Women in Ultrasound Leadership: Seeing the Future

At first, I was excited for the opportunity to write a piece for The Scan on Women in Ultrasound Leadership. I love ultrasound and I love trying to advocate for women in medicine, especially women in medicine leadership. Sounds great, right? Then my efforts quickly became like the purgatory on a page of my personal statement for internal medicine residency application. Next came a hard-core resurgence of the “Impostor Syndrome” I’ve been working pretty hard to quell, with the support of some great colleagues and friends. In case you’re one of the few people who have never experienced this, Impostor Syndrome is defined by Dr Google as “the persistent inability to believe that one’s success is deserved or has been legitimately achieved as a result of one’s own efforts or skills.” So, how do you write for yourself and try to encourage others to keep waging and winning these internal AND external battles? Especially when you so very acutely remember all those doubts (and *may* have had to take propranolol for near panic over giving a Meet the Professor session on POCUS at the American College of Physicians convention last year)?! Here’s how: You look at the numbers, get fired up, think about yourself in the past—plus all of the other women out there—and get down to it.Renee

Since you’re probably wondering who in the heck I am, and why I am qualified to write about women in ultrasound leadership, let me introduce myself. I am a lifelong Oregonian outside of 3 years in Boston at Massachusetts General Hospital for my internal medicine residency. During my residency, I fell in love, first with simulation as an educational method, and later with point-of-care ultrasound (POCUS). I felt these methods could do so much to advance the care of medical patients beyond the ED, where POCUS was most common. Then, I returned home to my first attending role in the Division of Hospital Medicine at Oregon Health & Science University (OHSU). My passion for ultrasound developed further as I learned additional clinical uses and saw just how much you could use ultrasound to teach residents and students in the foundational sciences and beyond.

With the knowledge, support, and sponsorship of my former provost, Dr Jeanette Mladenovic, I started my ultrasound leadership journey. My first experience with the incredibly welcoming national POCUS community was when the World Congress of Ultrasound in Medical Education came to OHSU in October of 2014. With Dr Mladenovic’s encouragement, I helped out with logistics, including scheduling and faculty, room, and machine assignments, and did a bit of teaching. But mostly I fan-girled over my POCUS heroes, learned, and connected. There were probably only 10–15 other internists that year, but I was so inspired by their work and the POCUS community in general that I will forever fondly remember that meeting.

Since then, via connections, friends, mentors, and sponsors made at that meeting, I have been able to teach at national internal medicine (IM) pre-courses, give lectures, webinars, and podcasts, and create and deliver local, regional, and national/international POCUS curricula at OHSU, including for the AIUM (where I now also serve on the Board of Governors).

It’s been a wild ride, and I’d like to take a quick pause to define and highlight the concept of sponsorship, and what it has done for me. “The Real Benefit of Finding a Sponsor” in Harvard Business Review (HBR) asserted:

“The Sponsor Effect” defines a sponsor as someone who uses chips on his or her protégé’s behalf and advocates for his or her next promotion as well as doing at least two of the following: expanding the perception of what the protégé can do; making connections to senior leaders; promoting his or her visibility; opening up career opportunities; offering advice on appearance and executive presence; making connections outside the company; and giving advice. Mentors proffer friendly advice. Sponsors pull you up to the next level.

Another HBR piece I love highlights the importance of women supporting each other, instead of responding to inequality in the workplace by holding down other women. The article describes sponsorship as “connecting a protégé with opportunities and contacts and advocating on their behalf, as opposed to the more advice-focused role of mentorship.”

Setting aside the actual promotion piece of sponsorship (given the rather structured, CV-driven nature of the academic promotion process) in my mind really drills down to someone with influence going above and beyond suggesting high-yield activities and relationships for a mentee. Instead, a sponsor makes those connections for them, putting their name up there for that national committee, speaking role, suggesting them for that multi-site study, etc.

So why am I telling you all this? Because we NEED TO ACT. Across the spectrum, there are profound discrepancies between the two sexes: woman are paid less, promoted less, funded less, published less, and finally, invited to speak & peer review less (https://www.bmj.com/content/363/bmj.k5232).

I want to acknowledge that both men and women in the POCUS and ultrasound communities have supported me, but we all have more to do. The ultrasound community is not immune to the “manel.”

“Conceptually, the reason why a panel would be organized in the first place, whether at a conference, on cable news, or as part of a legislative session, is to ensure a diversity of opinions and perspectives are brought to the issue up for discussion…The term manel has, like its predecessors, become a useful way to take note of a circumstance in which men may not realize that something they’re involved in has the effect of marginalizing women.”

Once we acknowledge that there is gender inequality, we can all play an active role in addressing it. Here are a few places to start:

  • Don’t wait for women to come to you. Step up and volunteer to be a sponsor without being asked.
  • Nominate a female colleague for an award.
  • If you find yourself on a planning committee, make sure speaker suggestions include women as well.
  • Be fair in your authorship, and make sure if you suggest peer reviewers you suggest women and In fact, being inclusive of women can translate to all aspects of your life!

