Teaching methods, facilities, and institutions in student ultrasound education (SUSE): e-learning, simulation, and ultrasound skills labs

Over the years, medical education has changed significantly. New technologies and teaching methods have greatly transformed how teaching and learning are conducted. This evolution is also evident in student ultrasound education (SUSE). The integration of electronic learning (e-learning), simulations, and Ultrasound Skills Labs (USSL) is reshaping the way ultrasound education is delivered and aims to bridge the gap between theoretical knowledge and clinical practice.

E-learning has significantly transformed the landscape of ultrasound education^{(1,2,3,4,5,6)}. This shift was further accelerated by the COVID-19 pandemic, which necessitated a rapid transition from traditional lecture-based instruction to remote learning – particularly in medical settings, where hospitals were often inaccessible to students^{(7,8,9,10,11)}. Remote learning approaches now encompass a wide range of digital resources, including electronic textbooks, educational websites, instructional videos, online courses, webinars, and social media platforms^{(12,13,14,15)}. These resources, available commercially and through free-access initiatives such as Free Open Access Medical Education, offer learners flexibility, enabling them to study independently and at their own pace⁽¹⁶⁾. This digital transformation aligns with the expectations of a new generation of students who are increasingly accustomed to using digital tools for both learning and daily life^{(12,13,17,18,19)}. Technological advancements, especially in simulation-based education, have further reshaped the delivery of educational content^(20,21,22). Ultrasound education readily incorporates e-learning, with both advantages and challenges^{(15,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38)}.

Alongside e-learning, simulation-based medical education has become essential for enhancing ultrasound training. Simulation platforms, such as virtual reality (VR), augmented reality (AR), and immersive virtual reality (IVR), now play a pivotal role in ultrasound training by offering a safe, controlled, and replicable environment for students to develop their practical skills without risking patient harm, especially in invasive fields such as interventional ultrasound (INVUS)^{(39,40,41,42)}.

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) recommends using simulation equipment to train interventional skills before performing INVUS procedures on patients⁽⁴³⁾. Computer-based or VR simulators have been developed to present a wide range of typical and rare clinical pathologies. These databases are especially interesting for more experienced users. Therefore, simulation-based learning has traditionally been introduced in the later stages of ultrasound training⁽³⁰⁾. Here, we discuss the advantages and challenges of integrating simulation into the early steps of student education, including its role in understanding anatomy and three-dimensional spatial relationships.

To create an appropriate space for conducting simulations and integrating theoretical knowledge with clinical practice, skills labs have become increasingly important in medical education. In Germany, many universities have integrated skills labs into their curricula, offering structured exercises through which students can develop specific competencies under the guidance of experienced instructors and student tutors. USSL, explicitly dedicated to ultrasound training, have now been incorporated into most medical programs. These facilities offer students opportunities to participate in diverse learning formats, including curriculum-based exercises, peer teaching, independent practice sessions (“free scanning”), and Objective Structured Clinical Examinations (OSCE)⁽³⁸⁾.

This study aims to evaluate and explore the integration of various educational tools, including e-learning platforms, simulation-based training, and USSL, into SUSE. It seeks to identify the benefits and challenges associated with these tools and provide recommendations for creating a balanced curriculum that effectively prepares students for the demands of clinical practice.

E-learning approaches offer numerous benefits for both educators and learners. A primary advantage for learners is the increased accessibility and control over their education. This flexibility allows learners to select their preferred learning environment. Furthermore, e-learning provides the ability to choose the timing and pace of instruction, enabling learners to adjust the speed of content delivery to suit their individual needs⁽¹¹⁾. Unlike traditional group classroom settings, e-learning allows learners to slow down or accelerate the material as needed and to review resources multiple times for better comprehension⁽⁴⁴⁾. This self-guided approach aligns educational content with the learner's requirements and facilitates an appropriate allocation of study time and review.

This evolution in educational strategies reflects broader shifts within medical education, underscoring the need for educational systems to adapt to the digital era in which learners are immersed^(12,45,46). Despite clinical information typically being “showcased” in traditional seminars and lectures, one of the advantages of incorporating e-learning into ultrasound medical education is the unique opportunity to demonstrate, explore, and understand clinical cases, including rare case presentations, on a continuously available platform. In traditional settings, students and healthcare professionals often depend on actual patient encounters, which may not always expose them to rare or unusual conditions. However, with e-learning platforms, learners can access a vast database of both standard and special cases simultaneously.

E-learning resources can incorporate dynamic ultrasound videos, offering significant advantages over static images found in traditional textbooks. These videos enhance the understanding of three-dimensional anatomy and probe motions, which are crucial aspects of ultrasound technology. The ability to observe real-time ultrasound loops helps students understand the nuances of image acquisition and interpretation, making it a more effective learning tool.

