Category Archives: Medical Education

Getting Sonography Students Hands-on Experience

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As the Program Director of a Commission on Accreditation of Allied Health Education Programs (CAAHEP)-accredited General sonography program, I have a request for all OB/GYN practices. Please open your practice to accept sonography students. The future of the OB sonographer depends upon it.

If schools cannot provide graduates with good entry-level OB skills, there will not be enough sonographers to fill the OB sonography positions within private practices and this includes the MFM specialties.

Student rotations are down because the sonographers are too busy to allow students to scan. I have been given the following reasons why they are too busy:

  1. Patients are scheduled every 30 minutes all day.
  2. Work-ins are expected to be added daily into the already booked schedule
  3. It is not uncommon for a single sonographer to perform 15–20 patients per day.
  4. There are usually no breaks except for lunch, maybe.
  5. Some practices have more than one sonographer but each performs the same amount of studies so there is no relief person to help out.

This type of scheduling (over-scheduling) sets up a whole new set of questions.

  1. How long can one sonographer sustain such a schedule without suffering from burn-out and choose to leave employment?
  2. How long can one sonographer sustain such a schedule without suffering from repetitive stress injuries that will force their retirement?
  3. If sonographers are having to rush through studies to get all of the patients through, what are they missing?
  4. What is the satisfaction level of the patient who feels they are on an assembly line when getting their sonogram?  I do believe this is one reason many “peek-a-boo -see your baby” businesses are flourishing; OB patients want to experience fetal bonding with their families, time for which the private practice schedules do not allow. (“The AIUM advocates the responsible use of diagnostic ultrasound and strongly discourages the non-medical use of ultrasound for entertainment purposes.” See The Issue with Keepsake Ultrasounds for more information.)

Although there is value in observation, which the students may be allowed to do, nothing can replace a hands-on experience with supervision and instruction. And, yes, labs help, but the accrediting bodies require our students to scan patients not models.

For at least 2 decades, educators have struggled to find OB clinical sites that would allow their students to gain the scanning skills needed to complete their clinical competency exams, which are required for graduation. With no resolution in sight, even the Joint Review Committee on Education in Diagnostic Medical Sonography (JRC-DMS) and CAAHEP have recognized that some General accredited programs could not meet all the standards and, therefore, have now provided us a way to separate out the specialties. This allows for the deletion of the OB specialty from their accredited programs. This is a way for educators to deal with the problem of not being able to gain access to 2nd- and 3rd-trimester OB patients for their students, but it will ultimately be bad news for the OB community in general.

I believe the sonography community is an intelligent and creative group. We can find ways to integrate students into a busy environment. I actually have some clinical sites that do a very good job of it. I encourage you to think outside of the box and let’s get creative so that the schools will be able to provide qualified graduates when they are needed. If we don’t, we will begin seeing private OB “cross-training” on the job, again.

Is that what we really want? Comments, opinions, rebuttals, suggestions are encouraged and I look forward to reading them all.

Kathy A. Gill, MS, RT, RDMS, is a Program Director of the Institute of Ultrasound Diagnostics in Spanish Fort, Alabama. Kathy has been a Registered Diagnostic Medical Sonographer since 1977 and has been involved in sonography education for 30+ years.

Interested in learning more about ultrasound in medical education? Check out the following posts from the Scan:

POCUS in Primary Care: Advice for Incorporating Ultrasound into the Clinic

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The utility of point-of-care ultrasound (POCUS) is readily apparent in a busy Emergency Department (ED) or Intensive Care Unit. Now, as healthcare in the U.S. changes and decentralizes, widespread POCUS in primary care is poised to show its value to medical systems in a way that will eclipse its impressive origins in hospitals. However, there are many reasons primary care ultrasound hasn’t taken off…yet. Among them is that effectively incorporating POCUS into a clinic can be hard work with many upfront challenges. The following is some advice on overcoming these challenges, focusing on 3 areas.

  1. Determine your desired scope of practice and manage expectations
  2. Get really good at POCUS
  3. Optimize your clinic POCUS workflow

1. Determine your desired scope of practice and manage expectations

Learning to use ultrasound is very similar to learning a musical instrument—you don’t jump in with Chopin, you start off by playing Chopsticks or practicing chords. When determining their intended POCUS scope of practice, outpatient clinicians need to consider that the things they are most interested in doing right away might be some of the more technically demanding or challenging things to learn. Here are some good examples of common outpatient POCUS goals and more appropriate starting points for beginners:

Body RegionAspirational POCUS ApplicationAppropriate POCUS Starting Point
AbdominalGallstones, Cirrhosis, AppendicitisAscites
CardiacLVH, Pulmonary HypertensionPericardial Effusion
PulmonaryPneumoniaPleural Effusions and Pulmonary Edema
MusculoskeletalRotator Cuff TearsKnee Effusion

