Learning, Training, and Teaching Ultrasonography – Problems and Perspectives

Looking into the body by means of ultrasonography (US) has found a multitude of medical applications - it is much shorter a list on medical areas which can do without US as compared to those who need it. Since its first tentative steps in medicine in the late sixties of the last century,

knowledge on and expertise in US has grown in a snowballing manner, US machines developed to multifunctional high tech devices, producing real time information on function and morphology in a unique discrimination power, an evolution driven by inventive and imaginative engineers and physicists - as a rule, professional users intelligence lagged behind technical creativity; and last but not least, US - when accessible and available - has gained a firm place in public perception.

So - what about us as US operators, as professional users - how and by which means can newcomers and (semi-)professionals acquire, train, and learn more on US in all its complexity?

1. First and foremost, novices in US can learn and understand US only by own performance, best on "their" clinical patients, in daily practice, and under competent guidance. This is as trivial as it is true, and it applies for any other practical skill as well. In US, however, specific situations of frustration ("I do not see anything on the screen") and of challenge ("to see or not to see!"), have to be accepted and conquered - to start with, preferably in hands-on teaching and sessions. This is time consuming for trainee and teacher - an effort needed and rapidly paying back. Fears regarding responsibility in US examination - to overlook or misclassify - are constant companions. Shortcomings in anatomy knowledge must be overcome. Spatial perception in even small anatomical and functional regions of interest must be understood, and then

2. referred properly to other team member's understanding and acceptance. Precise and preferably standardized wording of US real time findings and interpretations is another requirement - as a rule, one good picture saying more than hundred words, and one US movie saying more than numerous pictures. And by the way, a simple picture in moderate printer size and quality is not really fancy.

3. All this can be like a steep mass of rocks difficult to climb on without getting lost. Nevertheless, number one invitation - do it, perform US on your own - is the leading challenge.

4. A systematic approach is desirable, with a mix of expert controlled learning, preferably hands on and theoretical education by lectures and reading. As a rule, such concentrated training is available in courses only, best performed in hospital settings with a high grade of integrated clinical US expertise. Such concentrated learning phases will strengthen and encourage the operator to meet everyday clinical challenge in US-guided patient care.

5. With growing personal US expertise, any form of learning communication is needed, as for an example by

looking into an abdomen - previously scanned by US - as a guest in the surgical operation theatre, or - even better - being the US performing surgeon oneself; making use of US textbooks, journals, e-literature, case-of-the-month pages (from EFSUMB, DEGUM, Sonoworld, and others), etc.; participating in any form of Seminar, workshop, congress in US; sending specific questions for a second opinion to another physician ultrasonographer or even by using other sectional imaging modalities; etc.

Learning and performing US in this manner will be more and more a pleasure for the performer, intensifying and enriching all virtues of physical examination by ecoscopia ("looking by means of sound", the truly adequate expression for US used in Italy).

6. Teaching US always means learning more for the teacher, too. This especially holds true for teaching not in the well known at home environment, but abroad, in a different setting and in a no-routine situation. The ideal teacher is experienced with a long own history of growing US expertise, preferably with experiences not limited to Europe.

7. Teaching will be efficient rather in a systematic than in an incidental manner, of course. In my three decades in teaching medical doctors, visiting their own environment with a "Flying Faculty" meets much better with the needs of the trainees as compared to (expensive and time consuming) invitations to the teacher's place.

8. As in any skill, some of the beginners will acquire US examination technique and interpretation (very) quickly, some will need maybe a bit more time and - sad but true - a few will maybe stay with an insurmountable problem with US.

9. Elaborate course programs are highly appreciated with the trainees - however, learning by doing is as a controlled process less an only tolerable than rather a necessary part of the US learning process - no one is born a master. Learning by doing is a specific need with US training, best in an individualized manner. Supervision by the teacher working with a small group of trainees hands on and in interactive lecturing which preferably is based on US movie clip material. In my practice and idea, US is always directly embedded in the wholesome process of diagnostic and therapeutic care of the patient. And this is done by the medical doctor clinically in charge of the patient him/herself. Since any interface inevitably leads to a loss of time and information, and thus hamper performance quality, the do it yourself manner undoubtedly is the more efficacious one.

10. Moreover Doctor performed US does not only improve and speed up markedly decision making and therapy follow up - US examination scenario means some minutes of exclusive dedication of the doctor to the patient. This is well understood and appreciated by the patients examined, experiencing their doctor personally operating a high tech device with all its attractivity and to some extent even its magic. And of course, modern patients demand such a mixture of technical tools and man provided medical care - at least in richer areas of the globe.

11. However claiming US performance for one medical specialty exclusively - as some radiologists might have tried - is misleading. Benefits from and impact of US as a whole are too strong for such restrictions. No one is a sole possessor of this fine method. US will be in an adequate position when it is accessible to all those who make use of it in a responsible way for any form of patient care, preferably by medical doctors, or by well trained and supervised paramedical staff members.

Luca Neri, founder of WINFOCUS and father of emergency US, once reported on his experience in introducing a simple US device to an outpost of medical care which he was running for some years in a rural setting in equatorial East Africa. Within a very short period of time, he was overrun by people who wanted to have a look into their bodies with this machine, performed by the doctor capable of operating it. These citizens, these patients - knowing all in animal anatomy - directly understood the vast potential of US, not needing teaching or other information. The majority of our global population (>80 %, L.Neri), however, has no access at all to US at all.

This is another story? Not really - it is part of the integral problems in US use and under-use (which is sort of no-good-practice as well). Compared to its key benefits, US is grossly underused worldwide - and this is understood more and more, which again increases the need for qualified teaching of the fine arts of ultrasonography.