Nearly all medical specialties use ultrasound for diagnosis and intervention.1 2 Point-of-care ultrasound (POCUS) enables clinicians to perform ultrasonographic examinations at the bedside to assess urgent cases.3 The advantages of ultrasound examination include portability, lower cost, and the ability to perform multiplanar and repeated scanning without ionising radiation. Because ultrasound is the most operator-dependent imaging modality, formal education that covers appropriate and optimal use, specific imaging techniques, and its limitations is required.4

Ultrasound education is usually targeted towards postgraduate radiologists, with some piecemeal training in other specialties. However, the provision of undergraduate ultrasound education (UUE) is increasing.1 5 In a recent survey, 72.6% of medical schools in the United States who responded reported having an ultrasound curriculum.5 In another survey, the theoretical background of ultrasound was taught in 87% of the universities in Europe who responded, although only a minority had incorporated ultrasound into the preclinical curriculum.1 Undergraduate ultrasound education can enhance understanding of basic medical sciences, such as anatomy and physiology, provide a bridge from basic science to clinical science, and improve the physical examination skills of students.4 However, two reviews of this topic found conflicting results regarding the value of ultrasound use among medical students.6 7

Despite being recommended by the World Federation for Ultrasound in Medicine and Biology (WFUMB),8 UUE is not popular in Asia according to our understanding. We recently ran a WFUMB-AFSUMB (Asian Federation of Societies for Ultrasound in Medicine and Biology) programme to provide UUE in Asia. In this commentary, we report the utility of UUE in Asia and the challenges around its implementation.

Between April and June in 2022, a pilot survey consisting of four open questions about UUE was sent by the AFSUMB to the presidents or representatives of 16 affiliated societies.9 The main outcome measure was the response to the question ‘In addition to students of medical schools or clinical departments, is there ultrasound education provided to other students in medical college?’ Qualitative analysis was performed on the data collected. Detailed survey results can be found in the online supplementary Appendix.

Of the 16 AFSUMB-affiliated societies, 10 (62.5%) responded. Training for undergraduates (medical students or allied health professionals) was provided in three places (30%), namely, mainland China, Hong Kong, and Taiwan. Limited ultrasound education was provided in five places (50%), namely, Japan, South Korea, Singapore, Thailand, and Vietnam. The societies in Bangladesh and India reported that there was no systematic UUE (Table 1).

Except India, nine of the ten societies (90%) reported that the determining factor in deciding the provision of UUE was whether graduates would be required to perform ultrasound examinations in hospitals after graduation. The way in which ultrasound imaging was practised and which specialities routinely performed it differed between the societies and geographical locations surveyed (Table 1). For example, student radiographers in Taiwan and mainland China received training, as may be expected, but in Hong Kong, student midwives also received training and performed obstetric examinations once qualified. In Taiwan, qualified radiological technicians performed ultrasound examinations but their final reports must be approved by a physician. In Singapore, there was an initiative whereby medical students were regularly exposed to radiological practice from the start of their education in the hope of attracting more residents to the speciality.10 In Japan, UUE was provided to medical students who were designated to provide medical care, which would include ultrasound examinations, in rural areas after their graduation.11 Basic education was provided to student nurses in mainland China, despite them not being allowed to perform ultrasound examinations once qualified. In South Korea, there was no education for allied health students; however, there was no sonographer role as medical doctors conducted all ultrasound examinations. However, if the main aim of UUE is to improve anatomical knowledge and physical examination skills, it is questionable whether the time and money required to implement it would be justified.6

Unlike the usual issues that hamper the introduction of UUE, the major issue identified in India was the Preconception and Prenatal Diagnostics Techniques (Prohibition of Sex Determination) Act 2003, which bans the use of ultrasound machines by medical students, technicians, and nurses. Although similar laws regarding sex selection for non-medical reasons are in place in other Asian countries with high child sex ratios, to what extent this prohibition has an effect on UUE in those countries is unknown.12

In Hong Kong, an ultrasound e-learning module was provided by The University of Hong Kong and The Chinese University of Hong Kong to enhance and facilitate students’ learning by making the material more accessible, relevant, and effective (online supplementary Appendix).8 13 14 The use of such an e-learning platform is one of the solutions to the problems identified around the integration of ultrasound into medical education, namely, a lack of trained faculty, requisition of ultrasound machines for teaching, and limited space in an already full curriculum.4 13 14 The WFUMB is developing e-learning that focuses on the development and distribution of e-learning materials and web-based simulations to supplement theoretical knowledge.8 To improve practical skills, the use of healthy volunteers, mannequins or clinical skills laboratories is required.4 8 11 Finally, collaboration between ultrasound societies and medical schools is important for a successful UUE programme (Table 2).8 15

Point-of-care ultrasound was introduced in the two medical schools in Hong Kong and in Taiwan. After following a transthoracic echo programme on a 2-week anaesthesia rotation, most students had learned the basic views and had generally favourable success rates in identifying obvious cardiac anomalies, although with some variability.16 These results were consistent with a previous critical review.6 With the development of portable or affordable handheld ultrasound devices and the growing body of evidence supporting its extensive utility, POCUS has been widely accepted since its introduction. It is therefore reasonable to suggest that POCUS training can be incorporated into undergraduate medical education.2 11

This was the first survey conducted by the AFSUMB involving the presidents or representatives from affiliated societies in various places in Asia, although not all societies responded. Since responses were not directly collected from medical schools and/or colleges, it is possible that the information might not have been up to date. The responses were descriptive in nature, precluding statistical analysis. In-depth, repeated surveys of medical schools are required to gain a better appreciation of the situation regarding UUE.

As the use of ultrasound and POCUS by various medical specialties increases and the cost and size of ultrasound machines decreases, we envisage that medical students will be increasingly expected to use ultrasound, or at least understand its use after their graduation.2 The motivation of students to learn ultrasound techniques is closely connected to their future career as doctors17 and their feedback to such education is often positive.16 Medical schools may adopt different teaching methods due to variations in teaching methods between different universities (Table 2).1 5 8 Medical systems also vary significantly across Asia.8 18 19 20 21 The problems associated with ultrasound teaching can be partly solved by adding, for example, an e-learning platform for theoretical education and training in POCUS as an elective programme, as discussed above.4 11 13 14 15

The current state of UUE in Asia is in its infancy, as well as being relatively varied because of the different educational and medical systems. We believe that the utility and challenges found in the present survey will be useful to educators, institutions, and societies for the development of UUE.

Concept or design: KY Leung, YL Wan.
Acquisition of data: All authors.
Analysis or interpretation of data: KY Leung, YL Wan.
Drafting of the manuscript: KY Leung, YL Wan.
Critical revision of the manuscript for important intellectual content: All authors.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

This commentary received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This study was reviewed and approved by the local institutional review board at Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan as an exempt study because it did not involve patients or human images. All representatives of the responded societies gave consent for their participation.

The supplementary material was provided by the authors and some information may not have been peer reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by the Hong Kong Academy of Medicine and the Hong Kong Medical Association. The Hong Kong Academy of Medicine and the Hong Kong Medical Association disclaim all liability and responsibility arising from any reliance placed on the content.

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