training for Registered Diagnostic Medical Sonographer (RDMSV) certification in order to be a more effective instructor in medical education. R
Faculty Views on the Role of Ultrasound in Anatomy Education The overall standardized Cronbach’s alpha of 0.744 indicated a reasonably strong correlation between responses to the Likert items evaluating faculty perceptions. Furthermore, an alpha of 0.766 and 0.835 demonstrated a robust correlation between items on the following subscales respectively: value of US to anatomy education (2 items), and value of US to future careers (3 items), further supporting the reliability of the survey instrument. The Kendall’s tau-b test found significant correlations between responses to 18 out of 21 Likert items (Table 3), indicating strong associations between most items and acceptable construct validity for the survey instrument. The three nonsignificant associations pertain to the only negatively-worded item on the scale (“US is too difficult for nonclinicians to learn”); it is possible that the wording of this item impacted its validity. To place faculty perceptions on the role of US in anatomy education into a larger perspective, available responses from 459
Table 3. Results of Kendall’s Tau-B Correlation Analysis Evaluating the Validity of the Likert Items
Item
Ultrasound reinforces key anatomy concepts
Ultrasound reinforces clinical correlates
