The Challenge Of Educating Residents And Fellows In Ultrasound

Dr. Ted's presentation at pacori 2019

1. The Challenge of Educating Residents and Fellows in Ultrasound Theodore J. Dubinsky MD, FSRU,FSAR Laurence A Mack Endowed Professor of Radiology, Obstetrics and Gynecology, and Reproductive Health Sciences University of Washington Editor in Chief, Ultrasound Quarterly

2. The Challenges Knowledge / Information Scanning skill 3D awareness Biopsy / Procedure skills When do they need to know it? How do we assess that they’ve learned it? Education in US

3. Resident Education Guidelines What residents need to know Society of Radiologists in Ultrasound Resident Curriculum Dubinsky, Theodore J. MD; Garra , Brian S MD; Reading, Carl MD; Moshiri , Mariam MD; Baltarovitch , Oksana MD; Harris, Robert MD; Angtuaco , Teresita MD; Scoutt , Leslie MD; Pattiel , Harriet J MD; Nazarian , Levon S MD; Hashimoto, Beverly MD; Hamper, Ulrike M MD, MBA, FACR Ultrasound Quarterly: December 2013 - Volume 29 - Issue 4 - p 275–291

4. The Diagnostic Radiology Milestone Project A Joint Initiative of The Accreditation Council for Graduate Medical Education and The American Board of Radiology July 2015 https://www.acgme.org/Portals/0/PDFs/Milestones/DiagnosticRadiologyMilestones.pdf

5. American College of Graduate Medical Education (ACGME ) Medical Knowledge Educational Attitude Perception and Judgement Technical Skills Clinical Effectiveness Communication / Consultation General Guidelines for Resident / Fellow Education

6. American College of Graduate Medical Education (ACGME ) 1. Consultant 2. Competence in Procedures 3. Selection and Optimization of Images 4. Interpretation of examinations 5. Professional values and ethics 6. Effective communication with patient, families, and caregivers 7. Effective communication with members of health care team 8. Quality improvement 9. Health care conomics 10. Patient safety 11. Self directed learning 12 Scholarly activity Milestones

7. Milestones Level 1: The resident demonstrates milestones expected of one who has had some education in diagnostic radiology. Level 2: The resident is advancing and demonstrating additional milestones . Level 3: The resident continues to advance and demonstrate additional milestones; the resident consistently demonstrates the majority of milestones targeted for residency. Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target. Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the

8. Stages of Education Beginner: Knowledge of Basic Anatomy Advanced Beginner: Knowledge of Basic Pathology Competent: Knowledge of advanced pathology and the performance and interpretation of color Dopper US Proficient: Ability to assimilate clinical information and radiologic imaging studies to manage cases and consult effectively Expert: Ability to scan all types of cases and perform US guided procedures What level of competence have they achieved?

9. US Curriculum Physics and Elastography Abdomen Kidneys, Ureters, Bladder, Prostate OB – 1 st , 2 nd , 3 rd Trimester Thyroid / Neck Vascular Pediatrics Gynecology Scrotum MSK Thorax Breast

10. Example 1

11. Ectopic Pregnancy Beginner – Normal ovary and uterus Advanced Beginner – Knowledge that pregnancy status is essential to know Adnexal mass, echogenic fluid Competent: Blood flow within mass Proficient: Recognition of ectopic pregnancy H emoperitoneum Report of clinical significance of findings to referring physician Expert: Ability to scan case and demonstrate all findings

12. Example 2

13. Anencephaly Beginner: Knowledge of fetal cranial anatomy Advanced Beginner: Knowledge of findings of snake eyes, lack of head Competent : Recognition of no flow in cranium Proficient: Diagnosis of anencephly Expert: Ability to scan to confirm findings

14. Example 3

15. Cholecystitis Beginner: Layers of GB wall Advanced Beginner: Dilatation, GB stone, Debris, thickened striated wall Competent: Increased flow along anterior wall Proficient: Recognition of advanced cholecystitis Expert: Ability to confirm abnormalities

16. Example 4

17. Appendicitis Beginner: Knowledge of layers of appendix Advanced Beginner: Thick appendix prominent inflamed mesoappendix loss of layers Competent: Increased blood flow in wall of appendix Proficient: Recognition of advanced appendicitis with potential to perforate soon Expert: Ability to find and confirm findings of appendicitis

