Chapter 1. Training and Program Development

Establishing a training program in point-of-care ultrasound is an exciting and rewarding experience. The impact of ultrasound on the clinical practice of medicine becomes so clear that many clinicians, after acquiring basic ultrasound skills, wonder how they got along without this technology. This chapter outlines the process for developing a point-of-care ultrasound training program and addresses the common questions encountered when starting a new program.

Point-of-care ultrasound examinations are performed in real time at the bedside by clinicians to answer specific questions in order to expedite care and improve patient care. These studies are not intended to provide comprehensive surveys of anatomical areas nor are they mere extensions of the physical examination.1 Point-of-care ultrasound provides imaging to rule in or rule out specific disease entities for which timely treatment is crucial (e.g., ruptured abdominal aortic aneurysm, ruptured ectopic pregnancy, and cardiac tamponade) or for whom invasive intervention could be especially unsafe (e.g., paracentesis, abscess drainages, and foreign body removal). As such, these studies require the highest levels of competence, accuracy, and clinical acumen.

In order to establish a high-quality point-of-care ultrasound program, ultrasound directors must:

1. Determine type of examinations to be performed.

2. Develop a program implementation plan.

3. Obtain leadership approval of the implementation plan.

4. Acquire an ultrasound machine.

5. Train the group.

6. Incentivize group members to complete training and credentialing.

7. Perform problem solving, quality assurance, and ongoing training.

A critical factor in the timely implementation and success of an ultrasound program is to have the full support and active assistance of the department leadership. Also, appointing a dedicated ultrasound director with protected time is the best approach because each step in program implementation is very time intensive.

Ultrasound use continues to expand along with technological advances and improvement in individual operator expertise. It makes sense to start with applications that will get the most use in a particular practice setting. For example, in a small community hospital, evaluation of cardiac arrest may be more pertinent than trauma evaluations. Likewise, in centers without 24-hour ultrasound services, it may be important to learn ultrasound for the evaluation of ectopic pregnancy and cholecystitis. We recommend starting with applications unique to the ED for which timely diagnosis and intervention are critical. This includes the focused assessment with sonography for trauma (FAST) examination, evaluation of cardiac arrest states, and evaluation of hypotension. In addition, procedural applications, such as intravenous line placement, paracentesis, thoracentesis, and abscess localization and drainage, are becoming standard of care.2 Training in emergency medicine residency programs, however, should cover all of the primary applications and include exposure to emerging applications (Tables 1-1 and 1-2).

A new point-of-care ultrasound program should strive to identify all of the ultrasound examinations that are of interest, both now and in the future. Making this decision early allows the program to seek leadership approval for all of these examinations from the beginning instead of having to apply for additional approval later. It also allows the program to define equipment needs prior to initial equipment purchase. Otherwise, additional purchases may have to be made as new applications are brought online.

Some medical centers may choose to focus on just one or two ultrasound applications at a time. This allows everyone time to concentrate their efforts on becoming proficient with each application and to learn the technical pitfalls inherent in those particular applications. By keeping the entire training group on the same application(s), the ultrasound director can focus quality improvement (QI) efforts on those specific applications, using reviews of specific cases to educate and train everyone involved. After quality performance levels are achieved, new applications can be introduced in a similar fashion one at a time until all of the applications are taught. In our experience, this is the most effective means for starting a program and allows for a safe and effective implementation of ultrasound into clinical care.

Since point-of-care ultrasound focuses on critical questions or interventions, rather than requiring “minimal training,” the clinicians actually require the best training and highest standards of competence. In our experience, this is best accomplished by focused and appropriately directed program implementation and training.

The program implementation plan defines all aspects of the ultrasound training program. The plan guides the ultrasound director through all the administrative and teaching aspects of the program and serves as a reference for requirements in training. The most straightforward way to develop a plan is to model it after another group or institution's plan, adapting it for the local clinical and political environment. Many residency programs are willing to share their program plans. The program plan should, at a minimum, include the following elements:

• Definition of specific privileges.
• Training and credentialing.
• Method of recording results.
• Performance improvement plan.
• CME requirements.

Definition of Specific Privileges

This section defines exactly how focused ultrasound examinations will be used. For example, a specific privilege may be: “Documentation of free abdominal fluid in trauma patients.” This could also be shortened to “Documentation of free abdominal fluid” if there is an additional desire to diagnose ascites. Some institutions allow graduated privileges, meaning that clinicians can do more with their ultrasound examinations as they gain experience (Table 1-3). This approach is beneficial in that it allows earlier implementation of point-of-care ultrasound into patient care while establishing ongoing quality control parameters. Earlier implementation helps maintain momentum in the training program as clinicians see the benefits of their training sooner; however, graduated privileges create a more complex training program.

