First-year medical students use of ultrasound or physical examination to diagnose hepatomegaly and ascites: a randomized controlled trial

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To compare point-of-care ultrasound and physical examination (PEx), each performed by first-year medical students after brief teaching, for assessing ascites and hepatomegaly. Ultrasound and PEx were compared on: (1) reliability, validity and performance, (2) diagnostic confidence, ease of use, utility, and applicability.


A single-center, randomized controlled trial was performed at a tertiary centre. First-year medical students were randomized to use ultrasound or PEx to assess for ascites and hepatomegaly. Cohen’s kappa and interclass coefficient (ICC) were used to measure interrater reliability between trainee assessments and the reference standard (a same day ultrasound by a radiologist). Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were compared. A ten-point Likert scale was used to assess trainee diagnostic confidence and perceptions of utility.


There were no significant differences in interobserver reliability, sensitivity, specificity, accuracy, PPV, or NPV between the ultrasound and PEx groups. However, students in the ultrasound group provided higher scores for perceived utility (ascites 8.38 ± 1.35 vs 7.08 ± 1.86, p = 0.008; hepatomegaly 7.68 ± 1.52 vs 5.36 ± 2.48, p < 0.001) and likelihood of adoption (ascites 8.67 ± 1.61 vs 7.46 ± 1.79, p = 0.02; hepatomegaly 8.12 ± 1.90 vs 5.92 ± 2.32, p = 0.001).


When performed by first-year medical students, the validity and reliability of ultrasound is comparable to PEx, but with greater perceived utility and likelihood of adoption. With similarly brief instruction, point-of-care ultrasonography can be as effectively learned and performed as PEx, with a high degree of interest from trainees.



Confrontare l’ecografia con l’esame obiettivo (EO), entrambi eseguiti da studenti del primo anno di medicina a seguito di un breve insegnamento, nella valutazione dell’ascite e dell’epatomegalia. L’ecografia e l’EO sono stati messi a confronto riguardo: (1) all’affidabilità, la validità e le prestazioni, (2) confidenza diagnostica, facilità d’applicazione, utilità e applicabilità.


E’ stato effettuato uno studio randomizzato controllato presso un singolo centro di terza fascia. Gli studenti di medicina del primo anno sono stati scelti casualmente per effettuare l’EO o l’ecografia, per valutare la presenza di ascite ed epatomegalia. Il Kappa di Cohen e il coefficiente di correlazione interclasse (ICC) sono stati utilizzati per misurare la concordanza inter-osservatore tra la valutazione da parte dei tirocinanti e lo standard di riferimento (un’ecografia effettuata nello stesso giorno da un radiologo). Sono stati comparati sensibilità, specificità, accuratezza diagnostica, valore predittivo positivo (VPP) e negativo (VPN). Per valutare la confidenza diagnostica e la utilità percepita da parte dei tirocinanti è stata utilizzata una scala Likert a 10 punti.


Non sono state rilevate significative differenze tra la concordanza inter-osservatore, la sensibilità, specificità, accuratezza diagnostica, VPP e VPN tra il gruppo dell’ecografia e quello dell’EO. Tuttavia gli studenti del gruppo dell’ecografia hanno fornito punteggi più alti per quanto riguarda i livelli di utilità percepita (ascite: 8.38 ± 1.35 vs 7.08 ± 1.86, p = 0.008; epatomegalia: 7.68 ± 1.52 vs 5.36 ± 2.48, p < 0.001) e probabilità di adozione (ascite: 8.67 ± 1.61 vs 7.46 ± 1.79, p = 0.2; epatomegalia: 8.12 ± 1.90 vs 5.92 ± 2.32, p < 0.001).


Quando eseguita dagli studenti di medicina del primo anno, la validità e l’affidabilità sono risultate comparabili tra ecografia ed EO, ma con maggiori utilità percepita e probabilità di adozione. Con tempi d’insegnamento simili rispetto all’EO, l’ecografia può essere efficacemente appresa ed eseguita, con un alto grado di interesse da parte dei tirocinanti.

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The authors thank Dr. Rajesh Gupta for his advisory role in the application for Research Ethics Board approval, Dr. Paraskevi (Laurie) Vlachou for lending her radiology expertise for reference standard diagnostics, Matthew Kowgier for his contribution as statistician, and Julianne Bagg for logistical help in conducting the study.

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Correspondence to Jonathan Ailon.

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All authors declare that they have no conflicts of interest related to this study.

Ethical standard

Our study has been reviewed by the Research Ethics Board of Saint Michael’s Hospital and the University Health Network (Toronto, Canada).

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All patient participants and medical trainees gave their informed consent prior to their inclusion in the study and had the opportunity to withdraw consent at any time during the study. All details that might disclose the identity of patient and trainee participants have been omitted.

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Arora, S., Cheung, A.C., Tarique, U. et al. First-year medical students use of ultrasound or physical examination to diagnose hepatomegaly and ascites: a randomized controlled trial. J Ultrasound 20, 199–204 (2017).

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  • Point-of-care ultrasound (POCUS)
  • Bedside ultrasound
  • Rational physical examination
  • Education
  • Hepatomegaly
  • Ascites