Simulation-based education in ultrasound – diagnostic and interventional abdominal focus

Abstract

Simulation-based training (SBT) is increasingly acknowledged worldwide and has become a popular tool for ultrasound education. Ultrasound simulation involves the use of technology and software to create a virtual training setting. Simulation-based training allows healthcare professionals to learn, practice, and improve their ultrasound imaging skills in a safe learning-based environment. SBT can provide a realistic and focused learning experience that creates a deep and immersive understanding of the complexity of ultrasound, including enhancing knowledge and confidence in specific areas of interest. Abdominal ultrasound simulation is a tool to increase patient safety and can be a cost-efficient training method. In this paper, we provide an overview of various types of abdominal ultrasound simulators, and the benefits, and challenges of SBT. We also provide examples of how to develop SBT programs and learning strategies including mastery learning. In conclusion, the growing demand for medical imaging increases the need for healthcare professionals to start using ultrasound simulators in order to keep up with the rising standards.

Keywords

simulation - continuing medical education - clinical training - ultrasound

Introduction

The use of simulation-based training (SBT) in ultrasound has become increasingly popular in recent years. It is an effective tool for healthcare professionals and students to learn ultrasound technology and diagnostic and/or interventional techniques. It provides a safe, stress-reduced, controlled environment for learning and practicing various ultrasound procedures [1] [2] [3] [4]. The effect of using simulation based training has been well-documented [5] with several studies demonstrating the sustained effect in clinical performance [6] [7] [8] [9] [10] [11] [12]. Research indicates that simulation-based training improves performance [1] [13] [14] [15] and is regarded as a useful complement to learning and developing skills [16]. In medical departments with a high number of learners, simulation-based training also has the potential to reduce the pressure from daily clinical supervised training. SBT in ultrasound can provide basic skills and competences, giving learners a more advanced level of proficiency when starting clinical training.

Ultrasound simulation covers a broad range of opportunities and is currently available for educational support in many clinical skill laboratories in university hospitals [17]. SBT can be used for all levels of healthcare education [2] [18] allowing healthcare professionals to gain confidence and most importantly achieve basic skills and competences prior to performing procedures on patients [19] [20]. Ultrasound simulation serves as an adjunct to the traditional educational approach of “see one – do one, teach one” [21]. This apprenticeship training is a widely used method to learn new skills and usually involves a learner working alongside an experienced educator. This is an effective method but can be compromised by a lack of basic skills or knowledge in learners or if clinical training is rushed by busy clinical schedules or limited time. Apprenticeship training and ultrasound simulation are two valuable approaches and by combining these two, clinical skills laboratories can provide a comprehensive training program. For inspiration and knowledge about specific simulators, Østergaard et al. compare the four most used abdominal simulators [1].

A structured simulation-based curriculum ensures that all learners achieve the same basic knowledge, skills, and competencies. Finally, it is crucial that simulation-based training ends with evaluation of competencies using assessment instruments with validity evidence.

Simulation in abdominal ultrasound

Abdominal ultrasound simulators are widely used and can provide information about abdominal anatomy, pathology, organs, diagnostic education, knobology, transducer placement, and training in interventional procedures such as catheter placements, needle biopsy, and invasive procedures ([Fig. 1]).

Fig. 1 Abdominal ultrasound simulators.

A simulator offers unlimited time for practice and includes time to study, reflect, or find additional information that learners may need to supplement their learning outcomes. It is a major advantage that simulators allow learners to make mistakes without any real consequences [22] or harm to patients. Furthermore, learners can study at their own pace and have the freedom to ask questions and make mistakes without being judged [22]. Textbox 1 shows the considerations when starting an SBT course.

Available abdominal ultrasound simulators

The choice of simulator model depends on a combination of existing curricula and the learners’ requirements, resources, and course learning objectives. Some types are better suited for group learning, while others may involve isolated learning and practice [23] [24] [25]. An overview is presented in [Table 1]. It is important to recognize that simulators have a broad range of fidelity and usability variations [2] meaning that one type of model may not be suitable for all. We focus on two main types (simple physical phantoms and computer-based), each with their own advantages and limitations.

Table 1 Available types of ultrasound simulators.

Types of ultrasound simulators	Real ultrasound machines and phantoms
	PC, tablet, or phones
	Virtual simulators/virtual reality
	Augmented reality
	Mock scanners/transducers
	Animal models

Simple physical phantom ultrasound simulation

Physical ultrasound phantoms [26] [27] [28] are a common type of phantom and are designed to reflect human tissue. These phantoms may contain anatomical components like blood vessels and organs, with some models simulating pathologies, for example, a tumor and/or cysts. They are also useful for demonstrating anatomy and/or pathology.