Furthermore, even if you appropriately start small and easy, chances are you will at some point perceive that you are terrible. This is normal and experienced by many POCUS experts when they first started. Keep at it, and ensure you have a marathoner’s mindset; remember it’s no quick sprint and requires a stepwise approach. You can learn more about a specific approach to teaching and a framework for growing a POCUS skillset for generalists (PEARLS) by watching the AIUM webinar, “PEARLS: A Physical Exam with Pocket Sized Ultrasound for Routine Use,” here: https://youtu.be/ywuIeoEfG1I

2. Get really good at POCUS

Easy as that, right? Unfortunately, learning POCUS in the clinic is HARDER than learning POCUS in the hospital setting. The time constraints are just as bad as in the ED and, generally, the pathology is much less frequent and more subtle when present. Obtaining cardiac windows in the patient who can’t get out of their wheelchair or rollator let alone climb up to the exam table is not an uncommon circumstance. So how do you get really good under these circumstances? Three key interconnected principles dominate the philosophy we try to instill in our learners as part of our training:

  • Scan Routinely
  • Practice Deliberately
  • Track Your Experience (Build Your Portfolio)

Scan Routinely is probably the most controversial of these, and for me, also the most important. The routine performance of “educational” scans during residency, fellowship, or other training period is the bedrock for successful training and is generally accepted in the POCUS community. This allows one to practice deliberately and pursue a path towards mastery.

The number 1 biggest mistake I see in the early plateaued POCUS learner is they are only performing scans if they feel it is clinically indicated or they have a specific clinical question they expect POCUS to help them answer. If you are not routinely using POCUS you will likely not achieve or maintain the experience where your POCUS skillset will be clinically useful to you.

My threshold for incorporating ultrasound into my evaluation of patients is probably much lower than other POCUS users, and my experience has been that this has helped me tremendously. This experience has supported the perspective that POCUS should be viewed as a vital clinical skill to be perpetually maintained and improved upon, not a separate and distinct diagnostic test to be brought out only when patients fit into narrow predefined boxes.

Finally, even if you do not incorporate images into the EMR or bill for your exams (and there are many reasons why you should not do this early on), you should routinely save your images and build a portfolio. Committing your interpretations to a log, on paper or electronically, allows you to attain vital feedback through your longitudinal experience and patient follow-up. It also allows you to more easily seek expert mentorship, teach others, and can serve as inspiration if your motivation or progress seems to drop off.

3. Optimize your clinic POCUS workflow

Like many aspects of clinic, part of optimizing your POCUS workflow involves training your staff. In many ways, it helps to treat the POCUS device like the clinic EKG machine. If you know you will likely include POCUS because of the chief complaint (eg, dyspnea, flank pain, or lower extremity swelling) have staff put the patient in the most suitable room and ensure they are properly undressed/draped in advance. Train staff to be comfortable handling the device, cleaning it, and setting it up in the room with patient information entered in (if applicable). If you unexpectedly determine POCUS is needed during an encounter but setup is suboptimal, see another patient while the patient and room are prepared. Also, consider restructuring how you examine patients. Often time constraints do not permit the traditional order of history -> traditional examination -> ultrasound examination, and you will be more efficient by incorporating ultrasound sooner and blending history and pertinent traditional exam maneuvers along the way.

Finally, when first starting off, when incorporating routine scanning into your workflow, keep a narrow focus and a set time limit (<5 minutes). Don’t be shy about using an alarm on your phone to keep yourself honest. You may need to focus on obtaining a single high-quality view, and then add additional views as you’re able while still staying under time. Taking 20 minutes to perform POCUS in the middle of a packed clinic is another common mistake that can torpedo a workday and create negative associations that increase reluctance to practice and utilize POCUS.

Once you obtain some basic skills at POCUS and have a good clinic workflow, you’ll quickly get a few early saves and successes that enhance your dedication and propel you forward. Before long, you will wonder how you ever did without it!

Mike Wagner is looking to the camera while semi recumbent on a patient bed. He is holding an ultrasound transducer in his right hand and his pants leg has been pulled up to bare his knee.
Mike Wagner, MD, FACP, FAIUM, during a remote/virtual teaching session.

Mike Wagner, MD, FACP, FAIUM, is an Associate Professor of Medicine at the University of South Carolina School of Medicine in Greenville.

Want to learn more from Mike Wagner? Check out these resources from the American Institute of Ultrasound in Medicine:

Ultrasound Education in the Post-COVID Era

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In his book, The Innovator’s Dilemma, Clayton Christensen discusses the idea of disruptive technology. This market force that challenges industry norms can create new opportunities but also requires traditional market fixtures to adapt in order to maintain effectiveness.