This visual and dynamic representation bridges the gap between theoretical knowledge and practical application, leading to a deeper and more intuitive understanding of ultrasound techniques. Digital learning material also has the advantage of being updated more quickly than print resources^(15,47).

An added benefit of e-learning is its potential to foster collaborative learning through interactive features such as discussion forums, real-time feedback, and peer-to-peer learning modules. These tools can create a sense of community among learners, even when they are geographically dispersed. Collaboration in a virtual environment allows students and educators to share their knowledge, solve problems collectively, and gain insights from diverse perspectives. For example, virtual simulation-based learning has shown promise in developing diagnostic skills in medical education by encouraging teamwork and critical thinking.

Lastly, it has been widely acknowledged that a lack of resources is one of the most common challenges when implementing an ultrasound education program⁽⁴⁸⁾. E-learning requires an initial cost for creating and hosting material, but not necessarily for the educator or learner. Many resources are free to use and, therefore, can provide low-cost education by reducing the need for in-person ultrasound educators, thereby cutting down both educator time and financial expenses. E-learning tools can also be designed to be interactive, further enhancing attention and engagement^(12,13).

E-learning resources allow students from different regions to access training materials, regardless of local infrastructure or expertise. This “democratization” of education promotes the opportunity for students to acquire ultrasound knowledge regardless of their geographical location. By using e-learning, educational institutions can bridge disparities in training and promote a globally consistent standard in SUSE.

Like many modern technological approaches, the greatest strength of e-learning has also become a significant concern. The ubiquitous availability and expansion of educational resources pose a risk of inadequate and uncontrolled education. It can be challenging to verify the identity and expertise of creators, and the risk of misinformation is a common issue⁽⁴⁹⁾. Furthermore, it is rare for an e-learning resource to undergo the rigorous peer-review and editing process typically applied to published journal articles or textbook chapters⁽⁵⁰⁾. While metrics have been developed to rate the quality of free online resources^(51,52), each resource must be used with healthy skepticism and caution, and ideally reviewed by an expert educator before being recommended for use by learners. Artificial intelligence (AI) might help verify and match the material to traditional content and aid in reviewing open-access information^(39,40,53). The vast amount of available content, along with the possible lack of categorization by difficulty level and learning objectives, can overwhelm users. This lack of structure may hinder users' sense of progress and achievement, potentially leading to frustration and decreased motivation.

Another concern is that some e-learning resources may fail to provide the full breadth of a comprehensive, interdisciplinary ultrasound education curriculum. Because many free resources aim to engage as many learners as possible, there is a bias toward featuring content that might seem more exciting or topical⁽⁵⁴⁾. This issue is primarily relevant for learners independently consuming ultrasound education, apart from an organized program. The simple solution to this phenomenon is for educators to create comprehensive curricula that balance e-learning with traditional resources, ensuring that important topics are not omitted.

A further challenge with e-learning is the difficulty of assessing its effectiveness and the extent of knowledge acquired by learners. E-learning may depend on factors such as the quality of digital content, the degree of students' self-motivation, and the integration of e-learning into a broader educational strategy. In traditional face-to-face teaching methods, educators can interact with learners, ask questions, and receive immediate feedback on their understanding and learning progress. This interactive element is often absent in e-learning environments, where the lack of direct supervision makes assessing the degree of understanding more difficult. While quizzes and automated assessments can indicate learning progress, they do not necessarily capture the depth of understanding or the ability to apply knowledge in practice, especially for practical skills such as ultrasound. Incorporating structured feedback mechanisms and interactive sessions into e-learning could address this limitation and provide a more comprehensive picture of learner performance^(12,13).

Hands-on, proctored education remains essential for developing psychomotor skills needed for proper ultrasound examination techniques, including image acquisition and interpretation. Thus, although e-learning offers flexibility and accessibility, its success likely depends on thoughtful implementation and complementarity with traditional teaching methods.

Simulation-based training has become a cornerstone of SUSE, offering numerous advantages over traditional teaching methods. Simulation-based training is particularly beneficial in developing practical competencies that must be achieved according to the consensus criteria for objective structured assessment of ultrasound skills (OSAUS)^(4,55). These include applied knowledge of the ultrasound machine, image optimization, systematic examination, and interpretation of images⁽⁵⁵⁾. Training modes within simulators engage learners to continuously adapt hand movements and probe placement for optimal image acquisition in standard planes. Ultrasound simulation allows students to learn according to their needs, training speed and requirement of repetitions, as there are no considerations about using living models⁽⁴⁾. On the other hand, students tend to learn in groups, so providing healthy ultrasound models, especially for the first training steps, may not present a significant challenge.

Errors are an inevitable part of any learning process. Therefore, simulation-based training should be included in medical curricula, especially for INVUS^(43,56). Simulation settings allow students to learn through making mistakes without patient endangerment. A Danish study on simulation-based obstetric ultrasound training demonstrated that encouraging mistakes during training, as opposed to the traditional error avoidance strategy, resulted in better performance scores and improved transfer into clinical settings⁽⁵⁷⁾.