Physical phantoms are obtainable in different sizes, shapes, and complexity depending on their intended use. Phantoms with a high complexity level will typically be custom-made for a specific purpose and can be expensive to purchase. However, physical ultrasound phantoms may be limited in their ability to simulate physiological motion. Ultrasound phantoms have a limited number of pathologies and are therefore often used for point-of-care ultrasound (POCUS) training, as they focus on specific pathologies. [Fig. 2] shows a training simulation situation on an abdominal simulator, while [Fig. 3] shows an example of an ultrasound simulation setup.

Fig. 2 Example of a training simulation situation.

Fig. 3 Simulation setup examples.

Computed-based ultrasound simulators

Computer-based ultrasound simulators are software programs that simulate the ultrasound imaging process by generating ultrasound images based on user input such as imaging process and acquisition [29]. Computer-based simulation will typically be based on virtual patients and the ultrasound images are generated based on the learner’s input from transducer movement, pressure, and angle. Some computer-based simulators have incorporated feedback. One drawback is the lack of physical simulation compared to physical phantoms, e. g., learners will not experience how breathing or coughing affects image quality, what amount of gel is appropriate to apply to the probe, and how to avoid and interpret imaging artifacts.

Computed-based ultrasound simulators may include online interactive models or applications (apps), virtual reality, tablets, phones, keyboard, and mouse, mock scanners, multiple choice tests and games [19] [30].

Hybrid virtual reality simulators are widely used and are a combination of physical and computer-based simulation [2] [3]. They combine the software program with a mannequin, e. g., using a magnetic field for synchronizing the hand movement to generate the corresponding ultrasound image. Virtual reality offers a realistic simulation environment, where learners can practice the scan procedure, image interpretation, and patient collaboration. Some virtual reality systems have incorporated instant feedback to learners, e. g., transducer angulation or pressure. An advantage of both the computer-based and the hybrid ultrasound simulators is that they often have a larger case curriculum including anatomy and various pathologies [2]. Textbox 2 provides key points for setting up an SBT course.

Development of a simulation-based program in abdominal ultrasound

Effective training is a challenge and requires careful planning, preparation, and systematic implementation [31]. To develop effective simulation-based training programs for abdominal ultrasound simulation, we propose following a structured approach such as the 6-step curriculum development model by Kern et al. [32]. We modified this model based on previous educational papers [16], providing a step-by-step guide that will help educators to develop an ultrasound simulation-based program in 6 steps.

Step 1: Perform a general needs assessment.

The needs assessment process is essential for identifying the training needs of your learners, which in return, helps you to develop a tailored simulation-based curriculum. This approach ensures that the training program effectively caters to the specific needs of the learners.

Step 2: Identifying your target group and setting (targeted needs assessment).

Develop your simulation-based training programs based on who your learners are and what level they are at.

Step 3: Identify learning goals and objectives and how to measure learning outcomes.

Determine what you want to achieve with the simulation-training program, for example, to learn basic ultrasound knobology, improve technical imaging skills, or to learn how to identify pathologies. Plan how to measure that the learning goals are met. Assessment instruments with validity evidence are recommended and are available for some of the ultrasound procedures [16] [33].

Step 4: Determine the appropriate type of simulator and educational strategies.

Many ultrasound simulators are available commercially and each type has pros and cons. It is important to find one that meets your learning goals and objectives. The curriculum could include a combination of educational and hands-on training sessions that focus on specific tasks, skills, procedures, and levels.

Step 5: Implementation of the program.

Implement the program following a structured approach. Careful planning of the implementation process is key to a successful training program. Involve relevant stakeholders when planning for implementation to increase buy-in and penetration. Ensure that the resources needed to run the simulation program are identified, e. g., hiring and training faculty members.

Step 6: Evaluate the program continuously.

Evaluate the effectiveness of the training program and make ongoing adjustments. Listen to feedback provided by educators and learners.

Simulation-based assessment

Simulation provides a safe environment, not only for training but also for assessment. Simulation-based assessment offers an alternative to more traditional clinical tests, such as objective structured clinical examination (OSCE) or direct observational of procedural skills (DOPS). During an OSCE, learners are given a series of stations to complete, each with a defined task related to a particular skill, and subsequently with performance assessment. DOPS requires continuous supervision of learners including a feedback loop on performance. Simulation-based assessment can provide assurance that learners have obtained basic competencies within the given curriculum and are ready to progress to next level. Overall, ultrasound simulation assessment provides an efficient, targeted, and safe method for skill evaluation.

