Tag Archives: medical school

Impact of Ultrasound on Medical Imaging: 1967–2021

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In 1967, a weekly feature for medical school seniors was the ‘bullpen’ in the Charity Hospital amphitheater. Students were assigned a patient and given 30 minutes to do a history and physical exam and then present their differential diagnosis and recommendations to an attending. Diagnosis was almost exclusively based on the history and physical examination. Laboratory studies were generally confined to basic electrolytes, a CBC, urinalysis, sputum stains, and a chest x-ray.

This prepared me well for internship and residency on the Osler Medical Service at Johns Hopkins Hospital. Interns were on call 24 hours a day for 6 days a week and usually spent 16 to 18 hours a day attending patients at the bedside.

On Osler, there were no computers and handwritten or typed paper records hung on a chart rack. The wards were not air-conditioned, and yellow curtains separated each of the 28 beds. There were no patient monitors, IV pumps, or respirators, and interns performed all of the basic lab work on their patients. Nursing care was excellent; the house staff and nurses worked as a team caring for the patients. Lack of technology was compensated for by close and direct interaction with the patients and their families, and the practice of medicine was extremely satisfying and filled with empathy and compassion.

The patient was the object of all of our attention. In the late 1960s, imaging was limited and played a relatively minor role in diagnosis and management. Defensive medicine was not a concern.

Following my internal medicine residency at Hopkins, I spent the next 3 years in the immunology branch of the National Cancer Institute in Bethesda. The research centered on the new field of bone marrow transplantation and treatment of graft vs. host disease.1 Whole-body radiation prepared candidates for transplantation and my experience in dealing with near-lethal doses of radiation led me to pursue a career in radiation oncology.

After completing a residency in general and therapeutic radiology in 1975, I joined the staff of the Ochsner Clinic in New Orleans, practicing a combination of radiation therapy and general radiography and fluoroscopy. Imaging was film-based, with studies hung on multipanel viewboxes for interpretation and a hot light for image processing. Cases were dictated directly to a transcriptionist in a cubicle next to the reading room and were typed and signed in real time. The daily workload included 40 to 50 barium studies along with numerous oral cholecystograms, intravenous urograms, and chest and bone radiographs. Specialized imaging consisted of polytomography, penumoencephalography, lymphangiography, and angiography. Evaluation of the aorta, runoff vessels, and carotid vessels was performed by direct puncture. Women’s imaging consisted of xeromammograms, hysterosalpingography, and pelvimetry. Image-guided intervention was nonexistent.

That year, ultrasound was in its early clinical development and I acquired a machine and placed it in the radiation therapy department and began scanning patients from the nearby emergency department. At that time there were no other sectional imaging modalities (CT was not yet available for clinical use.).

A large part of the challenge of ultrasound was learning anatomy in a completely new way. As a result, my groundwork in understanding sectional anatomy came from ultrasound. Ultrasound, unlike CT and MR, permitted imaging not only in standardized axial planes but allowed scan planes in virtually any orientation, requiring a very detailed knowledge of anatomy.

In 1976, upon the retirement of Dr. Seymour Ochsner, I became Chair of the department at Ochsner. This provided me with an opportunity to re-equip the department at a time that the entire field of imaging was undergoing immense change. With ultrasound, new findings were being reported regularly2, and the overall quality of ultrasound images often exceeded those of early body CT scans.

The development of Doppler ultrasound in the late 1970s further expanded the applications of ultrasound, although prior to the introduction of color Doppler, this was mainly of interest to vascular surgeons, and diagnosis was based on waveform analysis rather than imaging.

An important technological development at the end of the 1970s was real-time ultrasound, leading to the rapid development of new applications in obstetrical, abdominal, pediatric, and intraoperative imaging3,4.

