SEARCH

SEARCH BY CITATION

Keywords:

  • Ultrasonography;
  • Training;
  • Rheumatology practice;
  • Assessment

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Objective

To evaluate the training and practice of specialist practitioners in musculoskeletal ultrasonography (MUS) with the aim of developing an expert-derived consensus of educational standards for rheumatologists performing MUS.

Methods

A panel of worldwide experts in MUS was identified by literature review, consultation with members of training committees, and peer recommendation. Using a postal questionnaire, information was obtained about personal experience, current practice, training regimen, and participation in competency assessment.

Results

International experts in MUS were identified (57 in total: 37 radiologists, 20 rheumatologists). Response rate was 70%. Radiologists had been performing MUS for longer than rheumatologists. Both rheumatologists and radiologists conducted the same number of MUS sessions per week, although radiologists examined more patients. More radiologists performed MUS for muscle and ligament injury, nerve lesions, soft tissue masses, and of the groin (P < 0.01). The number of training hours was similar. Approaches to training varied, although attending a training course and scanning with an expert was more common among rheumatologists (P < 0.001). More than two-thirds of the group had not undergone any form of competency assessment.

Conclusion

This study highlights differences in training and practice between individual expert ultrasonographers and between specialty backgrounds. In particular, there appears to be no formal training regimen and competency assessment is uncommon. The establishment of a core set of internationally applicable educational standards for MUS training for rheumatologists is required.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Musculoskeletal ultrasonography (MUS) is an effective imaging tool for evaluating joint and soft tissue structures; evidence to support its role in rheumatologic practice is mounting (1–7). The wider availability of high-quality affordable MUS machines, together with the positive impact that imaging can have on diagnosis and management of the rheumatic diseases, means that more rheumatologists are now performing MUS examinations as part of their routine clinical practice (8, 9). This has important educational implications and presents a number of challenges to radiologists and rheumatologists alike (10, 11). At present, no governing body has been established to oversee and direct the training of rheumatologists in MUS and establish guidelines for clinical governance. There are no recommendations regarding what is appropriate for a rheumatologist to examine with MUS or the skills they require to do this effectively. Furthermore, there is no consensus as to what length of training might be needed or the nature of competency assessment that is required.

The importance of training in MUS for rheumatologists has been recognized at a European level by the European League Against Rheumatism (EULAR) with the formation of The Working Group for Musculoskeletal Ultrasonography in Rheumatology, which has begun to develop guidelines for equipment specification and image acquisition (12). Short introductory MUS courses are available in a number of countries, but their aim is to present basic concepts and aid understanding rather than provide formal training. In addition, the role of imaging is now included in the core curriculum for postgraduate training in rheumatology throughout Europe. Therefore, a clear need exists for an international standard educational program of training with accredited assessment of competency for rheumatologists performing MUS, in keeping with the concepts of good clinical practice and clinical governance.

In an attempt to obtain information regarding current practice, methods of training, and assessment among musculoskeletal ultrasonographers, we identified and surveyed a group of international experts in MUS to gain an overview of their experiences and opinions with regard to these important questions.

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

A cross-sectional written questionnaire survey of an international panel of experts in MUS was undertaken. We selected our experts by reviewing Medline literature to identify authors of relevant peer-reviewed publications, identifying members of teaching faculty of MUS training courses, and consulting committee members from the EULAR and British Society of Skeletal Radiologists MUS working groups and the Musculoskeletal Ultrasound Society to identify individuals regarded as experts by their peers.

A pilot questionnaire was designed and included sections on demographics, specialty background, duration of MUS experience, extent and content of current practice, training regimen, and participation in competency assessment. This questionnaire was subsequently refined following local pilot testing and feedback. The modified questionnaire was then distributed to all experts by mail together with a letter from the study authors explaining the project. The questionnaire consisted of a series of open and closed questions and the recipients were asked to answer these questions with free text or by ticking the relevant box corresponding to a Likert scale. Space was also left after each question for any additional comments. Subsequent written, e-mail, and personal telephone reminders were made to the nonresponders after 4, 7, and 10 weeks.

Data evaluation and statistical analysis were carried out using SPSS version 10 [Chicago, IL]. Nonparametric statistical tests were used to assess levels of significance (continuous ordinal data were compared using the Mann-Whitney test; noncontinuous categorical variables were analyzed using Pearson's chi-square test).

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

Composition of experts.