Mastery learning

Assessment of skills can vary between theoretical, practical, and a combination of the two.

Simulation-based training and tests can be a way of implementing mastery learning where the educational goal is a preset skill level [34] [35].

The method lets learners use variable time, learning patterns, and scanning volumes in pursuit of the preset skill-level. This is assured by a final validated test. Mastery learning could complement, and possibly relieve, the educational skill measurements of time or “number of scans”, as these measurements do not necessarily correlate well with actual competency levels [36]. A simulation-based test is also suitable for continued measurement, which is useful to spot poor performers or educational stagnation.

In combination with academic and clinical knowledge assessments, the educator can evaluate the learners’ skills. It is important that the test can assess participants and divide them into categories, e. g., novice, intermediates, and expert level [37]. Assessment can include MCQ including knowledge of sonoanatomic structures, technical knowledge, and pathology knowledge [37] and may include a pass/fail score [37] [38]. Individual feedback or a checklist may also be an integrated part of the assessment. [Fig. 4] shows an illustration of a learning curve.

Fig. 4 Example of a learning curve.

Benefits and challenges of abdominal simulation

Ultrasound simulation offer a range of benefits and challenges for medical professionals. An example of a benefit is the “as low as reasonably achievable (ALARA) principle”, and SBT offers a method where learners don’t need to take this into account. With a tailored simulation-based training program, learners have the opportunity to fully immerse themselves, resulting in an effective learning outcome and experience. Learning requires devotion and dedication, this is also true for SBT which can be hindered by, e. g., limited time, expiration of a software license, or limited access to the simulator. Furthermore, there is always a risk of skills diminishing over time [39], and learners who receive SBT typically obtain higher assessment scores [6] [40], highlighting the invaluable role of ultrasound simulation. However, knowledge on maintaining required skills is not uniform and more research is needed [41]. While the benefits are clear, maintaining the simulator system and educators’ competencies requires ongoing resources and focus. [Table 2] provides an overview of the benefits and challenges of abdominal ultrasound simulation training [42] [43]. Textbox 3 provides an example of an SBT course.

Table 2 Overview of benefits and challenges setting up a simulation-based training course.

Benefits	Challenges
Independently available	System maintenance
Some simulators can provide individual feedback	None or limited clinical access to patients
Supervisor-independent	Lack of personal supervision
Patient safety	No direct translation into clinical practice
Can be used as a refreshing element	Skills and knowledge decrease if simulation training is not immediately continued
Accessible to all levels of healthcare professionals	Limited resemblance to everyday life in the clinic
Reduces anxiety and promotes self-efficacy	Difficult to understand how much pressure is needed during ultrasound abdominal examination
Improves knobology, skills, and competences	Difficult to choose the best simulation system
Improves hand-eye coordination	Can be difficult to master and requires allocation of time
Highly appreciated and motional educational tool	Costly to buy and implement (cost/benefit)
Allows standardized ultrasound exams, evaluation, and testing	Limited real-life communication training
Individually tailored learning strategies, e. g., time	The acquired skills have to be practiced with real ultrasound machines afterwards

Future perspectives

Technology development in ultrasound simulation systems may lead to more realistic simulation allowing better education, by providing an immersive and interactive training environment. In time, abdominal ultrasound simulation will likely become a more accessible tool in smaller clinics and hospitals due to lower prices and increasing demand. Abdominal ultrasound is already a widely used and important tool in telemedicine and simulation may play a future role in telemedicine, helping remote medical professionals gain the necessary skills and experience to provide quality ultrasound examinations. Real-time feedback and assessment could be integrated into the simulation allowing learners to monitor their progress and identify their training needs/knowledge gaps.

Conclusion

The potential of ultrasound simulation is vast and will likely increase in the future. Abdominal ultrasound simulation systems have great potential with respect to improving the skills of medical professionals, avoiding risks, increasing patient safety, providing instant feedback, building up confidence, and providing opportunities to test new equipment and techniques. In light of the increasing demand for medical imaging, it is vital that healthcare professionals have the required skills and experience. Abdominal ultrasound simulation will continue to play an important role, with possibilities to simulate complex imaging techniques and to keep focus on the improvement of learner’s skill.

Conflict of Interest

Declaration of financial interests

Receipt of research funding: no; receipt of payment/financial advantage for providing services as a lecturer: no; paid consultant/internal trainer/salaried employee: no; patent/business interest/shares (author/partner, spouse, children) in company: no; patent/business interest/shares (author/partner, spouse, children) in sponsor of this CME article or in company whose interests are affected by the CME article: no.