Developments in computers in the early 1980s led me to an opportunity to participate in the development of exciting new technologies, including a breakthrough involving ultrasound and providing a method to image Doppler information. Working with a small company in Seattle and a large prototype device, we generated the first images of blood flow in the abdomen and peripheral vessels using color Doppler5,6. Color Doppler, by allowing Doppler information to be shown in an image rather than as a waveform, was important in getting radiologists interested in Doppler. Today, color Doppler is an integral part of the ultrasound examination.

A less successful application of ultrasound in the 1980s was in the evaluation of the breast. Early breast scanners produced quality images by scanning the breast, as the patient lay prone in a water tank. Unfortunately, breast ultrasound was promoted aggressively by many manufacturers and by the mid-1980s was discredited as a useful addition to mammography. By the mid-1990s, however, advances in breast ultrasound demonstrated an important role in the evaluation of breast masses, making ultrasound an indispensable part of breast imaging and leading to the BI-RADS breast imaging and reporting system for ultrasound7–9.

Ultrasound also has had a major impact in providing guidance for minimally invasive diagnostic procedures. Fine-needle biopsy of lesions of the liver, kidney, retroperitoneum, as well as peripheral lymph nodes and the thyroid, have become a standard part of the diagnostic workup.

A radiologist of 50 years ago would not recognize the field if he or she were to return today. In fewer than 50 years, the computer has changed the practice of medicine. More precise and early diagnosis are clear benefits of the technology of the 21st century, but are accompanied by the perils of over utilization prompted by defensive medicine with interests of the physician potentially overshadowing those of the patient.

Although the contribution of these advances has benefited countless patients, many of the rewards of the practice of medicine have been diminished. In looking back at my 50 years of practicing medicine, recalling my final grand rounds at Charity Hospital, I appreciate the diagnostic skills acquired through history and physical examination, as well as the relationship I had with my patients during my clinical years. To me, this represents the real definition of being a physician. In many cases, these simple tools were often as effective, and certainly more satisfying, than today’s tendency to view the patient as the result of an imaging test rather than a person.

Christopher R. B. Merritt, MD, is a Past President (1986–1988) of the American Institute of Ultrasound in Medicine (AIUM) where he led the development of the AIUM/NEMA/FDA Output Display Standard, and served as a founder of the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL).

References

  1. Merritt CB, Mann DL, Rogentine GN Jr. Cytotoxic antibody for epithelial cells in human graft versus host disease. Nature 1971; 232:638.
  2. Merritt CRB. Ultrasound demonstration of portal vein thrombosis. Radiology 1979; 133:425–427.
  3. Merritt CRB, Coulon R, Connolly E. Intraoperative neurosurgical ultrasound: transdural and tranfontanelle applications. Radiology 1983; 148:513–517.
  4. Merritt CRB, Goldsmith JP, Sharp MJ. Sonographic detection of portal venous gas in infants with necrotizing enterocolitis. AJR 1984; 143:1059–1062.
  5. Merritt CRB. Doppler colour flow imaging. Nature 1987; Aug 20; 328:743–744.
  6. Merritt CRB. Doppler color flow imaging. J Clin Ultrasound 1987; 15:591–597.
  7. Mendelson EB, Berg WA, Merritt CRB. Towards a standardized breast ultrasound lexicon, BI-RADS: ultrasound. Semin Roentgenol 2001; 36:217–225.
  8. Taylor KWJ, Merritt C, Piccoli C, et al. Ultrasound as a complement to mammography and breast examination to characterize breast masses. Ultrasound Med Biol 2002; 28:19–26.
  9. Berg WA, Blume JD, Cormack JB, et al. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA 2008; 299(18):2151–2163.