Point-of-care Ultrasound (POCUS) has emerged as a disruptive technology in medical imaging. It relies heavily on education, both for new learners and also for those continuing to advance their knowledge base as skilled sonologists. As ultrasound technology improves and the scope of POCUS expands, two important facets of ultrasound education are collaboration and innovation. 

Ultrasound has traditionally been confined to specific rooms within the house of medicine. However, POCUS has grown to include a variety of specialties. Emergency medicine, critical care, hospital medicine, outpatient clinics, and even surgical specialties have all benefitted from “Ultrasound First” and the diagnostic specificity of ultrasound. But just as every disruptive technology creates challenges for traditional users, the democratization of ultrasound has required new users and traditional imaging specialties to rethink the imaging paradigm. 

Since each specialty (traditional or new adopter) comes to the table with a unique skillset and expertise, we benefit from collaboration. In the same way that a rising tide lifts all boats, cross-departmental collaboration allows for a broader understanding of the interplay between a patient’s anatomy, physiology, and ultrasound findings. 

In our institution, we have sought to use ultrasound as a tool to build bridges between departments. We have brought sonologists from various specialties together to teach anatomy with ultrasound. We have brought our ED residents to the MICU to scan patients with known pathology and MICU fellows to the ED. We have conducted cross-departmental ED/Radiology case conferences discussing the use of bedside ultrasound and traditional imaging. In each of these examples, we have sought ways to build collaborative relationships with other departments and benefit from each other’s particular perspective and experience. 

Ultrasound proficiency requires a firm foundation of both didactic knowledge and psychomotor skill. There is a significant interdependency between the classroom and the bedside. By restricting access to both spheres, COVID-19 has interrupted our normal way of living and educating and created a number of challenges to continuing ultrasound education. But, like a silver lining behind every dark cloud, the distance that COVID has created physically has drawn us together in unique ways. Distancing, occupancy limits, and virtual interactions have required us to reimagine ways of reaching learners. 

A large part of our continuing ultrasound education is a regular ultrasound lecture series. Virtual education has allowed for more flexibility with attendance. Individuals who traditionally could not attend an in-person lecture due to time or geographical constraints can now participate. We previously included learners from various departments within our institution. However, with virtual lectures, we have included students, residents, fellows, and faculty from other institutions throughout our greater region.

In addition to increasing the participant base, virtual education has allowed us to tap into a broader faculty base. The traditional model of medical education relies on in-person lectures and didactic education. Virtual education opens opportunities to include regional, national, and international experts. Prior to COVID, a visiting lecturer would have to take time away from their personal practice and travel to a particular place. Now, a speaker can attend via Zoom or other platforms. This has allowed us to invite outside experts to our educational forum. And for faculty looking to build an educational portfolio and progress through the academic ranks, virtual education allows for junior faculty to gain experience as visiting lecturers. 

As we emerge from the COVID era, I personally look forward to losing the masks, gathering together again, and seeing the word “virtual” used less ubiquitously in the English lexicon. But our imperative as ultrasound educators is to learn from the ways that COVID has changed our existing models for education and has caused us to adapt to new teaching methods. We should embrace the disruptive technologies of the past year and find ways to blend the advantages of cross-departmental, in-person learning with cross-institutional virtual education. To the extent that we are successful in this endeavor, we will find increased cohesion as a community, improved educational opportunities for our learners, and, ultimately, improved outcomes for our patients. 

Matthew Tabbut, MD, FACEP, is Director of Emergency Ultrasound at MetroHealth Medical Center in Cleveland, Ohio.

Interested in learning more about POCUS? Check out the following posts from the Scan:

Sink or Swim? Modifying POCUS Medical Education Curriculum During the Coronavirus Pandemic

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Modifying a point-of-care ultrasound (POCUS) medical education curriculum initially designed for 4-year matriculation into a 3-year experience is undoubtedly challenging. This 1-year shortening, combined with the added constraints of mandated social distancing guidelines of the coronavirus pandemic, caused us to search for concrete answers to these new directives that would lead us to either sink or swim in this new ocean of learning.

Claude Bernard, a 19th-century French physiologist, remarked that “it is what we think we know already that often prevents us from learning.” This educational concept was true with our efforts to modify a successful ultrasound in medical education curriculum and transform it into a case-based learning approach for a condensed 18-month pre-clerkship ultrasound curriculum.

How we had conducted ultrasound labs previously would have to be revisited, revised, and revamped to transform the curriculum successfully.

Planning began to modify the ultrasound curriculum for the 18-month pre-clerkship experience approximately 2 years before the pandemic was even on the horizon. In-person meetings were held with fellow faculty to discuss and debate the patient-centered learning course’s mission and goals and where the ultrasound curriculum would be housed. Our discussions took place with ease, and ideas for collaboration easily flowed. Plans were made for in-person, hands-on scanning where students scanned each other, volunteers, or standardized patients, without giving any thought to the physical contact.

