Imaging: A novel paradigm for medical undergraduate training
1 Tabinda hasan; 2 Tehseen FM Ali
1Faculty of medicine
2 Health sciences
Name of corresponding author-
Dr Tabinda hasan
Faculty of medicine
Post box 114
Email of corresponding author-
The clinical encounter, an interactive and highly visual process begins quite early during undergraduate years where medical students learn to 'peer into the living human' through many different imaging modalities. These images form an essential component of the learning process in medical education. Recent advances in diagnostic imaging offer new ways to teach basic sciences to medical students, including functional and molecular imaging, multi planar imaging, virtual endoscopy and spectroscopy. The broad dissemination of 'view point dependent cut out models' and 'moving internal organ systems' , developed using free form projection technology promote students understanding of normal morphology, physiology and pathology using graphical expression and direct manipulation. Picture Archiving and Communication Systems allow transfer of diagnostic images to multiple sites, for educational as well as clinical purposes. Imaging not only improves intricate spatial relations knowledge and procedural skills, but also provides a conductive environment in which the whole class can simultaneously access the image database for an interactive learning opportunity. Availability of medical images in the classroom enhances the proficiency and efficiency of student's learning time. Current reforms in modern medical curricula and the establishment of an increasing number of new medical schools coupled with prompt electronic availability of image systems further underlie the prospects of an expanding role for imaging in medical education. The increasing sophistication with which imaging can depict the human body promises its pivotal contribution towards making the knowledge of the human body easier for tomorrow’s doctors to acquire and to retain.
Key words: imaging, medical education, radiology
The enormous advances in information and technology have changed the trends of 21st century medical education. Today, numerous means and resources are available to depict the normal and the abnormal in the human body. Electronification of higher education has increased the ways in which information can be displayed, stored, assimilated and transferred. Images form an essential component of the learning process in medical education. Recent advances in morphologic and diagnostic imaging offer new ways to teach basic sciences to medical students.
MATERIALS AND METHODS
An extensive review of published medical literature was done to assess the role of imaging in current medical education. General and Meta search engines were used to scan journals, digital libraries, electronic websites and gray literature database. A total of 100 articles ranging from the year 2000-2010 were scanned to derive inferences regarding the pedagogical role of imaging.
80 articles met the inclusion criteria based on their context relevance regarding imaging based methods used in medical instruction and their pedagogic implications. Published literature suggests that images form an essential component of the learning process of medical undergraduates. Recent advances in diagnostic and descriptive imaging offer new ways to teach basic concepts to medical students.
Medical image teaching systems:
According to many educationalists, "the enormous advances of image based learning "are not to be undermined. The underlying concept is the logical-psychological sequence of vision based transmission of information, which is easier to assimilate and longer to retain in the learner's mind. According to the famous 20th centaury educational psychologist E. Dale, what one 'sees' stays longer than what one 'reads'.
Beginning with introduction to anatomy during their first year of medical school, students examine images and drawings of the human body to learn about the basic structure of man. While the understanding of the human body underlies much of medical education, the demand of educational programs has substantially changed within the past years. Today, along with the age old ‘traditional cadaveric dissection’, there are numerous alternative resources available to demonstrate anatomy, like digital computer programs, virtual models and scan image banks.[2-5]
Along with covering gross morphology, a step further into the understanding of structures at the micro level takes the form of histology. Through histological images, photographed through the microscope at different magnifications and highlighted with a variety of stains, students delve into the ultra structure of tissues. The concept of structures at macro and micro levels facilitates the development of cognitive frames for differentiating the physiological from the variational and the pathological. [6,7]
Medical students learn to examine the human body from all its functional aspects in a 'state of real time-action' through many different dynamic imaging modalities that let the learners peer into the living human: computed tomography scans (CT) and images created by radiation from isotopes (f-MRI) that differentially bind to various tissues. f-MRI scans beautifully depict the functional sequences in organs like the brain and muscles during different phases of illumination synchronized with the levels of cognitive and psychomotor activities. Indeed, imaging has significantly emerged as a 'Benchmark' of displaying human body configuration in all its gross, surgical, functional and pathological frames. This has facilitated efficacy in academics, diagnostics and therapeutics. Functional imaging optimizes the resources of health systems by saving labor, time and costs incurred in identifying and resolving medical conditions.
Computer managed illustration programs:
Computer-based imaging programs give a comprehensive understanding of three dimensional spatial concepts. These digital programs are user friendly, less tedious and time saving. They also prove to be more cost effective in the longer run because they allow 'multiple re-use' of the source. They are excellent for making repetitive ,quick visual comparisons of structures and provide an ever widening scope in facilitating transportation to multiple locations, revisions, online / distance mode self directed and independent learning. Computerized image banks are predominantly emerging as an efficient criterion for structured assessment and evaluation of medical trainees. Their pedagogical affectivity and can be further increased when combined with other multimedia communication aids like audio-visuals, projections and human interface.
