Musculoskeletal ultrasound: changing times, changing practice?
- Correspondence to Bruce B Forster MD FRCPC, Professor and Head, UBC Department of Radiology, Room 3350-950 West 10th Avenue, Vancouver BC, Canada V5Z 4E3;
- Accepted 25 October 2010
The paper by Finnoff et al (see page 1144) is an important first step in formalising a detailed curriculum for ultrasound (US) education for sports medicine fellows.1 It is also advantageous in that it is based on the existing American Institute for Ultrasound in Medicine (AIUM) curriculum, as this agency has a wealth of experience in sports medicine.
As radiologists, we are acutely aware of the great value of sonographic assessment of musculoskeletal (MSK) injuries. Non-radiologist clinicians have also recognised this utility, and begun to use laptop-sized US units which are able to achieve an image quality that is satisfactory for examining MSK systems as long as high-frequency (10–12 MHz) probes are utilised. The more recent availability of truly hand-held units has generated even greater interest in sonographic augmentation of the physical examination, although currently these ultraportable machines are used mainly for basic assessment of, for example, free fluid in the abdomen in trauma cases, and are not designated by the vendors for MSK use. Other advantages of US, such as a lack of ionising radiation, ability to perform a dynamic examination, high spatial resolution and ability to guide intervention, further exemplify this modality's important role in diagnosis and management of MSK conditions.
Benchmarking essential hands-on expertise
US requires hands-on expertise more than any other imaging modality. Canadian radiology residency programmes require a minimum of 6 months of US experience, albeit in all body systems, in order to practise in Canada. The MSK system is widely considered to be one of the more difficult body systems to master, and additional training, over and above the 6 months of residency experience, is often offered by MSK imaging fellowship programmes. However, there are too few radiologists or US technologists to meet the needs of our patients, whether at the field-of-play, in the hospital or in the office. Thus, in the interest of optimising patient care, it is reasonable for sports medicine physicians and fellows to be offered training. However, in order to ensure quality outcomes, several benchmarks must be considered:
Collaboration with related specialties: in a competence statement on cardiac CT and MR2 the American College of Cardiology Foundation and the American Heart Association consulted with the American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Atherosclerotic Imaging, Society for Cardiovascular Intervention and the Society for Cardiovascular MR, all of which include cardiology and imaging specialist members. Such wide discussion increases the likelihood of a comprehensive programme and improves buy-in from multiple disciplines. The scenario of cardiologists performing coronary CT angiography, when the vast majority had never formally been involved in this modality before, is not unlike the current scenario with sports medicine clinicians and US.
Minimum education, training and experience, specified and verified: it is vital that trainees undertake MSK US training within programmes that are accredited, and that a minimum number of cases performed by the candidate under expert supervision be specified. Furthermore, if the intent is for the candidate to perform general MSK US, then all anatomical regions within the MSK system should be covered. Finnoff et al1 propose that fellows ‘attempt’ to meet the AIUM guidelines of 150 cases performed, interpreted and reported, and 40 h of category 1 American Medical Association's Physician's Recognition Award credits, unless within 2 years of a fellowship which has accredited US content. It would not be acceptable to have a voluntary standard; all fellows in such a programme should be mandated to meet these requirements in order to practise, and furthermore, all fellows should be required to submit proof of their experience to their facility prior to practising within the modality. Ideally, such records would be required by a credentialling body such as the AIUM or the American Medical Society of Sports Medicine, which would then issue a certificate of competence.
Requirement for hands-on experience: although many forms of sonographic training exist, such as video, web-based learning, DVDs etc, quality US training is distinguished by hands-on image acquisition, for which there is no substitute. Radiologists in teaching institutions have extensive experience in resident hands-on training and in ensuring competence in US examination, and would be an important resource for development of programmes such as that suggested by Finnoff et al.1
Advanced levels of competence: competency criteria could be two-tiered, with one level for purely diagnostic studies, and a second tier for sonographically guided intervention, the latter requiring added, mentored training.
Determination of competency: as well as proof of training and experience as outlined above, competency could be ascertained by observation of skill in image acquisition, video review of cases, over-reading of cases by experts, simulator training or traditional examination, all of which are suggested as reasonable methods by the American College of Emergency Physicians (ACEP) policy statement in their Emergency Ultrasound Guidelines.3
Ongoing quality assurance: the ACEP suggests at least 10 h of continuing professional development credits per 2-year cycle to maintain competency in US in emergency medicine. Other programmes such as monitoring of diagnostic accuracy compared with surgical gold standards where appropriate, or other imaging modalities, would also ensure ongoing best practice.
Field-of-play/bedside US: these examinations, reported in the linked paper by James et al (see page 1149), will in the future involve ultra-portable units, and raise additional questions, such as image storage and reporting.4
So, although the article by Finnoff et al1 helps to establish some specific curricular objectives, there do remain unresolved details, which would be essential to ensure quality performance and interpretation of MSK US examinations. As multimodality imaging experts, radiologists can assist our colleagues in sports medicine in reaching some of these important quality targets, whether through performance of additional US examinations in difficult cases, interpretation of other imaging modalities such as CT or MRI to aid sonographic diagnosis, curriculum design or through suggestions to ensure competency. As long as quality patient care is achieved, we are all winners.
Competing interests None.
Provenance and peer review Not commissioned; not externally peer reviewed.