Who’s Doing Your Scan? The German Perspective on Ultrasound Services: Ultrasound is More Than a Technique, it’s a Medical Art

Dear Paul and Mrs. Edwards,

As a former editor of the UiM/EJU, I read your editorial “Who’s doing your scan? A European perspective on ultrasound services” [1] with great astonishment. Since publication of the article, I have received numerous outraged emails from physicians in Germany. Despite the title, the editorial presents only a one-sided description of the topic “from a British or Anglo American view point” where ultrasound is the domain of radiologists and is performed by sonographers. It does not reflect the reality in continental Europe and our high medical demands on ultrasound.

Ultrasound practices in Germany, Switzerland, Austria, and a few other countries are only mentioned briefly. These practices correspond to a completely different, historically established examination philosophy and are not the result of physicians having more time here than in Great Britain (GB).

As most readers of UiM/EJU know, ultrasound in daily clinical practice (use) originated more than 40 years ago in Germany. The main message of the groundbreaking publication by G. Rettenmaier [2] in 1976 was that fast B-mode ultrasound represents an expansion of physical examination by technical means. Clinicians, internists, gynecologists, and pediatricians recognized real-time ultrasound as a medical-clinical tool comparable to the stethoscope. It became an indispensable part of examination by a physician, and in our countries is consequently referred to as “clinical ultrasound” [3] and as a “dialog-based examination method” [4]. The probe acts as the palpating hand while the physician communicates verbally with the patient. This allows the clinician to record a more in-depth case history and also allows for more precise determination of the problem. The critical synthesis of imaging and symptoms allows definitive diagnoses that would not be possible without ultrasound, clinical knowledge, and consultation with a physician.

In contrast, the imaging-based field of radiology views ultrasound as a technical and thus delegable service. Radiologists underestimated the information provided by the first fast B-mode ultrasound units (Vidoson) that generated moving images of the interior of the body during ultrasound-guided palpation with visualization of the parenchyma. Radiologists in Germany therefore showed only limited interest in the technique in contrast to radiologists in Switzerland and Austria.

In fetal imaging and treatment, our colleagues in obstetrics have established global standards for diagnosis, training, and quality control (DEGUM 3-level model). It would be inconceivable also for us in this discipline to assume medical responsibility for a diagnosis (often with far-reaching consequences) delegated to and made by a sonographer.

Discipline-specific diagnostic ultrasound is a mandatory part of specialist training in all clinical disciplines in Germany and is overseen by the relevant medical association. However, this is not appropriately addressed in the editorial [1]. As a result of their medical education, physicians are competent to perform clinical ultrasound examinations. Additionally, they must simply learn ultrasound physics, equipment handling and US examination technique. Instead of the British National Health Service, Associations of Statutory Health Insurance Physicians are responsible for the approval and billing of approx. 80 % of outpatient services and for quality control in Germany.

Since ultrasound is performed in almost every practice in Germany, it can be performed immediately when indicated instead of with a time delay at a separate radiology center. Competent single-source diagnosis establishes trust and often allows one-stop shopping [5]. The patient is able to see and participate in the examination so that the physician and patient are on equal footing. Ultrasound is the physician’s “sixth sense”. I don’t know of any other noninvasive medical examination technique that can provide so much information so quickly. The editorial criticized ultrasound for being too expensive and taking too long to perform. Radiologists may have this impression since they typically view expensive and oftentimes also trivial medical problems on screen without interruptions from patients.

What is presumably not known in GB is that there is currently a controversy in Germany and Austria regarding ultrasound assistants. Trained medical employees have long been used for organizing, documenting, and assisting in examinations and interventions. It is imaginable to also use these employees for screening in a simple and focused setting, for organometry or for registration of technical parameters. Whether they can also independently perform, for example, automated ultrasound examinations in 3 D technique (e. g. ABUS) depends on the extent to which the examination procedure and the examined region can be reproduced and are fully documented. Our colleagues in radiology rightly criticize the fact that US examinations, in contrast to CT and MRI, are not fully reproducible. Therefore, the person performing the service must bear ultimate medical responsibility, i. e., a physician cannot assume responsibility for the findings of a sonographer.

Applying the British model for sonographers in Germany would result in a risk of the following scenario: Sonographers would have to perform ultrasound significantly more cheaply as a “technical service”. This would jeopardize the existence of the method as a medical service. Interest on the part of physicians in scientific ultrasound would be lost and the DEGUM would surely lose 3/4 of its members. The effect on this journal and the EFSUMB would be devastating since the DEGUM represents their economic base. Our colleagues in radiology who discussed eliminating US from their training requirements without replacement three years ago surely would not have been interested in hiring and training sonographers for poorly paid ultrasound examinations.

This supremely valuable medical art would be lost, effectively setting examinations back to palpation in the time of Vesalius.

A loss of clinical ultrasound (performed by a physician) would be to the detriment of the patient. Patients would no longer be able to undergo an examination including open and honest consultation with a physician and they would almost certainly experience delayed diagnosis and increased exposure to radiation. In the case of abdominal pain, the physician would have to refer the patient for examination days or even weeks later by an assistant.

The rapid emergence of POCUS (point of care ultrasound) in emergency departments in the USA provides current and impressive confirmation of our point of view. In the land of sonographers, physicians are finally beginning to perform ultrasound examinations (after more than 40 years) and are even creating training programs and physician positions for US. What good news for ultrasound performed by physicians!

• References

• 1 Edwards HM, Sidhu P. Who’s doing your scan? A European perspective on ultrasound services. Ultraschall in Med 2017; 38: 479-482
• 2 Rettenmaier G. Sonographic status of upper abdomen. Diagnostic significance and indications of the ultrasonic sectional examination of the upper abdomen. Internist 1976; 17: 549-564
• 3 Seitz K, Schuler A, Rettenmaier G. (Hrsgb.) Klinische Sonografie und sonografische Differenzialdiagnose Band I und II. Stuttgart: Thieme Verlag; 2008
• 4 Maio G. Medicine and the holistic understanding of the human being: ultrasound examination as dialog. Ultraschall in Med 2014; 35: 98-107
• 5 Seitz K, Piscaglia F. Ultrasound: the only “one stop shop" for modern management of liver disease. Ultraschall in Med 2013; 34: 500-503