Learning anatomy requires complex three-dimensional visual-spatial understanding⁽⁵⁸⁾. Anatomy training with ultrasound simulators, compared to traditional formalin-fixed cadavers, offers several advantages. Ultrasound simulators can be used for as long and as often as necessary, providing an equal or better understanding of anatomical relationships with the surrounding body⁽⁵⁹⁾. In addition, ultrasound is a widely used tool in everyday clinical practice, which can lead to long-term retention of anatomical knowledge, while anatomical knowledge from the study period often diminishes over time. In the end, neither dissection, cadaver models, virtual models, nor simulation can replace the demonstration of dynamic functions in a real clinical setting.

Understanding real-time ultrasound images in two dimensions while learning anatomical relationships within the body remains a common didactic challenge. However, using three-dimensional model applications has helped students better understand ultrasound applications according to a Taiwanese randomized controlled trial⁽⁶⁰⁾ and a recent systematic review⁽⁶¹⁾.

Simulation-based training can be helpful even for the very first steps of obstetric ultrasound training⁽⁶²⁾. A French study involving twenty medical students found benefits for the simulation-trained group, including time-saving effects and the achievement of basic practical skills before examining real patients⁽⁶³⁾.

A randomized controlled trial tested the efficiency and feasibility of an ultrasound simulator for self-directed learning of cardiac anatomy compared to cadaver and plastic models in 50 preclinical anatomy students in Australia⁽⁵⁹⁾. Just three hours of simulator training appeared equivalent to using human cadaver models in mastering multiple-choice questions, and it was perceived very positively by the students. The limitations of cadavers – such as the loss of color and shape due to fixation – could be overcome, and ultrasound simulation proved helpful for orientation within three-dimensional cardiac anatomy and its relationships with surrounding organs, in contrast to dissected cadaver models.

Simulations can present realistic case scenarios, thereby integrating pathologies into SUSE. Additionally, they provide the opportunity to create standardized pathologies for knowledge assessments, testing participants' ability to differentiate between conditions. Acute pathologies, which are otherwise challenging to simulate in practice settings, can be effectively addressed in simulations, allowing for the practice of clinically relevant scenarios and the ability to train progressively, step by step. Simulation-based learning offers the advantage of training standardized examination processes for focused assessment with sonography for trauma (FAST). A blinded controlled study with medical students preparing for FAST demonstrated that simulator training was equal to traditional training⁽⁶⁴⁾.

Furthermore, a small randomized controlled trial with Canadian medical students with prior experience of point-of-care-ultrasound (POCUS) found that two additional self-directed simulator sessions (each two hours long) led to a significant improvement of visual and practical examination skills for shock assessment⁽⁶⁵⁾. Similar results were shown in a recent larger Danish randomized controlled trial with final-year students⁽⁶⁶⁾ using IVR with head-mounted devices. The self-directed VR lessons led to equivalent basic POCUS skills in terms of image optimization, systematic approach, and interpretation, compared to traditional instructor-led lessons. Maintenance costs for both education modes were similarly estimated.

Although simulators can replicate common pathologies, they are limited by the fact that handling can only be taught and learned in real-life settings with hands-on training. Simulated patient composition and compliance cannot be compared to real-life scenarios. At least some human attributes could be trained indirectly using VR simulation with simulated patient histories for students before clinical practice⁽⁶⁷⁾. Additionally, extensive simulation exercises limit the opportunity for real patient contact, which can impair the development of communicative medical skills.

The significant costs associated with simulation training, encompassing purchasing, maintaining, and upgrading equipment and software, can strain educational budgets substantially, potentially diverting resources from other critical areas. The technical complexity of implementing and maintaining simulation systems also requires specialized staff and continuous training, adding to the financial burden.

Moreover, the effectiveness of simulation-based training can vary widely depending on instructors' proficiency with the technology and their ability to integrate it into the curriculum seamlessly. Instructors who lack adequate training or experience with simulation technology may not utilize it to its full potential, which can diminish the overall educational benefit⁽⁶⁾.

Feedback is one of the most important factors ensuring teaching success⁽⁶⁸⁾. Expensive high-fidelity simulators alone offer only modest benefits if there is no adequate feedback provided to trainees^(69,70).

Additionally, there is for a risk that students may develop a false sense of confidence or competence, as the controlled simulation environment may not accurately reflect the unpredictability and pressure of actual clinical situations. It is essential to balance simulation-based training with ample real-world clinical exposure to address these challenges, ensuring students gain comprehensive and practical experience. Furthermore, ongoing investment in instructor training and curriculum development is critical to maximizing the educational benefits of simulation technology while mitigating its drawbacks⁽⁶⁾.

