I strongly feel that echo training should be part of curriculum for training undergraduate and postgraduate students.This will enhance their practical knowledge and make them good doctors and the community will benefit as whole.

I strongly recommend the idea that echocardiography facility has be available at the clinical examination set up for cardiology practitioners. And so is the ultrasonography facility for the internal medicine specialists. 

What's the benefit?  This arrangement will enhance diagnostic accuracy, and therapeutic specificity at the top two places. In addition, this process will also reduce the communication gap between the primary care provider and the diagnostic lab. Thirdly, the patient can save time and get treatment more accurately. 

However, the training can be targeted at the graduate study at resource limited countries. 

It depends where you are working now. As the physician who is working for private hospital in big city such as New York, Los Angeles or else it could be done.

But for physician who is working in less developed countries such as in asia or africa, it would not easily apply. Echo will play very important role in cardiology, it will beat stethoscope. 

For giving exposure to the students, would be very good. If you ask them to perform it, it is okay. If there is a certified board, it would be better. And do not make them forgetting their clinical skill. That is real "art of medicine". 

Yet, it is my personal opinion only. 

Published experiences have shown that hand-held echographic devices,may  help to improve physical exam skills in medicine students, and that  diagnostic performance of students after short training in some very basic situations are at least equal to that of experienced staff using only more "classical" diagnostic resources like inspection, ... and even cardiac auscultation

In my view YES. Always doing the necessary correlations with pathophysiology and history clinical examination.

My answer is Yes. The ecocardiography must be a daily usefull tool for bedside diagnosis. Undergraduate and postgraduate students need to learn the benefits and limitations of this technology not to discard but to reinforce the clinical skills the students must get.

First I would like to support the use of a stethoscope. It is more than usefull in detecting congenital and acquired heart diseases, it is cheap and can simply be used everywhere. Echocardiography is one of the best tools for further diagnostic evaluations. So it should be part of the bedside teaching at least for postgraduate students.

Recently, Italian Society of Cardiovascular Echography group (chaired by Gullace) published two papers on: Reclassification of echocardiography according to the appropriateness of use, function-and competence-based profiles and application and  Educational pathway, competence, indication and quality process of the new classification of echocardiography according to the appropriateness of use and application (you'll find them in my profile on ResearchGate). Trying to interprete the changing sitruations and needs in the application of the ultrasound in Medical diagnosis expecially in Cardiovascular diseases, we proposed four applications, one of which is Fast Echo (for Emergency physicians, general practitioners) and another one is Basic Echo (for cardiological visit extended). Moreover, we proposed the educational pathways for them. According with this, I think that Echo is a diagnostic tool that belongs to those who know to use it; then, educational pathway tailored on the operator, function and  objectives of use is important and should be applied at any level of educational program to students required to have the basic cultural buggage in Cardiology, Vascular, Internal Medicine and Emergency. Obviously, it is important to emphasize that  in this situation the Echo use provides information to put in clinical context and not a diagnosis. In the light of this, I think that the clinical application of ultrasound  should be part of educational program in Medicine, leaving the teaching of specific applications to postgraduate specialistic courses. We do not forget that when a student starts to learn how to visit the patient he needs to know what happens inside the body he is investigating in that moment.Technology is advanced (miniaturization of machines) and we must use it (with skill and appropriateness) for what we need (information or diagnosis) to improve our knowledges and intervention.

Undoubtedly Echocardiography is the best diagnostic imaging tool which helps in accurate diagnosis. I agree with many others who had already stated that it should not take away the clinical evaluation skills. Now a days you seldom see listening to the heart with stethoscope. At least undergraduate medical student should be kept away from this sophisticated machine .

Definitely YES! Besides being a fantastic diagnostic tool in clinical practice for 4 decades now the Echocardiogram images make it easier to understand the anatomical and physiological functions/dysfunctions of the heart and easily establishes the clinical correlation with most of its pathologies. It also makes it easier to correlate with auscultatory findings. All medical students should be exposed to echocardiography in the first couple of years of medical school. And the same applies to the ECG of course.

Students should have an opportunity to use ultrasonic equipment, particularly for the heart, pleura, and abdomen.  It stimulates their appreciation of living anatomy. If they can understand the basic technique, there is no reason why they could not use in in early post-graduate practice to answer simple management questions (is there a pleural effusion? is there a pericardial effusion? is there bowel motility?) To restrict their use of it because of limited training is like trying to confine the use of the stethoscope to specialist chest or heart physicians.  The practical limitations to this approach will be the availability of the equipment (getting cheaper all the time) and its ability to automatically optimise image quality.

As an old cardiologist, my opinion is: YES for secondhand diagnostics, but NOT for a primary bedside diagnostics. My reason is:

I never forgot one  of mine very early experience (1953 ) when I had one female patient with a full mitral stenosis palpatory and auscultatory findings completely disappearing everytime she changed her position in a bed! My diagnosis was: Probable pedunculated left atrial Myxoma with periodical partial  obstruction of mitral orifice ! And it was exact, as confirmed by successful operation. Naturally, in those times there were not todays auxiliary diagnostic possibilities, so we were forced to perform and to follow our critical meanings before making an ultimate decision 

Young medical people must be trained to follow exact bedside clinical diagnostics and not to fly to auxiliary machines everytime, before they made their personal opinion.