Finally, my message to junior female colleagues: Focus on your strengths and what you have to give. Don’t be like me and be petrified by your lack of formal training, supplemental degrees or certificates, being the only woman or internist or sonographer in the room. No one knows everything. Own what you don’t, be honest, and do NOT let obsession with limitations or perfection be the enemy of good. Take it from me. And if you don’t have one, get out there & find yourself a sponsor. Okay, actually that was my message to all female colleagues!

In closing, I am thankful for the ultrasound community and all of the opportunities I have had to contribute to the AIUM mission and ultrasound use in general. I am honored to be on the Board of Governors for an organization with a female CEO. I am proud to be on faculty at a university with a female Dean, Provost, Chief Medical Officer, and Assistant Dean of Undergraduate Medical Education. Finally, I am thrilled to contribute my love of POCUS as both an educational & diagnostic tool, along with my love of “gab” & connections to help promote and bring this community closer together in any way I might.

 

Do you know of a woman whose career advanced with the help of a sponsor? Have you been a sponsor? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Renee Dversdal, MD, FACP, is Associate Professor of Medicine and Director of OHSU Point of Care Ultrasound as well as General Medicine Ultrasound Fellowship Director at Oregon Health & Science University, Portland, Oregon.

The Democratization of Point-of-Care Ultrasound

The subtle sound of a distant explosion rang out. We barely flinched, numb to the sound that was a near-daily occurrence at our remote outpost in war-torn Afghanistan in 2005. Minutes later, a fast-approaching Humvee suggested that this time, something was amiss. The sight of a bloodied soldier draped over the vehicle’s hood provided confirmation.

CPT Jonathan Monti, left, and Lt. Col. Robert Craig, in the army physical training shirt, treat a trauma casualty at Forward Operating Base Ripley in 20005.

As we scrambled to prepare our dusty, sparsely equipped treatment tent, casualties poured through the door. A young Afghan man, triaged as minimally injured, lay in front of me, peppered from head to toe with small shrapnel wounds. His wounds were indeed benign-appearing, as his triage category suggested, but penetrating wounds can be deceptive. I struggled to gauge whether his lack of responsiveness to my questions was due to our language barrier, or something more sinister like blunt or penetrating head trauma. His primary survey was otherwise unremarkable…nosignificant external hemorrhage, airway intact without labored breathing. His blood pressure was borderline low, not an uncommon finding in the thin/healthy. 

I dusted off the nearby SonoSite 180, now widely considered to be the first portable ultrasound device of its kind. Most of its knobs were still foreign to me, and my inexperienced eyes struggled to interpret the grainy images. His belly and lungs appeared unremarkable, but scanning through his subxiphoid region, the black stripe encircling his heart jumped out at me, inconsistent with my already-anchoring bias of a traumatic brain injury, but consistent with the images I had only seen in Ma and Mateer’s landmark text.

I quickly called the surgeon, whose experience with the device barely surpassed my own. After a quick look at both the machine and text, he commanded his team to prep the operating suite, an equally dusty, adjacent tent. Minutes later, the surgeon’s skillful incision of the patient’s pericardium evacuated the now-tamponading bloody effusion, revealing the tiny piece of shrapnel embedded within the patient’s right ventricular wall and saving the patient’s life.

On that day, the humbling and lifesaving power of point-of-care ultrasound (POCUS) was revealed to me. As a junior clinician with limited trauma experience, I had no formal ultrasound training, mentorship, or experience. Yet this machine, when coupled with only a book, and the desire to learn, allowed me the opportunity to overcome the shortcomings of my physical exam skills, my resource constraints, and my cognitive bias, and the mistriage of another, to ensure a patient received the timely and definitive care he deserved. In the decade or so since, I have been fortunate to serve my patients while under the tutelage of several POCUS experts whose altruistic and thoughtful mentorship allowed me the opportunity to cultivate my passion for this powerful tool, while also imparting the nuances and limitations of POCUS, frequently leading me back to a common question:

How can we best harness the full power of POCUS?”

There is a rapidly growing body of evidence that suggests that clinicians of various skill levels can effectively employ focused POCUS applications with minimal training. Though not without risk, POCUS is no different from other clinical skills; performed with variable competency regardless of profession, specialty, or scope of practice. Some will evoke the mantra of “a fool with a tool is still a fool,” which may certainly be true, but it is unfair to assume that foolhardiness is necessarily bound by profession, experience, or even breadth/depth of training.  

