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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 1  |  Issue : 2  |  Page : 109-115

Echocardiography as an important tool for teaching and learning in the preclinical phase of the medical school curriculum


1 Department of Cardiology, University Hospital Sharjah, Sharjah, UAE
2 Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah, UAE
3 Basic Medical Sciences, College of Medicine, University of Sharjah, Sharjah, UAE; Department of Physiology, Michigan State University, East Lansing, Michigan, USA

Date of Submission23-Oct-2021
Date of Decision20-Feb-2022
Date of Acceptance21-Feb-2022
Date of Web Publication28-Mar-2022

Correspondence Address:
Adel B Elmoselhi
College of Medicine, University of Sharjah, Sharjah.
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/abhs.abhs_3_21

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  Abstract 

Background: A transformation in medical education is currently underway, prioritizing competency and clinical integration with basic sciences. This study explores the feasibility of the early echocardiography (Echo) experience as an adjunct tool for teaching heart anatomy and physiology to second-year medical students. Methods: The study was conducted on 99 students in a problem-based learning curriculum. Students were introduced to cardiac anatomy and physiology as well as to the basic principles of ultrasonography before the Echo sessions. A pretest was conducted at the beginning of the Echo theoretical session, consisting of 10 questions on Echo images. The practical sessions included hands-on experience on standardized patients with a checklist of commonly demonstrated structures in left parasternal and apical four-chamber windows. A posttest with the same questions was repeated after the clinical sessions. Results: The posttest outcome revealed a significant improvement in identifying the cardiac structures and function compared with the pretest (P-value ≤ 0.0001). Although the students were very accurate in identifying heart chambers and valves without assistance, the pulmonary artery and valve in the parasternal short axis were mainly able to be identified with assistance. Further, 92% of students admitted that prior basic knowledge is essential for Echo image identification, and 86% stated that integrating this experience helps consolidate different phases of the cardiac cycle. Conclusion: The Echo’s spatial orientation with prior basic knowledge seems to provide an effective tool in consolidating medical students’ understanding of heart anatomical relations and cardiac physiology.

Keywords: Echocardiography, hands-on experience, learning, medical curriculum, medical education, practical session, teaching


How to cite this article:
Shehata MS, Eladl MA, Alhuarrat MA, Elmoselhi AB. Echocardiography as an important tool for teaching and learning in the preclinical phase of the medical school curriculum. Adv Biomed Health Sci 2022;1:109-15

How to cite this URL:
Shehata MS, Eladl MA, Alhuarrat MA, Elmoselhi AB. Echocardiography as an important tool for teaching and learning in the preclinical phase of the medical school curriculum. Adv Biomed Health Sci [serial online] 2022 [cited 2022 Jun 30];1:109-15. Available from: https://www.abhsjournal.net/text.asp?2022/1/2/109/341179




  Background Top


The curricula in most medical schools worldwide are composed of two foundations to develop a doctor’s knowledge and skills: the basic and the clinical sciences.[1] There is, however, a significant variation in the implementation of these dual foundations. It is widely understood that an integrated approach results in a more effective learning experience for medical students. However, there is still a lack of consensus on how these two components should be integrated.[2],[3] There are two broad approaches to integration: one that introduces clinical knowledge early in the medical student’s training, which is thought to facilitate the student’s memorization and understanding of basic concepts; the other, which introduces basic knowledge in the student’s clinical years, called the “flipped curriculum,”[4] on the premise that this enables competence in the rapidly developing field of medical research as well as the reinforcement of clinical knowledge.

It is crucial to consider the two types of curriculum approaches as vertical integration of basic and clinical sciences. A further necessary integration is horizontal integration, the concurrent delivery of disciplines such as physiology, anatomy, and pathology.[5] The popular problem-based learning (PBL) medical curriculum is a prime example of vertical and horizontal integration that facilitates the spiral integration of knowledge development.[6]

Achieving a highly effective integration of the medical training syllabus presents various unique challenges.[5] In addition to the effort it takes to plan and prepare a comprehensive integration program, care must be taken to streamline the content to avoid repetition yet provide necessary reinforcements throughout the program. Examinations and assessments that test the capacity of reasoning based on acquired clinical and basic knowledge must be created. Further, an integrated syllabus requires a more demanding level of collaboration among faculty across the disciplines. Faculty training and development is an ongoing necessity and requires a level of adaptability and innovation that may be met with resistance among faculty who are asked to change their approaches for teaching and assessment. Altogether, the ideal balance between clinical and basic knowledge is a gold standard that requires constant evaluation and refinement across the spectrum of stakeholders.

