Radiologists Relinquish Ultrasound

If you heard the phrase point-of-care ultrasound five years ago, there’s a good chance you cringed or became suddenly protective of your business. This trend for nonradiology providers to conduct ultrasound exams at the bedside initially sent the industry into a panic – but, that worry has now turned to calm acceptance.

According to experts, point-of-care ultrasound (POCUS) provided by other clinicians isn’t hurting your business. In fact, it can actually be an unexpected benefit to your daily workflow.

“There’s been a change in the last five years in the response to the use of point-of-care ultrasound by providers who aren’t radiologists,” said Brian Coley, MD, professor and radiologist-in-chief at Cincinnati Children’s Hospital. “People have come around to not seeing this as big a threat to actual practices and departments. They’ve realized that if we engage, we can be part of helping to direct how ultrasound use happens both locally and on the large scale.”

POCUS has the distinction of being one of the few things in medicine that one specialty has poached from another – the most famous instance being the use of a stethoscope by a wide variety of health care providers rather than solely physicians. Initially, when other specialties began using POCUS, opponents were driven by worries about nonradiologists having adequate training, image quality, proper documentation, and potential billing abuses. Proper guidance, however, has helped stave off these issues.

To date, the areas that have seen the biggest POCUS developments have been in emergency department care, cardiology, and physical therapy.

The Radiologist’s Role
The POCUS trend is growing, but radiologists are still seen as health care’s imaging experts, and you know best what must be included in all documentation to ensure proper billing and reimbursement. So, you can’t shy away from offering your opinions and input about the appropriate scope of use for other clinicians, Coley said.  

Instead, get involved in discussions with hospital administrators and medical executive committees to discuss the best ways nonradiologists can provide POCUS services. Be sure you are part of creating any system in which you aren’t the sole ultrasound provider.

“Radiologists need to honestly assess the scope of services they are able to provide and see where other clinicians can step in,” he said. “We need to participate in appropriate training, credentialing, and monitoring. If we don’t, someone else will come in and do it for us in a fragmented way.”

The Impact of POCUS
At the very least, Copley said, clinician-conducted POCUS can make your workflow, as health care’s imaging experts, easier. The ever-growing patient population kick-started by health care reform has caused a spike in the number of requests for imaging studies – a volume that far surpasses what you and your colleagues are able to perform. Consequently, allowing other trained providers to assume responsibilities for some services, such as line or nerve block placements or fluid drainages, makes sense.

“Other clinicians can do the less-complicated cases, leaving our ultrasonographers to focus on bigger, more complicated cases,” he said.

Transferring these uses of ultrasound to clinicians could also eliminate your need – should you have it – for hiring additional staff. And, in many cases, you might see your referrals – and, consequently, your bottom line – increase, he said. As referring physicians increase their use of POCUs, they are more likely to see things they don’t recognize, and they could choose to send their patients to you for a more experienced opinion.

In fact, Copley said, existing data strongly supports improved patient outcomes with clinician-performed POCUS. Evidence shows the aforementioned procedures are performed more deftly and with better results when ultrasound guidance is present.

John Cronan, MD, chair of diagnostic imaging in Brown University’s Warren Alpert Medical School, agreed. Ultrasound, he said, is a flexible, intuitive tool that strengthens medicine’s oldest means of diagnosis – the physical exam.

“Ultrasound is a very useful technology for clinicians to use with the physical exam. It replaces being poked and all the guesswork, so it’s better for patient care,” he said. “Without ultrasound, the physical exam is a joke – it’s archaic and a waste of time.”

He did, however, warn against ceding jurisdiction over too many ultrasound applications to nonradiologists. Patient care could falter and mistakes could be made, he said, if clinicians ventured into applying their ultrasound skills to investigating more complicated cases they aren’t qualified to diagnose.[[{"type":"media","view_mode":"media_crop","fid":"38621","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6781148604384","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3854","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 133px; width: 199px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©sfam_photo/Shutterstock.com","typeof":"foaf:Image"}}]]

There are other risks to using POCUS in emergency department settings, said John McGahan, MD, a radiologist at the University of California-Davis. While bedside ultrasound can save time, especially if a hospital doesn’t have around-the-clock radiology coverage, there’s a chance that images might not be recorded in a patient’s medical record. Not having those studies on file could hamper a physician’s ability to treat a patient, as well as create the possibility for duplicative studies.

Training the Future Clinician
Many clinicians are learning to use ultrasound technology on the job, but there’s also an ongoing push within medical education to make mastering the fundamentals of this technology part of training.

To reach this goal, the University of California-San Francisco (UCSF) launched a POCUS training program, pairing the radiology and anatomy departments with physical diagnosis courses to teach medical students the correct ways to use ultrasound and how to understand what they see.

“I realized I had to do this because, if I didn’t, someone else would,” said Emily Webb, MD, a UCSF associate professor and abdominal imaging specialist. “I wanted to maintain control over the content.”

According to Webb, who runs the training program and published a paper in Academic Radiology on the early results, a committee – comprised of an emergency medicine doctor, the physician responsible for physical diagnosis courses, and two radiologists (including Webb) – designed the POCUS training curriculum. The radiologists teach students how to use the ultrasound machines, how to stand, and how to identify visualized organs. The emergency medicine doctor provides opportunities for first-hand experience. The program, she said, is designed to give students a thorough – though rudimentary – understanding of this modality.

“We’re trying to concentrate on the skills every medical student should graduate with, such as the ability to identify fluid in the abdomen,” she said. “There’s no need for students to rotate through radiology to learn POCUS because what we teach is more complex. It’s a waste of their time and not what we want to do.”

Since the program’s launch in 2014, though, applications to UCSF’s radiology program have surged, she said, bucking the national trend of declining numbers.

Although garnering consensus for and designing the program was far easier than anyone anticipated, there is one specific challenge to making it work, she said. Implementing the program properly requires a significant time commitment. Teaching POCUS correctly can only be done in small groups – approximately four students at a time – so attending physicians must be willing to sacrifice many hours for this teaching. However, many trained students are now seniors and can take on teaching the first- or second-year students.

So far, the success of the program has been in giving students a strong background in ultrasound basics without giving them the sense that they are ultrasound experts.

“It’s important for radiologists to be involved , not just to teach students the basic skills the best we can, but to also incorporate into training the fundamental lesson of knowing when they need to make more advanced imaging the next step,” Webb said. “We don’t want students having an exaggerated sense of their own skills.”

Ultimately, she said, the use of ultrasound has already expanded, and it is radiology’s job to take the lead role in ensuring that it’s used correctly in the future.

“The time for the argument that ultrasound is ours and only we should do it is over,” she said. “Students will be using this, regardless, and they might as well have some idea of what they’re doing.”