The notion that POCUS can/should only be monolithically employed by a limited number of broadly/extensively trained physicians may be yet another example of the monoculture of thought that continues to plague our healthcare system. Certainly, any diagnostic testing should be performed thoughtfully; but do we limit who can use the stethoscope, or order a CBC, based upon title or his/her knowledge of Bayesian principles, Fagan’s nomogram, or pre/post-test probabilities and test-characteristics? Do all successful clinicians adhere to these principles with each and every test they order? Are there other factors to consider when ordering diagnostic testing, particularly in the resource-constrained areas where POCUS can have the greatest impact?

Until POCUS is adaptably and appropriately employed by all those who provide care, regardless of practice setting and scope, its full benefit and potential, especially to those living in medically underserved areas, cannot be realized. Some will inevitably oppose this concept, citing concerns with expertise, patient safety, documentation, reimbursement, etc. Ironically, it is these same arguments that emergency physicians faced 2 decades ago before successfully overcoming significant resistance to fully integrate POCUS into emergency medicine practice.

POCUS leaders are uniquely poised to best mitigate the risks associated with POCUS use through the provision of expanded training opportunities that are well-crafted, appropriately focused, and variably commensurate with clinicians’ skills, cognition, practice setting, and scope. Some of our most innovative POCUS educators are already doing so, whether by incorporating POCUS into the physical exam, or training nurses to perform diagnostic ultrasound, or training medics to employ ultrasound in austere locations. The rise of artificial intelligence/machine learning is already reducing the training burden traditionally associated with POCUS.

POCUS is a rare technological tool; one that is portable, versatile, and liked by both patients and clinicians alike. It can expedite diagnosis and care, improve the accuracy of our physical exam, and help us overcome our own anchoring bias while reducing the risk of procedural error, healthcare cost, and iatrogenic radiation exposure. Though it may not impact a majority of patients, for those it does, that impact is often significant. But the most uniquely promising characteristic of POCUS that we should all embrace is its ability to bring better-informed clinicians of any ilk, back to the bedside where they belong, wherever those in need of care may be.


Do you believe the democratization of point-of-care ultrasound can enhance patient care? Share with us your thoughts or your efforts to do so: comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Dedicated to the memory of CPT Jeremy A. Chandler, 1st BN, 3rd Special Forces Group, whose life was lost while bravely serving his country on that fateful day, August11th, 2005, in Tarin Kowt, Afghanistan.
https://www.greenberetfoundation.org/memorial/jeremy-a-chandler/

Jonathan Monti, PA-C, RDMS, is an Associate Professor of Emergency Medicine PA Studies at Baylor University and president of the Society of Point-of-Care Ultrasound (SPOCUS). He is currently conducting research on the unconventional employment of ultrasound in the U.S. Armed Forces as an employee of the Henry M. Jackson Foundation for the Advancement of Military Medicine.

Teaching Point-of-Care Ultrasound

Ultrasonography (US) is now used in some fashion by most specialties, and in graduate medical education, performing a US examination is now a routine expectation in the fields of emergency medicine, surgical critical care, diagnostic radiology, pulmonology, and gynecology. The American Medical Association has confirmed that physician‐performed US is within the scope of practice of appropriately trained physicians and recommend that training and education standards be developed by individual medical specialties.

In light of its clinical and education utility, it is reasonable to expect that US would be taught during medical school. Some national and international bodies, including the AIUM, have proposed curricula for medical students. While its level of use is variable, several schools have described integrated US into undergraduate medical education. Several studies have shown that students are able to and want to learn point-of-care US (POCUS) in medical school. Let’s review some tips for engaging medical students while teaching POCUS.

1. Hands-on time

Allow the medical student to have hands on the probe as much as possible. Limit lecture time to only that which must be done in lecture format. Make sure group learning time is done in small groups with maximal time for each student to use the probe. Give them time to work through different positions and views to help identify windows and quality images. Use your verbal commands to direct them instead of taking the probe. If you are going to take the probe, put your hand over theirs.

2. Engage the student

Find a use for ultrasound that is relevant to the student’s specialty of choice. Most specialties now have some use for ultrasound. IF you cannot identify a use for ultrasound in the specialty of choice, consider teaching general skills like US-guided IV insertion. Describe how US was or would have been useful during residency.

3. Make it fun

Use simulation liberally. Consider having a game or competition (see Sono-games, SonoSlam, or other similar competitions for potential ideas). Multiple homemade procedural models have been described and are inexpensive. Medical students, in general, love practicing procedures and are mostly competitive by nature. There are several ways for the more experienced student to improve their US skills in a fun manner. Some ideas include identifying inanimate objects blindly that are immersed in water, a competition like fastest FAST exam, or making a procedural simulation competition.

4. Short and sweet

Keep sessions engaging by spreading practice out over time. Again, keep lectures as brief and need-to-know as possible. Most medical students will only need a brief physics review and do not, for example, need to know the Nyquist limit. They need to know how to answer focused questions with ultrasound. Students will lose interest if doing the same exam over many hours. Consider spreading sessions, especially image review sessions, out to 1 hour or less over several days. Intersperse different types of ultrasound (e.g., abdominal, cardiac, pulmonary, vascular) within the same session to keep students engaged.

