Ultrasound: current status and position of SERAM

The use of ultrasound is widespread in many different areas of clinical practice. Ultrasound is included in the radiodiagnosis training plan and in the training plans for other medical specialities. In some areas, ultrasound is considered a routine clinical tool, becoming decentralised from radiology departments and extending to other specialities, where it is used in decision-making to complement the clinical diagnosis.^1,2

At present here in Spain, we as radiologists are the specialists with the most comprehensive knowledge of ultrasound, and our departments have the means necessary to offer the technique continuously and under regulated conditions, as a routine part of the diagnostic process.

However, the new generations of radiologists seem to be showing perpetually less interest in ultrasound imaging. There are a variety of reasons for this trend, including the allure of advances in other techniques such as computed tomography or magnetic resonance imaging, the need for their constant physical presence in the examination room, the consequent direct contact with the patient and a continuously high workload, and the scant professional gratification that comes from a high rate of low-yield examinations.

This distancing has resulted in a lack of interest in advances in new ultrasound tools, such as elastography or contrast-enhanced ultrasound, which are more widely used by other specialists. It has also led to radiologists participating less in ultrasound-related research. In fact, the only radiologists taking part are those whose professional activity is mainly ultrasound-based, and they are becoming fewer and farther between.

In this context, to which we have to add the long waiting lists for ultrasound examinations in our departments, the Spanish Society of Medical Radiology (SERAM) is trying to find solutions to help improve this situation. A recent survey carried out by SERAM and addressed to radiology department sections, branches and heads included the following questions:

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  What type of ultrasound training do residents receive?

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  Are there waiting lists in ultrasound imaging? If so, what solutions could be implemented to reduce them?

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  Are there difficulties in filling positions for radiologists?

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  What do you think about the incorporation of diagnostic imaging technologists (DITs) for the acquisition of images in certain ultrasound studies?

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  What do you think about ultrasounds being performing by primary care (PC) or emergency physicians in your setting? Is there regulated ultrasound training for these specialists?

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  Do you think it is best for SERAM to lead ultrasound training for non-radiologists and DITs?

Of the 182 surveys sent out, 54 responses were received (29.7%).

The results showed that the majority (74%) are not concerned about the training of residents in ultrasound, that problems with ultrasound waiting lists are widespread (90%) and that the inclusion of DITs trained to perform ultrasound is one of the solutions implemented to reduce them, with the approval of 61% of those surveyed.

The majority of the respondents (78%) said they did have problems finding radiologists, and 92% conceded that ultrasounds were performed by PC and emergency physicians, without coordinated training in most cases.

The proposal of SERAM leading the regulated training of technicians and other specialists by skill levels was supported by 72% of respondents.

In short, long waits for ultrasound scans are a problem across most of Spain. It is not easy to find radiologists to perform these examinations and PC and emergency doctors performing ultrasounds having had inadequate training, with consequent questionable quality, is common practice. The majority support SERAM taking the initiative to endorse and lead ultrasound imaging training by skill levels.

On the world map, there are two opposing versions of the role and status of ultrasound.^2,3 One considers it a clinical tool, which has been broken out of the radiology departments to become a bedside element for patient management, controlled by non-radiologist physicians, and which requires intense training programmes in ultrasound imaging, both in undergraduate and postgraduate studies. At the other extreme is those who consider it an imaging technique that is performed and reported, in 90% of cases, by highly qualified technical personnel (the British “sonographers”) who work within the radiology departments.

Although each of these contrasting views has many arguments for and against, SERAM has decided to adopt a position somewhere in between the two that better adapts to the environment in which we operate.

It would be misleading to deny the role that ultrasound has as a clinical management tool for many specialists, but we must ensure that it is used appropriately. It is therefore vital that:

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  The personnel who perform ultrasound scans have the necessary training.

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  Each ultrasound be accompanied by a medical report that integrates the findings of the examination and those obtained from other paraclinical tests or clinical data.

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  These studies be filed in the hospital's picture archiving and communication system (PACS) for possible re-evaluation.

It is up to us to ensure that these requirements are met.

At the same time, we cannot disregard how helpful it would be to have trained DITs for performing less complex or low-performance ultrasounds.

One of the DIT's many functions is to carry out technical procedures and perform quality control on them. The suboptimal training that health technicians receive in Spain makes it difficult to integrate ultrasound into the basic training plan. We therefore need to develop models for performing the different ultrasound scans, as well as training programmes that ensure that the examinations are performed according to suitable quality standards. Training programmes designed according to skill level would allow both DITs and non-radiology medical specialists access to training regulated and endorsed by SERAM, to which they could refer when necessary.

The recent European Society of Radiology (ESR) European consensus document on recommendations for the use of ultrasound imaging,¹ which has caused some controversy,^2,3 defines as a key point that radiologists should take a leading role in training and governance of the use of ultrasound. In light of the decentralisation of ultrasound, they propose collaboration between medical professionals to develop training programmes and ultrasound imaging guidelines that ensure the necessary quality standards and that can be used by both radiologists and non-radiologists.

For years, the need to reserve the role of performing ultrasound scans to medical personnel has been defended, under the pretext of the wide interoperator variability or the need to evaluate the findings in the clinical context.^1,4 The development of standards for the different ultrasound scans by organ and system would reduce that variability, and having the studies reported by a radiologist would guarantee evaluation of the findings in a clinical context. Once again, our stance would be somewhere between those who consider the benefit of using ultrasound in the clinical context to be key, endorsing its use by specialist doctors who treat the patients' symptoms, and the radiologists who are more reticent about sharing ultrasound and claim their knowledge about imaging tests as a whole is essential to extract more information from the findings.

Training in ultrasound endorsed and governed by radiologists would, on the one hand, allow DITs to access posts for performing certain ultrasound examinations, reviewed and reported by radiologists (which would speed up the performance of these procedures and could help reduce waiting lists), and on the other, facilitate the use of ultrasound by certain non-radiology specialists in an effective and regulated manner based on skill level. In both scenarios, the objective is to ensure high-quality and cost-effective clinical practice, which will definitely be beneficial for healthcare systems and ultimately also for patients.