Declaration of non-financial interests

The authors declare that they have no conflict of interest.

• Literatur

• 1 Østergaard ML, Nielsen KR, Albrecht-Beste E. et al. Simulator training improves ultrasound scanning performance on patients: a randomized controlled trial. Eur Radiol 2019; 6: 3210-3218
• 2 Østergaard ML, Konge L, Kahr N. et al. Four Virtual-Reality Simulators for Diagnostic Abdominal Ultrasound Training in Radiology. Diagnostics (Basel) 2019; 9
• 3 Konge L, Albrecht-Beste E, Nielsen MB. Virtual-reality simulation-based training in ultrasound. Ultraschall in Med 2014; 35: 95-97
• 4 Nayahangan LJ, Dietrich CF, Nielsen MB. Simulation-based training in ultrasound – where are we now?. Ultraschall in Med 2021; 42: 240-244
• 5 McGaghie WC, Issenberg SB, Petrusa ER. et al. A critical review of simulation-based medical education research: 2003-2009. Med Educ 2010; 44 (01) 50-63
• 6 Tolsgaard MG, Ringsted C, Dreisler E. et al. Sustained effect of simulation-based ultrasound training on clinical performance: a randomized trial. Ultrasound Obstet Gynecol 2015; 46: 312-318
• 7 Barsuk JH, Cohen ER, McGaghie WC. et al. Long-term retention of central venous catheter insertion skills after simulation-based mastery learning. Acad Med 2010; 85 (10) S9-S12
• 8 Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011; 364 (08) 749-757
• 9 Tolsgaard MG, Rasmussen MB, Tappert C. et al. Which factors are associated with trainees' confidence in performing obstetric and gynecological ultrasound examinations?. Ultrasound Obstet Gynecol 2014; 43: 444-451
• 10 Taksøe-Vester C, Dyre L, Schroll J. et al. Simulation-Based Ultrasound Training in Obstetrics and Gynecology: A Systematic Review and Meta-Analysis. Ultraschall in Med 2021; 42: e42-e54
• 11 Zhao Y, Zhou P, Zhu W. et al. Validity evidence for simulator-based obstetric ultrasound competency assessment tool: a multi-center study. Ultraschall in Med 2023; DOI: 10.1055/a-2122-6746.
• 12 Freundt P, Nourkami-Tutdibi N, Tutdibi E. et al. Controlled Prospective Study on the Use of Systematic Simulator-Based Training with a Virtual, Moving Fetus for Learning Second-Trimester Scan: FESIM III. Ultraschall in Med 2023; 4: e199-e205
• 13 Terkamp C, Kircher G, Wedemeyer J. et al. Simulations of abdomen sonography. Evaluation of a new ultrasound simulator. Ultraschall in Med 2003; 24: 239-244
• 14 Østergaard ML, Ewertsen C, Konge L. et al. Simulation-Based Abdominal Ultrasound Training – A Systematic Review. Ultraschall in Med 2016; 37: 253-261
• 15 Arya S, Mulla ZD, Kupesic Plavsic S. Role of pelvic ultrasound simulation. Clin Teach 2018; 15: 457-461
• 16 Østergaard ML, Nielsen KR, Albrecht-Beste E. et al. Development of a reliable simulation-based test for diagnostic abdominal ultrasound with a pass/fail standard usable for mastery learning. Eur Radiol 2018; 28: 51-57
• 17 Damewood SC, Lewiss RE, Huang JV. Ultrasound simulation utilization among point of care ultrasound users: Results of a survey. J Clin Ultrasound 2018; 46: 571-574
• 18 Clark AE, Shaw CJ, Bello F. et al. Quantitating skill acquisition with optical ultrasound simulation. Australas J Ultrasound Med 2020; 23: 183-193
• 19 Alexander LF, McComb BL, Bowman AW. et al. Ultrasound Simulation Training for Radiology Residents-Curriculum Design and Implementation. J Ultrasound Med 2022; 42
• 20 Brown SD, Callahan MJ, Browning DM. et al. Radiology trainees' comfort with difficult conversations and attitudes about error disclosure: effect of a communication skills workshop. J Am Coll Radiol 2014; 11: 781-787
• 21 Canty D, Barth J, Yang Y. et al. Comparison of learning outcomes for teaching focused cardiac ultrasound to physicians: A supervised human model course versus an eLearning guided self- directed simulator course. J Crit Care 2019; 49: 38-44
• 22 Dyre L, Tabor A, Ringsted C. et al. Imperfect practice makes perfect: error management training improves transfer of learning. Med Educ 2017; 51: 196-206
