Ask The Expert: Optic Nerve Sheath Diameter and Intracranial Pressure

In 2001, the Accreditation Council for Graduate Medical Education (ACGME) mandated that all emergency medicine (EM) residents be competent in emergency ultrasound (EUS). In 2012, the Emergency Medicine Milestone project, cosponsored by the ACGME and the American Board of Emergency Medicine, made EUS an official milestone to be measured in each resident. To ensure residents meet this criteria, EUS curricula need to accomplish the following three tasks: to teach content knowledge and psychomotor skills, to give feedback, and to assess for competency. We describe common approaches to these three curricular components with suggestions on how a program can improve on the methods they already use. We also describe some less common educational interventions that may be worth considering.

There are multiple ways for a program to accomplish the first task of teaching content knowledge and psychomotor skills. The initial step before giving residents assignments, quizzes, or textbooks is to work backwards and ask, “What is the body of knowledge that I want residents to master? What are my educational objectives?” Listing these objectives in a detailed syllabus will help you choose the combinations of online videos, quizzes, simulation teaching, and other learning methods that will best suit your program. These objectives may be slightly different for each ultrasound (US) division. For example, a residency where fewer first trimester transvaginal pelvic studies are performed in the emergency department (ED) may want to dedicate more simulation sessions on a pelvic model trainer. Making this syllabus available to residents is also important, as it describes the body of knowledge that they are responsible for and also allows them to better customize their independent learning.

For programs with fewer fellowship-trained ultrasound division members, teaching both content knowledge during quality assurance (QA), and psychomotor skills during scanning shifts can be a challenge. The time needed to perform other administrative duties like QA reviews of archived scans performed in the ED or billing for scans may compete with dedicated time for teaching residents. It may also be difficult for US faculty to personally staff a majority of scan shifts without adequate protected time from clinical duties.

To maximize the effectiveness of teaching US scanning techniques, programs with limited ability to be present with a trainee in real time at the bedside can set aside dedicated time on simulators or models to teach more technically challenging applications such as endocavitary scans or US-guided peripheral IVs. This will ensure that trainees are provided with real-time teaching and feedback, especially if there is less supervision during scan shifts. In addition, a worthwhile goal for all programs, and especially for smaller US divisions, would be to ensure sufficient US training for the entire attending staff in the use of basic ultrasound applications. When residents work on shifts with EM attendings who are all comfortable with US, they will have more opportunities to perform US, practice their psychomotor skills, and learn to integrate US into the clinical care of patients. Instead of learning to perform and interpret US from a few US faculty, they will be trained by all the faculty members. Devoting dedicated US training to an entire ED will require time and support from the leadership of the ED, but will pay off for resident learning.

To maximize the learning environment for teaching during QA, asking residents to complete assignments prior to their EUS rotation can make even a smaller division’s teaching time more effective. Through a flipped classroom model, residents who are introduced to material prior to the rotation may be more engaged during QA, and discussion about the material can be more in-depth and memorable. Content assignments can include online videos and websites, web-based quizzes, and textbooks. A good place to start is by assigning residents your own curated list of resources that address the learning goals of your syllabus and then listing any other resources as extra options for residents to learn from. In addition, providing a variety of learning resources (e.g. quizzes, videos, paper texts) allows residents of different learning styles to choose the resource that best fits them.

Other ideas for teaching content are to take advantage of both small and large group teaching. The basis of smaller, “one-on-one” level specific teaching is that the pace of learning is not one-size-fits-all. When an entire group of learners of different levels goes through images during QA, discussions about content may be too fast for a novice or too slow for an advanced learner, both of which can result in learner disengagement. However, when one faculty member teaches to one level, content can be taught at a pace that best fits the knowledge level of the residents. For example, a faculty member may spend an hour reviewing normal and abnormal images with all the second-year residents on the rotation separately from all the other learners. This smaller group teaching method can be complemented by a larger group lecture series. Sometimes, educators may find it hard to fit in the teaching of more advanced topics due to time constraints of the EUS rotation. A monthly longitudinal lecture series during resident conferences can cover advanced topics not normally taught during the EUS rotation. They are also great opportunities for ultrasound fellows and senior residents to lecture on topics of interest.

The second curricular task of providing constructive resident feedback is best performed by using objective evaluations and is therefore linked to the third task of assessment of competency. After an objective assessment, specific feedback is given, and then the resident practices deliberately with that feedback and undergoes a repeat assessment to evaluate for improvement. Psychomotor skills can be assessed through an objective structured clinical exam (OSCE) or a standardized direct observation tool (SDOT) and content knowledge can be assessed through a written examination. The advantage of testing each separately is that you will be able to identify residents that may be excellent in one and have deficiencies in the other. This makes it much easier to decide on the type of extra support and resources a resident will need.

As with most feedback, the more specific it is, the more effective it will be. However, your feedback can only be as good as your assessment tool. Does your SDOT identify residents who have poor image optimization skills? Does your written exam identify residents who may inappropriately use ultrasound to rule out aortic dissection? If your assessment tool is comprehensive enough, you will be better able to identify specific deficiencies and give appropriate feedback. This feedback can be in the form of real-time feedback after the SDOT, assigning further assigned readings or videos, or extra teaching or scanning sessions.

Finally, a summative evaluation performed at regular intervals can help a program monitor each resident’s progress and assess for competency at graduation. With regular evaluation, weaknesses can be discovered earlier, and a learning plan can be constructed for each resident so that there is enough time to address all deficiencies. This is preferable to discovering knowledge gaps near the end of residency. In addition, it is extremely important to highlight residents’ strengths and enthusiasm in each evaluation. EUS is an exciting field and encouraging specific interests and passion within residents is essential in promoting an ultrasound supportive culture within an ED as well as developing future leaders in US education and research.

It is a privilege to teach EUS to residents, knowing that our impact will extend beyond the borders of our EDs to patients our residents will care for after they graduate. Our hope is that some of these suggestions may be helpful to EUS programs, as the continuous improvement in our EUS curriculum will be important to meet the growing use of ultrasound in patient care and will ensure that EM continues to be in the forefront of point-of-care ultrasound education.

Judy Lin, MD
Simran Buttar, MD;
Lawrence Haines, MD, MPH
Maimonides Medical Center