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. 

Connect

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.

SonoBowl: A Game, A Challenge, An Education

SonoBowlOn July 12, 2018, 4 teams of 4 sonography students each competed in the inaugural SonoBowl, a game pitting the students’ ultrasound knowledge and skills against each other. Howard Community College (HCC) hosted the event, which the American Institute of Ultrasound in Medicine (AIUM) sponsored, and teams from Howard Community College; Montgomery College; Pennsylvania College of Health Sciences; and University of Maryland, Baltimore County participated. Although only 4 students from each team could participate, many more attended to observe.

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SonoBowl teams: HCC Sound Dragons are in red (as is their dragon), UMBC Dopplergangers are in black, PA Penguins are in white (4 in front), and MC Ultrasonic are in white (middle and back rows). AIUM staff are in blue.

If you are interested in hosting your own SonoBowl, you’re in luck. AIUM will be sharing instructions on recreating it, enabling schools around the country and abroad to create their own SonoBowl, where sonography students can come together to compete in ultrasound with question-and-answer sessions, scanning, and case challenges. The following is a review of the inaugural  SonoBowl. If you want all of the details, you’ll need a copy of the SonoBowl Playbook. If you are interested in receiving a copy of the SonoBowl Playbook, please let us know.

HCC and AIUM worked together to quickly pull this event together in just 2 months, including 6 conference calls and meetings—planning the itinerary, developing questions and case challenges, inviting teams and registering them, and setting up the event. Development began in May and concluded with the event, which included:

    • Round 1, Who Gives a Kahoot?: 30 multiple-choice questions and 1 bonus multiple-choice question on Kahoots;20180712_094549
    • Round 2, Mission I’m Possible: 3 rounds of scanning testing vascular, obstetric, and abdominal knowledge; and
  • Round 3, Have You Hertz About My Case Study?: A case challenge.

Round 1 was a question-and-answer session. Each team was supplied (by HCC) with a tablet to use for answering the questions as quickly as they could, as wins were based on speed as well as accuracy. The questions were developed by AIUM with input from Directors and faculty from the schools.

IMG_0591Round 2, which can be seen in this video, was a hands-on demonstration of the students’ skills. The teams were given 15 minutes at each station, equipped with an ultrasound machine and a model, to complete their task and answer the questions, which were provided on a form in an envelope and could be completed on a provided clipboard. A proctor at each station reviewed the image obtained for the task and indicated on the form whether it was correct and whether the answers to the question were each correct. After 15 minutes, the teams would rotate stations until all teams had competed at each station.

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For those students who attended but were not participating, a scavenger hunt was developed to fill this time. The students were randomly divided into 4 teams, each of which included students from each of the schools. Each team was given a campus map and a list hinting at 15 things to find around the campus. They were tasked with answering questions for some and taking a selfie at each to prove they found them. For example, one such hint was “Orange is definitely your color! Take a selfie with your face in the circle,” referring to a sculpture outside one of the buildings. Once Round 2 was complete, a lunch was provided.

Round 3 began with an announcement of where each team stood in the competition; HCC DMS Sound Dragons were in 4th place with 58 points, MC Ultrasonic was in 3rd with 66 points, and
UMBC Dopplergangers and PA Penguins were tied with 74 points each. Knowing how many points they had and the topic of the case study (gynecologic ultrasound), each team then indicated how many points they were willing to wager for the final round. All teams wagered their full points balance.

The teams were given a brief history for a case and shown the ultrasound images associated with it, then were given 1 minute to indicate which of 4 diagnoses was the correct one. After time was up, each team was asked to show their wager, beginning with the last place team, and the scores were adjusted based on their wager and whether they answered correctly. For this inaugural SonoBowl, MC Ultrasonic won the day with 132 points and was awarded the trophy to hold onto until next year’s SonoBowl, when it will be back up for grabs. Each of the winning team’s members also won a free AIUM student membership for a year and an insulated lunch bag containing AIUM gifts.

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If you are interested in receiving a copy of the SonoBowl Playbook, please let us know.

The American Institute of Ultrasound in Medicine is a multidisciplinary medical association of more than 9000 physicians, sonographers, scientists, students, and other health care providers. Established in the early 1950s, the AIUM is dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of guidelines, and accreditation.

