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.

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.

Why I Love Credentials

My name is Mike. I am many things, including a veteran, a business man, a coach, and a sonographer. And while the “things” I am change over time, one thing has remained the same: I am a student! This is thompsonmost evidenced by the 8 professional credentials I currently hold.

I have found that after being in the field of ultrasound for more than 2 decades, credentialing and continuing education can distinguish the enthusiastic sonographer from the merely competent one. With the introduction of more focused credentials such as musculoskeletal, breast, pediatric, phlebology, and advanced cardiac subspecialties, sonographers can now stand out from the crowd in terms of awareness and competency while at the same time being on the cutting-edge of the latest techniques and literature.

Acquiring a new credential, or even just studying for the registry examination, requires you to learn valuable new knowledge that may impact the way you treat and diagnose patients. For example, while I was preparing for the RPhS registry, multiple sources recommended a pneumatic compression device to augment venous flow while a patient is standing as an alternative to the patient performing the Valsalva maneuver in order to induce and record venous reflux. For me, this method has helped me better evaluate for this condition with less strain on the patient while eliminating communication barriers that may exist. If I hadn’t been preparing for that exam, I probably would never have learned this technique.

While some credentials are necessary for certain jobs, multiple credentials prove to existing and future employers that you take your profession seriously and you don’t settle for the minimum standard. I am not saying you need to get multiple credentials. If your professional interest does not reach beyond one credential, that is fine, but few ultrasound labs today only perform only one specialty. Echocardiography labs and vascular labs are growing together as cardiovascular labs, and many departments are requiring a more comprehensive knowledge in ultrasound. Credentialing yourself to the highest degree may get you the new job you pursue or secure the one you have. While increased pay is always a motive, sometimes the satisfaction of being able to set yourself apart from others in the field can be just as rewarding.

Some sonographers have the position that if the credential doesn’t come with a pay raise, it’s not worth it. With reimbursement cuts and higher credentialing standards being proposed by private and government payors, my opinion is that keeping your job is a pay raise.

Why do you hold the credentials you have? What are your go-to resources? What book would you like to see written? Share your thoughts and ideas here and on Twitter: @AIUM_Ultrasound.

Mike Thompson, MPH, RDMS, RDCS, RVT, RPhS, RVS, RCS, RCCS, is Owner of Diagnostic Resources in Perry, Georgia.