5. Start early

Expose students to US early on in medical school. Consider adding it to anatomy or physiology classes while students are still in their pre-clinical years. If you do not have the swing to add a formal session to preclinical years, consider having voluntary “anatomy review” sessions using US. Try to get enough interest to start an interest group for students that is student-run. This will allow them to take some of the responsibility for scheduling and promoting events and you can focus on what you do best, teaching US.

Ultrasonography is coming to medical education and will continue to grow in use. While students going into specialties like radiology and emergency medicine may instantly be engaged in US teaching, consider ways to engage other students. There is a role for US in nearly every specialty.

Sonographers can and should play a key role in teaching medical students techniques for US. Sonographers perform these exams every day for many years. They have tricks for obtaining quality images and many sonographers are also quite good at interpreting exams, as well.

Embrace medical students and engage them with your passion for ultrasound. Show them how it will be helpful to them in the future. Take an active role in medical student education and watch the use of ultrasonography in medical practice continue to grow.



Do you have suggestions for teaching POCUS to medical students? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Joshua J Davis, MD, is an Emergency Medicine Resident at Penn State Milton S. Hershey Medical Center.

Why Teach Ultrasound?

Sonosorority on ultrasound teaching rounds: (left to right) Michelle Nasal, Grace Rodriguez, Jessica Everett, Erin Wendell, and Tatiana Thema, with Creagh T. Boulger, MD.

Early in my career, I recall my choice to pursue my academicniche in ultrasound and more specifically ultrasound education being questioned. “Why would you do that?” “How are you going to get promoted?” “This is just a fad!”. For a moment I paused wondering if I should heed this advice. Was I making a mistake? I am happy I did not dwell on that moment because I would not be where I am, I would not have gotten promoted, I would not have touched so many learners, met so many amazing people, and helped so many patients.

One of my first patients as a doctor illustrates why I teach ultrasound. I was a brand-new doctor maybe 10 days under my belt. I walked in the room of my patient. They were in clear discomfort, I was nervous. I pushed on their abdomen. Unsure, I walked out to my supervisors and said: “I think I have an acute abdomen in bed 10.” We paged surgery and were ordering other imaging when my now-mentor, Dave Bahner, suggested we do a FAST exam. This was before the ultrasound invasion in medical school and my only exposure to ultrasound was limited and in OB and the trauma bay. He immediately noted significant free fluid and presumed rupture of a neobladder. The patient went promptly to the OR. This opened my eyes and sparked the passion for ultrasound that has fueled my career. I could use this machine to look inside and help patients on the outside.

So why teach ultrasound and who should you teach?

I teach ultrasound because…

It enables me to bring 2-dimensional anatomy to life. One of my greatest joys is showing a new medical student, undergrad, or high school student their own heart beating right in front of them and see the awe in their eyes.

It makes complicated concepts simple. I recall the challenge in medical school of the preclinical years 1 and 2. Understanding systole, diastole, cardiac valves, and flow. On paper, these are complicated and merely rote memorization. Watching these events occur on ultrasound in real time and how they are altered by simple maneuvers such as Valsalva or squatting truly aids in full understanding of the concepts.

Ultrasound is always relevant. One of my favorite courses to teach is ‘The Approach to Undifferentiated Shock’. This is attended by all fourth-year medical students. By the fourth year in medical school, many students are distracted by interviews and matching and have already chosen their respective fields. I love this course because as a teacher, I get one last chance to show them the light, or rather sound, and how it could help them if they encounter a patient in shock. I ask each of them their field of choice and if they see ultrasound having a role in their career. Many will nod affirmatively to appease me but by the end of the course, they are asking if we can teach them more ultrasound before they graduate. Ultrasound helps me connect and let them know how we use ultrasound to understand the causes of shock and how to manage these patients. This ability to break down silos and demonstrate how useful it can be across many specialties that care for patients is one of my favorite aspects of teaching bedside ultrasound.

Innovation

Ultrasound is such an exciting new tool and developed into a new field. New probes, technology, and applications are always evolving and changing how we use it to care for patients.

Ultrasound education is equally as exciting and dynamic. Because of challenges such as limited curricular time and tight budgets we have gotten creative to teach ultrasound. Ultrasound education has led the way with new concepts such as remote instruction, flipped classroom, near-peer training, learning through modeling, and gaming.

Mentorship

I have been fortunate to be blessed with amazing mentors who have given me amazing opportunities. The ultrasound community is small and welcoming, as well as young, fresh, and innovative. One of the greatest joys of teaching ultrasound has been the relationships I have made. I have found wonderful mentors but also been able to be a mentor. To watch my students turn into fellowship directors, division heads, and national speakers has been one of the greatest rewards. I have seen that hard work, loving what you do, and helping others learn ultrasound is a winning strategy for me and possibly you too.