Sonographers and Contrast-Enhanced Ultrasound

Now that contrast-enhanced ultrasound (CEUS) has been approved in the United States for several abdominal applications in adults and pediatrics, I decided to take a deeper look into the sonographer’s role in CEUS. Traditionally, sonographers perform ultrasound examinations based on a protocol, construct a preliminary ultrasound findings worksheet, and perhaps discuss the findings with a radiologist. And now CEUS has transformed traditional ultrasound and gives physicians and sonographers additional diagnostic information related to the presence and patterns of contrast enhancement.DSC00125

Based on sonographers’ traditional scope of practice, some questions came to mind. What is the training process for sonographers to learn CEUS? How should CEUS images be obtained and stored? How should CEUS findings be communicated?

I envision CEUS training for sonographers broken down into stages, where they begin by learning the basics and eventually transition to where they can perform and record the studies independently. The first stage for sonographers is the ‘CEUS learning curve.’ In this stage, sonographers become familiar with basic CEUS concepts, eg, understanding physics of contrast agents and contrast-specific image acquisition modes, CEUS protocols, and typical patterns of contrast enhancement seen in various organs. In addition, an important part of the training is recognizing contrast reactions, and learning IV placement, documentation and billing related to CEUS.

The next stage involves sonographers performing more patient care and gaining scanning responsibilities. Sonographers place the IV and prepare the contrast agent. The scope of sonographer responsibilities does not generally include contrast injection (although it is reasonable since CT, MR, nuclear medicine, and echocardiography technologists routinely place IV lines and inject contrast). It should be noted that CEUS examination usually requires an additional person (physician, nurse, or another sonographer) to assist with contrast injection while the sonographer performs the ultrasound examination. In the beginning of sonographer training, it is very beneficial to have a radiologist present in the room to guide scanning and appropriate image recording.

In the third stage, a well-trained sonographer is more independent. At the completion of the examination, the sonographer will either send clips or still images to a physician to document the CEUS findings and discuss the procedure. Ideally, a worksheet is filled out, comparable to what is done today with “regular” ultrasound.

The majority of CEUS examinations are performed based on pre-determined protocols, usually requiring a 30–60-sec cineloop to document contrast wash-in and arterial phase enhancement. After that continuous scanning should be terminated and replaced with intermittent acquisition of short 5–10-sec cineloops obtained every 30–60 sec to document late phase contrast enhancement. These short clips have the advantage of limiting stored data while providing the interpreting physician with real-time imaging information. Detailed information on liver imaging CEUS protocols could be found in the recently published technical guidelines of the ACR CEUS LI-RADS committee.[i] Some new users might acquire long 2–3-minute cineloops instead, producing massive amounts of CEUS data. As a result, studies can slow down a PACS system if departments are not equipped to deal with large amounts of data. In addition, prolonged continuous insonation of large areas of vascular tissue could result in significant ultrasound contrast agent degradation limiting our ability to detect late wash-out, a critical diagnostic parameter required to diagnose well-differentiated HCC. Any solution requires identifying and capturing critical moments, which will be determined by a sonographer’s expertise. Exactly how sonographers can ensure CEUS will successfully capture the most important images is a critical question that must be answered and standardized.

Ideally, leading academic institutions should provide CEUS training for physicians and sonographers. I have seen and attended CEUS continuing medical education courses and they are a great way for physicians and sonographers to learn CEUS imaging. CEUS is a step forward for sonographers and will potentially transform our scope of practice. The technology will advance the importance of sonographers and diagnostic ultrasound, and importantly it will improve the care of our patients.

Acknowledgements:
Dr. Laurence Needleman, MD
Dr. Andrej Lyshchik, MD
Dr. John Eisenbrey, PhD
Joanna Imle, RDMS, RVT

[i] Lyshchik A, Kono Y, Dietrich CF, Jang HJ, Kim TK, Piscaglia F, Vezeridis A, Willmann JK, Wilson SR. Contrast-enhanced ultrasound of the liver: technical and lexicon recommendations from the ACR CEUS LI-RADS working group. Abdom Radiol (NY). 2017 Nov 18. doi: 10.1007/s00261-017-1392-0. [Epub ahead of print]

Has CEUS helped your sonography career? How do you envision CEUS being incorporated in your work? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Corinne Wessner BS, RDMS, RVT is the Research Sonographer for Thomas Jefferson University Hospital in Philadelphia, Pennsylvania. Corinne has an interest in contrast-enhanced ultrasound, ultrasound research, medical education, and sonographer advocacy.