Privileges and training should be constructed toward the identification of specific findings (e.g., presence or absence of gallstones) and not toward the general evaluation of disease processes or anatomic structures (e.g., evaluation for “cardiac disease” or “right upper quadrant abdominal pain”) consistent with existing guidelines. A useful resource for defining a particular examination is the Emergency Ultrasound Imaging Criteria Compendium.3

Training and Credentialing

Training

Multiple guidelines for training in ultrasound have been published.3–8 The American College of Radiology (ACR) and the American Institute of Ultrasound in Medicine (AIUM) have established guidelines4,5 for learning comprehensive examinations, but have not published guidelines for point-of-care ultrasound. In 1994, a model curriculum for training in emergency ultrasound was published by the Society for Academic Emergency Medicine (SAEM) and subsequently modified as new evidence and experience emerged.6 In 2001, the American College of Emergency Physicians (ACEP) published initial emergency ultrasound guidelines outlining utilization for six “primary applications” plus use for procedural guidance. The Council of Emergency Medicine Residency Directors (CORD) outlined ultrasound training standards for emergency medicine residency programs in 2008. They listed four primary applications (FAST, emergent cardiac, abdominal aortic aneurysm, intrauterine pregnancy) plus procedural guidance as the minimum skill set, but highly recommended training in at least six additional applications. ACEP published revised guidelines on ultrasound training that have expanded the list of “Core Applications” to a total of 11 applications1 (Table 1-1). Although this expanded list provides support for additional uses, it is recognized that not all facilities may have the need to utilize all of these applications in their specific clinical practice setting. Specific didactic and experiential training criteria are outlined with a minimum of 25 training cases documented for each core application of interest. The ACEP guidelines are recognized as the current standard for training in point-of-care ultrasound.7,8 Ultrasound directors still have some degree of latitude in designing their individual programs, but should consider CORD as well as ACEP guidelines when designing minimum training criteria. A program should also include minimum requirements for each of the following areas:

• Minimum overall didactic hours.
• Minimum overall didactic content.
• Minimum number of overall ultrasound examinations performed.
• Minimum didactic content pertaining to the specific examination.
• Minimum number of examinations performed to look for the specific finding (either positive or negative).
• Minimum number of abnormal examinations.

Credentialing

Credentialing applies mainly to hospital-based or clinic-based clinicians who wish to perform focused ultrasound examinations on patients in the hospital. Standard methods of credentialing are crucial to safely and effectively implement a successful ultrasound program. The cornerstone of the credentialing processes revolves around a required number of technically proficient scans and interpretations, as outlined in the training requirements. However, as a minimum number of exams may not ensure competency, some centers may choose to use other means of establishing competency such as proctoring and submission of a case portfolio. Noncredentialed clinicians should not discuss any of their results with either patients or consultants during the training period to avoid any misunderstandings about the accuracy of results. Well-intentioned clinicians could place their patients at risk by doing so and would be legally liable for any misinterpretations or outcomes that resulted from such communications. Once clinicians are credentialed by the hospital they may begin using examinations for patient care. If a graduated credentialing program is used, the clinician may be able to use some findings for patient care, but is considered “in training” for other findings.

Incentives for Completion of Training and Credentialing

Most busy physicians will not complete credentialing requirements in a timely manner (or ever) unless it is considered mandatory. The ultrasound director typically has little authority to compel other group members to complete “mandatory” training. This is why an ultrasound program must have full support and active assistance of the department leadership. Only department leaders can compel members to complete any mandatory activity. There should be consequences for those who choose not to put forth the effort to complete the credentialing process. This may sound draconian, but it is the only practical way to get all members credentialed in a timely manner, especially in a large group. For practicing physicians, incentives could include tying financial bonuses to completion of the credentialing process.

Method of Recording Results

Numerous methods are available to document the results of the ultrasound examinations. Two questions that need to be answered are as follows: (1) How will interpretations be documented and (2) How will images be saved? The answer to the latter question is especially important, as it will influence the type of ultrasound equipment purchased. Documentation of interpretations can be as straightforward as writing results on the chart or as comprehensive as entering them in the hospital information system so they are available to all interested health-care providers. For billing purposes, a “separately identifiable written report” must be generated for each ultrasound examination performed, although this report can be part of the ED record.9 One solution is to develop a form for the sole purpose of reporting emergency ultrasound results. These forms can then be included in the medical record. The advantage of the form is that it can be devised so as to restrict interpretations to those findings that clinicians are privileged and help clinicians avoid making interpretations beyond their level of skill. An example of such a report form is shown in Figure 1-1.