Clinical Excellence

I make myself endlessly available to my learners and that offer does not end at graduation. More so than any award I have ever gotten, the greatest accomplishments of my career are the notes, emails, and texts saying thank you: ultrasound saved my patient last night. Those clinical wins where a patient benefits from a bedside ultrasound make every late night of lecture prep worth it.

So, why teach ultrasound? Ultrasound is the future of medicine and medical education. Get involved!

Why do you teach ultrasound? What do you value most about teaching the next generation of ultrasound users? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

Creagh Boulger, MD, RDMS, FACEP, is Assistant Professor, Assistant Director of Ultrasound, and Assistant Fellowship Director of Emergency Ultrasound at Ohio State University Wexner Medical Center.

Training and Integrating Sonographers via Dedicated Preceptors

Hiring new staff members is risky business. Despite all the resources invested in identifying and evaluating qualified candidates, there’s no guarantee they’ll be a good long-term fit for the department. As new staff members begin to settle into a new job, there are a variety of reasons why they might ultimately leave the position. Many of these reasons can be traced back to deficiencies in orientation and training programs. With this in mind, it is of the utmost importance to invest appropriately in the onboarding process. A successful onboarding and training program provides benefits to the candidate and the organization.IMG_2125

My experience with these processes comes primarily from my current position as the Ultrasound Educator at St. David’s North Austin Medical Center in Austin, Texas. A huge portion of our sonographers are hired and contracted to maternal-fetal medicine (MFM) clinics around the Austin area; working for Austin Maternal-Fetal Medicine. Expectations for these sonographers are high. They perform all ultrasound examinations common to maternal-fetal medicine practice, including fetal echocardiography and diagnostic 3D/4D techniques. The scarcity of qualified candidates means that we often hire candidates from out of state, and integration to the department and community are among our primary concerns; having a structured training program helps with that.

New employees spend their first 2 days on the job attending facility orientation. Their third day of work is their first day in the MFM department. They’ll meet with leaders and physicians, and tour all relevant areas. In addition, I spend some time with them reviewing the training process and setting expectations. At this time, we pair them with a Sonographer Preceptor. The preceptor/trainee assignment is, of course, subject to change, but we try to limit this as part of the goal is to provide some stability and consistency during the training period.

The standard training period is 3 months in duration, although, we have extended training in some cases up to 6 months. This period may look different for various candidates based on their prior experience level. However, there are several characteristics that remain fixed:

1. One-on-one work with a preceptor

The Sonographer Preceptor is expected to directly observe while offering real-time feedback, every part of the trainees workday. This level of intensity may only be reduced after consultation with the Ultrasound Educator.

2. Weekly preceptor feedback report

This weekly report is filled out by the Preceptor and reviewed with the trainee. They review things that are working well and also plan which tasks need additional focus for the following week.

3. Image review with the Ultrasound Educator

On a weekly or biweekly basis, the trainee will meet with the Ultrasound Educator to review the Preceptor feedback report and review a selection of examinations from the prior week.

4. Didactic and written material for review

Each candidate is supplied with protocols, American Institute of Ultrasound in Medicine (AIUM) guidelines, review articles, and some pre-recorded lectures that cover essential quality standards and approaches for the department.

This high-touch training period helps to ensure that we have a strong understanding of the progress being achieved and can quickly adjust if we do not see steady growth.

Many people will recognize that it takes years to develop strong, comprehensive skills, in the performance of MFM ultrasound examinations. So what can we expect to accomplish in only 3 to 6 months? Upon completion of the training period, the sonographer should be able to:

  1. Complete normal fetal anatomic surveys, fetal echocardiograms, and other examinations in non-obese patients, demonstrating an understanding of proper technique, measurements, and optimization.
  2. Exercise professional discernment by getting help when their own efforts do not produce the answers or quality they expect.

These two goals may initially appear to be overly simplistic, but they work together beautifully in the transition out of the training period and into independent performance. Completion of normal (relatively easy) examinations proves that they understand the target. They understand what normal looks like and the essential techniques involved. The second point is key as it gives department leadership the confidence to allow them to work independently, because we know that they understand what good enough is, and we know that they have the resources they need in order to help them when they cannot meet expectations on their own. This is an important skill that never expires. This is relevant for sonographers, physicians, and other health care practitioners throughout their careers. Knowing when you’ve hit your limit and when to seek additional counsel is key to providing the best care to our patients (regardless of one’s particular level of expertise).

These two benchmarks, along with ongoing quality assurance efforts, help give us confidence in our team even as they continue to grow their individual skills and proficiencies over the coming years.