To My Fellow Sonographers

Dear fellow sonographers,

I am proud to say that I have worked as a sonographer since 1983 and have been on an incredible journey for 34 years. I started out at the Washington Hospital Center in Washington, DC, as a radiologic technologist and had the privilege to work on the job as a sonographer. I have evolved, grown, and through my profession, I have continued to educate myself. When I passed the ARDMS certification in 1984, I decided that I would continue to set goals for myself and keep my career in ultrasound exciting and challenging.

Over the next 33 years, I worked in a Radiology office, in private practice, and in maternal-fetal medicine. Now, I am honored to be part of the American Institute of Ultrasound (AIUM). So, why am I saying all this? Because I now want to encourage all of you to use my experiences to take your profession to the next level.

My personal goal is to educate sonographers. To encourage sonographers to love their jobs and be the best. Times have changed, especially in the ultrasound world. Doing an OB exam and showing only a 4-chamber heart is no longer enough. Now, we are expected to do outflow tracts, aorta, ductus, and sometimes the infamous 3-vessel trachea view.

If you are asking what is the 3-vessel trachea view? Well, let me just tell you about this amazing cardiac image. If you can acquire and document a normal 3-vessel trachea you can rule out Transposition of the Great Arteries (TGA), Tetralogy of Fallot (TOF), and Right-sided Aortic Arch. You can also be the hero of the office when you go to your doctor at your practice and say “Hey, the 3-vessel trachea view looks abnormal, what do you think?” Not only will you impress them and possibly save a life, but you will earn respect and, hopefully, you are reminded as to why you wanted to be a sonographer in the first place.

I have always loved my job and continue to learn every day. There is a whole world of ultrasound information out there. I challenge you to go beyond what you know to get the job done, be the best, and always treat your patient as your best friend, whoever that might be. My challenge for you is to read about the 3-vessel trachea view and, if it is not a part of your daily OB routine, add it.

Please join me and expand your education!

Haylea Weiss, RDMS (AB FE OB/GYN)
American Institute of Ultrasound in Medicine

Apply for AIUM’s new Sonographer Scholarship Grant, a program that provides $500 and free registration to an AIUM post-graduate event. Applications due March 1, 2018.

Internal Medicine and Bedside Ultrasound–A Match Made in Heaven

I am an internist who does bedside ultrasound. This has not always been true. From 1986, when I got my MD from Johns Hopkins School of Medicine, to November 2011, I was a traditional internist, taking care of a panel of patients in a small university town in Idaho. I saw my patients in the office when they could walk or wheel in with their problems and in the hospital when they were sicker. I took call for my partners on rotating weekends and holidays. I occasionally ordered ultrasounds and echocardiograms and thought of them as blurry representations of internal structures that could be magically interpreted by radiologists.

In 2011, events such as the growing up of our 2 children allowed me to reconsider my choices of what to do with my MD. I had always wanted to do medicine in resource-poor settings overseas. I had often been curious about locum tenens work in other states, which would involve adventure and exposure to new practice styles and surprisingly generous compensation compared to my predominantly outpatient practice. I also had an urge to binge on continuing medical education courses, which I had denied myself for years due to responsibilities at home.

Janice Boughton, MD

One of the CME courses I treated myself to was an introductory course in emergency ultrasound through Harvard/Massachusetts General Hospital. It was wonderfully taught and I was immediately hooked. Ultrasound at the bedside would transform my practice and had the potential to transform the whole practice of internal medicine! The Cupid of bedside ultrasound had sunk his arrow straight between my eyes.

I went on to take more courses in bedside ultrasound both in person and online and bought myself a small pocket ultrasound, which rapidly developed my imaging skills. I began to use ultrasound clinically as a diagnostic tool within weeks of my first exposure. I discovered over-expanded bladders, failing hearts, pleural effusions, ascites, or lack thereof in my patients with big bellies. I became a better doctor and enjoyed my job more. My patients were happy to have benefitted from what looked to them like Star Trek technology.