Several options exist for the saving of images, including thermal printing and myriad of digital recording options. If results are to be included in the medical record, thermal images provide the easiest option, although with the growing use of electronic medical records, it may be possible to incorporate digital images into the medical record. For some applications, images need to be posted on the medical record in order to bill.9 If images are to be archived separately from the medical record, digital storage or videotaping can be used; however, archiving images outside the medical record creates compliance problems with medical record confidentiality and lack of access by other clinicians. Some programs use digital video recording for quality assurance and teaching purposes only.

Quality Improvement Plan

Any department implementing a new ultrasound program should place a strong emphasis on QI. No other area of emergency ultrasound training will provide as many teaching opportunities as a well-run QI program. If the resources or experience are lacking initially to overread all of the program's ultrasound images, then finding a trained colleague in another location to assist with this endeavor is an option. There are pitfalls common to every application of ultrasound that can serve as a springboard for providing feedback and teaching within the program. This is clearly one of the most advantageous methods of enhancing both the technical and interpretative skills of clinicians.

The cornerstone of the QI program is review of examinations by the program's director. For a very active group of clinicians performing focused ultrasound examinations, it will be logistically difficult to review every ultrasound examination so a method for selecting examinations for review must be decided upon. Examinations can be reviewed on either an indicated basis or a random basis. Indicated reviews occur when a certain indicator is met, such as a reported discrepancy between the focused ultrasound examination and another definitive study or procedure, or when a case is referred by a colleague because of questions regarding the accuracy of the examination. Random reviews are conducted by randomly selecting a predetermined number, or percentage, of examinations to assess the overall performance of the group.

Problems that are encountered during the QI process should be categorized as to their importance. The following represents one method of categorization.

Level I: Minor

Level I deviations usually consist of some problem with the technical component of the examination (e.g., gain too high) or disagreement on diagnostic criteria (e.g., labeling a common bile duct as mildly dilated at 6.5 mm when for the patient's age, this was a normal measurement). Level I problems have no direct bearing upon the medical management of the patient. Typically, when this level of disagreement is found, a documented written or electronic copy of the disagreement is sent to the recipient.

Level II: Moderate

Level II deviations consist of discrepancies in interpretation between the clinician's recorded image(s) and the QI review. In these cases, the undiagnosed or misdiagnosed pathology is nonemergent. For example, the clinician may record a gallbladder examination in which gallstones were diagnosed. Upon review, the QI review discovers a classic novice pitfall of a hyperechoic duodenal area that is mistaken for gallstones. Typically, when this level of disagreement is found, a chart review is undertaken to determine if subsequent care of the patient was appropriate. Depending on the follow-up that was provided and the patient's clinical condition at the time of disposition, the action taken can range considerably.

Level III: Major

These problems consist of significant discrepancies between the clinician's recorded image(s) and the QI review. For example, clinician records a pelvic ultrasound examination on a pregnant patient as an intrauterine pregnancy. The QI review finds no evidence of an intrauterine pregnancy, but does note free fluid in the pelvis and a 3 × 4 cm adnexal mass. In this case, the chart is immediately pulled and reviewed. Depending on the follow-up provided or whether a confirmatory study was obtained, the patient may be immediately contacted. The patient is then given follow-up instructions appropriate to the changed diagnosis.

Feedback on reviews, both positive and negative, should be provided to the clinician, along with constructive suggestions for improvement. On occasion, mandated remedial education or training may be appropriate at the discretion of the program's director. Records should be kept on providers so that concerning trends can be recognized and addressed. Actions taken to address such problems as well as the outcome of such actions should be recorded. These records are confidential peer review in nature and should be labeled as such. Results of QI activities should be regularly reported to the appropriate QI organization in the department, hospital, or clinic.

Continuing Medical Education

As with training requirements, there are no well-established guidelines to dictate the amount of CME one needs to maintain competency in focused ultrasound. A reasonable number of education hours, along with continued bedside ultrasound use, should easily maintain skill levels and, preferably, even advance them. “Reasonable” should be determined in light of all the other requirements for continuing education within a specialty. If physicians normally receive 50 hours a year of continuing education in all areas of their specialty, then it would seem excessive to insist that 20 or even 10 of those hours be specific to ultrasound. Likewise, in a residency program, it does not make sense to require 15–20 hours a year of ultrasound didactic education if the entire didactic curriculum is only 200 hours per year. In a survey of 42 academic ED ultrasound programs, the question was asked, “How much CME is needed to keep ultrasound skills up”? Responses varied from 0 to 30 hours, with a median of 8 hours.10 Ultrasound directors should consider all the above factors when making a decision about CME requirements.

The ultrasound program's director is an individual with expertise in focused ultrasound that oversees the training program at an institution or a clinic. This should ideally be a physician who has completed a fellowship in emergency point-of-care ultrasound in order to ensure the highest level of expertise. When this is not possible, a physician with comparable experience (>1000 ultrasound examinations performed, training in image review and program administration) should be carefully recruited, as this person would represent the program as a liaison to the department of radiology and all other clinical departments. Because of the administrative duties required to maintain a successful point-of-care ultrasound program, many departments spread the ultrasound director's duties among several clinicians.

