Although the “stethoscope” was developed almost 200 years ago by René-Théophile-Hyacinthe Laennec and is unquestionably the foundation for classical teaching of the diagnostic physical examination, it is also true that generations of medical students have been exposed to this misnomer. The stethoscope, hung proudly around every medical student’s neck, is indeed a “stethophone,” as it allows listening ( steth = chest, phone = sound) to the human body rather than truly seeing ( scope = to look in) into it. Recent developments in ultrasound technology have resulted in miniaturization of ultrasound devices, which can be readily carried in a lab coat pocket and used at the bedside to generate high-quality ultrasound images of cardiac structure and function. These devices can provide immediate feedback and extend the information base of the traditionally acquired history and physical examination, contributing to improved cardiac differential diagnosis formulation. By visualizing cardiac anatomy and dynamics immediately, using a true stethoscope, the user can refine clinical decision making and optimize the choice of further testing and treatment. Indeed, the use of these devices in routine clinical practice, akin to the manner in which the traditional stethoscope has been used, may potentially enhance, expedite, and improve cost-efficient care. However, as this technology has only very recently evolved, there is as of yet no standardized approach for teaching the skills necessary to use these devices optimally, nor is there a systematic approach to assessment of the learner’s capabilities and the impact on patient care.

Historically, the knowledge base necessary to use the more sophisticated conventional ultrasound scanners has been acquired only at the postgraduate and specialty training levels, at which programmatic instruction and assessments are well established, with numerous accreditation bodies providing benchmarks for expertise and “quality control.” Traditionally, ultrasound assessments have been performed on large scanners located in imaging areas within radiology, cardiology, and obstetrics departments. With the advent of portable scanners in the 1990s, it became possible to scan patients in real time at the “point of care,” and many other specialties such as emergency medicine, surgery, critical care, and others began to embrace ultrasound technology and change their practices. Thus, a technology innovation enabled diverse new groups of users to perform focused ultrasound assessments, which has been further accelerated by the most recent technologic development of “handheld” or “pocket-sized” ultrasound units. Indeed, point-of-care ultrasound can be viewed as a “disruptive” innovation, changing the paradigm of consultative imaging by specialists to one whereby imaging may be performed at the bedside by the clinicians directly responsible for a patient’s care. This activity has the potential advantage not only to enhance the rapidity of imaging access but also to improve the imaging examination through focused acquisition and interpretation guided by the diagnostic context formulated by the consultant directly evaluating the patient. These miniaturized ultrasound devices truly provide widespread opportunity to extend the physical examination of both novice and expert caregivers by seeing directly into the body at the bedside. The equipment is now readily available, at a price point that is not prohibitive to potential mainstream users. The key issue, then, is the development of appropriate training and education of caregivers in their use, so that they will benefit patients, through enhanced cost-effective delivery of care, and not harm them through underdiagnosis or overdiagnosis.

Approaches to point-of-care assessments of patients with portable, handheld ultrasound (HHU) units and their integration into both medical teaching and clinical practice are in the “emergent” and “early adoption” stages of new technology. Several medical organizations have recently developed expert consensus and guideline documents aimed at introducing and guiding the use of HHU, particularly as it pertains to cardiac imaging. The American Society of Echocardiography has recognized that these devices are capable of performing focused cardiac ultrasound (FCU) assessments as an adjunct to the physical examination. Whereas HHU describes a portable miniaturized ultrasound device that can be used to examine any organ or system in the body, FCU is specifically defined as a focused examination of the cardiovascular system performed by a physician using ultrasound (at the bedside with an HHU device) as an adjunct to the physical examination to recognize specific ultrasonic signs that represent a narrow list of potential diagnoses in specific clinical settings. However, the American Society of Echocardiography has also noted that comprehensive echocardiographic examination requires “image acquisition by trained sonographers and image interpretation by skilled echocardiographers.” Recommendations for cardiac ultrasound training for nonechocardiographers include three core components: didactic education, hands-on image acquisition, and image interpretation experience. Similarly, the European Association of Echocardiography, now rebranded as the European Association of Cardiovascular Imaging, has recognized the utility of these devices and published recommendations on their use in the clinical arena by profiling the educational needs of potential users other than expert imagers. Thus, although it is clear that the opportunity for widespread use of HHU exists, the awareness of the clinical applications and limitations of FCU and methods to acquire the appropriate training are yet to be clearly defined. Moreover, because ultrasound applications are not limited solely to the cardiovascular system, numerous other medical, surgical, emergency medicine, radiologic, and ultrasound imaging specialty organizations, as well as medical educational associations, have recently contributed to a growing body of literature on the use of ultrasound in clinical practice and education, spurred by the recognition of the potential for the portable devices to provide a true “real-time window” into the human body. Recently, a dedicated educational organization, the Society for Ultrasound in Medical Education, has been developed specifically to address the need to incorporate learning ultrasound image acquisition and interpretation skills into the general medical curriculum. Indeed, the American Society of Echocardiography endorses that “it appears feasible and appropriate to begin FCU training in medical school curriculums, where it can be taught in conjunction with history and physical examination training.” However, there currently exist just a very small number of medical schools that have successfully integrated ultrasound instruction into their curricula, and the teaching and use of ultrasound in this context have not yet been widely accepted or implemented. Current and future generations of “tech-savvy” students will be demanding instruction in such technology, and thus, this issue is a pressing one for the ultrasound community at large and the echocardiography community in particular. The current thinking is that the optimal time for integration of ultrasound teaching is likely during medical school, when learners are “pluripotent” and more accessible. Demonstration of a positive impact on the accuracy of cardiac bedside diagnoses beyond the traditional physical examination with the use of HHU devices has been previously demonstrated in fourth-year medical students after 10 days of intensive instruction and even in first-year medical students with 18 hours of ultrasound training, who outperformed the physical examination findings of board-certified cardiologists. More recently, pocket-sized handheld cardiac ultrasound examinations by medical students and junior residents have been found to increase diagnostic accuracy for systolic dysfunction compared with history and physical examination.