I expected at any point that someone in the diverse hospitals where I served as a locum tenens hospitalist would ask for my credentials or forbid me to use ultrasound. I expected skepticism by cardiologists with whom I worked. I expected radiologists to be upset at me. I even did a 1-month UC Irvine mini-fellowship and ARDMS certification as a sonographer. These experiences gave me a vast amount more expertise and confidence but were mostly to ward off imagined disapproval. Yet nobody ever made me present my certification. Nobody disapproved to my face except one radiologist, who I’m still working on. Cardiology consultants were tickled to get imaging information in addition to history and vital signs. I may have benefitted from being in hospitals where people were too busy taking care of patients to fuss with me. It really seemed, though, that the vast majority of people with whom I worked realized that I was a better doctor with an ultrasound than without.

I have gone on to teach bedside ultrasound and participate in research on malaria and schistosomiasis with medical students in Tanzania. I have taught basic ultrasound to overburdened healthcare workers and physicians from Doctors Without Borders in South Sudan during its ongoing civil war. Knowing how to teach basic bedside ultrasound means I am valuable in resource-poor settings even if I can only stay for a couple of weeks. I have been able to teach my internal medicine colleagues in the US along with residents and medical students, which has been a wonderful opportunity for a nonacademic rural physician.

So what’s my point here? As an “early adopter” of bedside ultrasound in internal medicine, I have made myself a test case. So far these are the results:

  1. It wasn’t too hard to learn enough ultrasound to be a better doctor.
  2. There was never a time when I was too much of a novice to benefit from bedside imaging, yet every time I ultrasound a patient I learn something new. I can’t foresee a time when my learning will be complete.
  3. There has been surprisingly little push-back and a gratifying amount of appreciation.
  4. Bedside ultrasound is the perfect extension of the physical exam in internal medicine. It brought back my joy in physical diagnosis. We should all be doing it!

Have you used ultrasound in your internal medicine practice? Have you gone after ultrasound education after obtaining your degree? How can medical education be modified to encourage the widespread use of ultrasound by future internists? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Janice Boughton, MD, is an internist working as a staff Hospitalist at Gritman Medical center as well as is a locum tenens physician at other northwest hospitals. She also supervises and serves in rural health clinics, and blogs about bedside ultrasound and other issues at http://whyisamericanhealthcaresoexpensive.blogspot.com/?m=1.

The National Ultrasound Interest Group (NUSIG)

The National Ultrasound Interest Group (NUSIG) is a student-led organization founded in 2014 to promote ultrasound in undergraduate medical education. You may know us as the force behind planning national level events like SonoSlam. The bulk of NUSIG’s work, however, is sharing education and leadership resources between Ultrasound Interest Groups (USIGs) across the country. Each of the five regional representatives contact medical schools in their areas to exchange ideas, plan co-sponsored events, and see how NUSIG can assist them in evangelizing ultrasound.

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NUSIG provides everything from information on getting equipment and funding, to original educational content. Our podcast on iTunes (quickly closing on the 1,000 download mark) currently features a journal club series. Each episode is hosted by a different school evaluating an ultrasound-related article.

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Our next series is how to plan an Ultrafest, where we interview schools experienced in putting on these events. Our hope is that these USIGs can learn from each other, and other schools might be inspired to start their own UltraFest once it’s been laid out how. In the future, we aim to collect medical student level ultrasound lectures from across the country and publish them for anyone to view. Our vision is to serve as a central repository for the best medical student educational content available. Lastly, our twitter feed regularly features current ultrasound research articles and retweets outstanding free open access medical education content.

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If you want to learn more about us or get involved, check out our website at www.nationalusig.com, and follow us on Twitter and Facebook @NtlUSIG. You can find us on iTunes by searching for “NUSIG podcast.”

Are you a member of the National Ultrasound Interest Group? Did you attend this year’s SonoSlam? If so, share your thoughts and feedback. Comment below or let us know on Twitter: @AIUM_Ultrasound.

Mat Goebel is in charge of Social Media for the National Ultrasound Interest Group and is a medical student at the University of California at San Diego.