It’s All About The Students

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A relatively new AIUM award, the Peter H. Arger, MD, Excellence in Medical Student Education Award honors an AIUM member whose outstanding contributions to the development of medical ultrasound education warrant special merit. At the 2015 AIUM Annual Convention, David Bahner, MD, RDMS, was presented with this award. Here’s what he had to say about this honor and the future of medical ultrasound education.David Bahner

What does it mean to you to be named only the second recipient of the Peter H. Arger Excellence in Medical Student Education Award winner?
I am very honored to be recognized by the AIUM and feel it is an honor to receive this award named after a pioneer in imaging, Dr Peter H. Arger.  Dr Arger’s passion for medical education and his commitment to ultrasound is well known.  It is my hope to continue those activities in medical education that Dr Arger pioneered in his work with the AIUM. Watching the first award winner, Dr Richard Hoppmann, receive this award last year was a thrill because it meant that the AIUM was recognizing the importance of medical ultrasound education. I am grateful for this great honor and hope to live up to the substantial role model Dr Peter Arger has been for this important area in ultrasound.

Why is ultrasound in medical education so important?
In the past, the feeling that ultrasound is operator dependent has been a drag on its impact within medicine. However, since medical education has been changing at many institutions because of electronic medical records, changes in curricula, and changes in technology, opportunities for point-of-care ultrasound now abound. Add to that the fact that ultrasound has become portable and affordable, and we see more operators embracing this modality. Unfortunately, the training for this device many times doesn’t starts until residency or even after clinicians have completed their medical training. By that time, however, the technology has outpaced the education. If the future can be planned to prepare 21st century clinicians to use this ultrasound tool, implementing this within medical school allows “pluripotent” students the ability to learn the foundations of ultrasound before entering residency.

What do you see as the biggest barrier to having ultrasound integrated into the medical education curriculum?
The lack of trained faculty either funded or supported in this process of training medical students is the biggest barrier to implementing ultrasound training in medical school. This lack of faculty is coupled with a “crowded’ curriculum where medical educators don’t see the benefit of adding ultrasound at the expense of removing other parts of the curriculum. The true insight is that ultrasound can be integrated into many parts of the medical student curriculum when both teachers and students embrace learning how to use ultrasound.  For example, anatomists learning how to scan or family practitioners working with ultrasound to guide procedures are possible solutions to these barriers.

You are a born and bred Ohioan. Why are people from Ohio so proud of Ohio?
It probably has something to do with the history of the state and how that has played into innovation, politics and competitiveness. Ohio is best known for the Wright Brothers who hailed from Dayton and used their hard work and innovation to change the 20th century with the discovery of lift and flight. Politically it has been an influential state in most presidential elections. Plus, 6 presidents are from Ohio. Ohioans are fierce competitors and extremely proud of the 16 national football championships earned by The Ohio State University. Oh, and the Pro Football Hall of Fame and Rock and Roll Hall of Fame are located within Ohio. We have a lot to be proud of.

Personally, my family grew up in Ohio and I feel a bond with the change of seasons, the geography, the history, the people, and the culture of hard work and helping others. I am an American, an Ohioan, a doctor, an educator, an innovator, and a Buckeye.

What role does or should ultrasound play in medical education? What are you proud of? Where did you learn your ultrasound skills? Comment below or let us know on Twitter: @AIUM_Ultrasound.

David Bahner, MD, RDMS, is Professor and Director of Ultrasound in the Department of Emergency Medicine at The Ohio State University College of Medicine.

Simulators Role in Ultrasound Training

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I believe the future of health care will involve the expanded use of diagnostic ultrasound, which will be accomplished through the use of an enhanced version of today’s handheld ultrasound scanner. I envision this “sono-scope” to be a wireless, lightweight, handheld imaging device with a long battery life and high-quality image capture that will expand the capabilities of the stethoscope.

The compact, portable ultrasoundpedersen_image scanners began entering the medical imaging marketplace around year 2000. Since then the market has grown dramatically, and the portable scanners have bifurcated into two broad groups: (i) The pocket-sized or handheld scanners (HHUS) and (ii) the larger, full-featured point-of-care ultrasound systems (POCUS).

These devices provide doctors with an extension of their senses and augment existing tools. But to be truly transformational, users need to receive ultrasound training from the beginning of their medical career, which will allow them quickly to “rule in” and “rule out” possible diagnoses and lead to earlier treatment decisions and/or more relevant further tests.

