Expanded ultrasound provision needs to be supported by improvements in training
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j205 (Published 17 January 2017) Cite this as: BMJ 2017;356:j205
Abstract
High quality training and ongoing experience are the keys to ensuring the benefits of wider ultrasound are delivered, says Alex McDonald
Ultrasound has the potential to provide safe, immediate, real time bedside diagnostic information that can help patient management and optimise patient safety. To realise these benefits, however, operators need high quality, ongoing training with competent mentors, and training on approved programmes.
Advances in ultrasound technology have created machines capable of very detailed imaging. Capability has expanded into new areas such as contrast enhanced ultrasound (for imaging renal and liver lesions and characterising those indeterminate on computed tomography) and elastography (for analysing breast lesions and to non-invasively investigate for liver cirrhosis).
Advances have also created smaller machines that can be found outside the traditional areas of radiology and obstetrics and gynaecology. These include point-of-care machines in intensive care, anaesthetics, emergency, and respiratory departments. The benefits that ultrasound can bring—particularly in improving the safety of interventions, such as intercostal drainage1—mean that it is now a part of some specialty training curriculums.
The Royal College of Radiologists (RCR) has produced guidance to ensure full diagnostic scanning competence for medical and surgical specialties.2 Other courses and competencies have been developed by different specialties, focused on a specific area and often used to confirm (“rule in”) a suspected diagnosis.
Image generation
Ultrasound investigations are limited by operator technique and interpretation, as well as by software and hardware. Advances in portability bring the risk that some machines may be used for tasks they were not intended for—for example, some machines may focus on contrast resolution for interrogating small lesions but be inappropriate for abdominal aorta screening.
Inappropriate transducer, preset, harmonics, gain, depth, window, or focus settings, and a variety of other artefacts can alter the image and may confuse the operator unless they have been trained to recognise and adjust for them. Patient factors—such as body habitus and alternative anatomy—also confound adequate image generation. There is huge potential for misinterpretation, negatively influencing patient management. Misinterpretation can also lead to litigation.3
Training
High quality training and ongoing experience are the cornerstones of competent practice. Radiologists train intensively to gain competence, starting in specialty training years, with sonographers completing a consortium for the accreditation of sonographic education certified diploma or masters level course before qualifying.
These courses are also open to non-radiologist doctors. They consist of lectures and assignments on theory, tested in written examinations, and practical experience under formal mentoring, examined by logbook reviews and objective structured clinical examinations.
Other training pathways have been proved to be equivalent in safety to radiologist training in a focused area.4 In one study, radiologists trained the physicians who then gained comparable diagnostic accuracy.4
Instruction by competent clinicians—be that a radiologist, trained specialist, or sonographer—is necessary for any successful training. Simulators can aid learning scanning technique, but patient experience is essential.
Safety
Ultrasound enjoys a reputation as one of the safest imaging modalities; however, consideration of this aspect is still needed—particularly in obstetric and ophthalmic practice, but also in the expanding field of contrast enhanced ultrasound. Training is important, alongside guidelines on maximum scanning times to minimise harmful effects.5
Governance
Continued practical scanning exposure and the discussion of cases with mentors and colleagues is needed to maintain skills and recognise limitations.
Although agreed scanning protocols can seem cumbersome they are useful to remind operators of the standards required for each scan.
Some ultrasound machines can’t print or save images. Image storage is important (preferably to an electronic picture archiving and communications system) because it provides a visual record, allows case review, and gives the opportunity to improve practice through mentor and peer discussion.
From a service perspective, it is important that equipment remains fit for purpose. The RCR recommends reviewing machines every 4 to 6 years,6 with the European Society of Radiology recommending equipment replacement every 10 years.7
Footnotes
Competing interests: We have read and understood BMJ’s policy on declaration of interests and declare that we have no competing interests.