Everybody (expecially old cardiologists that grew up professionally from cardiology of signs through phonomechanocardiography and X-ray) are worry (as we were) to teach students the standard diagnostic process (that includes history, symptoms, physical examination, auscultation, clinical assessment, etc); and this is obviously correct and it is the right approach to patient's problem. Technology must be used in this context to get information that allow to better understand signs and clinical situation and to make strides in the diagnostic process. But, technological medicine is evolving and medicine is changing. The miniaturization of technology pushes students and doctors to learn to use it in medicine in an appropriate way and within the clinical context but to day in this process, more and more detailed information and time to get them push doctors to skip some step. This suggests that something in professional approach should be revised and the diagnostic process should be redesigned including bedside technology in the clinical context of signs. Echocardiography with portable or pocket machines (Fast Echo: look for waht you need in the clinical context and when you need it) is an example.

I do agree with Dr Gullace.  Your eyes are the initial diagnostic tool, but followed soon by your ears. Even then, by asking questions, you bias the information reaching your ears, so the essential training is to be able to ask the correct questions. Your conclusions will steer your hands, then your stethoscope, and then other technology. This sequence is a fundamental of training.

Regards

John Partridge

I think I want to clarify my understanding about the discussion. Using bedside echocardiogram and ultrasonogram is not at the expense of compromised clinical aptitude, e.g., seeing, listening or palpation skills. Rather, adding those facilities will confirm and expedite the clinical skills of the practitioner, and reduce the systemic delay in the healthcare services. Let's discuss with a case study. A young adult in his twenties came to the doctor's clinic with chest pain with neither any EKG findings nor clinical evidences of failure or shock yet. Obviously the triage may not send urgent blood works for  enzymes. In this scenario, a bedside echocardiography may be life saving. There are quite a large number of critical scenarios that can be supported effectively by bedside echo. It is not a rocket science for a medical practitioner. Just think of the role of frozen section biopsy that support surgeons at operation table for making critical decisions. This is one of the many situations where we need the EF value or the diagnosis of dissecting aorta to be identified urgently- a single minute is critical. 

OK. I agree, technology has changed many things in our attitude and  also contributed  toward early accurate diagnostics and an adequate therapeutical approach.

But, it is very regretable that young postgraduates and even some specialists favor technology before performing bedside academic differential diagnostics which inevitably lead to the  loss of supreme professional skills. OK; "time is  money", but doctors should be accurate doctors in any possible condition. .

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Undergraduate teaching: I have been using echo images and video loops for illustrating the undergraduate teaching in cardiovascular diseases and the students have to become familiar with hemodynamic principles such as Bernoulli, the continuity equation, the evaluation of pulmonary pressures. This works well and should contribute to inform students on how performant cardiovascular imaging presently is. 

Graduate teaching: echo-doppler is one of the cornerstones of the training of the general cardiologist and this is clearly formulated in the ESC core curriculum, which is enclosed.

In most (not all) ESC countries physicians still perform their echo's themselves. This decreases the threshold of using the echo in all situations from emergency to bedside and outpatients.

The dark side of the low threshold for using echo is the rapid decrease of clinical skills, which I observe in consecutive generations of cardiological trainees. 

Dr Nedok is right. But these are the aberrations of our profession, including psycholigical aspects, history taking, technology use, etc. (how many of us, in talking with the patient, look at what there is behind that patient is telling us, putting attention to his gestures, expression, motivations, etc.?. How many of us usually remember that patient, in telling his history, is suggesting unconsciously his diagnosis that we must take into account?) The diagnostic process is complex, hence we need to translate difficult into simple for patient's benefit and for a good and effective teaching to students. This  suggests the need to redesign the modern diagnostic process opening a wide discussion on what is to day the right approach to the proccess that, patient's problem-oriented, aims to take care of the patient with his desease and not of the desease.

I cannot agree more with all comments. Physical exam remais a very important tool in the initial evaluation of cardiac and non-cardiac patients. But let's not forget Clinical History, particularly in patients with suspected coronary artery disease (how many normal coronary angiograms have we seen in the cath lab!!!). The lesson for medical students is:Technology should always complement history and physical. 

Well, to clarify, maybe the best answer should be:YES In  evidently very emergency situations (i.e.suspect  dissection of the aorta, rupture of the heart, tamponade ), after fast orientation of the experienced doctor, but  NO in all other less or non dramatic states

Bedside clinical diagnostic according to the well established rules of the art of medicine should be performed as a key of doctors behavior, especially in teaching hospitals.  After that, bedside technology may/should  be used not only to proove the conclusion, but also as a teaching protocol..

In conclusion,  emergency and non-emergency cardiology should have different protocols of treating the patients. .    

Well, on one hand, students need to get acquainted with all aspects of medicine during their studies. Considering the importance of echocardiography today and its usefulness, it appears reasonable to provide basic knowledge to students.

But there are several other points i´d like to mention here: Has Your staff been trained in echocardiography thoroughly? Having worked in cardiology and internal medicine I´ve seen a lot of departments trying to provide echo training to students, while their own staff is not able to perform the examination. And from my point of view, scarce capacity for training this technique should be guided to your staff first.

Then, i´ve seen far to many echocardiograms, which don´t get to the point. That means, that sometimes important findings are missing in the report, like RV function, valve quantification, regional wall motion abnormalities and so on. These are important findings and have to be diagnosed. Teaching only basic knowledge in echocardiography means risking the quality of the procedure. I heard many colleagues arguing, they "just want to be able to have a look at LV to judge systolic function". But this requires at least 200 exams (for overall eyeballing of systolic function), 2000 exams for regional wall motion abnormalities not to be missed and does not cover diastolic dysfunction, which is equally important. Just one of many examples...

While it is very rewarding to train students, echocardiography needs highly skilled examiners and I´d suggest training all young internists intensively before training students.

I feel echocardiography is an important noninvasive tool for understanding the cardiac anatomy and pathophysiology in health and disease.All undergraduates should be exposed to this tool during teaching of cardiovascular diseases for better understanding.All postgraduate students in Medicine should be encouraged in recording ,analyzing and interpreting cardiac echoes.