As the use of ultrasound at the point of care increases across many medical specialties, it is important to consider the impact on medical student education of integrating ultrasound learning into the medical curriculum. To what extent and when should ultrasound be an integrated part of the curriculum: preclinical, clinical clerkship, and/or residency training? Increasingly, students, interns, and residents are exposed to ultrasound use on clinical rotations. Beyond the clear application “at the bedside” during the clinical training experience, ultrasound can serve to augment an existing curriculum in anatomy, physiology, physical examination, pathophysiology, and therapeutics. It is increasingly apparent that the actual performance and interpretation of ultrasound information in real time is likely to become an emerging skill set to be expected of medical students.

Thus the study “Development and Evaluation of Methodologies for Teaching Focused Cardiac Ultrasound Skills to Medical Students” by Cawthorn et al . in this issue of JASE is extremely timely and relevant. These investigators evaluated the feasibility and effectiveness of various implementation methodologies in a novel medical school educational program designed to introduce the acquisition and interpretation of FCU images by medical students. The authors describe a two-phase program whose goals are to (1) assess the time at which the introduction of FCU skills would be appropriate for medical school learners and (2) assess the ability of simulation-based and electronic module–based methods, in comparison with traditional didactic teaching methods, for delivery of the knowledge. The overall objective of their research was to develop and evaluate a novel curriculum for training medical students in the use of FCU. In the first phase, 12 first-year medical students underwent FCU training over an 8-week period. In the second phase, 45 third-year medical students were randomized to one of three educational programs. Program 1 consisted of a didactic lecture-based approach with training in scanning by a sonographer. Program 2 coupled electronic education modules with training in scanning by a sonographer. Program 3 was fully self-directed, combining electronic modules with scanning training on a high-fidelity ultrasound simulator. Image interpretation skills and scanning technique were evaluated after each program. First-year medical students were able to improve interpretation ability modestly and to acquire limited scanning skills. Third-year medical students exhibited similar improvements in mean examination score for image interpretation whether a lecture-based program or electronic modules were used. Students in the self-directed group using an ultrasound simulator had significantly lower mean quality scores than students taught by sonographers. Thus, Cawthorn et al . conclude that that third-year medical students were more readily able to acquire FCU image acquisition and interpretation skills after a novel training program than first-year students, and that electronic educational modules were as effective as traditional lectures to deliver this knowledge, but that simulation-based learning was not as effective as hands-on sonographer and expert-led teaching for acquisition of the scanning technique skills. They also make important observations regarding the feasibility of cardiac image acquisition by the novice learners. They found that the parasternal views were more easily acquired by the medical students in comparison with apical views, consistent with previous work indicating that novice learners find apical views (especially the apical two-chamber view) more difficult to acquire than parasternal long-axis views.

The information conveyed in this important report clearly demonstrates that the learning program has been well thought out and carefully designed by an experienced and knowledgeable team composed of expert echocardiographers, sonographers, educators, and information technologists. They incorporated standardized echocardiographic techniques and evaluated using objective skill testing. The assessment of the comparative efficacy of simulation versus hands-on learning is unique, and the findings are valuable. Their results should inform future FCU curricular design to use strategies with an emphasis on integration of online modules for knowledge base and hands-on training for image acquisition, emphasizing more intense instruction on those views that are more challenging while recognizing potential pitfalls and limitations in technical skill development. Their observations provide additional evidence to the emerging body of literature assessing the development and foundation for integration of HHU into the standard medical school curriculum (cardiac and other applications: abdominal, vascular, obstetric), while recognizing the importance of incorporating appropriate competency benchmarks.

