Experiential learning, defined as “learning through experience,” will always be central to medical education. Dr. Eric Savitsky and Dr. Dan Katz report.
Recently, performance-based learning has progressively been touted as an alternative to the traditional time-based learning paradigm. This is occurring in an era of cost containment and fiscal austerity within healthcare and medical education. As such, cost- and time-efficient training approaches are critical in preparing the next generation of physicians to respond to future healthcare challenges.
Point-of-care ultrasound is an example of a game-changing technology that has been historically hindered by the high opportunity cost of training users. The time, complexity, and cost of training have kept this life-saving technology on the sidelines. Fortunately, advances in computational science and technology have created nascent opportunities for wide-scale adoption of ultrasound by medical care practitioners. The SonoSim® Ultrasound Training Solution will be used as a case study to explore the practical considerations involved in delivering competency-based ultrasound training to medical care providers in a learner-centric manner.
The Rapidly Changing Graduate Medical Education Landscape
Macroeconomic changes are occurring in healthcare, largely driven by the vision of transforming the United States healthcare system from a volume-based, fee-for-service model to one focused on patient outcomes and value. Similar changes have been occurring in organizations tasked with preparing the next generation of physicians. Graduate medical education (GME) is supported by $15 billion per year of US tax dollars, with more than 90 percent of this funding coming from Medicare and Medicaid programs (2012 data). The recently released Institute of Medicine (IOM) report “Graduate Medical Education That Meets the Nation’s Health Needs” declares “an unquestionable imperative to assess and optimize the effectiveness of the public’s investment in GME.” It calls for eliminating the current Medicare GME payment model. The IOM report calls for redesigning payment methods to reward performance, ensure accountability, and support innovative approaches to GME and its financing.
The gap between new physicians’ knowledge and skills and the competencies required for current medical practice was identified as a major problem. How to finance, scale, and propel the evolution of GME is a controversial and widely debated topic. However, the need to adapt GME to meet the rapidly evolving challenges of preparing the next generation of physicians is well established.
The Next Accreditation System (NAS), developed by the Accreditation Council for Graduate Medical Education (ACGME), details specialty-specific milestones as the foundation for an outcomes-based resident evaluation process. The explicitly stated intention behind these ACGME actions is to “base residency program accreditation on educational outcomes, demonstrating to the public the effectiveness of competence-based education, and changing a system that does not encourage innovation and has become prescriptive” (Nasca, 2012).
The NAS specialty-specific milestones were initially implemented in July 2013, representing a progression of ACGME-driven restructuring that began in 1999 with the introduction of six domains of clinical competency into graduate medical education. As an example, Emergency Medicine milestones assess resident performance in six ACGME-defined core competency domains (Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems-Based Process). Each milestone is measured along with respect to five levels, ranging from entry-level (Level 1) to expert (Level 5). Of interest, only 47 percent of attending physicians surveyed in a 2014 study rated themselves as meeting Level 4 or 5 criteria for ultrasound skills. Attendings reported less perceived competence in ultrasound skills compared to other milestones (Peck, 2014).
The Evolving Challenges of Preparing Students
Medical institutions and physicians are under constant pressure to deliver more specialized and efficient patient care. Undergraduate medical education programs will need to seek alternatives to traditional time-based approaches to curricular design in order to prepare their students for these challenges. Moving towards performance-based learning and away from traditional time-based learning models has been identified as a potentially more efficient educational paradigm (Frank, 2010). As noted earlier, accelerating the integration of ultrasound into medical education has the potential to radically improve medical care, while simultaneously illustrating the virtues of performance-based learning.