A note on Preceptor selection

Key to the success of this process is the selection of Sonographer Preceptors. These team members fill two distinct (individually important) roles: technical trainer and social integrator. With that in mind, selection of the individuals who fill this role is very important. Social characteristics we look for are warmth, kindness, extraversion, and the tendency to be inclusive. Technical expertise is evaluated based on history, quality assurance, physician feedback, and ability to evaluate and explain abnormal cases.

Full-time training in a one-on-one environment for 3 months or more at a time can be emotionally and mentally exhausting (even if rewarding). With this in mind, we try to maintain several Preceptors on our team so that these sonographers are able to work independently for extended periods between training new employees.

The social and integrative aspects of our Preceptor Program are not formally defined, yet the benefits are clearly evident. We see that our new employees make strong connections with their preceptors and other team members, frequently having lunch together and engaging in other extracurricular activities during time off.

It is important to point out that preceptors should typically be individual team members—not leads, supervisors, or managers. These formal leaders have other administrative duties that will inevitably get in the way of the one-on-one, full-time training involved in a preceptorship. Of course, leads, supervisors, and educators, may set aside time for some training of new hires, and this is certainly beneficial. For example, in our departments, I frequently set aside time to work with new hires or existing employees on specific skills such as 3D/4D, fetal echocardiography, or abnormal cases. Sonographers enjoy these sessions and benefit from them, but that does not replace the benefit of having a dedicated preceptor.

People don’t stay in jobs where they feel disconnected from the culture and community. This training program, with assigned preceptors, helps to meet the human need for connection in addition to building and verifying technical skills that are necessary for success.

For additional reading:
https://www.forbes.com/sites/forbeshumanresourcescouncil/2017/09/21/seven-ways-to-integrate-new-hires-and-make-them-feel-welcome-from-the-first-day/#1282eff640f6
https://www.thebalancecareers.com/employee-orientation-keeping-new-employees-on-board-1919035
https://trainingindustry.com/blog/performance-management/dont-ignore-training-when-onboarding-new-employees/

Does your practice have a mentor program for sonographers? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Connect

Will Lindsley, RDMS (FE, OBGYN, AB), RVT, is an Ultrasound Educator in Maternal-Fetal Medicine and Fetal Echocardiography in Austin, TX.

Evidence-Based Sonology: Changing the Practice of POCUS

Let’s say you are working in a busy emergency department. You get a call that a patient is being brought in by ambulance in cardiac arrest. You quickly assemble your team, assign roles, and discuss the plan—just in time for the patient to arrive. A paramedic performs one-arm compressions on an elderly man, pale yellow–his mouth stented open with a laryngeal mask airway. Your swarm of providers descends upon the patient, performing their jobs simultaneously in perfect concert. Airway, ventilations, rhythm checks, epinephrine: everything is running smoothly, but the patient is in pulseless electrical activity. During a rhythm check, someone looks at the heart with ultrasound. You glance at the screen and see a blurry subcostal cardiac view. You can barely make out the pericardium, but you see a weak contraction of the ventricles; there’s still no pulse. Compressions are quickly resumed. You consider all of the information – what are the chances this patient will survive? Should we keep going? Should I place a transesophageal probe? Wait, do I even have one of those?! Is ultrasound enough evidence to determine if further efforts are futile? Amidst your thoughts you hear a loud and eager call out: “I got a pulse!”. The team buzzes again – blood pressure, electrocardiogram, labs, vasopressors, cooling. You wonder, “Why did I even do that ultrasound? Is there any evidence it helps?”.

The difficulty encountered in this scenario is one that occurs countless times across the world’s hospitals each day. Point-of-care ultrasound (POCUS) has exploded off the shelves over the past decade. It has been borrowed from the hands of sonographers and cardiologists and made available to anyone who can afford a machine (training course optional). Overall, this has been a remarkably positive movement. Safer procedures, faster diagnoses, and sometimes a replacement for more potentially harmful imaging modalities. However, it is not without dangers. Those who use it aren’t always looking for the evidence for POCUS, as if it is somehow outside of the requirement for evidence. Others might not use this modality when it is indicated, ignoring the evidence that supports the use of POCUS. Both practices are unsafe. This is a big problem…but it’s one we can fix with the concept of evidence-based sonology.

Practicing based on the best available evidence has been a cornerstone of medicine since its advent; however, only more recently has it seen a visible resurgence. Now that it is in vogue there are physicians who are evidence-based medicine (EBM) specialists, there are EBM blogs and EBM courses. We teach our learners EBM principles and practices. So why has POCUS almost eluded this trend? Why would the evidence for POCUS not be examined with the same perspicacity as resuscitative endovascular balloon occlusion of the aorta (REBOA) in the emergency department, for example? I have some theories. In the early days, POCUS was practiced by a few champions with a dream who understood how POCUS could revolutionize practice. However, ultrasound equipment was not yet widely available. This limited initial studies to case reports and case series on new uses, touting primarily theoretical benefits to patients. As anyone who has used ultrasound knows, this tool holds a powerful allure by allowing its user to magically look into the body and directly visualize physiology and pathology. It is easy to imagine that after a while you build up a confidence; when you see something it must really be there. In a sense, the rapid outbreak of ultrasound use and the ever-expanding list of applications outran the available evidence basis.

