Simulation-based training has emerged as a valuable tool in the medical field for the development of technical skills. Recently, several studies have suggested that a transthoracic echocardiography (TTE) simulator would be a useful instructional tool. Moreover, effective medical education is essential for medical students to become familiar with medical science. The addition of TTE simulation may improve echocardiographic acquisition skills and speed learning in cardiology medical training programs. The goal of this prospective randomized study was to examine the use of a simulator to teach basic principles of echocardiography and TTE skills of image acquisition to medical students.
A total of 89 fifth-year medical students at Tokushima University were enrolled in this prospective randomized study, which was conducted from October 1, 2014, to July 31, 2015, during their bedside learning period in the section of cardiovascular medicine. In Japan, medical training takes 6 years. Fifth-year and sixth-year students are assigned to clinical clerkships in each department, 2 to 4 weeks in duration, and experience bedside learning with patients.
Groups of four students each were randomized into either simulator or control groups using a computer-generated random sequence in Microsoft Excel (Microsoft Corporation, Redmond, WA). One of the groups included five students. All medical students participated in the first classroom session. Thereafter, the simulator group participated in a simulator training session and the control group participated in a textbook learning session. In the second classroom session, both groups had hands-on training using commercial echocardiographic machines. Finally, all participants underwent assessment of echocardiographic performance and completed a survey of satisfaction ( Figure 1 ).
The first TTE classroom session lasted ≥60 min for each group. All students were instructed on cardiac anatomy, indications and limitations of TTE, and the basics of echocardiographic examination. After the first classroom session, the control group learned about standard transthoracic echocardiographic views with the help of an echocardiography textbook. All control group students listened to a lecture on the acquisition of echocardiographic views, using a textbook for examples. The simulator group learned the same standard views by using a TTE simulator (VIMEDIX; CAE Healthcare, Quebec City, Quebec, Canada). Each participant had 15 min of hands-on scanning time while the other participants observed. In the group with five students, each participant had 12 min of hands-on scanning time. Each hands-on scanning session lasted 60 min, including scanning and observation.
In the second TTE classroom session, all participants tried to obtain seven transthoracic echocardiographic images from three imaging windows (parasternal, apical, and subcostal) on a healthy volunteer in our department. This session lasted ≥60 min for each group, and each participant had 15 min to obtain the seven transthoracic echocardiographic images. These seven images from three imaging windows were selected because they are the most revealing for the assessment of left ventricular systolic function (parasternal long axis, short axis, four chamber, two chamber, and three chamber), left ventricular diastolic function (transmitral flow velocity pattern), and preload (diameter of the inferior vena cava). The images were obtained using a commercial echocardiographic machine (Aplio SSA-770A; Toshiba Medical Systems, Tochigi, Japan) in this session. All students being examined did receive hands-on instructions to obtain the seven transthoracic echocardiographic images before the examination. After two classroom sessions, experienced doctors certified by the Japan Society of Ultrasonics in Medicine evaluated the performance of TTE using the assessment sheet, blinded to group name ( Figure 2 ). The students were asked to obtain seven views, either without assistance or with the assistance of the examiner. The transthoracic echocardiographic examination consisted of seven views, awarded 3, 2, 1, or 0 points for each view, according the quality of the images and the need for assistance. The maximum score achievable was 21 points. The time to completion of the entire examination was recorded. Finally, all participants also completed a self-assessment survey rating their satisfaction levels with this session. The self-assessment questionnaire was graded on a scale of 1 to 5 regarding satisfaction level of echocardiographic instruction session (1 = poor, 5 = excellent). The study was approved by the Institutional Review Board at Tokushima University Hospital. Participation was voluntary, and all eligible medical students provided consent to participate in the study. Data are presented as mean ± SD. Student’s t test was used for comparison of continuous variables between the two groups. Statistical analysis was performed using statistical software (SPSS, Chicago, IL). Statistical significance was defined by P < .05.