Free form projection technology:
Virtual models, developed using free form projection technology, promote medical students understanding of human morphology using graphical expression and direct manipulation. A powerful medical education system using dynamic models has emerged, where students can learn the internal organ's flexibility, complexity of body structures and palpation techniques, through the dynamic reaction of internal organs according to the user's action. [8,9]
Moving internal organs systems: These incorporate some image based internal organ models marked as “flexible” that move to the direction of gravity in different horizontal or vertical positions; as happens in a real human body, so as to give a more realistic feel to the user.
Viewpoint Dependent Cut-Out Models: These images are self adaptive and change their appearance according to the direction of the observers view point.
Palpation simulation training systems: These use physical touching on torso and generate visual feedback on a computer screen to rehearse palpation techniques, wherein medical students can grasp the exact point and correct pressure of palpation.
3 D virtual patient projections allow trainee doctors to visualize and diagnose ailments in high definition. Virtual patients are especially helpful in dealing with trainee overloads, time constraints and non complaint human models.
Virtual reality based imaging :
Virtual reality (VR) is the latest trend in medicine, where electronically created simulated environments are used to provide structural knowledge of the human body to medical learners as well as incorporating cultural components in the classrooms of community based medicine. VR has significant scope in analysis and treatment of medical conditions like phobias, stress disorders, addictions, binge eating, post operative or burn pain management and post-stroke brain retraining. VR can bring a version of the real world into the classroom and clinics. This provides 'risk free' training opportunities to clinical undergraduates. These programs can simplify complex procedures and shorten tedious lengthy, phenomenon of real life situations for effective medical training.
Augmented reality based imaging:
Augmented reality (AR) has been used in the medical education field for nearly ten years. It involves overlaying seemingly-real experiences on top of the learner's local environment. AR tools employ advanced computerized algorithms to produce live interactive images for assisting physicians and medical students in positioning implants, neurosurgical procedures and surgical education. Open source image guided procedures provide multidimensional framework for real-time visualization of surgical instruments relative to the patient’s anatomy by fusion of live endoscope or microscope video with stereotactic medical imaging data, real-time broadcast of intra operative data via telecommunication networks and intra operative access to a second opinion via interactive telecommunication from a remote expert. AR is a highly effective learning tool, allowing medical learners to peer ‘under the skin’ and reveal the inner workings of human body by literally ‘walking through’ the body and directly ‘seeing’ the functioning of organ systems. Other possible AR applications include leveraging and managing the massive mine of patient data for regulatory, record and research purposes.
Combining augmented reality technology with traditional haptic and collaborative technologies enables development of intricate concept demonstrators. These concept models are designed to combine the features of collaborative workbench with the concept of face-to-face discussions about a virtual object placed on a tabletop between two people. Ongoing research is seeking ways of using this technology to enhance long-distance clinical interaction between people who are jointly solving a problem or performing a task.
In-situ visualization in medical AR enables view of virtual data such as a 3D CT scan, with a video view of the real anatomy of a patient. Data can be aligned with the required accuracy so that surgeons do not have to analyze data on an external monitor in the operating room. Instead, surgeons get a direct view superimposed "onto" and "into" the patient. Hence, mental registration of the medical imagery with the operation site is not necessary anymore. Augmented medical images and virtual surgical instruments within the body provide the most intuitive way to understand the patient’s comprehensive anatomy within the region of interest. This allows for the development of a completely new generation of surgical navigation systems.
AR can considerably reduce the time of lengthy, tedious procedures; it can even replace dangerous 'real time experiments' with artificially created variables that work on pre-calculated electronic algorithms to yield real time data sets. Virtual /simulated environments in research labs are more 'compliant, safe and quick' to generate and to monitor for the researchers. Along a wider picture, it has huge scope in clinical data mining and expert lab information systems for creation of new, evidence based medical knowledge and designing earlier and more effective interventions.
Radiography of cadavers for teaching purposes was proposed more than 20 years ago, by Wilhelm Roentgen, the discoverer of X-Rays. Radiologists have been involved in medical instruction for decades and current reforms in the medical curriculum further underline an ever expanding role for imaging. Recent technical advances in radiology, such as multi-planar imaging, three-dimensional reconstructions, virtual endoscopy, functional, molecular imaging and spectroscopy offer new ways for teaching basic sciences to medical students. Picture archiving and communication systems (PACS) allow transfer of data to multiple sites, not only for clinical-diagnostic but also for educational and interdisciplinary communication purposes. 3D data sets from CT scans, allow multiple re-slicing of a body region in various planes. These advances provide new opportunities for demonstrating structure based information in the undergraduate medical curriculum as well the training of junior surgical trainees.