There was no thought to the exam rooms’ square footage or how students would enter and exit the ultrasound center. Live introductory lectures at the onset of each lab were planned for 25–30 students to introduce the case and review the scanning techniques and logistics for each lab session. The planning included no discussion of online learning or simulated scanning for students from a remote location. Ultrasound instruction would proceed into the new curriculum with a slight modification to how ultrasound content had been previously delivered.

Then, while finalizing our plans for a start date of August 2020, all in-person instruction was suspended for our institution. It was mid-March, and we had a nearly solidified sketch of the ultrasound lab logistics and learning methods for the inaugural class of the 3-year medical school and the 18-month pre-clerkship curriculum.

Nevertheless, that suddenly changed, and the uncertainty of instructing anyone in-person to do any part of the curriculum was up for discussion. The faculty was mandated to work from home away from the ultrasound center with its hand-held systems, full-size ultrasound machines, and simulation capabilities. Student interactions were reduced to phone calls, emails, and video interactions within online course offerings as each student cohort was scattered throughout the 159 counties of our state.

Learning to conduct curriculum meetings through online platforms filled our days. Trying to accomplish fully online ultrasound electives with a plethora of students and revamp the new ultrasound curriculum within the changing coronavirus guidelines stayed on our minds as we struggled through the spring and early summer.

Nevertheless, we made it!

When the inaugural class of the new pre-clerkship curriculum began, we laid out a plan to keep students, staff, and faculty safe through the 3W’s: wearing a mask, watching physical distance, and hand washing.

Facilities management personnel had surveyed our ultrasound exam rooms and learning spaces and posted how many students could be in each room. Hand sanitation stations and masks were made available for students as they entered the ultrasound center. Signage and arrows were erected to direct students in and out of the ultrasound center in a one-way fashion. An online meeting platform was set up in each exam room for students to hear live instruction before beginning the lab. Instructors utilized a laser point at each room’s door to direct student scanning and maintain social distancing. Students used hand-held ultrasound equipment with image transfer capabilities to obtain images needed to complete their online case-based ultrasound assignments. Although these safety measures were not visualized in our early curriculum planning meetings, the ultrasound curriculum was successfully delivered!

While we did not meet the goal of remote hands-on ultrasound instruction for all ultrasound labs during the pandemic, we learned to conduct in-person ultrasound scanning labs safely and effectively within a new accelerated medical school curriculum. The constraints and trials of a global pandemic did not preclude us from putting aside what we already knew and navigating a new course into the future!

Headshot photograph of the post author, Rebecca J. Etheridge. She is shown in front of a gray background wearing a blue suit jacket and has shoulder-length red-brown hair.

Rebecca J. Etheridge, EdD, RDMS, is an assistant professor at the Medical College of Georgia at Augusta University.

Interested in learning more about ultrasound education? Check out the following posts from the Scan:

A Loss of Great Magnitude

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Good-bye, Harvey Leonard Nisenbaum, MD

Head shot of Harvey Leonard Nisenbaum, MD, FACR, FAIUM, FSRU.

We have lost a leading expert in ultrasound education, AIUM Past President, Harvey Leonard Nisenbaum, MD, FACR, FAIUM, FSRU, who died on October 8, 2020.

Dr Nisenbaum was a leader in the field of ultrasound even just out of school, when, after completing his residency in diagnostic radiology at Montefiore Medical Center in the Bronx, New York, he became a lieutenant commander in the U.S. Navy and served as the director of ultrasound at the former Naval Regional Medical Center in Philadelphia until 1976. That is when he joined the faculty of Albert Einstein Medical Center in Philadelphia, where he became the head of the Ultrasound section, acting chairman of Einstein’s Department of Radiology, and president of the medical center’s staff.

Dr Nisenbaum couldn’t help but share what he knew to encourage the next generation of ultrasound advocates. And, in 1993, enabling him to connect with more students, he moved on to the Department of Radiology at the University of Pennsylvania Perelman School of Medicine and, ultimately, chairman of the Department of Medical Imaging at Penn Presbyterian Medical Center (PPMC) from 2001 to 2018 and Emeritus Associate Professor CE of Radiology.

“Under his leadership, the Department introduced tremendous scientific advances in Medical Imaging into clinical practice and greatly expanded its contribution to the hospital’s mission.”

— Penn Presbyterian Medical Center

To honor his legacy, they will award the Harvey Nisenbaum Award for Medical Imaging Research at PPMC for the first time in 2021, which Dr Nisenbaum learned of before his passing. The award will recognize medical students, residents, and fellows who continue his legacy at the Department of Medical Imaging by creating new scientific intelligence through research. He had also earned a Special Dean’s Award for his help in developing and implementing the ultrasound curriculum for the Perelman School of Medicine.