In this article, we share our positive experience in implementing and integrating Echocardiography (Echo) in the second year of our medical curriculum to promote students’ better understanding of basic concepts of heart structure and functions. Conventional learning resources such as didactic lectures and textbooks supplemented by dissection or inspection of formalin-fixed human cadavers provide a three-dimensional (3D) context. However, clinical integration and deep understanding of some anatomical and physiological concepts require further visual–spatial thinking.[7] Thus, medical students should observe and then mentally maneuver these 3D structures, feats achievable within a dissecting room or didactic physiology lectures.[8] However, the diagnostic practice of Echo provides students with the opportunity to consider anatomy in a variety of planes; further, it enables them to understand the dynamic nature of both anatomical and physiological concepts. For example, Echo demonstrates the movement of the heart chambers and valves, which facilitates the teaching of cardiac cycle phases, integrating the structure and function of the heart in real life during its beating. Moreover, the color Doppler enables the students to recognize the blood flow, which allows for examining the opening and closing of the heart valves through the entire cardiac cycle.[9] Early in medical students’ training, the introduction of the Echo is a rich field of a range of learning outcomes.

This study aims at assessing the feasibility of the early introduction of Echo as an adjunct teaching tool in medical curricula for the anatomy and physiology of the heart and at analyzing students’ feedback post-implementation of this experience.


  Materials and methods Top


Study design and setting

The research was carried out at the College of Medicine (CoM) of the University of Sharjah (UoS) in the United Arab Emirates. The CoM’s MBBS is a five-year program, with three years’ preclinical and two years’ clinical rotations. The content of preclinical years is delivered through an integrated, PBL, student-centered, and organ-systems curriculum. The cardiovascular is mainly taught in year two in a five weeks’ unit and later on, in multiple clinical rotations in year four. A quasi-experimental pretest/ posttest study design was used with a self-assessment form as the test and an anonymous perception survey given to participants after the study ended. After the approval from the Research Ethics Committee of the University of Sharjah, the Echo students’ experiences were conducted in a large auditorium at the University of Sharjah Teaching Hospital. The pre- and posttests, hand-on experience, and data collection were performed by a senior cardiologist, an imaging technician, and the anatomy and physiology professors responsible for teaching relevant parts in the cardiovascular unit of the curriculum.

Sample

The study took place toward the end of a five-week cardiovascular unit for second-year medical students in Fall semester 2019–2020. The class comprised 99 students who were introduced to the gross anatomy of the heart and physiology of the cardiac cycle in both theoretical and practical sessions during the early weeks of the unit. In addition, in their previous year, the students had established some understanding of the principles of ultrasonography; however, they had not been exposed to Echo images.

Process and variables

The study started with a theoretical session about the principles of Echo and the interpretation skills of Echo by the clinical cardiologist. Before this session, the purpose of this study was explained to the students, and they were allowed to ask questions. Then, the students were exposed to a slideshow pretest in which they were asked to identify Echo images. These 10 labeled structures are commonly demonstrated in parasternal and apical windows, including the Color Flow (CF), to demonstrate the filling phase of the cardiac cycle [Figure 1]. The pretest was intended to explore how the students would use their previous anatomical and physiological knowledge to identify and understand the same structures when they appear on the 2-D Echo images without prior experience in Echo principles. The students were not given the answers to the questions at that point and were informed that the results of the tests would not be counted.
Figure 1: Pre- and posttests projected to the students before and after the hospital hands-on experience. It was presented on a PowerPoint program shown on a big screen in a stadium.

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The next day, the students were assigned in groups of 20 to go to Sharjah University Hospital, Cardiology Department to have a one-hour hands-on experience using the Echo machine on simulated patients. The students were supervised by a cardiologist, together with a physiologist and an anatomist who were familiar with the use of Echo and the interpretation of images. The students were briefed on the machine they were to use, the probes, and the image orientation. The CF was also explained to demonstrate the different phases of the cardiac cycle. Students then started their hands-on experience under the supervision of the staff [Figure 2].
Figure 2: Students’ hands-on experience for the echocardiography in the medical school.

