End-of-Residency Perspective on Early Ultrasound Education

I remember clearly the first day I ever held an ultrasound probe. It was my second week of medical school, I knew next to nothing about medicine, and my faculty member turns to me and enthusiastically says “oh look, you have a few thyroid cysts.” I, of course, immediately thought a few things. First, how many are there, how big are they, what do I need to do, could it be cancer, and why is the faculty member so nonchalant about this.

The next thing I thought was “what is a thyroid”.

After the initial and very clearly unnecessary panic was over, I thought to myself that it was very interesting we were scanning things before we were taught about them in class. Throughout my training, I have come to realize how lucky I was to get such early exposure to ultrasound training and teaching. At Eastern Virginia Medical School, ultrasound was integrated into all aspects of the curriculum. This started in anatomy lab, continued into our second-year courses in pathology, and was a crucial part of 3rd year rotations where each rotation had several portable ultrasounds for students to use to scan. In the Family Medicine clerkship, we were tasked with scanning multiple people for AAA, and on surgery, we had to get 5 images of cholelithiasis. By the 4th year, faculty were using ultrasound to do procedural training and students were in the trauma bay performing FAST exams for the team. Although I thought this was the norm, I quickly found out on the interview trail that this experience separated me from a lot of my peers.

A selfie of a very young David sent to his clerkship director as proof he did his scans for the rotation.

In residency, we had a point-of-care or POCUS-centered curriculum. Although we all got the same instruction, I felt like my previous experience, and most of all my comfort with the probe, made me into the “ultrasound guy” of my program. While the immense clinical utility is not lost on any of my peers, the amount of time it takes to become comfortable just did not fit into the time constraints of residency.

While I do not think ultrasound can be filed under “you can’t teach an old dog new tricks,” I do strongly believe that integrating it into medical education early on is crucial for the future of medicine. Based on my conversations with colleagues at different schools and institutions, often, ultrasound training is saved for residents and fellows, and it really shouldn’t be. Although, this surely is based on several factors including class size, cost, requirement for specialization (eg, prenatal ultrasound for OB/GYN, MSK ultrasound for Sports Medicine and Orthopedics), and availability of sufficient machines.

One of the most frustrating things for me is the train of thought that imaging is ruining the art of the physical exam. While yes, many people will get a CT of their abdomen and pelvis in the ED, the dynamic and live view that ultrasound provides is invaluable in learning about anatomy. Multiple studies, including one that I have worked on, have shown that a longitudinal and integrated ultrasound curriculum improves procedural and physical exam skills. Many of these studies show that the biggest effect is when it is started early in training.

After being the confused MS1 who was freaking out about his thyroid cysts (which since have gone away by the way), and being slightly frustrated at the time that more work and learning was on my plate, it’s abundantly clear to me now that this is the direction that medical education needs to go. Every first-year medical student at every institution should have their hands on probes throughout their first year, especially while learning anatomy. My challenge to medical school leadership is to find a way to incorporate or expand on ultrasound in their curriculum. At first, your students will not be confident, and they will feel like they don’t know what they are doing, but it CAN and it WILL help in the long run. It certainly did for me.

David Neuberger, MD, is currently a 3rd year Family Medicine Resident at Emory University in Atlanta, GA. He will be pursuing a Primary Care Sports Medicine fellowship at the University of Louisville this upcoming year and has a special interest in ultrasound and ultrasound education.