Everyone’s a radiologist now
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39560.444468.AD (Published 08 May 2008) Cite this as: BMJ 2008;336:1041All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
The Article by Jacqui Wise is timely because we need as a medical community to develop a Strategy about diagnostic ultrasound as well as other modern technologies which perhaps previously were the province of "experts" but as the realisation of the benefits and facility of the tool become widely known there comes an overiding pressure to widen the access both for patients and clinicians. ECGs, Spirometry or Pulse oximetry were once the privilege of specialist coteries. There remain doubts amongst some about the validity of non specialists using these technologies but generally it has become accepted that with some training it is reasonable for the non specialist to use them for the benefit of patients and the service. No one says that everyone who uses a near patient investigation of any sort will never refer a patient for another opinion. But most of the time we recognise that these investigations complement clinical skills; they are no substitute. We also recognise that some are more suited to performing them than others. The use of any skill is dependent on realising the limits of your own skills and the investigation. However screening for aortic aneurysms does not appear to require clinicians at all and can be done by suitably trained lay persons.
The Scottish Association of Community Hospitals has long advocated the use of diagnostic ultrasound to extend the clinical skills of general practitioners particularly in Remote & Rural areas of Scotland. We have run three day Introductory courses in conjunction with Dr P "Budgie" Hussain and Dr David Kay, working towards Accreditation under the Royal College of General Practitioners/Royal College of Radiology Working Group guidelines 1993. We are grateful to NHS Education for Scotland who provided a grant to enable us to provide the courses over the past two years and also to Ramsay McIver for the provision of machines. As a result we have seen 40 GPs and some A&E & Urology specialists have completed the Introductory course under our auspices and those of the Aberdeenshire Community Health Partnership(CHP). More than 25 GPs have now been accredited across Scotland having done supervised practice and an accreditation assessment. In some areas of Scotland it has been difficult to obtain the cooperation of the local radiology directorates who feel unable to offer any supervision for practitioners pleading poverty of resources and time to train even their own trainees. Grampian however have collaborated with the local CHP to supervise the GPs and as a result over 1500 scans were done in rural Aberdeenshire by local GPs over the last year enabling improved access for patients in an area with notorious transport links and improved diagnostic prospects for the local clinicians.
We would suggest that the model we should espouse is that of collaboration as in a rugby team where people with different aptitudes and skills work together towards a common aim. We do not wish to return to the habits of the industrial age with rival tribes of blue collar workers claiming unique abilities to provide a service above anyone else. Such demarcation disputes were ultimately self destructive. We Scots led the world both in the development of the skills and in the disputes that ultimately led to the loss of those industries in Scotland. Professor Donald and Tom Brown did not work hard to produce a tool for the ivory towers.
We need to recognise our common aim to provide effective services for patients both individually and in our communities; we will only do this by being less precious and more open minded; supporting patients to help themselves and our multiprofessional teams to work to the best of their abilities, providing quality services as close as possible to the patients' homes. yrs Hamish D Greig.
Competing interests: Holder of NHS Education for Scotland grant to provide US courses for non radiologists particularly in Remote & Rural areas with Community Hospitals
Competing interests: No competing interests
The article by Jacqui Wise was very interesting. The timing of the introduction of ultrasound into clinical practise has meant that it has been taught to doctors in specialities where it may be of use. A time may be coming as is pointed out in the article where the basic examination skills of medical students are "inspection, palpation, percussion, auscultation and ultrasound".
I'll be honest, in my practise, I cannot recall the last time I percussed a chest or abdomen. Instead I tend to "inspect, palpate, auscultate and scan".
Whilst I am clearly no expert at ultrasound scanning, there seems to be a similar practise amongst my colleagues.
Competing interests: None declared
Competing interests: No competing interests
The issue of non-radiologist based speciality ultrasound represents a potential important increase in the quality of service provided to patients - that is, as long as the training and support available are adequate.
As per my quote in this article, I do believe that properly conducted and well thought out expansion of the thoracic ultrasound service to include respiratory physicians enables a better service to be provided to patients. However, this requires adequate training in the skills of ultrasound (which would not have been possible wihout the support of our radiologists) and also knowledge of the limits of both the technique and ones own skills and experience. Although we now perform a lot of thoracic ultrasound, we regularly refer cases to highly experienced radiologists (such as Dr Gleeson), and this facility is essential. Not only do radiologists have a better understanding of ultrasound in general (including the important limits to this technique), but they are also uniquely skilled in providing imaging expertise. Radiologists have access to and a thorough understanding of when other imaging modalities may be preferable.
In addition, as with all "new" techniques (at least for the non- radiologist) there is a danger of over confidence and over-reliance on the newly acquired skill. Access to supportive and skilled radiologists as part of a physician based ultrasound service is therefore essential and complementary.
