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.

What’s Your Dialogue?

Ultrasound image of a uterus showing the crown rump length of the fetus is 0.34 centimeters.

Beneath the paper drape of the “2:30 OB Confirmation” lies your next patient. Despite the application of the ultrasound study performed, a variety of stressors wreak havoc on a patient’s mental state prior to examination. The impact of what we say and how we say it, or the very lack of it, can shape a person’s view of testing, staff, or even healthcare as a whole. Yet, how much of an emphasis in ultrasound training is placed on effective communication? Especially in obstetrics where early pregnancy loss is prevalent, a blank stare at the monitor and averted eyes feels disconnected and insensitive. Let’s ask ourselves:

  • How do we, as ultrasound providers, communicate with our patients?
  • Do we attempt to provide comfort or empathy when needed?
  • How important is this interaction to our patients?

We owe it to quality patient care to take a deeper dive.

In settings where our patients show fear, stress, or grief, what’s your dialogue?
How should it look and sound?

Perhaps your patient, waiting nervously under the drape, presents with a poor OB history. Performing an ultrasound examination should encompass more than the stoic mechanical bedside manner. We should engage with the person behind the diagnosis code.

We see it often in OB. Despite reassurances of last week’s scan and normally-rising labs post early spotting, the patient leaves her appointment only to consult Dr. Google where she absorbs every related link about bleeding in pregnancy from previa to placental abruption. It’s been the L O N G E S T week of her life, and she’s sure fate will deliver yet another D&C instead of the child she desires. Miscarriage is the kind of trauma that leaves a woman emotionally scarred and fearful that history will repeat itself. It’s imperative we contemplate the real trepidation some patients feel for their examinations—and act accordingly.

Photo credit: Kat Jayne, pexels.com

For the brief time a patient resides in our care, we sonographers control the environment. We drive the equipment, manage the time, and guide our patients. It is completely within our power to greet them with warmth and direct eye contact, to adopt a caring tone in our explanations, to ensure comfort in our care, and to assure answers for their questions—where we can.

It’s a fine balancing act, isn’t it? …A tightrope walk between what we sonographers can share with an inquiring patient and what we cannot. Though protocols vary, we all surely must learn what information we are allowed to impart. Precisely how we convey it is up to us. After all, our patients must disrobe before a perfect stranger who is not their physician; in turn, we must overcome the propensity for a swift robotic contest against the clock to be more attentive. We may not manage a patient’s care, but for a short time, we are a patient’s provider and caregiver. The interchange with our patients is as much an integral part of our job as is concise reporting.

Effective patient communication should be a cornerstone of every curriculum and commence as early as learning sagittal versus transverse. Every veteran sonographer who relishes the confidence of cultivated skill and experience began the same way. Typically, navigating this technology for most students requires a long learning curve to perform it well and accurately. It’s quite easy for the initial focus to lie with capturing textbook images, not connecting with the patient. Learning appropriate and competent dialogue is as imperative as exam protocol. The new sonographer must observe and mimic this personal interaction before the first steps beyond the classroom.

Photo credit: Stas Knop, pexels.com

Conversely, the skillful sonographer, buried in the demands of a hectic patient load, may lose the tendency over time to prioritize this communication. Juggling the demands of a full schedule with urgent add-ons and after-hours call, we sometimes end up fanning the flames of burnout where a slide into the hurried robotic pace of patient-in, patient-out feels unavoidable. Don’t lose sight of the importance of your work and who depends on you. Every patient you scan lies on your table, and your’s alone. We are each responsible for the level of quality care we provide.

Now, examine your own daily patient interactions. Are they mechanical and rushed? Or do you take the time to employ earnest conversation? Do you attempt to allay fears or offer an empathetic tone when needed? Do you extend the care you would want, need, and expect if on the receiving end of healthcare? I challenge each of you to put forth the very same degree of consideration you’d like for your mother, your sister, your daughter, yourself…if the white coat fear was your own, if the anxiety of a test result was your own, if the pregnancy loss was your own. The appreciation our patients show can mystifyingly renew a sense of purpose in our work today and fuel our career tomorrow.

So, what’s your dialogue?

Sandra M. Minck, RDMS, is the creator of UltrasoundUnwrapped.com and @ultrasound_unwrapped on Instagram, a resource for accurate ultrasound information for expectant parents. She is the author of Ultrasound Unwrapped: A Pregnancy Image Guide, soon to be published.

