Simulation-Based Abdominal Ultrasound Training – A Systematic Review

Abstract

Purpose: The aim is to provide a complete overview of the different simulation-based training options for abdominal ultrasound and to explore the evidence of their effect.

Materials and Methods: This systematic review was performed according to the PRISMA guidelines and Medline, Embase, Web of Science, and the Cochrane Library was searched. Articles were divided into three categories based on study design (randomized controlled trials, before-and-after studies and descriptive studies) and assessed for level of evidence using the Oxford Centre for Evidence Based Medicine (OCEBM) system and for bias using the Cochrane Collaboration risk of bias assessment tool.

Results: Seventeen studies were included in the analysis: four randomized controlled trials, eight before-and-after studies with pre- and post-test evaluations, and five descriptive studies. No studies scored the highest level of evidence, and 14 had the lowest level. Bias was high for 11 studies, low for four, and unclear for two. No studies used a test with established evidence of validity or examined the correlation between obtained skills on the simulators and real-life clinical skills. Only one study used blinded assessors.

Conclusion: The included studies were heterogeneous in the choice of simulator, study design, participants, and outcome measures, and the level of evidence for effect was inadequate. In all studies simulation training was equally or more beneficial than other instructions or no instructions. Study designs had significant built-in bias and confounding issues; therefore, further research should be based on randomized controlled trials using tests with validity evidence and blinded assessors.

Zusammenfassung

Ziel: Das Ziel war es, einen vollständigen Überblick über die verschiedenen Möglichkeiten des Simulatortrainings in der Sonografie des Abdomens zu geben und dessen Leistungsfähigkeit zu untersuchen.

Material und Methoden: Dieser systematische Review wurde nach PRISMA-Leitlinien durchgeführt und sowohl Medline, Embase, „Web of Science“ und die Cochrane Bibliothek wurden hierfür durchsucht. Die Arbeiten wurden nach der Art der Studie in drei Kategorien eingeteilt (randomisierte kontrollierte Studien; Interventionsstudien und Beobachtungsstudien). Der Evidenzgrad wurde nach dem System des Centre for Evidence-based Medicine in Oxford (OCEBM) und die systematischen Fehler (Bias) wurden nach der Methode zur Bewertung des Bias-Risikos der Cochrane Collaboration bewertet.

Ergebnisse: Siebzehn Studien wurden in die Analyse eingeschlossen: Vier randomisierte kontrollierte Studien, acht Interventionsstudien mit Bewertung vor und nach der Intervention und fünf Beobachtungsstudien. Keine der Studien erreichte den höchsten Evidenzgrad, 14 hatten den niedrigsten Grad. Ein hoher Bias ergab sich für 11 Studien, vier hatten einen niedrigen Bias und zwei Studien hatten einen fraglichen Bias. Keine der Studien benutzte eine Methode mit etablierter Validität oder untersuchte, ob die an den Simulatoren erreichten Qualifikationen den klinischen Fähigkeiten in der Realität entsprachen. Nur eine Studie setzte verblindete Bewerter ein.

Schlussfolgerung: Die eingeschlossenen Studien waren heterogen bezüglich der Auswahl des Simulators, dem Studiendesign, den Teilnehmern und den Zielvorgaben; ebenso war der Evidenzgrad des Ergebnisses nicht ausreichend. In allen Studien war das Simulationstraining gleich oder etwas vorteilhafter als ein anderer Unterricht oder fehlende Anleitung. Die Studiendesigns hatten signifikante eingebaute systematische Fehler und Störfaktoren; deshalb sollte die weitere Forschung auf randomisierte kontrollierte Studien basieren unter Einsatz von Methoden mit Beweiskraft und verblindeten Bewertern.