In some instances, the ultrasound director is someone from outside the group who is hired on an hourly basis. Whenever possible, it is advantageous to establish this role within the group because the process of training other group members is continuous and easier to accomplish when the ultrasound director is readily available. The group should acknowledge that the ultrasound director will invest a considerable amount of time on initial training, and this time should be fairly compensated.

When performing focused ultrasound examinations in a hospital setting, the program must be hospital approved and credentialing must be in place. Going through such an approval process increases the scrutiny of the program by individuals outside the department and may generate valuable additional input into the program structure. Closer scrutiny by others will also lead to a more careful internal review of the program before presentation to the hospital, invariably leading to a better program. Approval also ensures that in the event of a significant problem, it will be more difficult for others outside the department to unilaterally persuade hospital governance to restrict the ultrasound program's activities. As with the overall program design, a hospital proposal can be modeled after a successful one from another institution.

Obtaining hospital approval of an ultrasound program should be seen as a political process, especially since there has been some resistance to point-of-care ultrasound programs from other imaging specialists.11–14 Knowing which physician groups side with the proposal and which oppose it before open discussion occurs may guide the process. Clinicians who tend to be most supportive are those who also want to establish ultrasound programs. This group includes emergency physicians, intensivists, hospitalists, internists, surgeons, nephrologists, and family physicians, among others. However, ultrasound allies and enemies vary from hospital to hospital, and making assumptions without investigation is not prudent. Clinicians who already use ultrasound in their practice, such as cardiologists, obstetricians, and gynecologists, may also be allies in this process.

The following are helpful to refer to in a proposal:

1. Specialty society policy statements regarding the use of focused ultrasound. In emergency medicine, for example, SAEM, the American Academy of Emergency Medicine, and ACEP have supported focused ultrasound use in the ED.15–17

2. The American Medical Association's Policy H-230.960 states that individual specialties have the right to determine how to appropriately use ultrasound in their practice.18

3. The percentage of residency programs in the individual specialty, as well as clinicians in the region and nationally, who are training in and using ultrasound. Has ultrasound become or is it becoming the norm locally or regionally? Is it a resident training requirement? Performing and interpreting point-of-care ultrasound is considered part of the core curriculum in emergency medicine.19

4. Numerous articles attesting to the safety and efficacy of focused ultrasound, especially in comparison to ultrasound examinations performed by traditional imaging specialists.20–23

This subject is covered in detail in Chapter 2, “Ultrasound Equipment.” When making the decision on a purchase of an ultrasound machine, the best advice is to compare different ultrasound machines as you would compare cars. There are a variety of bells and whistles on different systems. Likewise, the cost can vary significantly with each manufacturer. You need to kick the tires and “drive” each system to find what is right for your department. This can usually be accomplished at annual emergency medicine conferences or specialty society meetings.24–27 Another approach is to simply have two or three companies loan an ultrasound machine to you for several days. Asking a trusted and experienced colleague is another option. Determine what they liked and disliked about their machines. What equipment did they get that they do not use and what do they wish they had gotten? What kind of service do they get from the manufacturer? The relationship with the manufacturer is almost as important as the machine itself. Company representatives may assist with scheduled maintenance, urgent repairs, equipment upgrades, and in many instances, actual training within the program. Renting or leasing equipment may be a wise option while deciding on a particular manufacturer.

Several training options are available for the ultrasound director. Many directors completed one of many emergency ultrasound fellowships in the United States.29 Others may fill the needs of their department with solid training obtained during their residency and additional educational courses given by various specialty societies.24,25,27 There are numerous web-based ultrasound educational and CME sites to gain new knowledge, or polish up on specific didactic and case studies for various ultrasound applications.27,28

In the past, some emergency physicians learned ultrasound with the help of an experienced sonographer in their own hospital. It may be possible for the director-in-training to sit with a sonographer and perform examinations during normal working hours. This approach has the advantage of minimal cost, but is less time efficient since the trainee will be required to sit through many examinations that may not be applicable to the interests of that trainee. In addition, there are many examinations, like the FAST examination, that are not routinely performed by sonographers in the ultrasound suite. A better alternative is to hire an ultrasound-trained clinician on an hourly basis to individually teach in the ultrasound director's own clinical setting. The ultrasound director may require several months of training before they attain the expertise needed to train others within their group. It is imperative that the ultrasound director be well established before the rest of the group begins training. This is important to help facilitate the group through the “training doldrums,” when the frustrations of training tend to peak. It should be emphasized that the learning curve is quite steep at the beginning of training but is actually relatively short in length so that examination competency can be achieved with a manageable number of ultrasound examinations.

