SonoNews: Radiologists should guide point-of-care ultrasound training? …lets think about this…

In an insert of Diagnostic Imaging, Dr. Michael Blaivas (an emergency physician, past president of ACEP US Section, Section Chair of Emergency/Critical Care for AIUM, and basically about 3 or 4 more titles that would take a few more lines in this post to mention because he is that amazing) spoke about how radiologists have historically been threatened by and become obstructionists in its use by non-radiologists, then became less so as it was apparent that radiologists didnt have the time to do it  – possibly due to radiologist shortages and becoming focused on CT and MRI (according to Dr. John Cronan – chair of Radiology at Brown Univ), and now are not involved or part of the team with point-of-care ultrasound training – but they should be, according to Blaivas in this article by Sara Michael. However, this article concludes the wrong thing – in my opinion – and has misunderstood Blaivas’s point. Instead they reaffirm the angst felt by radiologists today and fail to explore why. Radiologists have submitted a “National Curriculum” for medical student education in ultrasound as well, that has come to add to further controversy as there are no other specialties involved in the discussion…. But, of all the medical student US curriculums out there, most, if not all, are coordinated by non-radiologists.

“Point-of-care ultrasound has become ubiquitous in medicine, from emergency departments to OB and trauma surgery. But that doesn’t mean it’s taking the modality away from radiologists.In fact, radiologists should be the ones guiding its training and promotion – not bemoaning and pushing back on the trend. “Radiologists are not involved in ultrasound education and promoting its use in point of care or elsewhere, but it would be nice to have more involvement,” Michael Blaivas, MD, an emergency medicine physician and past chair of the American College of Emergency Physicians ultrasound section, said during a presentation at RSNA 2012 this week. “It’s better to be seen as proponents of an application, guide it, and help with it, especially an application that is seen as critical at the bedside.” Radiologists are the ultrasound imaging experts, Blaivas said, and should be the first to share their expertise. The specialties shouldn’t be fighting each other, he said, but working to make sure the modality thrives for all clinicians. If radiologists were more involved in teaching, they could ensure quality in its use. “There really is a need for ultrasound education, and this is somewhere we can meet,” he said.”…”Today, [Dr Cronan] said, radiologists are “working feverishly to protect our income,” and the profession faces threats of commoditization with the rise of teleradiology and service-live imaging. Although ultrasound is likened to the stethoscope in its extension of the physical exam, Cronan noted, it’s used by many, understood by few.”

Ive been thinking a lot about it recently, and trying to understand radiologists’ continued angst about non-radiologists performing point-of-care ultrasound. I’ll start with these few points: radiologists do perform ultrasound studies – both limited and complete – and that hasn’t and shouldn’t change, they ARE imaging specialists. I do rely on them when my point-of-care ultrasound shows that a complete ultrasound study or a CT scan is needed. Many radiologists do not see the ultrasound studies that non-radiologists perform or how they are quality assured, and the fear of the unknown can drive quite a few political decisions. They have not been involved in point-of-care ultrasound training either, and this, in combination with the above, will give even more angst. I do agree, they SHOULD be a part of the education (and I know some will disagree with me) – this will have those who perform point-of-care ultrasound learn more techniques (with the applications that are also performed by radiology) and the radiologists will learn/see what we do, how we do it, and why it’s so important for us (and our patients) at the bedside. They will see that our images are actually quite good and that our QA and training direction is strict enough through our ACEP guidelines. Should they be in charge of it’s training? I dont think so. Is it an extension of the physical exam? No, it’s so much more than that. Here’s what keeps coming into my head:

1. The AMA passed a resolution that states ultrasound does not belong to any one specialty, but it can be incorporated into any specialty as defined by that particular specialty – later to also have a resolution that ultrasound is safe, effective, and efficient when used under the direction of an appropriately trained physician and should be supported in its educational efforts when integrating into medical education.

2. Many of the point-of-care ultrasound applications are not ordered/performed through radiology. Before emergency medicine and critical care docs started performing bedside ultrasound, they did not order an orbital ultrasound, an IVC ultrasound, a musculoskeletal ultrasound, a soft tissue ultrasound, an Aorta ultrasound, a cardiac ultrasound, a thoracic ultrasound, a procedural guided central or peripheral venous ultrasound…. through radiology. And, cardiologists did their echoes, OBGYN docs did their pelvic ultrasound over the last 15-20+ years, and, for the most part, trauma teams performed their own FAST scans.

3. Time matters. When there is a patient in shock, a crashing (or stable) trauma patient, and a patient who is acutely short of breath or with acute chest pain or acute abdominal pain or acute pelvic pain or with acute vision loss… and any procedure where ultrasound is needed…. we rule emergent conditions in and out and get that procedure done, quickly.

We need to have this conversation with our radiologists, let them know of our QA process, educate them on the way and the reasons we perform bedside ultrasound, and alleviate their (and all of our consultants’) angst about our ultrasound studies. The team approach to ultrasound training for medical students is very important, and they should be a part of that.