Point-of-care ultrasound can improve the standard physical examination, bedside clinical decision-making, and patient care and safety (Kendall 2007, Kobal 2005). Point-of-care ultrasound refers to the use of portable ultrasonography at a patient’s bedside for diagnostic (e.g. symptom or sign-based examination) or therapeutic (e.g. image-guidance) purposes (Kendall). While traditional methods of performing a physical examination are of critical importance, practitioners that become skilled in the use of point-of-care ultrasonography become uniquely empowered. Conditions such as cardiac valvular disorders that are inferred by auscultation can be visualized and quantified by ultrasound. Time-sensitive definitive diagnoses such as ruptured abdominal aortic aneurysms are made in minutes rather than hours.
Kobal et al. demonstrated the value of attaining competence in ultrasonography during medical school. He found that first-year medical students with 18 hours of ultrasound training outperformed seasoned cardiologists in detecting cardiac abnormalities (Kobal, 2005). Widespread adoption of point-of-care ultrasonography has the potential to save billions of dollars, revolutionize patient care, improve procedural efficacy, decrease complications, and limit patient pain and suffering.
Developing ultrasound competency and applying the results to clinical care is a complex process. It requires integrated cognitive (image interpretation) and psychomotor (optimal image window acquisition) skills. Once an optimal image window is acquired and correctly interpreted, the information needs to be correctly applied to patient care. The opportunity cost of training healthcare providers on ultrasonography is extremely high. Optimal training requires (1) a qualified instructor; (2) trainees; (3) an ultrasound machine; and (4) a patient with a pathologic condition.
All of these elements are necessary, and the process must repeat with a new patient presenting an alternative pathologic condition over an extended period of time. It may take months to years before a care provider is able to scan a sufficient number of patients with certain pathologic conditions (e.g. leaking abdominal aortic aneurysm) to develop competence, especially since certain conditions are rarely encountered. The inability to train on varied pathologic cases (abnormals) is a recognized impediment to ultrasound competency. Additional barriers include a lack of a standardized curriculum, paucity of ultrasound equipment for individual trainees, and inadequate number of trained faculty available to teach and assess ultrasound proficiency. Thus, the inherent difficulties associated with learning ultrasonography coupled with traditional time-based curricula hinder systemic adoption of ultrasound training during undergraduate and graduate medical education.
Case Study: SonoSim® Ultrasound Training Solution
The SonoSim® Ultrasound Solution was conceived in response to an unmet need for efficient and scalable ultrasound education and training. It delivers personalized ultrasound education, automated assessments, and hands-on training using real-patient based cases to medical students and residents via personal computers. It provides learners a flexible personal computer-based platform for rapidly attaining ultrasound proficiency and engaging in lifelong ultrasound learning. The SonoSim® Ultrasound Training Solution radically accelerates the time it takes to learn how to scan both normal and pathologic conditions in patients of varying sexes, ages, and body morphologies. Students have the ability to access and scan hundreds of virtual patients and an “on-demand” mentor is available anytime-anywhere.
Medical educators can now provide their students with a customized ultrasound curriculum in a modular (organ-based) format that provides maximal flexibility to ensure compatibility with a broad range of curricular needs and facilitates asynchronous learning. Furthermore, educators can make better use of their limited time and provide more effective bedside ultrasound teaching. The Ultrasound Training Solution provides program administrators with the ability to track user performance in an automated manner. This functionality serves as the foundation for future evolution of competency-based ultrasound training. The SonoSim® Ultrasound Training solution serves as a practical example of how an enabling technology can be applied towards addressing a well-defined medical training need. Current efforts involve integrating automated assessment metrics that measure validated ultrasound proficiency milestones into the training solution.
Role of Academic and Private Industry Partnerships
In 2010, Frank et al. reported that “adopting competency-based medical education on a larger scale would require new teaching techniques, new modules, and new assessment tools to be practical and effective” (Frank, 2010). This was reinforced by the recent IOM report, which restated the need for new educational technologies to support performance-based teaching initiatives (IOM). Academic and private industry partnerships that leverage the guidance and domain-expertise of medical educators and the private sector’s ability to deliver scalable performance-based training solutions will be required. The perception of academic and private industry collaboration has been tarnished by controversial relationships and widely repudiated abuses over the years. Unfortunately, these negative practices have overshadowed many positive successes that were enabled through well-designed and managed academic-private industry partnerships. Diligently designed and executed academic-private industry partnerships will be required to implement large-scale, robust performance-based medical education solutions that are responsive to stakeholder needs (e.g. ensuring data privacy).