However, several significant issues, both methodologic and philosophic, remain to be addressed.

First, what were the purpose and level of commitment to the implementation of training in bedside ultrasound as part of the medical education curriculum?

It is not clear if the purpose of training first-year medical students was (1) to enhance their proficiency in examining patients with known or suspected heart disease or, rather, (2) to enhance their understanding of cardiovascular anatomy, hemodynamics, and physiology while introducing the learners to technology that is likely to be of iterative value when they begin their clinical training, where they will actually use the devices as “an extension of the stethoscope” to assist in evaluating and managing patients. Logically, we would suspect it to be the second option, because the students were not yet seeing patients, but the investigators seem to have had in mind an “either-or” approach, to introduce ultrasound at only one level of the curriculum. This differs with the growing consensus from the handful of medical schools that have successfully established ultrasound curricula that are longitudinal programs, with the introduction of basic principles of ultrasound in the first year, along with imaging (most often on one another, in small groups) to explore and reinforce concepts covered in anatomy and physiology, followed by utilization while learning pathophysiology and physical examination techniques in the second year, and then application at the bedside during the clinical rotations of years 3 and 4. Recent reports in first-year and second-year medical students have found the addition of ultrasound training to be valuable not only in enhancing their understanding of anatomy and physiology but also in increasing their interest and motivation to improve their knowledge through experience in ultrasound imaging. The hands-on approach enabled by ultrasound imaging promotes interactive learning and intensifies understanding of the normal anatomic, mechanical, and physiologic principles that can serve as a foundation to build on the clinical scenarios of disease states (altered anatomy and pathophysiology) throughout medical training. This layered curriculum has already been implemented in several medical schools, with integration of ultrasound through preclinical and clinical courses, bridging the gap between basic science and clinical care. Learning with ultrasound has been likened to having a “virtual scalpel” to demonstrate anatomy on live subjects without harm. This allows a three-dimensional assessment of anatomic structures and the ability to visualize moving structures (such as the heart) in ways not possible with traditional cadaver dissection. Students learning physical examination skills can use ultrasound to enhance their understanding of surface anatomy and of organ size and location and correlate what they palpate or auscultate with the visual image of what precisely is occurring within the body. Thus, “one-stop-shopping,” as the authors apparently intended in introducing only cardiac (rather than multisystem) assessments, and at a later point in medical school training, may not be desirable or relevant.

In terms of the level of commitment to training in bedside ultrasound, it is important to recognize that the investigators did not test the learning program within their standard curriculum but outside the regular instructional hours, in an “extracurricular” format, and thus depended on the motivation of the individual students to learn. To evaluate compliance with the educational protocol, attendance was taken at each training session; however, compliance with self-directed learning components of the curriculum was not formally assessed. It will be of future interest, assuming that these results are deemed successful and implemented, to evaluate similar end points when the program is conducted within the standard curriculum. Because the training programs were entirely extracurricular, examination scores from these self-directed groups may represent lower values than may be expected if the training program was a required component of the medical school curriculum. As such, greater examination scores may be expected if the training programs became a compulsory component of the curriculum.

Second, how does one measure the effectiveness of teaching medical students to use ultrasound to examine the heart (or other organs)?

Can one judge both knowledge and technical skills from the quality of images recorded, or are there better approaches? There is inherent difficulty in determining competency assessment parameters; how do you separate learners’ technical ability to obtain an interpretable image from their “knowledge-based” interpretation skills of what it is they are seeing? Cawthorn et al . have thus unavoidably blurred the assessments of “image quality” (technical ability) and “accuracy” (knowledge). Perhaps it is a moot point, as to perform FCU adequately, it is necessary to have both image acquisition and interpretation skills. But to teach our learners and help them overcome obstacles within the learning process, it is necessary to make this artificial separation. It would seem reasonable that students be tested separately on a standardized set of images to interpret, for the assessment of knowledge base, while having a unique evaluation dedicated to testing capability of technical reproduction of standard views. However, the most important test, one that was beyond the scope of this study, will ultimately be whether the acquisition of these skills at an early stage by physician trainees translates into providers capable of improved quality of care and into better patient outcomes. It is unfortunate that the authors did not report on the students’ feedback regarding their experience using ultrasound as a learning tool, which is another very important aspect to be assessed, beyond measures of quality and accuracy. Others have reported learners’ responses to ultrasound implementation in the medical school curriculum as being nearly uniformly positive, with early exposure and training resulting in increased interest, competence, and confidence in diagnostic skill development.

Third, what are the challenges to establishing the routine use of ultrasound in medical school training?