18. Example 5

19. Medullary Nephrocalcinosis Beginner: normal medullary pyramids hypoechoic Advanced Beginner: Echogenic pyramids Competent: Extensive twinkle artifact Proficient: Hypercalcemic patient with MNC is probably hyperparathyroid Expert: Confirmation of echogenic renal pyramids

20. Example 6

21. Hepatic Metastases Beginner: Knowledge of hepatic anatomy Advanced Beginner: Recognition of hepatic masses Competent: Patency of portal and hepatic veins Proficient: Realization that metastases are present and a primary lesion should be sought out Expert: Scan of abdomen in to discover colon mass that sonographer did not scan

22. Scanning in Ultrasound How to teach this? What to teach? How to evaluate proficiency in this?

23. The Three Basics of Scanning Orientation Anatomic right and left Superior to inferior Windows Intercostal Subcostal Far posterior for kidneys Through bladder for ovaries Maneuvers Deep breaths LLD Upright

24. Three Ways to Learn to Scan On call Thrown into the pool method Follow sonographer See how they scan Repeat scan when there’s time Assign specific images from attending review Review case with attending

25. Procedures See the needle Hit the target

26. AIUM Guidelines Training Guidelines for Physicians Who Evaluate and Interpret Diagnostic Abdominal/General Ultrasound Examinations 500 Training Guidelines for Physicians Who Evaluate and Interpret Diagnostic Detailed Fetal Anatomic Ultrasound Examinations 100 / 25 major anomalies Training Guidelines for Physicians Who Evaluate and Interpret Diagnostic Fetal Echocardiographic Examinations 50 / 20 abnormal Training Guidelines for Physicians Who Evaluate and Interpret Diagnostic Ultrasound Examinations of the Female Pelvis 300 Training Guidelines for Physicians Who Evaluate and Interpret Urologic Ultrasound Examinations 50 exams Training Guidelines for Physicians Who Evaluate and Interpret Diagnostic Ultrasound Examinations of the Head and Neck 150 http://www.aium.org/resources/ptGuidelines.aspx

27. How Many Cases are Enough? Resident Training in Emergency Ultrasound: Consensus Recommendations from the Council of Emergency Medicine Residency Directors Conference Saadia Akhtar, MD, Dan Theodoro , MD, Romolo Gaspari , MD, Vivek Tayal , MD, Paul Sierzenski , MD, Joseph LaMantia , MD, Sarah Stahmer , MD, and Chris Raio , MD ACADEMIC EMERGENCY MEDICINE 2009; 16:S32–S36 a 2009 by the Society for Academic Emergency Medicine 150 US examinations in ‘‘critical ’’ or ‘‘life-saving’’ situations

28. OB / Gyn Lee, Wesley, et al. "Fetal ultrasound training for obstetrics and gynecology residents." Obstetrics & Gynecology 103.2 (2004): 333-338.) Hands-on scanning and observation were the most significant educational activities for ultrasound training. Ultrasound program directors generally rated the overall preparedness of residents as ranging from adequate to excellent. The most important learning obstacles were limited curriculum and faculty time. Most programs evaluated competency by direct observation of scanning skills. According to the CREOG survey, only 16.3% of residents indicated that the performance and interpretation of fetal ultrasound examinations were mandatory program requirements.

29. ER scanning assessment : practical exam 1) FAST examination 2) Emergent cardiac imaging 3) Evaluation of the aorta for AAA 4) Identification of early intrauterine pregnancy via transabdominal and transvaginal sonography 5) Procedural guidance for ER procedures 6) Identification of gallbladder pathology 7) Detection of deep venous thrombosis 8) Recognition of hydronephrosis and determination of bladder volume 9) Detection of subcutaneous fluid collection, abscess, and foreign body 10) Identification of pneumothorax 11) Identification of ocular pathology

30. Assessing Scanning Education Known pathology Can the resident / fellow find it? Normal anatomy Are images adequate Practical exams Test residents on a series of patients / volunteers

31. University of Washington Successfully interpret and report on 2 separate renal ultrasounds under direct supervision by an attending physician Yes No 1. The trainee completed this procedure.*   2. The trainee exhibited competency in all areas of this procedure.*   3. If No, the trainee requires additional experience in the following areas: 4. The trainee recognizes and manages complication of this procedure.*  

32. Degree of Difficulty

33. Conclusions: Well defined curriculum Levels of knowledge established Scanning skills less well defined Observation P erformance Assessment Procedures – visualize the needle, hit the target