Implementing a USSL offers numerous advantages. First, there is a high level of student interest in practical ultrasound training, which enhances the overall appeal of the course and the skills lab itself. The hands-on experience in the USSL promotes the development of basic clinical skills and enables students to practice and refine their techniques in a controlled environment. In this way, USSLs also improve patient safety by allowing students to gain experience before applying their skills in clinical situations. In addition, a USSL supports longitudinal learning by providing opportunities for continuing education and promoting long-term retention. It can also serve as a platform for research activities, contributing to advances in ultrasound teaching. Furthermore, it boosts the image of the university and the skills lab, potentially establishing the USSL as a flagship project.

However, several drawbacks must be considered. Significant investments are required, which might deprive other areas of necessary resources. Additionally, ongoing costs for rent, supplies, and equipment maintenance, often previously unbudgeted, must be taken into account. Currently, ultrasound training is optional in the skills catalog, and the success of such a program often relies heavily on the personal commitment of individual university instructors.

An USSL should be generally equipped with several ultrasound examination sites (the number depending on the number of students to be trained), e.g., 4–8 stations (one station for 20 students per year). Each station should include an ultrasound machine, an examination couch, and a chair. Consumables such as ultrasound gel, wipes, disinfectants, and couch covers should be readily available. In addition to the classic B-mode scan (including both low- and high-frequency probes), ultrasound systems should be capable of color Doppler and options for echocardiography. Other requirements for the ultrasound systems include new or used/refurbished ultrasound machines supplemented by handheld ultrasound systems (HHUS). The required space per ultrasound station is approximately 10–12 square meters, with a room for 2–4 systems requiring approximately 20–40 square meters⁽¹⁾. The facility should allow blackout conditions and adjustable lighting with smaller light sources or dimmer switches and a separate power supply for each examination station. Additional equipment includes Wi-Fi and/or network access, literature, display boards, clip charts or similar, and, if possible, phantoms or simulators. Supervision of the premises and equipment (by ultrasound tutors) and controlled access to the premises are also essential.

This review aims to evaluate and explore the integration of various educational tools, including e-learning platforms, simulation-based training, and USSL, into SUSE. It seeks to identify the benefits and challenges associated with these tools and provide recommendations for creating a balanced curriculum that effectively prepares students for the demands of clinical practice.

E-learning should be considered part of a comprehensive teaching approach that incorporates multiple learning methodologies, including hands-on training. For example, e-learning works best in conjunction with other complementary teaching methods, such as blended learning units^{(37,71,72,73)}. Blended learning combines the benefits of e-learning with the irreplaceable aspects of in-person hands-on training, resulting in better knowledge outcomes than traditional classroom instruction alone^(74,75). The versatility of e-learning allows for flexible deployment – before and after hands-on sessions or as a tool for periodic review to improve retention^(24,76,77). With the growth of more advanced simulation, VR, and AI in ultrasound education, there will likely be additional options for widespread remote learning in the future^{(4,5,6,33,39,40,66,78)}. By incorporating e-learning, educational institutions can bridge disparities in training and promote a globally consistent standard in SUSE. Concerns about content quality can be addressed through peer review and oversight by expert educators.

In addition to e-learning, simulation training is an important component of ultrasound education, providing a controlled and safe environment for students to develop their ultrasound skills independently. Implementing best practices in simulation ensures that learners gain proficiency and confidence, and promotes self-directed learning.

Students of all training stages and experience levels can benefit from simulation-based learning, which may range from simple self-made gelatin phantoms to complete VR simulations. Training on simulators should be embedded within a longitudinal ultrasound curriculum that also includes other methodological approaches, such as hands-on training sessions with qualified tutors. Transferring simulation-based learning concepts into clinical contexts should be organized during the implementation of simulation-based learning, as patient physiology, patient compliance, and the requirements for communication skills cannot be reflected and taught through simulators.

Establishing a USSL is an important and necessary part of a student ultrasound curriculum, primarily to effectively design and implement simulation training. Learning practical ultrasound skills is currently an optional part of the competency catalog. Still, it is recommended by German medical faculties and supported by the so-called National Competency-based Learning Catalog in Medicine (Nationaler Kompetenzbasierter Lernzielkatalog Medizin, NKLM)⁽⁷⁹⁾. Therefore, a USSL could be integrated into a skills lab and budgeted independently of whether the ultrasound curriculum is offered as a curricular or extracurricular component.

Overall, it is evident that teaching and learning methods have changed significantly in recent years. Integrating theoretically acquired knowledge with clinical practice has become integral to medical education. Especially in ultrasound training, the practical component of learning skills is essential. While there are both advantages and disadvantages, the new teaching methods have proven to be well-suited for medical ultrasound education and hold great potential to advance the development of ultrasound skills significantly.