Initial training can be either brief or extensive, depending on the training approach that is taken. One training model is the “parallel” model, where individuals are trained in several ultrasound examinations simultaneously. The other method is the “serial” model, where training occurs with one ultrasound examination at a time, without proceeding to another examination until a certain level of proficiency is achieved. The parallel model works best when individual trainees are able to dedicate a larger portion of their time away from patient care to learn a new set of skills, as is typical in residency training programs. The serial model has the advantage of requiring less time input to get a trainee to a minimum level of competency for one particular examination. Serial training is ideal for community-based practitioners who have less time for training and want to incorporate one set of ultrasound skills into their practice as rapidly as possible.

All training programs generally have the following components:

• An initial block of didactic instruction.
• An initial “hands-on” exercise.
• A required number of proctored examinations performed on actual patients.

In addition, the ultrasound director should consider some type of competency assessment after the completion of training with a written test, observed examinations, or both.

Initial Didactic Instruction

The initial didactic instruction is where members of the physician group get their “jump start” in training. Initial training may consist of anywhere from several hours of instruction, if training in only one examination type, to several days of instruction, if training in multiple examinations. At a minimum, an introduction to the basic physics of ultrasound is required to understand the capabilities and limitations of the technology. Understanding ultrasound physics, even at a basic level, is essential for acquiring and interpreting ultrasound images. In addition, there should be some specific didactic instruction on the examination(s) being taught. It is feasible for the ultrasound director to develop and perform the initial training block, especially if only a few applications are to be covered. If several applications are being taught, then it may be more practical to have group members attend one of the commercially available introductory ultrasound courses. Planning and giving a large hands-on ultrasound instruction block is time consuming. It is important, however, that the ultrasound director ensure that any outside course meets the training requirements established for their program. At an ultrasound course, 1–2 hours is generally spent on ultrasound physics and equipment instrumentation, and an additional hour or two on each specific examination type. Lectures should include discussions of the specific indications for the examination and review of the anatomy, including normal, normal variant, and abnormal ultrasound findings. Teaching should focus on surface transducer positioning to obtain the best “windows” for each application and minimize artifacts. Sonographic landmarks (key anatomical landmarks in a specific plane visible by ultrasound) for each application should be repeatedly stressed. The major finding for each application type (e.g., gallstones) as well as other pathology (e.g., common bile duct dilation, pericholecystic fluid, or thickened gallbladder wall) should be demonstrated, and the appropriate ways to use these findings for clinical decision-making should be discussed. Indications for outpatient referral for more comprehensive imaging or a confirmatory study should be covered. A comprehensive listing of suggested content for didactic sessions is available in the Model Curriculum for Emergency Ultrasound and the Emergency Ultrasound Imaging Criteria Compendium.2,5 Guidelines for an introductory course are outlined in the ACEP training guidelines.1 The problem- and symptom-based approach utilized by emergency medicine has quickly been adapted in other clinical specialties such as critical care, hospital medicine, and internal medicine.

Initial Hands‐on Exercise

The initial hands-on exercise is usually combined with the initial didactic instruction. During this exercise, image acquisition is practiced on normal models in a nonstressful, non–patient-care environment. Ideally, there should be no more than four learners and one instructor per ultrasound machine to maximize learner scanning time. Topics covered should include operation of the ultrasound machine controls, techniques for maximizing image quality, normal ultrasound anatomy, and systematic approaches to each application. Specific “pelvic” models are employed when endovaginal ultrasound is taught, and chronic ambulatory peritoneal dialysis (CAPD) patients may be employed to demonstrate free intraperitoneal fluid on ultrasound examination. CAPD patients can simulate a positive examination by infusing fluid into their peritoneal cavity at will, and can even vary the amount of fluid to give different appearances. In instances where budgetary or planning constraints exist, these sessions can be run with trainees examining each other. Although pathology will not (usually) be demonstrated using this approach, learners can effectively acquire techniques for good image acquisition and systematic examination. Repetitive hands-on scanning with normal patients will help learners discern normal and anatomical variants for each application. Knowing what normal looks like sonographically will help tremendously when it is time to interpret pathological findings. A newer teaching method is the ultrasound simulator that uses a mannequin and a computer to simulate scanning. The advantage of a simulator is that it can be programmed to simulate pathology, thus giving the trainee a more varied, yet standardized training experience. Finding enough patients with actual pathology to examine is one of the biggest challenges during training. Simulator technology holds great promise for the future of ultrasound training. Future privileging will likely be based on objective data obtained by scanning these mannequins. There are also various training “phantoms” and models, which are commercially available and can be used to practice skills such as vessel cannulation, peripheral nerve blocks, and foreign body localization. Models can also be homemade. Good phantoms can be created with various materials, such as rubber tubing, gelatin, or even raw chicken or beef. There are even homemade models for pericardial effusions.23

Proctored Examinations

Proctoring is the longest phase of training, often taking several months to complete. This is the part of the training process that often leads to significant delays or outright failure. The biggest challenge for an ultrasound director is to help learners maintain enthusiasm and focus during the proctoring process. This is the time when it is critical to have the full support of the department leadership and clear incentivized goals and expectations.