Key words

ultrasound - education - abdomen - simulation

• References

• 1 European Federation of Societies for Ultrasound in Medicine and Biology. Minimum Training Requirements for the Practice of Medical Ultrasound in Europe. Springer; 2013: 401-407 Report No.:
• 2 Hertzberg BS, Kliewer MA, Bowie JD et al. Physician Training Requirements in Sonography. Am J Roentgenol 2000; 174: 1221-1227
• 3 European Society of Radiology ES of R. Organization and practice of radiological ultrasound in Europe: a survey by the ESR Working Group on Ultrasound. Insights Imaging 2013; 4: 401-407
• 4 European Federation of Societies for Ultrasound in Medicine and Biology. Guidelines & Recommendations full list. Online publication. 2015 http://www.efsumb.org/guidelines/guidelines01.asp
• 5 Education and Practical Standards Committee, European Federation of Societies for Ultrasound in Medicine and Biology. Minimum Training Recommendations for the Practice of Medical Ultrasound. Ultraschall in Med 2006; 27: 79-105
• 6 Garg M, Drolet BC, Tammaro D et al. Resident Duty Hours: A Survey of Internal Medicine Program Directors. J Gen Intern Med 2014; 29: 1349-1354
• 7 Sidhu HS, Olubaniyi BO, Bhatnagar G et al. Role of Simulation-Based Education in Ultrasound Practice Training. J Ultrasound Med 2012; 31: 785-791
• 8 Blum T, Rieger A, Navab N et al. A review of computer-based simulators for ultrasound training. Simul Healthc J 2013; 8: 98-108
• 9 Lewiss RE, Hoffmann B, Beaulieu Y et al. Point-of-Care Ultrasound Education The Increasing Role of Simulation and Multimedia Resources. J Ultrasound Med 2014; 33: 27-32
• 10 Macdougall L, Martin R, McCallum I et al. Simulation and Stress: Acceptable to Students and Not Confidence-busting. Clin Teach 2013; 10: 38-41
• 11 Hopper AN, Jamison MH, Lewis WG. Learning curves in surgical practice. Postgrad Med J 2007; 83: 777-779
• 12 Moher D, Liberati A, Tetzlaff J et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009; 339: b2535
• 13 OCEBM Levels of Evidence. Online publication. 2015 http://www.cebm.net/ocebm-levels-of-evidence/
• 14 Higgins JPT, Altman DG, Gøtzsche PC et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928
• 15 Damewood S, Jeanmonod D, Cadigan B. Comparison of a Multimedia Simulator to a Human Model for Teaching FAST Exam Image Interpretation and Image Acquisition. Acad Emerg Med 2011; 18: 413-419
• 16 Chung GKWK, Gyllenhammer RG, Baker EL et al. Effects of simulation-based practice on focused assessment with sonography for trauma (FAST) window identification, acquisition, and diagnosis. Mil Med 2013; 178: 87-97
• 17 Salen P, O’Connor R, Passarello B et al. Fast education: a comparison of teaching models for trauma sonography1. J Emerg Med 2001; 20: 421-425
• 18 Alba GA, Kelmenson DA, Noble VE et al. Faculty staff-guided versus self-guided ultrasound training for internal medicine residents. Med Educ 2013; 47: 1099-1108
• 19 Webb EM, Cotton JB, Kane K et al. Teaching Point of Care Ultrasound Skills in Medical School: Keeping Radiology in the Driver’s Seat. Acad Radiol 2014; 21: 893-901
• 20 Oxentenko AS, Ebbert JO, Ward LE et al. A Multidimensional Workshop Using Human Cadavers to Teach Bedside Procedures. Teach Learn Med 2003; 15: 127-130
• 21 Keddis MT, Cullen MW, Reed DA et al. Effectiveness of an ultrasound training module for internal medicine residents. BMC Med Educ 2011; 11: 75
• 22 Mendiratta-Lala M, Williams T, de Quadros N et al. The Use of a Simulation Center to Improve Resident Proficiency in Performing Ultrasound-Guided Procedures. Acad Radiol 2010; 17: 535-540
• 23 Sekiguchi H, Bhagra A, Gajic O et al. A general Critical Care Ultrasonography workshop: results of a novel Web-based learning program combined with simulation-based hands-on training. J Crit Care 2013; 28: 217.e7-217.e12
• 24 Yoo MC, Villegas L, Jones DB. Basic Ultrasound Curriculum for Medical Students: Validation of Content and Phantom. J Laparoendosc Adv Surg Tech 2004; 14: 374-379
• 25 Monsky WL, Levine D, Mehta TS et al. Using a sonographic simulator to assess residents before overnight call. Am J Roentgenol 2002; 178: 35-39