Competing interests: None declared
Competing interests: No competing interests
Given the effectiveness of ultrasound scanning as a clinical tool it is perhaps inevitable in the long term that market forces will drive the increasingly compact ultrasound devices into wards and surgery’s to be used routinely by physicians and general practitioners. However, in her article Wise (1) does not make mention of the fact that ultrasound scanning is a very operator dependent modality where the accurate reporting of an abnormal finding is based on the confidence of the operator (2). This in turn is reliant upon maintaining skills by using ultrasound regularly as part of daily clinical practice. An ad hoc approach to maintain the necessary required standard would not suffice here and on the contrary, would generate unnecessary further imaging.
Furthermore, radiologists’ ultrasound skills are continuously honed in the department by correlating ultrasound findings with CT and MR, as well as case discussions in MDT meetings where both positive and negative feedback is of educational merit. The main concern with the explosion of ultrasound as a diagnostic tool is not if non-radiologists are adequately trained, but whether the necessary competency can be maintained.
1. Wise J. Everyone’s a radiologist now. BMJ. 2008 May 10;336(7652):1041-3.
2. Jang T, Naunheim R, Sineff S, Aubin C. Operator confidence correlates with more accurate abdominal ultrasounds by emergency medicine residents. J Emerg Med. 2007 Aug;33(2):175-9
Competing interests: None declared
Competing interests: No competing interests
The article by Jacqui Wise is really timely. All ultrasound trainees currently require a clinical placement which is supported by specialist trainers and these are typically situated in NHS Trusts. Where these placements already exist, there is already “competition” for machine time for training by both sonographers and specialist trainees in radiology. Access to ultrasound systems for training is also becoming increasingly difficult in the target driven NHS and there has been no workforce planning for sonographers with a resultant national shortage. It is not surprising therefore those non-radiology medics with an interest in ultrasound are finding it difficult to obtain clinical training.
The approach to early clinical training needs to shift away from the NHS Trusts. This is achievable if a skills laboratory is used. This allows trainees to acquire basic ultrasound scanning and interpretive skills under the guidance of expert trainers in a relaxed environment out with busy NHS Trusts, using human models who have given informed consent for scanning. Once trainees have achieved a defined level of skill they can then move into clinical practice in the hospital setting with a degree of proficiency to obtain true clinical experience of cases under supervision until signed off as competent. This model is being used to good effect here in this university for training of sonographers, radiologists, urologists, nephrologists and physiotherapists. A national strategy is required to support the development of these skills laboratories to ensure that the ever increasing demand for ultrasound training can be met.
After 17 years as an ultrasound trainer, a word of caution about ultrasound being done by all - ultrasound scanning requires good manual dexterity and spatial awareness. In conventional ultrasound the operator has to obtain scan planes and must reconstruct a 3-dimensional reconstruction of the body structures in their mind. Some people are not able to develop these skills and are therefore never able to practise ultrasound competently. It is essential that anyone who picks up a probe is properly trained and assessed to ensure patient safety.
Competing interests: None declared
Competing interests: No competing interests
The use of Ultrasound (USS) in Emergency Medicine (EM) has evolved over the last few years. USS is used in the trauma setting to detect free intra-abdominal blood (FAST). Other uses include detecting pleural or pericardial effusions,aortic aneurysms, localisation of foreign bodies, placement of drains or intravenous central lines and the detection of musculoskeletal injuries, eg, muscular or tendon rupture, haematomas.
Availability of this service within EM departments is not uniform. It is dependant on the consultant staff having the interest or skills to perform USS and upon finances being available to purchase USS machines. Training in USS is not mandatory to obtain a CCT and variable amongst EM SpR's.
The main issue in performing USS in EM departments is the competency level required to interpret USS images with a degree of diagnostic accuracy. Local training programmes, in conjunction with support from radiological colleagues, are required to maintain practical skills and image interpretation. Until this practice is widespread clinical governance issues may hinder the progress of this investigation in EM.
Competing interests: None declared
Competing interests: No competing interests
As a budding radiologist about to enter my ST training in August, I couldn’t agree more that ultrasound is a fantastic diagnostic tool. But would I want everyone performing it - no! Apart from the obvious problems directly affecting our own radiology training as a consequence, accountability and litigation will be big issues that many other specialties will be weary of, and will eventually shy away from.
Such radiological assessment is also at risk of taking away all clinical acumen; with more and more physicians relying on imaging to make a diagnosis, we are risking missing other ‘invisible’ pathologies. Does Dr. Woywodt really want to scan his patients himself ‘because he knows them very well’ – or is this merely a quick short-cut to avoid clinical assessment – and is he willing to hold responsibility for an ultrasound report when he misses a failing kidney one day? Such events are inevitable if ultrasound indeed becomes as widespread a bedside tool as many wish it to be.