Interested in learning more about communicating with patients? Check out the following posts from the Scan:

Interest in Interest Groups

Ultrasound in medical education is a powerful idea whose time has come. With its value in the clinical setting being increasingly recognized, leaders of a point-of-care ultrasound (POCUS) movement are making a strong case for introducing ultrasound early in medical training. Not only is it a useful educational tool to illustrate living anatomy and physiology, but it is also an important clinical skill- guiding procedure, improving diagnostic accuracy, and facilitating radiation-free disease monitoring. As the list of POCUS applications grows exponentially across specialties, I believe that to maximize the potential impact, it is vital to introduce this skillset early during the pleuripotent stem cell phase of a young doctor’s career.


Looking around, there are signs this movement is here to stay. Ten years after the first medical schools began integrating ultrasound into the curriculum, an AAMC report of US and Canadian schools stated that at least 101 offered some form of ultrasound education, with the majority including it into the first 2 years of the curriculum. If one visits the AIUM medical education portal (http://meded.aium.org/home), 77 medical schools list a faculty contact person involved with ultrasound curriculum development and integration.

It should be noted that the depth of content varies from school to school, as not all institutions value ultrasound to the same degree. Recommendations on core clinical ultrasound milestones for medical students have been published and results from a forthcoming international consensus conference will help improve standardization, though there will likely be much variability until it is required by LCME or included on board exams.

It is during this time of transition that the importance of ultrasound interest groups (USIGs) cannot be understated. USIGs provide a wider degree of flexibility often not possible within a formal curriculum, quickly adapting for changes not only for meeting times and group sizes but also topics and teaching strategies. Indeed, for schools without a formal ultrasound curriculum, it is often how one gets started. For ultrasound faculty, USIGs provide fertile ground for experimenting with new teaching ideas and cultivating both student and faculty enthusiasm for POCUS at one’s institution. For senior students, USIGs can provide opportunities to participate in research projects, serve as near-peer instructors, and participate at regional and international meetings. The spread of local, student-run Ultrafest symposiums is a testament to the power ultrasound has to draw people in and the impact students can have beyond their own institution. The AIUM National USIG (http://www.nationalusig.com/) provides a nice resource for further collaboration while student competitions like AIUM’s Sonoslam or SUSME’s Ultrasound World Cup showcase ultrasound talent and teamwork in an anti-burnout, fun environment. I have no doubt that some of these exceptionally motivated students will become future leaders in the field, as some already have (http://www.sonomojo.org/).

While many of these students will pursue and jumpstart their careers in Emergency and Critical Care Medicine, students from varying backgrounds and interests are needed in USIGs. The frontier of Primary Care ultrasound is wide open and may become crucial as we see more emphasis on population medicine and cost containment as opposed to fee-for-service models. With the exception of in the ER, the utilization of pediatric ultrasound has been surprisingly lagging and more POCUS champions are certainly needed here. In addition, the early exposure to POCUS can increase comfort with ultrasound and help drive novel developments by future specialists. Some lesser-known potential examples include advancing work already underway: gastric ultrasound for aspiration risk by anesthesiologists, sinusitis and tonsillar abscess drainage for ENTs, diagnosing and setting fractures for orthopedists, noninvasively measuring intracranial pressure by ophthalmologists and neurologists, and detecting melanoma metastasis by dermatologists. Until it is more widespread, a skillset in POCUS can be a helpful way to distinguish oneself in an application process and provides an excellent academic niche. After medical school, some USIG students will go on to form ultrasound interest groups in their specialty organizations, going beyond carving out a special area of interest for themselves and helping to advance the field and shape future policies.

Similar to other enriching things like viewing art and discussing philosophy, I believe all students should be exposed to ultrasound and given the opportunity to learn this skill. While I feel strongly that ultrasound should be a mandatory component of an undergraduate curriculum, I also recognize that not all will enjoy and excel in it, and many will settle for nothing more than the bare minimum. However, I believe the USIGs help us to motivate and empower those few individuals with the passion and grit to really help propel this movement forward and show the world what is possible. This is truly an exciting time. I hope you will join us.


Are you a member of an ultrasound interest group? Has it improved your skill set? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Michael Wagner, MD, FACP, RDMS, is an Assistant Professor of Medicine at the University of South Carolina School of Medicine in Columbia. There he serves as the Director of Internal Medicine Ultrasound Education for the residency program, Assistant Director of Physical Diagnosis for the undergraduate curriculum, and faculty advisor to the student ultrasound interest group. You can view his 2017 talk for the USCSOM USIG here (https://youtu.be/FfO7SXRwjLY) and an AIUM webinar with Janice Boughton on a pocket ultrasound physical exam here (https://www.youtube.com/watch?v=ywuIeoEfG1I).