Opportunities and Pitfalls
Potential benefits of performance-based medical education include accelerating proficiency development, individualized instruction, transparent standards, and improved accountability. A critical aspect of implementing any form of performance-based paradigm is identifying desired outcomes and precisely defining and measuring the processes leading to them. Medicine is rife with well-intentioned, but poorly conceived performance-based quality improvement measures. For example, attempts at improving management of patients with pneumonia resulted in a four-, then six-hour “time for first antibiotics dose rule” in patients hospitalized with the diagnosis of pneumonia. Difficulties associated with diagnosing pneumonia, among other factors, resulted in wasteful testing, inappropriate antibiotic administration, and failures to improve outcomes (Quattromani, 2011).
The success of future performance-based medical education initiatives will hinge upon successfully pairing interventions with desired outcomes. As noted earlier, experiential learning will always be a critical component of medical education. Certain skill sets and attributes (e.g. attitudes and personal values) do not easily lend themselves to discretization and quantification. Future progress will be contingent upon a graduated blend of performance-based initiatives and traditional “see one, do one, teach one” approaches to medical education. Ideally, this blended approach will evolve over time and will be guided by outcomes-based research results and accelerated by advances in the science of learning and enabling technologies.
As performance-based educational solutions are integrated into educational curricula, stakeholders must achieve the correct balance between promoting the pursuit of excellence in respective disciplines and achieving discrete achievement milestones. Achieving this balance will need to be actively pursued on a case-by-case basis, further reinforcing the importance of collaboration between stakeholders. Specific research topics in the domain of competency-based ultrasound training include elucidation of ultrasound skill acquisition and degradation metrics that leverage the latest advances in ultrasound education technologies (e.g. simulator-based training). These recent advances hold promise as methods for rapidly advancing the ability to accurately assess ultrasound proficiency and provide targeted learner feedback.
Lastly, there is an important need to better understand ultrasound skill decay, accompanied by the need for refresher training on specific ultrasound-based assessment, diagnostic, and image-guided interventions. Defining the optimal and minimal refreshment intervals and their impacts is vital to future advancement.
The need for robust performance-based medical education solutions is becoming more acute. The momentum for these new solutions has arisen from permanent and irreversible changes to the US healthcare system and medical education. Recent technological advances have provided the tools to improve traditional education, training, and assessment processes. The rapid creation of scalable, high-quality education and training resources will require close collaboration between multiple academic and private industry stakeholders. Performance-based ultrasound training has the potential to serve as a template for future performance-based curricular advances within other areas in medical education.
About the Authors
Dr. Eric Savitsky is a Professor of Emergency Medicine at the University of California at Los Angeles (UCLA) and is the inventor of the SonoSimulator®.
Dan Katz, MD is an Emergency Medicine physician at Cedars-Sinai Medical Center in Los Angeles, CA and is Vice-President of Business Development at SonoSim.
Institute of Medicine of the National Academies. Graduate medical education that meets the nation’s health needs. Available at http://www.iom.edu/Reports/2014/Graduate-Medical-Education-That-Meets-the-Nations-Health-Needs.aspx. Accessed November 15, 2014.
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Kobal SL, Trento L, Baharami S, et al. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol. 2005; 96(7):1002-1006.
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Peck TC, Dubosh N, Rosen D, et al. Emergency Physicians Report Performing Well On Most Emergency Medicine Milestones. J Emerg Med 2014;47(4):432-440.
Quattromani E, Powell ES, Khare RK, et al. Hospital-reported data on the pneumonia quality measure “time to first antibiotic dose” is not associated with inpatient mortality: results of a nationwide cross-sectional analysis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2011;18(5):496-503.