I have lost count of the number of times I have been on consultant ward rounds where scans have been requested at the end of the bed and the patient remains untouched by the clinician. Is the next step a mobile ultrasound machine on the ward round with the pitiable house-officer scanning everyone’s bellies. These are the beginnings of the radiological slippery slope. Maybe we should just put patients through a scanner as they enter the A&E department.
Dr. Maskell’s idea that ultrasound should be taught as part of the medical curriculum also strikes me as somewhat hasty. Do we really want to head towards a future of ‘non-touch clinical assessment’? Do we hear future examining Professors glaring from above their spectacles at the ultrasound screen rather than the sweaty final year medical student: “So tell me Mr. Carter, how many centimetres below the costal margin does your probe detect the liver to be?”
It will be a sad day for medicine when the skills of yesteryear passed on down generation’s withers away to produce the Cyber Medic. So no, I don’t think everyone should be a radiologist. Leave it to the experts.
Competing interests: None declared
Competing interests: No competing interests
I was disappointed that your article did not mention the use of ultrasound in the Emergency Department. Ultrasound is now part of the Emergency trainee's curriculum and there are clear guidelines published by the College of Emergency Medicine as to how this training should be obtained and how a trainee should maintain his or her skills. In our department we use ultrasound for seeking out abdominal aortic aneurysms, in trauma patients looking for free fluid and for insertion of central lines. The key to using this modality by non-radiologists is to recognise one's limitations and understand that it is for ruling in a condition and not ruling out pathology. We have set up a training programme for the trust to teach basic ultrasound skills to all those who insert central lines, as recommended by NICE, and this has been well received and supported by our radiology department.
Competing interests: None declared
Competing interests: No competing interests
I read with interest the article entitled "Everyone's a radiologist now". I agree that ultrasound examination is quick, easy and cheap, and should definitely be more widely available. It would however, necessitate adequate training for non-radiologists.
I read with deep concern Dr. Giles Maskell's statement that it would be "almost criminal" for a doctor to carry out an aspiration without using ultrasound. As an orthopod, I regularly aspirate knee joints without ultrasound guidance. The reason I am able to do this safely is because I have been trained to detect the presence of fluid in the joint using clinical acumen. On the other hand, I have had no training at all in ultrasonography. I am sure that Dr.Maskell would agree that the interpretation of an ultrasound scan is very operator dependent. In addition, imaging techniques should never take the place of a proper clinical examination. Such impetuous statements are more suited to the front page of a tabloid newspaper than a respected medical journal.
Competing interests: None declared
Competing interests: No competing interests
Ultrasound as a teaching tool in medical school
We read with interest Jacqui Wise’s “Everyone’s a Radiologist Now” feature. Of note, no mention was made of the integration of ultrasound into practical anatomy sessions at Newcastle University Medical School. As former anatomy demonstrators there, we had first-hand experience of the benefits of such teaching.. Students were shown how to visualise a range of structures, including the carpal tunnel, temporomandibular joint and the brachial plexus, and practiced locating such landmarks under supervision. Feedback from students was extremely positive in this respect, with the use of ultrasound stimulating an interest in – and enhancing the understanding of – applied anatomy. Discussions focussing on central line insertion during neck vein examination, for example, meant that students could start to appreciate the clinical applications of ultrasound.
However, whilst the use of ultrasound as an adjunct to clinical examination is a good idea in principle, the incorporation of such training into undergraduate medical curricula would be a logistical nightmare. In our experience, even demonstrating how to operate the equipment and supervising groups of students performing basic tasks can be a taxing and time-consuming process, particularly given that there is somewhere in the region of 200 students in a year group. To ensure all students are competent in using ultrasound clinically would require not only a huge input in terms of man hours (presumably such teaching would best be delivered by radiologists or sonographers, the majority of whom will also have not insignificant clinical commitments), but also substantial financial resources. Surely it is not possible for every medical school to benefit from affiliations with GE Healthcare (or similar)? There is also the very real risk that students, once qualified, will act outside their spheres of competence – and who will assume responsibility for potentially serious missed diagnoses?
It will be interesting to find out whether or not the University of South Carolina project succeeds – that is, if we can actually gauge the success (or otherwise) of such a project. However, while teaching ultrasound skills to the masses is an admirable concept (and surely there can be little doubt as to its value in clinical assessment), there is a long way to go before such dreams can be realised. The pragmatic approach employed by Newcastle University Medical School in teaching anatomy is ostensibly a good way to start.
Competing interests: None declared
Competing interests: No competing interests