Given that emerging data indicate near revolutionary changes that may occur with the application of point-of-care ultrasound using hand-carried miniaturized units, what remains is the challenge of systematic incorporation of ultrasound training into the 4-year medical school curriculum. What are the hurdles and obstacles to be overcome to achieve widespread integration? Certainly access to ultrasound equipment is essential and the initial obstacle. This difficulty is likely to diminish as further demand lowers per unit cost. In an era of exploding medical science information and competing modalities, the time allotment for teaching, and the ability to integrate into the existing and already saturated medical curricula, is key. However, ultrasound technology nearly uniformly enhances and augments the existing core curriculum, as portable, non-ionizing imaging can expedite the anatomic and physiologic information conveyed for many of the body’s systems, and thus dedicated “separate” time, other than teaching the basics of ultrasound physics and orientation, is not required. Our current generation of learners is intuitively wired for technology and gadgets, and HHU fits that capability precisely. Who among us have not given their smart phones or laptops to their children to figure out functions they are perplexed by? This is another argument for initiating instruction in ultrasound early in medical school education. However, we must invest time and effort in the development of motivated, dare we say passionate champions to train their multidisciplinary colleagues as faculty members for instructors and mentors. At the core, the major resistance appears to be cultural, or philosophical, even inertial. Why change? Most important, the value of the technology must be recognized and championed by the key leaders in the academic learning establishments, or they will be left behind. There is strong competition for the brightest students at our medical schools, and those that have innovative programs such as ultrasound integration flaunt these to attract the best and the brightest. Increasing numbers of medical schools now have startup pilot projects and are “testing the waters.” Indeed, we have recently developed a collaborative program between the Mayo Medical School in Rochester, Minnesota, and Mt. Sinai Medical School in New York to integrate ultrasound into the medical school curriculum, and we continue to refine our methodologies. Currently, students are initially exposed to ultrasound in the integrative anatomy and physiology laboratory during the first 2 years. Specifically, during the cardiovascular physiology block, didactic lessons and hands-on experience in basic transthoracic echocardiography imaging are done to build on and reinforce principles through the “integrated diagnostic experience.” A core principle of our integrated program is both the short-term and long-term assessments of implementation strategies and their impact on student, and subsequently, physician performance and patient outcomes.

The naysayers among us would claim that there is as yet no evidence, other than improved safety in the placement of central lines, that bedside ultrasound changes clinical outcomes, and warn of the dangers of inaccuracies in bedside HHU interpretations. They want quantitative data to know if students who are in the medical school programs that have embraced ultrasound integration in their curricula perform better on anatomy questions in standardized tests such as national medical licensing examinations, or are better in some aspect of the physical examination. It behooves us to provide this information prospectively, as we implement evidence-based training programs. Fortunately, as learning ultrasound and learning with ultrasound are well suited to novel approaches, as exemplified in the report by Cawthorn et al ., a variety of multimedia options, including online tutorials, interactive assessment tools, cases, and image archives, created by currently established programs are readily available and accessible for all to use as resources. Even social media have been used at The Ohio State University School of Medicine, where ultrasound educators used Twitter to deploy a curriculum of high-yield ultrasound concepts via “push technology” to followers in a pilot project. Continuing medical education opportunities for learning about ultrasound use in medical education are growing rapidly. The University of South Carolina has hosted the first two World Congresses on Ultrasound in Medical Education, in 2011 and 2013, and next year, Oregon Health & Science University in Portland will play host, where educators and learners from across the globe gather to present evidence for educational strategies, collaboration, and engagement in hands-on education sessions.

In summary, what can we learn from the study by Cawthorn et al ., and what is the future for ultrasound integration into our medical teaching?

Fundamental training in sonography has already been integrated into the curricula of several medical schools in the United States, and its adoption is growing because of the potential advantage these tools may provide in expediting appropriate and cost-effective patient-centered care. Acquisition and interpretation of focused ultrasound may emerge as core competencies required for graduating medical students. The results of this study may contribute to and further guide the establishment and integration of competency-based HHU training in medical schools. Although traditional imaging specialties will still retain high levels of mastery and have access to the most sophisticated equipment, increasingly, other clinicians will use focused ultrasound examinations to gain immediate and management-changing information about their patients. From the cardiovascular standpoint, it is imperative that imaging experts with advanced cardiac ultrasound experience lead and coordinate cardiovascular training and educational programs. Although HHU units are portable (by definition) and enable point-of-care assessment, there is potential for misuse of this technology by undertrained individuals, or physicians practicing outside their scope. Clearly, the best solution for this quandary is the acquisition of a solid and relevant foundation of knowledge in ultrasound during medical school training, including indications for use, image acquisition, interpretation, and application to clinical decision making. It would be our hope that the novelty of medical student education in ultrasonography will disappear, replaced by ubiquitous competence through “seeing is believing.”