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with standard deviation were calculated. Given the low number of participants, non-parametric Wilcoxon Signed-Rank tests were used to compare between time points. As the Larrivée et al. BMC Medical Education (2019) 19:474 Page 3 of 9 written test was assessed at three time points, a Bonferroni correction was applied for multiple Wilcoxon comparisons on this variable. Power calculations were performed using G*Power version 3.1.9.2 for Windows using data available from a similar project performed by Finnoff et al. [21]. With a power set a 80% and 0.05 threshold for statistical significance, four participants were required to obtain a significant improvement on a written test on ultrasound knowledge. Results Participants Ten residents participated in the online and practical ultrasound course and were recruited for the study. At the time, six residents were in their senior years (Postgraduate year 3 or more) and four were in their junior residency years (PGY 1 or 2). Prior to the course, interest in MSK POCUS was rated at 6.5 ± 3.6 out of 10 on a Numeric Assessment Scale (NAS). Exposure to ultrasound was minimal, at a mean of 1.5 ± 1.5 h in medical school and previous residency years. Residents have been mostly exposed to MSK POCUS in the orthopaedic sports clinic and the emergency department, followed by spine surgery operating room, and the radiology rotation (See Fig. 1). Each participant filled the pre-course questionnaires before getting access to the online tutorials, but two residents omitted to watch the material in time for the practical session. All of them were present for the whole duration of the practical session. Follow-up questionnaires and tests were completed at the required interval by every resident. Course appreciation The course was rated of high quality by the residents, with an average rating of 8.7/10 ± 0.82 for the overall quality. Other aspects of the course fared similarly, with quality of the online videos rated at 8.7/10 ± 0.87 and the quality of the practical session rated at 8.8/10 ± 1.37. The length of the course was rated as adequate by most residents, with six saying that the length of the online videos was “Just about right”, and all residents agreeing that the length of the practical session was also “Just about right”. Sections that gathered 50% or less approval rate were the video sessions describing the abnormal pathologies seen on ultrasound, and the anatomy of the elbow and ankle (See Table 1). Free text comments left by the residents also attested to an interest in learning more about ultrasound guided nerve blocks and hip joint aspiration. Eight residents answered they were very likely to recommend the course to other residents. However only three said they were “very likely” to incorporate MSK POCUS in their future practice, while six said they were “somewhat likely” to include it. Retention of knowledge and skills The average score on the written test was 50.7% ± 5.4% before taking the online and practical course. This score improved to 84.0% ± 3.4% immediately after the practical portion of the course. At 6 months, the average mark was 75.6% ± 3.0%. (See Fig. 2). Using pairwise Wilcoxon tests, the scores after the course and at 6 months both presented statistical improvement from the pre-course score (p = 0.005 and p = 0.008 respectively). This remained significant after Bonferroni correction. The difference in Fig. 1 Residents’ previous exposure to ultrasound by clinical setting. For each setting, the number of residents who have mentioned being exposed to MSK ultrasound is shown Larrivée et al. BMC Medical Education (2019) 19:474 Page 4 of 9 Table 1 Appreciation of curriculum length by residents Online portion Total length Ultrasound physics Setting up Normal anatomy Pathological anatomy Shoulder anatomy Elbow anatomy Knee anatomy Ankle anatomy Total length Far too the course, the number of residents answering each item is displayed Larrivée et al. BMC Medical Education (2019) 19:474 Page 5 of 9 scores between the post-course test and six-month test was not statistically significant (p = 0.075). Following the practical portion of the course, the residents’ average score at the graded shoulder ultrasound examination was 78.7% ± 3.1%. At the six-month examination, the average score had dropped significantly to 66.3% ± 10.7% (p = 0.018) (See Fig. 3). Comfort and use of ultrasound Six months following the course, the residents’ comfort while performing MSK POCUS significantly improved from 3.80 ± 1.5/10 to 5.90 ± 2.1/10 on the NAS (p = 0.005). This held true for all aspects of the ultrasound examination evaluated (p = 0.005–0.011, see Fig. 4). However, the number of times the ultrasound was Fig. 3 Practical shoulder exam scores. The average score (in percentage) and standard deviation of the practical ultrasound test are presented for the two timepoints following the course Fig. 2 Written ultrasound examination scores. The average score (in percentage) and standard deviation of the written ultrasound examination are presented for the three timepoints Larrivée et al. BMC Medical Education (2019) 19:474 Page 6 of 9 reported being used by the residents in clinical duties did not improve in the 6 months following the course when compared to the 6 months preceding it (0.9 ± 2.0 to 6.5 ±14.9 times used, p = 0.279). Taking a closer look at the individual numbers, five residents
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