Proctoring is when most of the practical learning occurs, and the most important part of the educational process. The goals of proctoring are to help establish basic ultrasound skills, solidify the approach to examination, verify the quality of images produced, and verify the accuracy of the examinations. As the clinician begins scanning a variety of patients in his or her own clinical environment, the relative complexity of the skill will become evident. The learner needs to be mentally prepared for this predictably difficult period so that frustration will not inhibit training. “Real-time” proctoring is extremely helpful in assisting the clinician through this period. Real-time proctoring involves having the proctor sit with and guide the trainee through examinations and is the best way to learn ultrasound. Ultrasound directors should perform proctoring in their department on real patients. This is the ideal situation, and applications can be added in stepwise fashion. Unfortunately, if the number of clinicians who need to be trained is quite large, this can also be quite time consuming. Another time-tested approach is to use real-time proctoring with sonographers within your hospital.

Some programs choose to do “delayed” proctoring, meaning trainees perform examinations independently, and then an experienced individual judges the quality and accuracy of the examinations at a later time. A common delayed proctoring technique is to videotape or record digital clips of examinations. This method results in slower training, but is usually less expensive than hiring a clinician for real-time proctoring and saves the ultrasound director from doing all of the real-time proctoring themselves. Another delayed proctoring option is to keep track of how trainee ultrasound results compare with other clinical information, including ultrasound examinations performed by traditional imaging specialists, other imaging studies (such as CT), or procedures. This method accomplishes verification of accuracy but does not fulfill the other goals of proctoring. Reviewing static sonographic images generated by trainees as the sole method to delayed proctoring is problematic, especially for negative examinations. Pathology may be visible in one imaging plane but not in another, and the inexperienced operator may simply fail to find and document the pathology. Static images that are clearly positive can be used for proctoring in a limited manner since it is more difficult to “create” a false positive image (though not at all impossible). If delayed proctoring is chosen as the predominant means of training, it would be wise to have the ultrasound director provide some real-time proctoring on an intermittent basis. This would include a hands-on skills session to teach trainees to document specific landmarks in each application as well as demonstrate technical skills and avoid common errors in these examinations. Proctoring is the longest phase of training, often taking several months to complete. The biggest challenge an ultrasound director faces is helping trainees to maintain enthusiasm for the training program as they begin to climb the steep learning curve.

Quality Assurance

One of the best education tools available to the ultrasound director is quality assurance. As ultrasound examinations are reviewed for quality, it is also an ideal time to discuss the appropriate landmarks for each application, how the acquired image might be improved, and the diagnostic interpretation of each study. Carrying out this process with colleagues, trainees, residents, or students can be extremely valuable. Almost any pathologic study can be difficult to interpret if adequate landmarks or appropriate images are not documented. Likewise, capturing only still images can make it difficult to differentiate normal from pathologic findings. For example, documenting a live pregnancy with just still images can be difficult. Documentation has to tell a story. Images of a live pregnancy have to verify where the pregnancy is located. There must be views of the endometrial echo of the uterus demonstrating the gestational sac of the live pregnancy within its borders. Otherwise, one cannot rule out an extrauterine gestation. The repetitive nature of reviewing multiple images and video helps the trainee understand the correct documentation of an examination.

Ultrasound directors often experience two major problems with their programs. The first is difficulty in convincing all members of the group to participate in training. The second is maintaining trainee enthusiasm during the long proctoring phase. Emergency physicians, faced with the difficulty of integrating ultrasound-training examinations with patient care during busy ED shifts, will find it tempting to put off using ultrasound. The following are some strategies to help avoid these problems:

1. Maintain easy access. The easier the use of the ultrasound machine, the more it will be used. An ultrasound machine in a “safe” but inconvenient place will not be used. The ultrasound machine should be kept in close proximity to patient rooms and in full view. Not only will this remind clinicians to use the machine, it will assist with security of the ultrasound machine since its absence will be noticeable. This is especially important in critical care settings, such as with hypotensive and cardiac arrest patients, where a machine that is not close at hand is infinitely far away.