Dr Nisenbaum was an active volunteer, he served on numerous committees, both at his hospital and for the many societies and organizations to which he was a member, including the American Institute of Ultrasound in Medicine (AIUM), which he joined in 1975. By 2009, he became President of the AIUM. During his tenure, donations to the Endowment for Education and Research to increased significantly, AIUM membership grew by 11%, and the online Career Center was launched as a new member benefit. Dr Nisenbaum was awarded the AIUM Presidential Recognition Award (twice; in 2006 and in 2012), and the Peter H. Arger, MD, Excellence in Medical Student Education Award (2020), which honors an individual whose outstanding contributions to the development of medical ultrasound education warrant special merit. Dr Nisenbaum earned this award for being instrumental in incorporating ultrasound into medical school curricula.

The Society of Ultrasound in Medical Education (SUSME), presented Dr Nisenbaum with the SUSME Legacy Award in 2013 for his outstanding contributions to ultrasound education. He served as president of the World Federation for Ultrasound in Medicine and Biology (WFUMB; 2015–2017), during which time 3 Centers of Education were created, in Paraguay, Moldova, and Sudan. Following his presidency, in 2018, he took a year-long sabbatical to volunteer even more of his time organizing projects to bring ultrasound to underserved countries.

In addition to these worldwide contributions, Dr Nisenbaum was also a past-president of the Pennsylvania Radiological Society, the Philadelphia Roentgen Ray Society, and the Greater Delaware Valley Ultrasound Society.

Dr Nisenbaum’s enthusiasm for ultrasound education along with his vast well of ultrasound knowledge and his willingness to share it have influenced countless students, physicians, and other medical professionals. He will be sorely missed.

Hey, Ultrasound! What Did I Do Without You?

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I trained as a physiatrist, which means a great deal of education on musculoskeletal conditions. Over the course of my residency training, I became more and more comfortable with bony and soft tissue landmarks for examination and targeting various joints, nerves, and tendons for therapeutic injections. As I was supervised by attendings, and carefully followed their instructions, there was no doubt in my mind that the tip of my needle was at the target intended. Why would I doubt a common practice that has been in existence for several decades?Mostoufi

As I started my fellowship in spine/pain/musculoskeletal care, I found the love of my life, the fluoroscope!!  Here, I had access to a tool that made life incredibly easy. I actually could visualize my targeted hip, shoulder, or facet joint, and inject some contrast to identify the needle tip within my target. I could precisely deliver therapeutic medications to a particular nerve root, and even identify vascular uptake and avoid procedural complications.

It was then and there that I realized that there were substantial shortcomings in what I learned as “landmark-based injections”. I realized that even though I had learned the proper “blind” procedure technique, there was no confirmation that my medication had reached its intended target. More importantly, if my patient did not respond to the procedure, I could not differentiate between a medical condition that was not responsive to the treatment versus shortcomings of un-guided procedures and inadequate delivery of medications to the targeted tissue/joint. For 12 years, I confidently treated thousands of patients by performing spine and musculoskeletal injections using my fluoroscope. I enjoyed using my C-arm, and life was pretty good.

In 2011, while attending a PM&R national conference, I sat through a 15-minute presentation on overdiagnosis of trochanteric bursitis. The speaker eloquently described fluoroscopic-guided bursa injection. This was something that I did on a regular basis as a diagnostic step. He then used ultrasound (US) images to demonstrate a few cases of gluteus medius tendinopathy and also trochanteric bursitis and how US can be superior to X-ray in therapeutic sub-gluteus maximus bursa injection. While sitting and listening, I recognized that it was virtually impossible to press against the lateral trochanter and be accurate about the diagnosis. It is also not possible to use fluoroscopy and be sure that the steroid or regenerative treatments are correctly delivered to sub-gluteus maximus bursa.

Remembering how helpful fluoroscope was to identify particular bony landmarks and assist with the proper treatment of spine and joint disease, here I was discovering a new tool that can enhance diagnostic and therapeutic skills in musculoskeletal care in particular soft tissue disease (nerves, muscles, tendons). This meant a fundamental change in the way I was going to treat patients but also a change in how I train the next generations of Physiatrists, coming through our residency program.

Fig 3aFig 3b

Learning to use the US, and incorporating it into the practice was much harder than I envisioned and also very expensive. At the time, there were limited well-structured educational resources available, and the learning curve was quite steep. As I was learning, I had to beg (or pay) my kids to become my scanning subjects!!