• 26 Knudson MM, Sisley AC. Training residents using simulation technology: experience with ultrasound for trauma. J Trauma 2000; 48: 659-665
• 27 Keddis MT, Cullen MW, Reed DA et al. Effectiveness of an Ultrasound Training Module for Internal Medicine Residents. BMC Med Educ 2011; 11: 75
• 28 Magee D, Zhu Y, Ratnalingam R et al. An augmented reality simulator for ultrasound guided needle placement training. Med Biol Eng Comput 2007; 45: 957-967
• 29 Tahmasebi AM, Hashtrudi-Zaad K, Thompson D et al. A Framework for the Design of a Novel Haptic-Based Medical Training Simulator. IEEE Trans Inf Technol Biomed 2008; 12: 658-666
• 30 Terkamp C, Kirchner G, Wedemeyer J et al. Simulation of Abdomen Sonography. Evaluation of a New Ultrasound Simulator. Ultraschall in Med 2003; 24: 239-244
• 31 Johnson WE, Estores D, Schocken D. Developing integrated active learning activities for first year medical school curriculum: enhancing learning of the basic sciences by including clinically relevant material. Faseb J 2013; 27
• 32 Rao S, van Holsbeeck L, Musial JL et al. A Pilot Study of Comprehensive Ultrasound Education at the Wayne State University School of Medicine A Pioneer Year Review. J Ultrasound Med 2008; 27: 745-749
• 33 Yarris LM, Gruppen LD, Hamstra SJ et al. Overcoming Barriers to Addressing Education Problems With Research Design: A Panel Discussion. Acad Emerg Med 2012; 19: 1344-1349
• 34 Norman G. Data dredging, salami-slicing, and other successful strategies to ensure rejection: twelve tips on how to not get your paper published. Adv Health Sci Educ 2014; 19: 1-5
• 35 Cook DA, Beckman TJ. Reflections on experimental research in medical education. Adv Health Sci Educ Theory Pract 2010; 15: 455-464
• 36 Downing SM, Yudkowsky R. Assessment in Health Professions Education. New York: Routledge; 2014
• 37 Fraenkel J, Wallen N, Hyun H. How to Design and Evaluate Research in Education. New York: McGraw-Hill Education; 2014
• 38 Konge L, Albrecht-Beste E, Nielsen MB. Virtual-reality Simulation-based Training in Ultrasound. Ultraschall in Med 2014; 35: 95-97
• 39 Konge L, Albrecht-Beste E, Bachmann Nielsen M. Ultrasound in Pre-Graduate Medical Education. Ultraschall in Med 2015; 36: 213-215
• 40 Sommer FG, Filly RA, Edmonds PD et al. A phantom for imaging biological fluids by ultrasound and CT scanning. Ultrasound Med Biol 1980; 6: 135-140
• 41 Norman G, Dore K, Grierson L. The minimal relationship between simulation fidelity and transfer of learning. Med Educ 2012; 46: 636-647
• 42 Ringsted C, Hodges B, Scherpbier A. “The research compass”: an introduction to research in medical education: AMEE Guide no. 56. Med Teach 2011; 33: 695-709
• 43 Hofer M, Kamper L, Sadlo M et al. Evaluation of an OSCE assessment tool for abdominal ultrasound courses. Ultraschall in Med Stuttg 2011; 32: 184-190
• 44 Miller GE. The assessment of clinical skills/competence/performance. Acad Med J Assoc Am Med Coll 1990; 65: 63-67
• 45 Dunning D, Heath C, Suls JM. Flawed Self-Assessment Implications for Health, Education, and the Workplace. Psychol Sci Public Interest 2004; 5: 69-106
• 46 Eva KW, Regehr G. Self-assessment in the health professions: a reformulation and research agenda. Acad Med J Assoc Am Med Coll 2005; 80: 46-54
• 47 Anderson MB. The Question of Competence: Reconsidering Medical Education in the Twenty-First Century. New York: 2014
• 48 Konge L, Annema J, Clementsen P et al. Using virtual-reality simulation to assess performance in endobronchial ultrasound. Respir Int Rev Thorac Dis 2013; 86: 59-65
• 49 McGaghie WC, Issenberg SB, Barsuk JH et al. A critical review of simulation-based mastery learning with translational outcomes. Med Educ 2014; 48: 375-385
• 50 Moak JH, Larese SR, Riordan JP et al. Training in transvaginal sonography using pelvic ultrasound simulators versus live models: a randomized controlled trial. Acad Med J Assoc Am Med Coll 2014; 89: 1063-1068
• 51 Konge L, Clementsen PF, Ringsted C et al. Simulator training for endobronchial ultrasound: a randomised controlled trial. Eur Respir J 2015; ERJ – 02352–2014