2. Examination efficiency. Point-of-care ultrasound examinations can add 5–10 minutes to a patient encounter (although they typically reduce overall length of stay in the ED), which can add up over the course of a shift. If clinicians perceive the ultrasound examination as a major time drain, they will not perform them. Bringing the machine to the patient's room at the time of first contact, if an ultrasound examination is anticipated, can reduce examination times. The examinations should be focused. If it is clear early in the examination that the examination will be technically difficult, the examination should be terminated and referred to a traditional imaging specialist. The goal of focused ultrasound is not to do all examinations, but to do those where immediate answers are necessary and/or those that can be performed efficiently.

3. Make it easy to keep track of training examinations. If trainees are required to bring or keep track of individual logbooks or digital storage, then the program will likely flounder. Books or thumb drives may be forgotten or lost, creating frustration on the part of trainees. It is imperative in the digital age to have all of the group's ultrasound studies available for review immediately on the ultrasound system (so colleagues/consultants can review scans) and/or the DICOM workstation. A designated computer and office space to review, store, and backup studies is paramount.

4. Introduce competition. Competition is an effective motivating factor if applied appropriately. Clinicians tend to be competitive. Periodically publishing the progress of trainees so that they can see how they compare with their peers can encourage those who might otherwise be ambivalent. At a minimum, it serves to remind everyone to continue practicing their ultrasound skills. Introducing a stepped system of achievement is also beneficial, especially if the first level can be achieved in a reasonably short period of time. Being allowed to proctor less experienced trainees can also reward trainees who have achieved designated levels of training.

5. Provide individual feedback for documented studies. A few motivational words can boost ultrasound numbers. Capturing images in which the trainee has documented good landmarks or pathology correctly and letting them know is uplifting. A screen capture of the image and “a good job documenting….” emailed to the trainee frequently inspires further positive results.

Registered Diagnostic Medical Sonographer (RDMS) is a certification that can be achieved after a prescribed period of training or experience and satisfactory performance on a standardized examination. The RDMS certification is recognized nationally as the standard of training for sonographers. This certification is available to physicians as well and some propose it as a logical step in the acquisition of ultrasound skills. Tests are given in several specialty areas including the abdomen, adult echocardiography, and obstetrics and gynecology. This certification, however, is directed toward comprehensive examinations rather than focused examinations. In order to be certified, an individual must pass both physics and instrumentation examinations and at least one specialty area examination. The advantage of RDMS certification is that it is a credential with which hospitals are familiar, and it may lend weight to the physician seeking credentialing in focused ultrasound. Information regarding RDMS certification can be found online (http://www.ardms.org/credentials_examinations).29

An elective in ultrasound during medical school or residency is a superb way to accelerate ultrasound learning. Electives are typically 2–4 weeks long and offer a trainee dedicated time to learn ultrasound without the distraction of other patient-care responsibilities. Setting objectives is the key to elective design. The elective director should be able to answer the question, “What should the trainee be able to do with ultrasound by the end of the elective?” Often, the objective is to perform a certain number of ultrasound examinations or it may be to meet the requirements for a particular privilege level. The goals should be made clear to the trainee at the outset of the elective.

Example activities include the following:

1. Performance of a certain number of examinations under direct supervision or by post hoc review of video or static images.

2. Assigned reading, either from texts or from journals.

3. Involvement with administrative aspects of the ultrasound-training program, including ultrasound machine maintenance, supplies, record keeping, and proctoring of other trainees. This is the contribution the trainee makes in return for the teaching time they receive. It is also an essential exercise for anyone considering directing an ultrasound program in the future.

4. Involvement with other special projects, including research, teaching, or creating teaching materials, such as an ultrasound teaching file.

5. Testing, both written and practical.

Here are example requirements for a 2-week elective:

1. A pre-elective meeting outlining the objectives of the elective.

2. Four to six hours of directly supervised scanning distributed over the elective period.

3. An additional 56 hours of time spent independently scanning.

4. Assigned readings from an ultrasound textbook.

5. A written examination at the end of the elective.

6. Tape review sessions as needed for item (3) above.

7. Special projects amounting to an additional 4–8 hours (e.g., submit two cases to the ultrasound teaching file).

Ultrasound is a skill of great interest to residents in emergency medicine as well as medical students applying for emergency medicine residencies. Anecdotally, the enjoyment and satisfaction residents have received while doing emergency ultrasound electives has made it one of the most popular rotations in many departments.