In contrast to a fluoroscope, it is nearly impossible to recognize an abnormal structure on the US unless you are comfortable with the normal anatomy. With a ton of hands-on workshops, mentorship, practice, and with assistance from my new found love of ultrasound machine, and guidelines from the AIUM, ultrasound has become easier and more enjoyable!! The abnormal findings became more clear and treatments more effective. In this process, I found out that patients enjoy looking at the US screen and being explained about finding on a screen full of gray, gray, and grayer lines and curves.

US has transformed how physiatrists practice and teach musculoskeletal medicine. Point-of-care US imaging allows for the residents and fellows to visualize various organs or structures within an organ, recognize healthy and diseased tissue, and diagnose the problem on the spot. This, in turn, will lead to a quick and targeted treatment and satisfied patients.

Examples of musculoskeletal (MSK) conditions that US has proven to be an effective tool to workup or treat includes rotator cuff and biceps tendinopathy, small or large joint injections, upper extremity nerve entrapments, muscle and tendon tears, peripheral nerve lesions, carpal tunnel syndrome (CTS), intersection syndromes, trigger fingers, plantar fasciitis, piriformis and sciatic complaints, treatments of bursitis or tenosynovitis, iliotibial  (IT) band treatment, ischiofemoral impingement, and many diagnoses for which dynamic testing proves to be beneficial.

Fig 6

Despite its cost and extensive training/certification needs, utilization of US in MSK care is predicted to be a standard of care in the next 5–10 years. As more and more practitioners are trained, its use for diagnostic or therapeutic purposes will become the norm.

Fig 7aFig 7b

I still love my fluoroscope and prefer its use in most spine procedures. Adding US has revolutionized my practice and allows me to be a better diagnostician, a better MSK doctor and a better educator for both my patients as well as future providers that come after me. In short, US has been a game-changer.

 

Ali Mostoufi, MD, FAAPMR, FAAPM, is an Assistant Prof. in PM&R at Tufts University, and the president of New England Spine Care Associates (NeSpineCare.com) and Boston Regenerative Medicine (BostonRegen.com).  As a spine and sports medicine practitioner, his clinical practice focuses on Interventional Spine, Diagnostic US, US-based therapeutic interventions and Regenerative Medicine in spine and sports.

Interested in reading more about musculoskeletal ultrasound? Check out the following posts from the Scan:

 

Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

https://connect.aium.org/home

 

The Personal Touch: The importance of human interactions in ultrasound

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As I write this, the novel coronavirus COVID-19 is spreading across the globe, inciting fear and anxiety. Aside from frequent hand-washing and other routine precautions, many leaders, officials, and bloggers are advocating for limiting person-to-person contact. This has resulted in cancelation of many professional society meetings, sporting events, and social gatherings, and has stimulated new conversations regarding working from home and virtual meetings. Although these suggestions have many clear benefits (such as the decreased burden of commuting; limiting the spread of infection), there are additional reports describing the impact loss of face-to-face interactions may have on job satisfaction, workflow efficiency, and quality.Fetzer-David-14-2

The current practice of medicine, more than ever, relies on a team approach. No one individual has the time, knowledge, or experience to tackle all aspects of an individual’s care. No one is an island. Unlike many television shows that highlight a single physician performing everything from brain surgery to infectious disease testing, the reality is that we each rely on countless other members of the healthcare team. That practice of medical imaging, ultrasound, in particular, is no different. Whether we work in a radiology, cardiology or vascular, or obstetrical/gynecology practice, the team, and more importantly the relationship between team members, is paramount to an effective and impactful practice.

As a radiologist in a busy academic center, I rely on and value my personal relationship with my team of 50+ sonographers. These relationships have been facilitated by day-to-day, face-to-face interactions, allowing me to get to know the person behind the ultrasound images. These interactions foster an environment of trust. For my most experienced sonographers, my implicit trust ultimately leads to fast, efficient and precise exam interpretations, while for sonographers I rarely work with, my index of suspicion regarding a finding is naturally heightened, impacting my confidence in my diagnosis and thus affecting my interpretation, and ultimately how my report drives patient care.

The trust goes both ways: a strong relationship also fosters honest communication whereby sonographers can come to me with questions or concerns regarding exam appropriateness, adjustments to imaging protocols, and the relevance of a specific imaging finding. The direct interaction provides an opportunity for sonographers, new and experienced, to be provided immediate direct feedback regarding their study—they can learn from me, and often I from them, making us all that much better at the end of the workday.

In addition to trust, open communication allows for users of ultrasound to take advantage of one of the key differentiating features of ultrasound compared to other modalities: the dynamic, real-time nature of image acquisition. Protocol variations can be discussed on-the-fly. Preliminary findings can be shared with the interpreter, and additional images can be obtained immediately, without having to rely on call-backs, inaccurate reports, and reliance of follow up imaging (often by other modalities). This ultimately enhances patient care and decreases healthcare costs. In our practice, we have the ability to add contrast-enhanced ultrasound for an incidental finding, allowing us to make definitive diagnoses immediately, without having to recommend a CT or MRI—this would not be possible if it were not for a personalized checkout process.