• 23 Bjerrum F, Sorensen JL, Konge L. et al. Randomized trial to examine procedure-to-procedure transfer in laparoscopic simulator training. Br J Surg 2016; 103: 44-50
• 24 Thomsen ASS, Kiilgaard JF, la Cour M. et al. Is there inter-procedural transfer of skills in intraocular surgery? A randomized controlled trial. Acta Ophthalmol 2017; 95: 845-851
• 25 Pietersen PI, Jorgensen R, Graumann O. et al. Training Thoracic Ultrasound Skills: A Randomized Controlled Trial of Simulation-Based Training versus Training on Healthy Volunteers. Respiration 2021; 100: 34-43
• 26 Rathbun KM, Brader WT, Norbury JW. A Simple, Realistic, Inexpensive Nerve Phantom. J Ultrasound Med 2019; 38 (08) 2203-2207
• 27 Surana P, Narayanan MK, Parikh DA. et al. A simple, low-cost, customisable ultrasound gel-based phantom. Anaesth Crit Care Pain Med 2020; 39 (06) 888-890
• 28 Schwartz CM, Ivancic RJ, McDermott SM. et al. Designing a Low-Cost Thyroid Ultrasound Phantom for Medical Student Education. Ultrasound Med Biol 2020; 46 (06) 1545-1550
• 29 Blum T, Rieger A, Navab N. et al. A review of computer-based simulators for ultrasound training. Simul Healthc 2013; 8 (02) 98-108
• 30 Dietrich CF, Lucius C, Nielsen MB. et al. The ultrasound use of simulators, current view, and perspectives: Requirements and technical aspects (WFUMB state of the art paper). Endosc Ultrasound 2023; 12: 38-49
• 31 Khamis NN, Satava RM, Alnassar SA. et al. A stepwise model for simulation-based curriculum development for clinical skills, a modification of the six-step approach. Surg Endosc 2016; 30: 279-287
• 32 Thomas PA, Kern DE, Hughes MT. et al. Curriculum development for medical education: A six-step approach. 2015: 1-300
• 33 Rasmussen NK, Nayahangan LJ, Carlsen J. et al. Evaluation of competence in ultrasound-guided procedures-a generic assessment tool developed through the Delphi method. Eur Radiol 2021; 31: 4203-4211
• 34 McGaghie WC. Mastery learning: it is time for medical education to join the 21st century. Acad Med 2015; 90: 1438-1441
• 35 Cook DA, Brydges R, Zendejas B. et al. Mastery learning for health professionals using technology-enhanced simulation: a systematic review and meta-analysis. Acad Med 2013; 88: 1178-1186
• 36 Barsuk JH, Cohen ER, Feinglass J. et al. Residents' Procedural Experience Does Not Ensure Competence: A Research Synthesis. J Grad Med Educ 2017; 9: 201-208
• 37 Pietersen PI, Konge L, Madsen KR. et al. Development of and Gathering Validity Evidence for a Theoretical Test in Thoracic Ultrasound. Respiration 2019; 98: 221-229
• 38 Jacobsen N, Larsen JD, Falster C. et al. Using Immersive Virtual Reality Simulation to Ensure Competence in Contrast-Enhanced Ultrasound. Ultrasound Med Biol 2022; 48: 912-923
• 39 Rowley KJ, Wheeler KM, Pruthi DK. et al. Development and implementation of competency-based assessment for urological ultrasound training using SonoSim: A preliminary evaluation. Indian J Urol 2020; 36: 270-275
• 40 Orr KE, Hamilton SC, Clarke R. et al. The integration of transabdominal ultrasound simulators into an ultrasound curriculum. Ultrasound 2019; 27: 20-30
• 41 Mackay FD, Zhou F, Lewis D. et al. Can You Teach Yourself Point-of-care Ultrasound to a Level of Clinical Competency? Evaluation of a Self-directed Simulation-based Training Program. Cureus 2018; 10: e3320
• 42 Lawaetz J, Soenens G, Eiberg J. et al. Facilitators and Barriers to Implementation of Simulation Based Education in Vascular Surgery in Europe. Eur J Vasc Endovasc Surg 2023; DOI: 10.1016/j.ejvs.2023.06.009.
• 43 Hosny SG, Johnston MJ, Pucher PH. et al. Barriers to the implementation and uptake of simulation-based training programs in general surgery: a multinational qualitative study. J Surg Res 2017; 220: 419-26.e2

Publication History

Received: 09 September 2023

Accepted after revision: 05 February 2024

Article published online:
21 March 2024