A review of a subset of ultrasound-related abstracts showed that there is now increasing research, although most of it would be classified as quasi-experimental, which may not be enough to inform practice.1 But the times, they are a’ changin’. Now ultrasound is ubiquitous, at least at most academic centers, in emergency departments, ICUs, and other places that care for the acutely ill. Therefore, the body of literature is growing, and now we just have to pay attention to it. Enter evidence-based sonology (EBS).

Your first question is probably – sonology? What’s that? Did he just misspell sonography? No. Sonology is a term that implies an expertise in the entire spectrum of POCUS. Not only the acquisition (the “-graphy”) of the images, but additionally the indications for performing it, the interpretation, and the subsequent appropriate medical decision making.2 This is important because the evidence for this modality could fall apart at any one of these levels, so practitioners must be attuned to the hurdles of each step. Your second question probably is, isn’t this just EBM? Of course! But it is something that we could improve, and therefore we need to rebrand this practice to continue teaching it as a concept to anyone that uses POCUS. There are several reasons why this is important. As POCUS becomes more integrated into medical practice, it is important that we are all on the same page. Research helps us understand the benefits and limits of this tool for each application. It helps us to know the best time to use the tool, how accurate it is when we use it, how it affects patients when we use it, and potential harms associated with it.EBS Graphic

So where do we go from here? There are 3 main ways you can practice EBS:

  1. Know the evidence
  2. Model the evidence
  3. Make the evidence (AKA perform research)

As far as knowing the evidence, this is nothing new for anyone practicing in a medical field. You know how to get a hold of journals. These days it’s easier than ever. You can even use social media, podcasts, and blogs to further distill the information for you. Just make sure you read the original evidence yourself and develop your own decisions about how it will change your practice. Secondly, you have to actually implement what you learn. Obviously, not all research articles are practice-changing, but many will at least add something to your understanding of POCUS in clinical practice. For example, in the aforementioned case of cardiac arrest, recent literature could have informed many steps of using POCUS. Cardiac activity on ultrasound has an odds ratio of 3.6 for survival to admission.3 Patient’s in PEA with cardiac activity on POCUS might benefit from continuous adrenergics instead of standard ACLS.4 Furthermore, an understanding that there is the risk of misdiagnosis of cardiac standstill and the risk of delaying chest compressions, might make you pay closer attention to these details during use of POCUS.5,6 Practicing with this evidence is not only the safest practice, but for those at teaching institutions, it can help create a newer generation of EBS followers. Lastly, make the evidence. Do the research. If you have a question, go find the answer. Collaboration is easier now that ultrasound is more widespread, as is evidenced by more multi-center trials.7-9 Talk about research ideas at national meetings and consider research groups for important questions.

There is now a greater evidence basis for POCUS than ever before. No longer are we restricted to a few case reports and our own intuition. We have randomized controlled trials; we have meta-analyses; we have real patient-centered outcomes. Know the evidence, model the evidence, and make the evidence. These are simple practices that we need to support for the sake of our patients. Now it’s up to you. Will you start practicing EBS? Think of creative ways to begin promoting this concept today.

References:

  1. Prats MI, Bahner DP, Panchal AR, et al. Documenting the growth of ultrasound research in emergency medicine through a bibliometric analysis of accepted academic conference abstracts. [published online ahead of print April 15, 2018]. J Ultrasound Med. doi.org/10.1002/jum.14634.
  2. Bahner DP, Hughes D, Royall NA. I-AIM: a novel model for teaching and performing focused sonography. J Ultrasound Med. 2012; 31:295–300.
  3. Gaspari R, Weekes A, Adhikari S, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016; 109:33–39.
  4. Gaspari R, Weekes A, Adhikari S, et al. A retrospective study of pulseless electrical activity, bedside ultrasound identifies interventions during resuscitation associated with improved survival to hospital admission. A REASON Study. Resuscitation. 2017; 120:103–107.
  5. Huis In ‘t Veld MA, Allison MG, Bostick DS, et al. Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions. Resuscitation. 2017; 119:95–98.
  6. Hu K, Gupta N, Teran F, Saul T, Nelson BP, Andrus P. Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med. 2018; 71:193–198.
  7. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med. 2014; 371:1100–1110.
  8. Atkinson PR, Milne J, Diegelmann L, et al. Does point-of-care ultrasonography improve clinical outcomes in emergency department patients with undifferentiated hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators. Ann Emerg Med. 2018; 72:478–489.
  9. Gaspari R, Weekes A, Adhikari S, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016; 109:33–39.