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After the manual demonstration, the students filled out a self-assessment form in which they indicated how each of the checklist structures was manually identified [Table 1]. They had to choose one of the three options opposite to each structure: identified without assistance, identified with assistance, or not identified. The three main views under question were: the parasternal long axis, the parasternal short axis, and Apical S chamber views. The students then took a posttest to identify the Echo appearance of the checklist structures as they were shown on the same images of their pretest.
Table 1: Self-assessment form given to students after the manual demonstration with echocardiography.

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By the end of this session, the students were asked to voluntarily participate in an anonymous survey of their perception of the use of Echo in teaching the anatomy and physiology of the heart [Table 2]. Items in the students’ perception form corresponded to Likert-type rating scales to show the level of agreement or disagreement according to a five-point Likert scale.
Table 2: Questionnaire given to students at the end of the study.

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Statistical analysis

This study was conducted by using SPSS (Windows Version 23, SPSS Inc., Chicago, IL, USA). Our main test used to sort the data was the Paired t-Test, which was used to check whether there was any statistically significant difference between the two conditions in the study, pre- and posttest. In addition, frequencies taken from SPSS were plotted on Excel regarding the self-assessment test and survey questions to generate figures that represent the data in an accessible format. Students who were in both pre- and posttest are the only ones included in the t-test analysis.


  Results Top


Pre- and posttest analysis

Seventy-five students were subjected to the pretest, and ninety students were subjected to the posttest. Only the students who attended both tests (66) were considered in this part of the study.

The score range in the pretest was 0% to 80% (average score ± SD, 65% ± 17.5%), whereas the score range in the posttest was 40% to 80% (average score ± SD, 95% ± 10.3%). There was a significant correlation between the pretest and posttest results (P-value = 0.0001). These points were demonstrated as a mean knowledge score versus the two study groups, pre- and posttest [Figure 3].
Figure 3: The mean knowledge score (along with the standard deviation) for both pre- and posttest groups in the study.

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In the pretest, it is noted that the aortic valve and interventricular septum were commonly mistaken as the tricuspid valve (15 students, 22.7%) and the interatrial septum (17 students, 25.7%), respectively. There was no other specific pattern in the other wrong answers. In the posttest, most of the wrong answers were confined to the demonstration of the filling phase of the cardiac cycle. No specific pattern was found in the self-assessment checklist.

Survey answers

As for the questionnaire, answers for “Strongly Agree” and “Agree” were combined in one group and the other answers were combined in another group. A diagram plotting these answers is shown [Figure 4] to demonstrate how accepting of the idea of integration the students were and how it affected their view of basic knowledge, as 88% of students strongly agreed that the Echo had stimulated their interest in anatomical and physiological basic science concepts. Also, 86% of students agreed that the Echo experience was helpful in consolidating their understanding of anatomical relations and cardiac functions. Further, 92% of students found that prior anatomy and physiology knowledge is essential before having an integrated Echo session.
Figure 4: Diagram summarizing students’ answers in the survey at the end of the study regarding the whole experience.

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  Discussion Top


The ideal learning outcome for medical students using the PBL and TBL approaches in their curriculum is the balance between the vertical and horizontal integration.[10],[11] This study looked at how the vertical integration of Echo starting early on in the medical curriculum enhances the cardiovascular structure and function’s teaching and learning process. The spatial orientation offered by the Echo with prior basic knowledge seems to provide an effective tool in consolidating medical students’ understanding of heart anatomical relations and cardiac physiology. This was evidenced by the increase in the mean knowledge score of the posttest versus the pretest results. Consolidation and memorization happen in the brain after it receives the visual and auditory sensory input as “sensory memory,” which is then transferred to working short-term recollection, ultimately to be stored in the long-term memory.[12] Each transformation requires certain conditions for a successful transition, and the presence of a catalyst eases such transitions. Taking the initial transformation as an example, attention is required to progress from sensory to working memory; however, because of our limited capacity as humans to remain attentive, not all sensory information is registered in the working memory.[12] Integrating clinical Echo as a novel skill to second-year medical students and the required theoretical comprehension of cardiac anatomy and physiological activity appears to ease the first transformation of knowledge.

