New (or not‐so‐new) tricks for old dogs: Ultrasound imaging in anatomy laboratories

In searching the ultrasound literature, we found two recent editorials (Pearlman, 2010; Moore, 2011) on the use of ultrasound in medicine, and curiously, both referred to the adage: “It is hard to teach an old dog new tricks.” This proverb, which can be traced to the 16th century in Master Fitzherbert's The Book of Husbandry (Fitzherbert, 1882), is used today to imply that it is almost impossible to change timeworn habits and attitudes. For example, a father who, for decades, has picked up the phone to call his kids every Sunday morning is unlikely to switch to using text messages or FaceTime on a smart phone with great enthusiasm. The thick of nostalgia is often the greatest buffer to change. These articles, however, use the adage to equate the old dog with the average clinician, ultrasound being the “new trick.” Pearlman (2010), in his article, suggests that this proverb is an oversimplification, and may not apply today; certainly not to today's anatomists—the old dogs among the new—especially with regard to learning new tricks in ultrasonography. Not only are the old dogs learning new tricks, they are learning to teach the tricks in the anatomy classroom. Ultrasound, which is based on high-frequency sound waves for imaging, is not so new a trick, as it turns out. Ultrasound has been successfully utilized in health care for some time (since the early 1960s) with early adopters being those practicing obstetrics, gynecology, and cardiology. In the past, diagnostic medical sonography as an imaging modality was, and in many places still is, exclusively operated by highly trained medical specialists (radiologists) and certified ultrasound technicians who have been trained in an extensive (12–18 month) curriculum. Changes in our health care system have led to a wider distribution of this technology into different disciplines: emergency medicine now uses point-of-care FAST ultrasound examination; internal and family medicine employ ultrasound both in the clinic and in the hospital for thyroid examinations and bedside tests for pleural effusion (American Institute of Ultrasound in Medicine and American College of Emergency Physicians, 2014; Coltrera, 2014). We are continually learning how ultrasound can safely expedite patient care, improve cost effectiveness, and increase patient satisfaction (Moore, 2011). Thus, more medical students are interested in learning basic ultrasonograpic skills before they graduate. In the last decade, ultrasound has established a firm presence in medical schools—almost 62.2% of US medical school schools have ultrasound training incorporated into the curriculum (Bahner et al., 2014). In many instances, an introduction to ultrasound training occurs during the gross anatomy course. Schools have developed ultrasound courses (Syperda et al., 2008; Wong et al., 2011), short ultrasound demonstrations (Stringer et al., 2012), or fully integrated ultrasound curricula (Hoppmann et al., 2011). Early successes incorporating ultrasound into anatomy curricula were first reported in the mid-1990s with Teichgräber et al. (1996) and Heilo et al. (1997) and later by Reidenberg and Laitman (2002), Wittich et al. (2002), and Tshibwabwa and Groves (2005). Many educators view ultrasound as an instrument that can bridge the gap between the static form of anatomical specimens and the dynamic aspects of functional (often called living) anatomy. Ultrasound images are generated in real time by the user (students manipulate the ultrasound probe with their own hands) and show organs and their features from a unique, and more fluid, standpoint when compared with other more expensive and static modalities commonly used in today's anatomy courses, such as CT and MRI scans. Students can further their hands-on scanning experience with their own peers in the classroom and gain three-dimensional appreciation of anatomical landmarks. Ultrasound allows students to better understand the three-dimensional spatial relationships between organs, fascia, fluid, and air spaces in the body. With recent advances in portable scanner technology, imaging software incorporates color Doppler presentation modes which allow for appreciation of blood flow, in velocity and direction. Ultrasound education, therefore, contributes to an overall understanding of the human body (Swamy and Searle, 2012; Sweetman et al., 2013) and certainly belongs in the early medical school curriculum. Regarding student perception of ultrasound in anatomy, responses have thus far proven to be positive. Some studies have demonstrated improvement in students’ knowledge of anatomy when augmented with ultrasound as compared to traditional teaching methods (Ivanusic et al., 2010; Brown et al., 2012) as well as improved retention of anatomical knowledge for national board examinations (Kondrashov et al., 2015). A study recently published in Anatomical Sciences Education showed that anatomists can teach living anatomy to first-year medical students using ultrasound with minimal training, just as well as trained clinicians (Jurjus et al., 2014). In this issue of Anatomical Sciences Education, readers can enjoy three interesting papers related to ultrasound education in anatomy. Dr. Jamniczky and her team from the University of Calgary in Canada demonstrate in their work that a basic introduction to ultrasound during anatomy is more beneficial to students than if introduced later in the curriculum in physical examination skill tutorials. They found that learning the technical aspects of operating the scanner and generating optimal ultrasound images—knobology—concurrently with learning physical examination skills can result in cognitive overload for a novice learner (Jamniczky et al., 2015). The authors recommend that learners be trained sufficiently in “knobology” before being asked to apply ultrasonography in clinical training. The second paper by Dr. Moscova and her colleagues describes the incorporation of hands-on ultrasound sessions in the new curriculum at the University of Sydney Medical School in Australia (Moscova et al., 2015). The authors describe ultrasound sessions and tutorials they have designed for exploring the abdomen, pelvis, and vascular systems. For these sessions, they use volunteers recruited through the university e-mail list servers and with direct advertising. The third paper by Dr. Hall and collaborators from Yale School of Medicine debates anatomical nomenclature as it relates to ultrasound images, using the liver as case in point (Hall et al., 2015). The authors discuss the nuances of correlating structures seen on the ultrasound monitor with anatomical structures found during dissection of the same region. It would appear that ultrasound, a not-so-new technology, but relatively new to the anatomy laboratory, is with anatomists to stay, and gladly so as it bears the power to reinvigorate an old subject, one which has historically been based on a text of the dead. There is no other choice for anatomists than to embrace and to employ this technology for the good of their learners. Paraphrasing the title of Dr. Moore's editorial (Moore, 2011), we must conclude: for anatomists, both the new who are entering the field and equally the old dogs who have taught for a long time, learning the tricks of ultrasound is essential. Wojciech Pawlina, M.D.* Mayo Clinic College of Medicine Mayo Clinic Rochester, Minnesota Richard L. Drake, Ph.D.* Cleveland Clinic Lerner College of Medicine Cleveland, Ohio