Introduction
In the last two decades, our lives have changed more rapidly than ever before as a result of technical developments. Many aspects of our lives have already been “digitally transformed” and we take advantage of the resulting opportunities as a matter of course. Virtual conferences, digital apartment tours, data storage in the “cloud” and the omnipresent availability of global information on one’s own smartphone have permanently changed the way we deal with knowledge.
But what influence does digitalization have on ultrasound training? Have we already sufficiently exploited the possibilities of digital knowledge transfer in ultrasound teaching? The purpose of this editorial is to highlight the facets and possibilities of digital knowledge transfer in ultrasound and the associated demands on ultrasound professional societies.
In the last two years, the pandemic situation with related far-reaching contact restrictions has severely impacted traditional formats of medical education and training, thereby accelerating the development of digital instructional options. This has particularly challenged teaching staff and ultrasound course instructors to transform established classroom formats into hybrid and distance offerings in a short period of time using digital tools to ensure well-founded ultrasound education even in times of pandemic. This has resulted in a variety of digital formats, ranging from usual podcasts with a simple audio track to completely new, digital-driven hands-on teaching concepts. Examples include live demonstrations with camera-based visualization of transducer guidance [1 ] and, for students, the use of virtual reality formats with superimposition of images of anatomical structures on the patient’s body [2 ]. These digital productions, some of which are complex, have shown both the presenters and course participants the advantages as well as the technical challenges of the new digital material.
One key feature of these digital training formats stands out in particular: unlike in-person formats, a broad audience can be addressed, so that previously small seminar-sized presentations can now quickly reach hundreds of listeners in virtual conference rooms.
Which digital knowledge offerings in ultrasound are currently available, and how can high-quality digital training formats be integrated into existing course systems?
Overview of Digital Training Formats
Analogous to the variety of standard ultrasound textbooks designed for both beginners and ultrasound experts ranging from didactically elaborately designed course books to comprehensive monographs, digital offerings are likewise available in manifold diversity and quality. At the beginning of digitization, the presentations were mostly limited to embedding simple QR codes in existing ultrasound textbooks or enclosing data media with digital image material [3 ]
[4 ]
[5 ]. This made it possible to supplement the usual static images with more meaningful video clips and thus better meet the requirements of a dynamic investigation method. A further boost to development has been the ubiquitous availability of modern display systems with large data storage thus providing the possibility of making extensive reference works accessible to a large audience with the integration of efficient full-text search algorithms [6 ]
[7 ]
[8 ]. In recent years exclusively digitally-available knowledge databases, some of which are also textbook-like in character, have also become increasingly popular in addition to a mostly identical hybrid use of classic textbooks in both digital and analog form [7 ]
[8 ]. Now, in times of increasing workload compression in clinical practice, specialists have rapid access to medical knowledge. Two points are essential for the quality of these knowledge portals: (i) Experts in ultrasound diagnostic should be involved in the development and supervision, if possible with peer review procedures. (ii) Professional support by graphic designers and IT specialists is a prerequisite for embedding complex multimedia content and thus making full use of the opportunities offered by digital knowledge transfer. The SARS Cov-2 pandemic created a great need for, and interest in, rapid communication of new diagnostic findings. For example, numerous studies have been performed on the use of chest ultrasound in Covid-19-positive patients, thus resulting in part in extensive pulmonary ultrasound protocols [9 ]. Access to these protocols was quickly achieved via the DEGUM homepage [10 ] and was integrated into existing online textbooks immediately after publication, thus making them available to a wide audience [11 ]
[12 ].