I maintain that the main barrier for making the HHUS (and POCUS) every clinician’s examination tool of choice, is not the technology, but rather the lack of opportunity to acquire and develop the needed scanning skills.

Thus, finding training strategies that enable the integration of ultrasound into medical schools is an essential step in overcoming this barrier. If the next generation of doctors had ultrasound for diagnosis and guided procedures as a vital part of their training, they would quickly develop a natural comfort with this tool and, with time, increasing sophistication. A parallel can be drawn regarding the attitude toward acquiring computer skills. As recent as 40 years ago, the operation of computers was thought to be limited to a select, carefully trained group of specialists. Today, nearly everyone is able to operate computers at some level.

Effective training in medical ultrasound requires both clinical knowledge (understanding of anatomy, physiology, and pathology) and scanning skills (psycho-motor skills, which are the integration of motion and the mental processes of recognizing anatomic structures in 3D from the 2D images). While both clinical knowledge and scanning skills are essential, the former is often emphasized at the expense of the latter because clinical knowledge can be delivered cost effectively and in flexible formats through online courses (including MOOCs), self-study, and in traditional classroom courses. Scanning skills, on the other hand, are acquired through hands-on experience, by examining patients, preferably both healthy and with symptoms, under the guidance of an experienced sonographer. Here, the medical educational enterprise does not currently have the capacity to meet this training need. There are too few scanners available for learners to use. There are too few patients or human subjects in general available for scanning. Last but not least, there are too few qualified instructors who can guide the learning.

There exists a potentially effective approach to overcoming this limitation in delivering scanning skills training: The use of ultrasound training simulators. Simulation provides a controlled and safe practice environment to promote learning. The efficacy of the simulator-based training is well-established. For example, human errors related to airline accidents have decreased in large part due to flight simulator training. Likewise, high-fidelity medical simulations have been shown to be educationally effective, as evidenced by the strong correlation between surgical simulator training and improved outcomes. Several studies have demonstrated the learning value of simulator-based training in diagnostic ultrasound.

Just as HHUS and POCUS have proliferated over the last 15 years, so have ultrasound simulator products. Some training simulators cover multiple clinical specialties, while others are designed for a specific application. Typically, the learner scans a physical manikin with a realistic-looking sham transducer, which produces an image on the display corresponding to the position and orientation of the sham transducer on the manikin, along with an anatomy display of the location of the image plane through the body.

An important component of the simulator design is the degree to which the simulator provides structured learning with guidance, interaction, and assessment. While all simulators include educational modules, only a few offer self-paced learning and competence verification. All in all, today’s ultrasound simulators are sophisticated devices that are capable of meeting training needs on basic and even intermediate levels. However, because the purchase price is sufficiently high (from $10K to more than $100K) sonography programs and simulation centers at larger hospitals are typically the only facilities able to acquire this technology.

When the medical community is ready to embrace ultrasound as an imaging modality of first choice for doctors from all specialties, I am convinced that technological innovation will lead to affordable, yet customizable and realistic training simulators. In particular, what is needed are portable and lightweight simulators that run on ordinary, modern PC/laptops, making personal ownership of a simulator possible as well as allowing medical schools to purchase such simulators in large quantities. For individualized training, it is essential that the simulator be task-based and able to verify the acquired skills level. To deliver the best realism, the image material should preferably be acquired directly from human subjects, and to provide the optimal development and assessment of psychomotor skills, the scanning practice on the simulator should resemble actual patient scanning as closely as possible. Such low-cost training simulators can lay the groundwork for building up such ultrasound skills both among practicing specialists and students enrolled in medical schools.

Have you/do you use simulators in your ultrasound training? What are the advantages or disadvantages? What would make simulation training better? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Peder C. Pedersen is Professor of Electrical and Computer Engineering at Worcester Polytechnic Institute.