To master the skills necessary to integrate this powerful imaging modality into clinical practice, and especially for those considering a position as an ultrasound program director, a fellowship in ultrasound should be considered. Fellowships provide a means for intensive ultrasound training beyond that which is possible within the curriculum of an existing residency program. In order for a fellow to obtain a quality educational experience, programs will need a solid commitment from their departments to provide the necessary resources. Several vital elements are needed to foster this learning experience. First, there must be a physician who is qualified to mentor an ultrasound fellow. This person should invariably have an extensive experience in clinical ultrasound, along with a passion to teach. They should have research experience and academic involvement in one or more of their specialty's ultrasound committees. Second, the fellowship director's department must fully support their efforts to advance ultrasound education and provide protected academic time to mentor each fellow and train physicians within their own department. Departments should provide financial support for a quality ultrasound system and equipment, and administrative support for research. Third, the patient volume and demographics should be sufficient to provide the fellow with experience in all applications of focused ultrasound.30

While the curriculum may vary somewhat, the foundation of each ultrasound fellowship program is fairly similar. They provide each ultrasound fellow with a core content of subject matter that is covered within the 1-year program along with several other educational experiences covered in the preceding sections. Incoming fellows may have extreme variations in ultrasound education based on where they trained during their residency and how much experience they have accrued. The ultrasound director may focus on “core” content with a particular fellow, while only covering advanced applications with another.

Core Content of the Fellowship

The core content refers to the primary ultrasound applications, but can expand into additional applications, as the fellow's time and interest allow (see Tables 1-1 and 1-2). There are always new applications or different technical components of an existing application to learn. Like almost everything else in medicine, it is a dynamic process. The fellow can become the teacher in applications that are recently discovered or updated.

Quality Improvement

Fellows should be involved in the department's ultrasound QI program. This activity offers a high educational return for time invested since the mistakes of the group become lessons for the fellow. It also allows the fellow to see the structure and function of a QI program. The repetitive nature of reviewing multiple images helps the fellow understand the appropriate landmarks, image quality, and text annotation to properly document and interpret an ultrasound examination.

Journal Club

Reviewing the literature is an important component of an ultrasound fellowship. Although the structure in which this is accomplished may vary, a working knowledge of the pertinent literature is an integral part of the educational process. Structured journal clubs throughout the year serve to educate the fellow, resident, and students as well as provide an avenue to formulate other research ideas. A plan to include literature of core applications and advanced applications keep the fellow focused on the basic fundamentals as well as cutting-edge information.

Teaching Responsibilities

The ultrasound fellow should also be responsible for educating students, residents, and attending physicians. Protected clinical time for teaching is of great importance. Depending on the experience of the ultrasound fellow, this duty may vary considerably throughout the year. Some fellows may benefit from staying with the ultrasound directors group and observing teaching skills early on in their fellowship. There are several levels of ultrasound teaching steps. Step one includes having a solid knowledge of the didactic skills of each application being taught. Step two is to master the equipment being utilized to educate the students. Step three, which is the most difficult, is to educate course participants on the technical portion of the examination without removing the transducer from their hands. The best teachers are able to verbally walk the participants through the hands-on sessions without taking the transducer away to demonstrate what they are attempting to convey.

Future Directors

Most ultrasound fellows will start or direct an ultrasound program after graduating from the fellowship. This may involve implementing or enhancing an ultrasound program at an existing residency program or private hospital. The fellowship experience should include a road map for this important step. The administrative portion of the fellowship is customarily covered during the second half of the fellowship. This includes the likes of departmental policies on credentialing, ultrasound system maintenance, billing, QI discrepancies, and intradepartmental policies. They will need assistance in developing lectures, training courses, and various training aides for their program. The fellowship should also include networking with other leaders in their field who will provide them with an opportunity to share ideas, research projects, and shape the future of ultrasound.

One of the most common questions posed by physician groups about ultrasound is, “How much will it cost us?” Little has been published about the costs of an ultrasound program. Some of the costs are easy to define (e.g., equipment and supply costs and price of training courses) and some are not as easy to define (e.g., time spent developing a program plan or performing practice ultrasound examinations). The bottom line is that the use of point-of-care ultrasound to aid in the diagnosis and the care of patients is starting to become the standard of care in the ED. Physicians who are trained in ultrasound understand the advantage of this technology.

The second most common question asked by those who must make the balance sheet work for an office or department is, “Can we bill for this service?” The short answer is “yes.” A detailed discussion of the financial side of ultrasound is beyond the scope of this chapter, but there are certain issues worth mentioning. Performing and billing for a focused examination does not exclude a traditional imaging specialist from performing and charging for a comprehensive examination of the same area, even on the same visit. Serial focused ultrasound examinations, if medically indicated, can be billed individually (e.g., serial FAST examinations in a deteriorating patient) at this time. Emergency physicians do not have to meet the same reporting standard as radiologists in order to charge for ultrasound examinations, but they may, in some instances, be required to record images to receive full reimbursement. Hospital-based clinicians generally cannot own an ultrasound machine and charge a “technical” fee in addition to their usual “professional” fee for an ultrasound examination. Extensive and up-to-date information about ultrasound coding and reimbursement can be found on the ACEP website (www.acep.org).