Sound / resonance based imaging:
Ultrasound (US) is a diagnostic technique that sends high-frequency sound waves into the body via a transducer. The returning echoes are recorded and then used to build the reflective image of an internal structure.US is a popular diagnostic / therapeutic tool because of its non invasiveness and easy maneuver. In the medical scenario, US is used to reinforce students’ regional knowledge of body organs and positional relations through visualizing vital structures like liver, spleen, gall bladder and kidneys etc. in a multi dimensional plane inclusive of spatial rotations. Splendid three dimensional images are produced by third generation scanners which enable congenital disorders such as harelip and spina bifida to be diagnosed before birth. Once such disorders are detected, it may be possible to perform corrective surgery while the fetus is still in uterus. Doppler ultrasound heart imaging (also called doppler echocardiography) is a novel development of ultrasound scanning that is used to measure the speed of blood flow through the heart. This technique is useful in the assessment of medical disorders like congenital heart disease or valvular disorders. Blood flow patterns through the human placenta in pregnancy can be made visible through Color Doppler scans. Doppler ultrasound scans are capable of obtaining very high-definition images by linking ultrasound to a numeric color video. They use high-frequency sound waves to determine whether a pregnancy is normal, and can even register moving particles like blood. Adenocarcinomas and other types of cancers or tumors can be targeted and identified through contrast-enhanced ultrasound imaging. Although more expensive, Magnetic resonance imaging (MRI) offers even greater opportunities to demonstrate not only the anatomic makeup, but also the functional physiology and biochemistry of organs. Functional MRI can demonstrate complex levels of brain and muscle activation during a variety of tasks. MRI spectroscopy can display the relative concentrations of biochemical molecules in a range of tissues.
Imaging in distance therapeutics:
Today, novel concepts of Tele surgery, Tele medicine and Tele dermatology have become a possibility due to sophisticated imaging techniques that have transcended modern therapeutics beyond the physical barriers of time, place and contact. The prompt availability of electronic images for consultation, diagnostic and therapeutic purposes has facilitated treatment of patients from 'far out' areas in the face of barriers like distance, constrained resources, lack of personnel and outreach issues. It has also boosted efficacy of referral and inter or intra institutional clinical communication and collaboration.
Is imaging a perfect instructional medium in modern medicine?
With such vast educational possibilities offered by imaging, it could well be asked whether there remains any need to use traditional instructional aids in medical education. Many teachers stress that traditional pedagogic tools like cadavers, pro-sections, human models, wet specimens, soft parts etc. offer some benefits that cannot be achieved through digital images alone. There is still debate regarding the educational affectivity of solely image based teaching systems. Some evaluation oriented researches show an average performance of digital models and attribute the underlying reason to lack of full learner interactivity in a virtual, confined system. However, these studies differ in more than one variable and hence their results cannot be generalized on one common scale. Some structures may be hard to display adequately with current imaging techniques, for instance peripheral nerves with complex courses or very fine arterial networks and anastomoses. Furthermore, direct visualization of the real body or organs confers a ‘haptic’ appreciation of tissues and a feel of the real texture, hardness, friability, color etc of the human body in health and the discrete, insidious changes that appear in it as a result of disease. Additionally, an encounter with the 'real' provides students with an opportunity to confront life's emergency calls and issues surrounding disease, trauma and death in ways that synthetic images cannot. It also contributes to the development of affective attributes like bioethical skills and inner strengths.
Combining advanced imaging techniques with traditional instructional aids has been reported to generate a high level of student interest in medical classrooms.[7,10,11] Such complimentary amalgamation of tradition with electronic innovation has the potential to engage all of the learners senses (touch, sight, hear, psychomotor) in a fruitful pattern to generate an environment conductive to the process of learning. This not only improves a students’ ability to locate structures and identify pathology, but is also associated with long-term retention of a widened knowledge base.
In the near future, with an ever advancing information-technology, improved, multi-purpose image based pedagogic frameworks with dynamic features of sound, movement, reaction to variable stimuli etc will be incorporated and more types of contents will be added for assimilation and delivery of advanced medical knowledge. Although more research is needed in this area, current evidence suggests that sophisticated multi-planar imaging based instruction and traditional demonstration modalities may be complementary rather than competitive tools in medical education.
The knowledge of the human body is essential to the practice of surgery and to an appreciation of physiology; and the correct learning of them promotes the habit of attention, and of accuracy which is the associate of attention and the innate characteristic of a doctor at heart. Still, it may be questioned whether the result in terms of learning outcomes is proportionate to the time and labor expended during the process of instruction. The increasing sophistication with which imagery can depict the human body, combined with its ready electronic availability, means that digital programs can play a significant role in making the knowledge of medicine and science less tedious for tomorrow’s doctors to acquire and to retain. Current reforms in modern medical curricula and the establishment of an increasing number of new medical schools further underlie the prospects of an expanding role for imaging in medical education and in the framing of better oriented doctors.
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