Fifty-seven international experts in MUS were identified: 11 were based in the United Kingdom, 28 in Mainland Europe (Austria, Belgium, Denmark, Finland, France, Germany, Holland, Italy, Spain, Switzerland), 13 in North America, and 5 elsewhere (Australia, Asia, South America). This group was composed of 20 rheumatologists and 37 radiologists. The geographic distribution of experts divided per specialty can be seen in Table 1.

Table 1. Geographic distribution of expert group responders and nonresponders
 Rheumatologist (n = 20)Radiologist (n = 37)
ResponderNonresponderResponderNonresponder
  • *

    One incomplete, 1 anonymous.

UK6050
Europe12286
North America0049
Other (Asia, Australia, South America)0032
Total18222*15*

Response rate.

The overall response rate was 70% (40 of 57). This included a 90% response (18 of 20) from rheumatologists and 59% (22 of 37) from radiologists (see Table 1). One reply was anonymous and one was incomplete; these were not used. A breakdown of specialty background and country of origin of the responders and nonresponders can be seen in Table 1.

Duration and frequency of ultrasonography practice.

Overall, the median duration of MUS practice was 8–9 years (interquartile range [IQR] 4, 19). Individuals performed a median of 4–5 MUS sessions per week (IQR 2, 7) on a median of 21–25 patients (IQR 11, 35). Comparing specialties, rheumatologists had been performing MUS for a median duration of 6–7 years (IQR 2, 9) compared with 10–14 years (IQR 9, 19) for radiologists (P = 0.002); the median number of patients scanned with MUS by each respondent was 16–20 (IQR 11, 25) for rheumatologists and 26–30 (IQR 21, >35) for radiologists (P = 0.006); the median number of weekly MUS sessions undertaken by both rheumatologists and radiologists was 4–5 (IQR 2, 5 versus 2, 7; P = 0.327).

Current ultrasonography practice.

Most areas of the musculoskeletal system were scanned using MUS by almost all of the experts, with proportionally more radiologists scanning each anatomic area. The only region where there was a significant difference between specialties was the groin (P = 0.003), with fewer rheumatologists scanning in this area compared with radiologists. Other areas (see Table 2) included chest wall, trunk, spine and paravertebral areas, and mandibular and maxillary regions.

Table 2. Anatomic areas examined with ultrasonography
Anatomic areasRheumatologist (n = 18) %Radiologist (n = 20) %
  • *

    P = 0.003.

Hands89100
Wrist8995
Elbow9495
Shoulder89100
Hip8995
Groin*5095
Knee89100
Ankle and heel94100
Forefoot8395
Other1125

Indications for performing an MUS examination differed slightly between specialties. Rheumatologists' primary interest seemed to be in determining whether there was any evidence of inflammatory arthritis or to guide aspiration or injection. Radiologists also performed scans for these reasons but in slightly reduced proportions, although the differences were not statistically significant. However, significant differences were seen when the indication was muscle injury (P = 0.0001), ligament injury (P = 0.001), soft tissue mass (P = 0.003), or nerve lesions (P = 0.008), with more radiologists than rheumatologists performing MUS examinations in these circumstances. Other indications (see Table 3) included biopsy, monitoring the activity and progression of inflammatory joint disease, meniscal and labral lesions, limb and facial bone lengthening, joint instability, and cartilage injury.

Table 3. Indications for performing ultrasonography
IndicationsRheumatologist (n = 18) %Radiologist (n = 20) %P*
  • *

    Only significant P values are listed.

Inflammatory arthritis9480 
Tendon pathology9495 
Effusion94100 
Bursitis8395 
Muscle injury441000.0001
Ligament injury44950.001
Soft tissue mass611000.003
Nerve lesions50900.008
Guided aspiration8980 
Guided injection8380 
Other1125 

Training in ultrasonography.

The median number of hours of training that the respondents received in MUS was >100 (IQR 81, >100). This was not statistically significant between specialties, with rheumatologists receiving a median of 91–100 hours training (IQR 61, >100) and radiologists a median of >100 hours (IQR 91, >100; P = 0.206). The methods of training varied and included being self taught (74%), attending training courses (63%), working with an expert (50%), radiology specialist training (34%), and sabbatical/placement (13%). Table 4 compares the methods of training between rheumatologists and radiologists. Significantly more rheumatologists than radiologists had trained by working with an expert (78% versus 25%; P = 0.001) and had attended training courses (94% versus 35%; P = 0.0001), with the mean number of training courses attended being 3 (range 0–6). Surprisingly, only 45% of the radiologists reported that they had completed radiology specialist training, and interestingly 22% of rheumatologists also responded positively to this question. In addition, 1 rheumatologist and 1 radiologist had completed a diploma in MUS.