Do you already practice evidence-based sonology? If not, will you start?  Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

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Michael Prats, MD, is currently Assistant Ultrasound Director and Director of Ultrasound Research in the Department of Emergency Medicine at the Ohio State University Wexner Medical Center. He is the founder of the Ultrasound G.E.L. Podcast that reviews recent articles in point of care ultrasound. Follow him on Twitter by his handle @PratsEM or visit ultrasoundgel.org.

Exploring the Potential of Ultrasound for Endometriosis

Endometriosis is a benign and chronic condition that can cause women to experience pain and fertility problems. For a long time, and to an extent still today, surgery is required to diagnose the disease. However, in the hands of an expert, a transvaginal ultrasound can accurately map deep endometriotic nodules and identify pouch of Douglas obliteration in a noninvasive fashion (Figure 1). Though this statement exhibits optimism in the effort to minimize the use of invasive surgery for diagnostic purposes, there are a few limitations with ultrasound in this scenario.

Leonardi Fig 1

Figure 1: Ultrasound depiction of bowel deep endometriosis and negative sliding sign (can only be noted with dynamic movements) (left) and laparoscopic depiction of bowel deep endometriosis and obliterated pouch of Douglas.

This blog post will attempt to highlight a few key issues with ultrasound’s potential in the realm of endometriosis. We also encourage your comments below on how you feel about ultrasound for endometriosis. Ultimately, we must all be critical of what can and cannot be achieved with ultrasound to ensure appropriate day-to-day clinical practice. This then also allows us to pursue ongoing cutting-edge research endeavors.Leonardi

Our first limitation is in the definition of the word, “expert.”  Thus far, one might attach the term “expert” to those responsible for the bulk of the literature on ultrasound for endometriosis. Certainly, in the view of these academics, ultrasound can see much more endometriosis than previously thought. The belief in the value of ultrasound and expertise in scanning/interpreting scans may trickle down the typical training ladder to fellows, residents, and sonographers. But is there any formal teaching—didactic or tactile? Is there any formal assessment of skill to suggest a minimum level of competency? Is there, at this time, even an understanding of how to evaluate a trainees’ learning curve of endometriosis ultrasound? What is to there to stop an individual from claiming competency when ultrasound for endometriosis is still in its infancy? One concern with pseudo-experts is that they may actually impede the advancement of endometriosis ultrasound integration because surgeons do not verify their findings intraoperatively, leading to skepticism.

Another big problem with the current potential for noninvasive ultrasound diagnosis of endometriosis is the inability to visualize superficial endometriosis, the mildest form of the disease. In surgery, deposits of superficial endometriosis are generally small, only a few millimeters in width and depth, and discolored (Figure 2). They sometimes cause adhesions to form between structures, such as the ovaries and the pelvic sidewall or uterosacral ligament. Thus far, no one has been able to directly identify superficial endometriosis deposits on ultrasound. However, soft markers on ultrasound, such as ovarian immobility and site-specific tenderness (ie, the ability to elicit pain with the pressure of the transvaginal probe during the scan) may hold some secrets to the diagnosis of this enigmatic form of the disease. Until further research supports the routine use of these components in ultrasound for endometriosis, the superficial disease remains a surgical, and therefore invasive, diagnosis.

Condous and Leonardi Fig 2

Figure 2: Laparoscopic depiction of small superficial endometriosis deposit.

Despite these limitations and others not highlighted here, the ability to directly visualize the more severe forms of the disease (ie, ovarian endometriomas, deep endometriosis of the bowel, and pouch of Douglas obliteration) has led to two very clear and significant benefits. One, the patient may be able to receive a diagnosis of disease in a noninvasive fashion, which may guide treatment. Second, if surgery is elected as the treatment of choice, surgeons can prepare. If severe disease is noted on a scan, surgeons can anticipate advanced level surgery, which may necessitate skill from a minimally invasive gynecologic surgeon and/or colorectal surgeon. If no disease is identified on a scan, there will be superficial endometriosis or no disease at all in surgery.

Overall, we are at a much better place right now than we have ever been when it comes to ultrasound for endometriosis. There are still limits that must be addressed, many of which are actively being investigated by dedicated teams around the world. This blog commentary does not attempt to offer solutions to the obstacles highlighted. However, please feel free to comment below if you have any thoughts on an approach to these, or other, limitations.

Have you tried ultrasound for endometriosis? What is your experience with ultrasound and endometriosis? What are your thoughts on the limitations of ultrasound for endometriosis? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

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Mathew Leonardi, MD, FRCSC, is an Honorary Lecturer in the Department of Obstetrics and Gynaecology and PhD student at the Nepean Clinical School, University of Sydney, under the supervision of Associate Professor George Condous. His Twitter handle is @mathewleonardi