We continue to hear about changes in ultrasound workflow across the country: sonographers and physicians, small groups and large, academic and private practices have all considered or have already implemented changes that minimize the communication between sonographer and study interpreter. This places more responsibility on the sonographer to function independently, and minimizes or even eliminates the opportunities for quality control and education. Sonographer notes and worksheets, and electronic QA systems, are poor substitutes for the often more nuanced human interaction. In my experience, these personal encounters enhance job satisfaction, and the lack of it risks stagnating learning and personal drive. There have been many sonographers that have left local practices to join our medical center specifically to take advantage of the sonographer-radiologist interaction we continue to nurture.

Some elements driving these transformations are difficult to change: growing numbers of patients; increasing reliance on medical imaging; medical group consolidation; etc. Many changes to sonographer workflow have been fueled by a focus on efficiency (decreasing scan time, improving modality turn-around times, etc.). Unfortunately, these changes have been made with little regard to how limiting team member communication impacts examination quality, job satisfaction, and patient outcomes; for those of you in a position to address workflow changes, consider these factors. For sonographers yearning for this relationship, do not be afraid to reach out to your colleagues and supervising physicians—ask questions, be curious, and engage with them. Nearly everyone appreciates a human interaction, and even the toughest personality can be cracked with a smile and some persistence. In the end, it is the human interactions and the open and honest communication that not only make us better healthcare providers but happier and healthier human beings.

 

David Fetzer, MD, is an assistant professor in the Abdominal Imaging Division, as well as is the Medical Director of Ultrasound in the Department of Radiology at the UT Southwestern Medical Center.

 

Interested in reading more about communication? Check out the following posts from the Scan:

The Best of the Scan, 5 Years in the Making

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The Scan has been a home for all things ultrasound, from accreditation to zoos, since its debut 5 years ago, on February 6, 2015.MISC_SCAN_5_YR_ANN_DIGITAL_ASSETS_FB

In its first 5 years, the Scan has seen exponential growth, in large part due to the hard work of our 110 writers, who have volunteered their time to provide the 134 posts that are available on this anniversary. And it all began with Why Not Start? by Peter Magnuson, the AIUM’s Director of Communications and Member Services, who spearheaded the blog’s development.

In honor of this 5th Anniversary, here are some of your favorites:

Top 5 Most Viewed Posts

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1. Ultrasound Can Catch What NIPT Misses
by Simcha Yagel
(August 4, 2015)

Sonographer Stretches2. Sonographer Stretches for an ‘A’ Game
by Doug Wuebben and Mark Roozen
(January 31, 2017)

Keepsake3. The Issue with Keepsake Ultrasounds
by Peter Magnuson
(April 30, 2015)

Hip Flexor Stretch4. 3 Stretches All Sonographers Should Do
by Doug Wuebben and Mark Roozen
(January 19, 2016)

Anton5. From Sonographer to Ultrasound Practitioner: My Career Journey
by Tracy Anton
(October 23, 2018)

The Fastest Growing Posts
That Are Not Already in the Top 5

And we have plenty more great posts, such as:

Therapy Dogs
A Personal Vignette From the ’60s and ’70s
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Novice to Competence to Understanding Our Role as POCUS Educators

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Nights at the VA medical ICU could get lonely sometimes. When the hubbub of the day had drawn down and the critical care fellows had gone home, the work in the ICUs slowed.Headshot_kevin piro

I figured that I would make use of the time that had seemingly stopped. I grabbed the ultrasound and went to scan and chat with a friendly gentleman whom I had admitted the previous night. It became readily apparent that I was still a struggling learner at this point in my training. There was something that looked like cardiac motion, but not resembling anything like the diagrams and videos I had looked at on my own. It was an uncomfortable place to be.

I imagine that is where a lot of people get frustrated and stop, especially when they don’t have someone to encourage and nurture their continued practice. I had a different luxury. Just a few weeks prior, I had received an inquiry about participating in a new general medicine POCUS fellowship at Oregon Health & Science University, and I was instantly sold on its potential. Here was a chance to carve out a new path and to invest in a skill that offered me a skillset that could improve my patient care. And I knew that I would have the benefit of POCUS experts literally holding my hand as I learned the skill. What a luxury!

So, I kept scanning in the ICU prior to my fellowship. You know what I found? Patients are much more forgiving than we might imagine them to be. Most understand that hospitals are frequently places of learning and like to be engaged in the process and, as I stumbled through my next few exams, I was reminded of my Dad’s words of encouragement, “the only difference between you and an expert is that they have done it once or twice.” So I kept at it. I was terrible the next times too. But, it got easier and I felt less intimated with each scan I performed. By the time I hit fellowship, I was already moving in the right direction.

