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There aren’t established guidelines for how you should train physicians in ultrasound, according to Robert Jones, DO, FACEP, emergency ultrasound coordinator for the emergency medicine residency program at Doctor’s Hospital in Columbus, OH. You’ll need to devise your own internal guidelines for this, he says. "Otherwise another department will impose theirs on the ED," he warns. "This is similar to what happened a decade ago, when we were trying to use paralytics for intubation, and anesthesia departments tried to impose their own criteria on the ED."
To implement an ultrasound program successfully, invest in adequate equipment and training, says Michael Blaivas, MD, RDMS, director of emergency ultrasound at North Shore University Hospital in Manhasset, NY. However, opinions differ sharply as to how to handle education of physicians, he adds. There are two opposing views regarding the issue of training, says Blaivas. "One view is that ED physicians should be well trained and as competent at performing their studies as the radiologists," he says. "On the other side is the reality that such in-depth training is not necessary for many of the applications we perform."
There is pressure on some authorities in ED ultrasound to make ultrasound education an easy "package deal," says Blaivas. "You go for your weekend course, perform a few ultrasound scans when you get back home, and you are ready to ultrasound the world," he says. The truth lies somewhere in the middle, argues Blaivas. "Training for focused ultrasound applications obviously does not have to be as extensive as going through a radiology residency," he notes. "But a high enough standard needs to be drawn so that people are not dangerous when using this new technology."
To date there is no agreement on such a standard, Blaivas reports. "A painful reality for some is that just performing a certain number of ultrasound studies is not enough to make them competent," he says. "Not all individuals seem to pick up ultrasound skills at the same rate, and some not at all." The most important step is to monitor all ED ultrasound studies, to make sure everyone is accurate enough, Jones says.
As the first step, Blaivas recommends a comprehensive course that covers the physics of ultrasound and the applications that one plans on doing in his or her department . "The course should then be followed by lots of practice on an ultrasound machine, which should be available in the ED," he says. The next step is formal review of ultrasound examinations performed after the course by someone with considerable experience in ultrasound, Blaivas says. "That individual may be a radiologist or an ED physician," he notes.
Formal studies may be substituted for this, says Blaivas. "The results of formal testing are used by the ED physician as quality assurance," he explains. "In this manner, the newly trained ED physician accumulates experience and makes safe’ mistakes." The results of formal testing can be used by the physician as a good standard to check his or her own findings, Blaivas explains. "This is not as desirable as having an experienced individual help with the scans and over-read them, but is the reality in many settings," he says.
Blaivas recommends keeping a careful log with still images of the examination, along with the results of the follow-up study, and preferably video clips.
The physician is making "safe" mistakes because his or her own studies are non-diagnostic and no decisions are made from them without having the formal study, he explains. "The true clinical decision is made based on the formal study result," Blaivas says. "In essence, the mistake is never truly made or at least acted upon."
Further reading and continuing medical education course work is critical to improve knowledge and technique until a steady state of competence is reached and good accuracy with the chosen applications is ensured, says Blaivas.
Consider the cost of training personnel, says Blaivas. "This can be done by bringing in an education group to teach a one- or two-day course for all the ED physicians in the group at one time, or several people can be sent to a course at once," he notes. Blaivas estimates that a course where the teachers come to you will run from $400 to $700 per head, depending on which group you choose and where you are located. Another alternative is hiring someone with good experience to teach the rest of the group, Blaivas suggests. "A premium will have to be paid for this person’s skill," he adds. He notes that the expected stipend above the normal salary for this individual may range from $30,000 to $50,000. "Well-trained people are in extremely short supply at this time," he adds.