Rapid access to ultrasound pathologies is provided by digital ultrasound image and video collections [13 ]
[14 ]
[15 ]
[16 ]
[17 ] initiated and continuously updated by clinically active ultrasound specialists. These non-commercial and freely available ultrasound atlases are suitable for classifying one’s own ultrasound findings in everyday clinical practice as well as for ultrasound training. In addition, educational platforms are being developed in sonography covering most clinically-relevant topics from musculoskeletal sonography and emergency ultrasound to echocardiography and vascular ultrasound, and whose target groups include some non-physician professional groups (e. g., physician assistants). Some platforms are provided by the manufacturers of modern and compact handheld devices [18 ]. Complex examination steps are taught in a simple, easy-to-understand manner through elaborate multimedia tutorials. Experts in their respective fields from all over the world are often requested for this purpose, and the presentations are recorded in English [19 ]
[20 ]. However, commercial platforms usually only contain image material pertaining to their own ultrasound devices and their related ultrasound procedures, and are therefore not manufacturer-independent. Especially for the education of students, there are a variety of tutorials, often designed by individual ultrasound initiatives initially intended for smaller groups (local universities, ultrasound courses) and then redistributed via websites, YouTube or similar multimedia channels [18 ]. This often involves elaborately created content that is also used by young postgraduate assistants. In addition, complete courses are now also available in digital formats as material independent of time and place [11 ]
[21 ]. However, these course concepts are usually not certifiable by professional societies and do not include practical exercise components under individual supervision. It is therefore debatable to what extent such material can contribute to structured and professionally qualified ultrasound instruction. To compensate for the lack of hands-on experience, some of these online courses are now supplemented by local live events in small groups [22 ]
[23 ]. Likewise, “practical” training on the local computer is conceivable in the future or currently provided by simulator-based applications, which are often smartphone-based [24 ]. Continuing education and training in ultrasound diagnostics are also provided through international scientific conferences or as part of development advancement initiatives. Likewise, digitally-supported meeting and training culture are valuable in such instances. In addition, considerable time, financial as well as ecological resources can be saved. In development aid in particular, this can provide continuous and sustained support and supervision [25 ]. Telemedical care, especially for training purposes, can also open up exciting new perspectives [26 ]
[27 ].
Despite all the positive efforts towards digital ultrasound training, the absolutely necessary practice-oriented training component remains a dilemma. To date, there are limitations to virtual structured learning of practical processes and handling of the transducer as well as the direct supervision and interaction by an experienced trainer. The current certification requirements of the ultrasound specialist societies justifiably demand a high proportion of practical instruction in small groups, taught by qualified instructors. The integration of practical knowledge transfer into digital teaching formats must therefore be considered from the outset. This is the only way to enable the urgently needed certification of digital course offerings by ultrasound specialist societies in order to continue to meet future high quality standards. Concepts have therefore been tested in recent years in order to also be able to offer practical skills in the “virtual world”. Proposals and offerings range from smartphone-based ultrasound simulations [28 ]
[29 ] to low-cost technical options with a training transducer that can be connected to a computer for practicing device handling [30 ] to elaborate simulators that even allow superimposition of anatomic guidance structures on digital ultrasound volumes based on virtual-reality applications [2 ]
[31 ].
Proposal for the Integration of Digital Teaching Content in Ultrasound Education and Training
There is a great variety of digital products, and their availability increases almost daily. [Fig. 1 ] provides overview of various concepts. Up to now, there has been no central registration of the formats, e. g., by ultrasound professional societies, as has been common practice for DEGUM-certified classroom-based courses. It should be the task of the ultrasound associations to classify these various digital ultrasound training courses and to define standards for quality and content based on the established certification system for in-person courses [32 ]. Clinical sonography is an intellectually challenging combination of theoretical knowledge with established practical skills and clinical reasoning in direct interaction with the patient. The required skills can be taught by means of well-structured ultrasound courses. Neither exclusively digital teaching materials nor a series of in-person lectures meet this need. Instead, a combination of different teaching concepts is necessary, which should be adapted to the respective knowledge level of the participants. For beginners, the focus is on acquiring practical skills, whereas for specialists, a concentration on complex pathologies and their differential diagnosis is relevant. [Fig. 2 ] provides suggestions and talking points on integrating digital content into sonographic education and training. Different content and skills must be taught depending on the level of knowledge and training. Theoretical content in particular can be conveyed in digital form before the start of the live event and, for example, reviewed online in the form of a syllabus before the course begins.
Fig. 1 Exemplary overview of digital training formats in ultrasound. Source: 123Sonography GmbH; Amboss GmbH; Deepscope; © 2022 Scanbooster UG (haftungsbeschränkt), www.scanbooster.com – Scanbooster® is a registered trademark in Germany; Used with permission. Copyright 2022 SonoSim, Inc; Ultraschall-Klinikum Erlangen; Sonokurs Gießen; Dr. med. Valentin Blank.
Fig. 2 Proposal for the integration of digital content in ultrasound education and training. Orange = theoretical basics (digital); green = practical exercises (classroom format/supervision); blue = review of practical competence (classroom format). IUS = interventional ultrasound; CEUS = contrast enhanced ultrasound.
Summary
The demand for structured ultrasound training continues to be very high and currently well exceeds the availability of classroom courses. The Covid pandemic has exacerbated the situation due to the reduced number of course offerings. Class availability can be expanded by supplementary digital formats and offered to a greater number of participants. However, professional societies must evaluate and certify this content in order to ensure consistently high quality of structured education and training. A discussion on the integration of existing online offerings by DEGUM and the development of certified course formats are urgently needed.
