Traditionally, ultrasound training has occurred in clinical sessions with live patients and impacts almost every branch of medicine including internal medicine subspecialties (i.e., endocrine, gastrointestinal, renal), pediatrics, surgery, orthopedics, cardiovascular surgery, urology, ear, nose and throat (ENT), ophthalmology, family medicine, and obstetrics and gynecology. The competing pressures of service delivery, increase in quality standards, and limited access to patients especially during COVID, have hindered opportunities for this training. While ultrasonography is a key skill for obstetricians and gynecologists for comprehensive clinical assessments often in urgent conditions in labor and delivery and the emergency room, without a standard ultrasound curriculum across medical schools, there is variability in ultrasound skills that medical students bring to residency programs [1].

This variability in training continues in residency. Alrahmani et al. [2] reported from a survey from 93 obstetrics and gynecology (OB/GYN) programs, 23% of residents did not have any ultrasound-related didactics. Tolsgaard et al. [3] reported that trainees in OB/GYN have concerns regarding their confidence in performing ultrasound. Educators are constantly challenged to find methods to effectively train residents and medical students over a longitudinal experience without sacrificing quality. New technologies and web-based sources have opened novel educational applications in medical practice [4].

To help solve this problem, we drew on previous success with one of the first comprehensive programs available for OB/GYN ultrasound training [5], and designed one that was web-based. It has a curriculum based on the learning guidelines set forth by the American Academy of Family Physicians and other governing bodies of OB/GYN education [6, 7, 8, 9]. With five didactic modules and a sixth module in fetal biometry, it provides simulation training. We utilized this curriculum with Spanish medical students fluent in English to demonstrate student learning.

Twenty-seven students participated in this study. Twenty-six students (96.3%; 26/27 were able to demonstrate test score improvement. Each test was 30 questions with a possible score of 300. The post-test scores indicated increased knowledge about limited ultrasound. The Wilcoxon signed rank test shows that the observed difference between both measurements was significant, Z = –4.46, p 0.01. The median pre-test score was 160 whereas the median f post-test score was 290. Thus, we can reject the null hypothesis that the educational material did not improve test scores and we may assume that the educational program increased knowledge of ultrasound material.

Item difficulty was defined as the proportion of test takers who marked an answer correctly, with more difficult items being answered correctly less frequently than those items that are answered incorrectly. The closer the value was to one, the less difficult the question. All questions on the pre-test were difficult for the students, with most having a value below 0.3 (see Table 1). The discrimination index was above 0.2 for all questions with the exception of questions 10 and 17, indicating that students who scored well on the pre-test answered more difficult questions correctly than people who scored poorly on the pre-test, indicating that the questions were able to discriminate between high and low-performing students. For the post-test, most questions had a difficulty index above 0.8, meaning that after completing the course questions on the material were easier (see Table 1). This was an expected result as we used a criterion-referenced test. Many of the discrimination indices were between 0.0 and 0.3, which is consistent with our use of a criterion reference model.

Students enrolled in this course had positive learning outcomes and demonstrated the ability to manage their time to complete the modules in the assigned period. This study demonstrated the ability to provide easily accessible web-based ultrasound training for Spanish medical students fluent in English. This E-learning curriculum is a viable option for those who would like to use E-learning in conjunction with in-seat lectures to meet recent curriculum needs for medical students to have exposure to ultrasound training as required by the supervising medical student organizations.

Limitations of the intervention include the small number of participants with limited data for interpretation and possible language barrier issues with using Spanish medical students even though the students were all fluent in English. While we observed improvements in knowledge and skills with these students, a pilot study like this requires context to ascertain the efficacy of web-based education. Dietrich et al. [4] reported that pre- and post-test with ultrasound simulation have shown to be important for improving knowledge, motivation, and skill retention [10, 11].

Results of this intervention model confirm E-learning for ultrasound in limited obstetric can provide medical students a tool to take control of their education while allowing educators to shift their in-class curriculum to topics that need more attention. If our students are to meet the guidelines set forth by our governing bodies, we must continue to provide dynamic and time effective means of delivering the necessary materials. Due to the already widespread utilization of remote learning in other fields, this training could be expanded to include more in-depth exposure in obstetrical ultrasounds to medical students and residents in other medical disciplines, as well as augmenting the educational efforts to other future medical professionals (i.e., sonography students, nurses) who need to be familiar with ultrasound.

Data for this study are stored on a secured server per the study protocol. The authors do not wish to share study data due to confidentiality that could be breached when working with small numbers.

WW, MD, LT and BCC conceptualized and designed the research study. MCA, AMCD and AVH acquired data. LT and DJS analyzed and interpreted data, WW and LT wrote the manuscript DJS and BCC revised for intellectual content. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.

The CAMC/West Virginia University Institutional Review Board determined this project as exempt from review and provided an outcome of Non-Human Subjects Research.

The authors would like to thank Soli Deo Gloria Maternal Fetal Medicine (MFM), LCC for hosted the site training and providing all technical support without cost.

This research received no external funding.

Dr. Byron Calhoun sponsored the web-based course the students utilized in the ultrasound study but received no financial renumeration from anyone involved in the study. On behalf of the rest of the authors, the corresponding author states that there is no conflict of interest.