Multiple studies have found better teaching outcomes whenever ultrasound techniques, including Echo, were added to the teaching curriculum.[13],[14],[15],[16] However, in a study comparing two integration methods, Griksaitis et al.[15] have found no significant difference in the posttest memorization results when using ultrasound compared with cadaveric prosected specimens in the teaching of cardiac anatomy. This suggests that integration by itself is the essence of better outcomes, whereas the methods can differ as long as they are effective.

In follow-up research, Finn et al.[14] created a cross-over in the tutoring methods of both the ultrasound Echo group and cadaveric prosections, looking for a possible additive effect of the two modalities on the students’ knowledge. No significant difference was found, but clustering such different vertical integration methods may carry a hidden learning outcome beyond the basic test solving-knowledge. It could increase the overall understanding rather than only the consolidation of information.

From the teaching aspect, our results showed that the commonly mistaken identifiable areas in Echo images, such as the aortic valve and interventricular septum as well as the filling phases of the cardiac cycle, may require more attention during physiology and anatomy instruction and practical sessions to teach students to differentiate and identify them correctly. The usage of vertical integration clustering in these cases may be beneficial, and further research on this integration is recommended.

Limitations to the vertical integration include a method’s appropriate correspondence to the student’s academic level and the tutors’ commitment to the integration method. Tutors’ feedback can determine appropriateness after experimental sessions. A similar study by Hammoudi et al.[16] demonstrated that most teachers (81%) agreed to the suitability of ultrasound integration into second-year medical students’ curriculum. This attests the importance of thorough research before introducing a new method into the curriculum. Commitment of the teachers requires the attainment of the skills of using Echo correctly, as effective integration necessitates proper delivery and presentation of information. Faculty development training sessions along with ongoing support are crucial for the success of integration.[17]

From the survey offered to students at the end of this study, it was noted that the integration through Echo practical sessions is well received, and more sessions are requested. Students recognized how beneficial it was to them in terms of easing the understanding and memorization and increasing their willingness to go back and study in more detail the basic knowledge of heart anatomy and physiology. In conclusion, introducing hands-on Echo sessions in the early years of a medical curriculum is beneficial in facilitating and integrating basic and clinical sciences.


  Conclusion Top


The spatial orientation of Echo, along with prior basic information, appears to be a useful tool for preclinical medical students to consolidate their understanding of heart anatomical relationships and cardiac physiology.

Recommendations

The teaching and learning of cardiovascular structure and function is enhanced by vertical integration of Echo experience early in the preclinical medical curriculum. The benefits of active hands-on sessions of Echo need to be investigated further and inculcated in the preclinical curriculum to better prepare future medical practitioners.

Study limitations

The limitation of the study includes the small sample size of the students who participated as well as the limited number of Echo machines to allow more time for hands-on experiences. The limitation of the study includes the small sample size of the students who participated as well as the limited number of Echo machines that allowed time for hands-on experiences. Further, a case-controlled study would have determined the beneficial extent of the Echo experience of learning the principles of cardiac anatomy and physiology. In addition, the use of the student’s grades is another limitation here due to the integration used of exam questions. Both issues would be warranted to investigate in future studies after the COVID-19 pandemic disruption.

Acknowledgement

The authors would like to thank Ms. Juliet De Leon for her assistance with the Echo machine.

Authors’ contributions

MSA and MAE have equal contributions in this article. MSA, MAE, and ABE conceived the research concept. MSA, MAE developed the research design. MSA, MAE performed the field work and data analysis. MAE, ABE, and MAA prepared the first draft. All authors are responsible for the contents and integrity of this article. All authors have read and agreed to the final version of the article.

Ethical statement

The study was approved by the Research and Ethics Committee, Medical/Health Sciences Colleges, University of Sharjah with a reference number: REC/15/11/P002 on 10/ 05/ 2016. All standardized patients in the study provided informed consent and were paid accordingly.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Not applicable

Conflicts of interest

There are no conflicts of interest.

Data availability statement

Not applicable



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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