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 – 1st, 2nd, 3rd 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
– Hemoperitoneum
– 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
Performance
Assessment
Procedures – visualize the needle, hit the target