Q&A: A Nonradiologist Perspective on Using Ultrasound by Treating Physicians

When Diagnostic Imaging published a story on the use of point-of-care ultrasound by nonradiologists, some physicians took issue with comments that questioned the training, quality assurance, and ultrasound knowledge of those outside the radiology profession.

Compact ultrasound machines are gaining momentum in a wide variety of medical specialties, with U.S. sales increasing 21 percent in 2010, according to Klein Biomedical Consultants. (Read the main article for more on this trend.) As the small ultrasound machines become less expensive, they will be more accessible to practitioners in specialties other than radiology, and therefore more reasonable to incorporate into those practices, according to Deborah Levine, MD, chair of the American College of Radiology (ACR) Ultrasound Commission and professor of radiology at Harvard Medical School.

She noted her concerns about the use of compact ultrasound in nonradiology settings: “Is the machine of good enough quality to suit the purpose for which it’s used? Do you know how to use it? Do you have a QA [quality assurance] process? How do you store your images? Are your images and reports available for others outside of your own department to see?”

For a response to her concerns, we spoke to Christopher L. Moore, MD, assistant professor in the Department of Emergency Medicine at Yale University School of Medicine, who co-authored the New England Journal of Medicine review article behind our initial story (“Point-of-Care Ultrasonography” 2011, 364:749-57).

What’s the best way to train physicians in ultrasound?

In my opinion, the optimal way to train physicians is during residency. In emergency medicine residencies there is an ACGME [Accreditation Council for Graduate Medical Education] requirement for procedural competency in bedside ultrasound, similar to other specialties like obstetrics and cardiology. Nearly all emergency medicine residency programs have dedicated rotations for ultrasound, ongoing requirements for the number and type of scans, and quality assurance processes in place.

To be honest, many ER physicians are getting more hands-on experience in obtaining ultrasound images than radiology residents in some programs. In some places, the radiology residents are coming to the ER to train with them. In radiology there are sonographers or techs who do the actual image acquisition, which is great if the radiologist knows how to do that. But the danger is if the tech does all the image acquisition and the radiologist doesn’t know how to do that well.

When is it better to use a radiologist versus a treating physician for ultrasound?

Radiologists are very good at a comprehensive examination and oftentimes that’s required. However the ability to do focused point-of-care testing in the context of the clinical evaluation is extremely helpful. The examining clinician can have an advantage.

We taught some of our radiologists how to diagnose a pneumothrorax using ultrasound. We have diagnosed retinal detachments that radiologists weren’t comfortable looking at using ocular ultrasound. In emergency medicine, we don’t get a cardiologist to see everyone with chest pain. That would bankrupt the system. We don’t get the orthopedist to see every sprained ankle. If it’s a difficult case, it’s very important to get the appropriate consultant involved.

What kind of billing changes would you like to see in terms of ultrasound?

I would not be opposed to a CPT geared toward point-of-care ultrasounds rather than the current radiology paradigm. If it’s just part of the physical exam, there won’t [be] resources for the investment in the appropriate technology, QA, and training. If you don’t pay for it, there won’t be the resources and incentives to ensure that it’s done right, such as requiring image archival and a written report.