When I started my POCUS fellowship, I was fortunate to work with all sorts of supportive colleagues that allowed me to continue to grow. Where I had struggled to build a foundation on my own, colleagues collected from internists, sonographers, and EM physicians provided me with the scaffolding. They provided me with lessons. “Remember, air is the enemy of ultrasound” and “ultrasound does not give you permission to turn your brain off. It is a problem-solving tool.” They entertained clinical application questions. They gave back when I leaned in. These colleagues were an amazing support network and would help me construct the mosaic that I teach from now.

A few months into the fellowship, I could complete a competent exam comfortably. It came together one day for me when I completed a Cardiovascular Limited Ultrasound Exam (CLUE) on a pleasantly demented older man, who had shortness of breath likely representing heart failure. As I looked at his lungs, taking stock of the bilateral B-lines and pleural effusions that confirmed his diagnosis, I discussed and showed the findings with his daughter.

“This makes so much sense now!” she remarked. The lightbulb went on for her as I democratized her father’s clinical information. The lightbulb came on for me too as I had a sense of satisfaction of both feeling confident in my diagnosis, but also being better able to teach and engage a family in their medical care. My transformation from novice to competency was mostly complete.

Now, a little more than 2 years removed from my fellowship, I have a little more perspective on the road from novice to competency, not only from my personal experience but also from my opportunity to network with an amazing group of enthusiastic (IM) POCUS educators.

These educators are largely trained by their own curiosity, their attendance at POCUS CME courses, or by latching onto experts from peripheral medical departments. In essence, these educators are pulling themselves up by their own bootstraps in a time when there is a distinct scarcity of POCUS educators within Internal Medicine, which can leave the supposed “all-knowledgeable” physician in an uncomfortable place of vulnerability. They have shared the angst that POCUS is a particularly challenging skill to learn due to its humbling nature – we may not know how badly we were hearing murmurs as medical students, but I bet most learners can guess by looking at a picture how poorly they are doing when they are scanning. It was a feeling I shared back in the ICU as a resident, but our experiences diverged when I had mentors who invested in me learning this valuable skill.

But, these physicians who learned POCUS independently are now at the next, even harder, part. As new leaders, we must reach behind us and pull up the trainees, whether that be by creating the next POCUS fellowship, starting or improving a residency POCUS program, or simply training your fellow colleague. We are tasked with making new learners feel supported and encouraged, and to make this technology accessible in fields where POCUS is not the standard of care. We need to foster these learners’ growth so that they can arrive at their own lightbulb moment and so they keep scanning on the ICUs in the effort to improve the care they deliver.

 

What was your defining moment in your decision to go into ultrasound? Have you had a unique learning experience? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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Kevin M. Piro, MD, participated in and helped build a point-of-care ultrasound fellowship at Oregon Health & Science University (OHSU), becoming only the second general medicine-focused ultrasound fellowship in the nation. Dr Piro is now a hospitalist at OHSU.

A Model Citizen

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“Lie down on your back, your elbow is about to get a lot of gel on it,” said the proctor during our most recent AIUM headquarter course. As staff, we often have to step in and assist at meetings in ways we had not planned. This moment was not any different, but we do it because we want to understand and enhance the attendee experience. Turns out I have a “beautiful” elbow and yes, some of you beginners are pressing too hard.

Parreco scan

Sonographer Haylea Weiss scanning Jamie Parreco’s ankle.

As I had my second joint scanned, I thought, what a cool experience; my body is going to help advance the safe and effective use of ultrasound. I found myself offering to volunteer any chance I could, having my elbow, ankle/foot, and shoulder scanned in the end. I listened, watched, and learned as attendees explored.

So why am I telling you this? As a program/meeting planner, it was valuable for me to see things from a model’s perspective:Parreco ankle scan

  • You really should wear comfortable clothes.
  • Gel really will get all over you.
  • Talking to the attendee can help them learn.

 

Here at the AIUM, we offer great opportunities for models to get involved at our annual meeting and courses, but for those of you who have not gotten on one of those exam beds as a model in a while, I encourage you to do so. Everyone learns on that bed; ultrasound grows on that bed; your future sonographers and physicians need you on that bed.

We have a unique opportunity to provide true hands-on experience in our field and I encourage you to support that in any way you can. Who knows, you may learn a thing or two about your body as well. #snappinganklevictim

 

Have you ever been a model for a hands-on ultrasound course? Share your experience below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Jamie Parreco is Director of the Events and Continuing Education Services department at the AIUM in Laurel, Maryland.