Table 4. Training regimen in ultrasonography and participation in competency assessment
 Rheumatologist (n = 18) %Radiologist (n = 20) %
  • *

    P < 0.0001.

  • P = 0.001.

Methods of training  
 Self taught7870
 Training courses*9435
 Working with an expert7825
 Radiology specialist training2245
 Sabbatical/placement1710
 Other65
Competency assessment3330

Competency assessment.

Of the experts who replied to our questionnaire, only 12 (33% of rheumatologists and 30% of radiologists) had taken part in any form of assessment of their competency in performing MUS (see Table 4). The content of these assessments was variable but mainly consisted of a peer-review process. The various approaches included informal appraisal and demonstration of technique at a local level, studies of intra- and interobserver variation, formal examination, and presentation of a portfolio of personal MUS experience to a national expert committee. Only 2 respondents reported that they had been required to undertake a formal examination to assess their competency in performing MUS to a predetermined standard. All assessments took place at the end of a period of training and no one reported that they underwent regular appraisal or revalidation.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

This study highlights variations in practice and training between experts in the field of MUS. Similarities and differences have also been identified between individuals from the differing specialty backgrounds of rheumatology and radiology. A number of important issues have been identified.

Our research confirms that an ever-increasing number of rheumatologists are performing MUS. This is not only true in Europe, where rheumatologists have traditionally carried out MUS examinations, but also in other countries throughout the world. This is reflected in an increasing number of publications from rheumatology centers utilizing their own MUS expertise, as well as increasing numbers of rheumatologists now being accepted as members of teaching faculty for training courses in MUS. The increasing evidence base and wider availability of high-quality, affordable MUS machines is likely to account for the increasing popularity of this imaging technique among rheumatologists.

We were able to identify 20 rheumatologists and 37 radiologists who satisfied our criteria as experts in MUS. All of the rheumatologist MUS experts were from Europe, whereas the radiologist experts had a more international geographic distribution. This reflects the known differences in the specialty background of MUS practitioners between Europe and the rest of the world, and we deliberately attempted to reflect this in the composition of our expert panel. Although interest in MUS among rheumatologists in the North America is increasing, the greatest rheumatologist experience remains in Europe. There is a more uniform distribution of radiologist MUS experts throughout the world.

The excellent response rate from our rheumatologist experts may reflect their enthusiasm for learning and performing a new technique, previous personal contact with the authors, or personal interest because the focus of the questionnaire was to ultimately identify possible areas for inclusion in an educational program for rheumatologists. These reasons may also be reflected in the reduced response rate from radiologists. Additionally the radiologists' response rate may also reflect the opinion of some practitioners that specialists outside the field of radiology should not perform MUS, and indeed this was the view expressed by a small number of our expert panel. Additional evidence for this may be the relatively poor response rate from the North American radiologists who, unlike their European colleagues, may have less contact and be less familiar with practicing nonradiologist ultrasonographers and consequently may be less accepting of their role. However, in general, the radiologists completing this questionnaire were supportive toward rheumatologists undertaking MUS examinations, provided they were adequately trained.

Not surprisingly, our data confirms that radiologists have been performing MUS for longer than rheumatologists. Indeed, we attempted to reflect this in the relative proportions of rheumatologist and radiologist members of our panel of experts. Patterns of scanning appear to differ between specialties. Radiologists tend to scan more patients at a single sitting, although both specialties perform on average the same number of MUS sessions per week. This is probably explained by a difference in practice reflecting the nature of the 2 specialties. Radiologists tend to perform specific MUS lists for specific indications, whereas rheumatologists may also perform a list but may scan a larger number of joints in an attempt to answer a particular diagnostic or clinical management problem. Furthermore, rheumatologists may perform an MUS examination in addition to a clinical assessment during an out-patient clinic visit, which takes longer, thereby reducing the number of patients who receive a scan. It is unclear whether the rheumatologists counted a session as an out-patient clinic during which they may use MUS on only a relatively small number of patients.

Indications for scanning are broadly similar between rheumatologists and radiologists, although radiologists perform a greater number of scans for muscle or ligament injury, nerve lesion, and soft tissue mass (although the number of rheumatologists scanning soft tissue masses is probably higher than expected). Rheumatologists scan proportionately more patients for inflammatory arthritis, guided aspiration, or guided injection, although this did not reach statistical significance. This again probably reflects the practice of the 2 specialties. Rheumatologists also commented that they use MUS for monitoring the activity and progression of inflammatory joint disease, e.g., in the detection of new joint erosions. There was little difference in the musculoskeletal anatomic sites scanned by all experts except that, as expected, significantly more radiologists routinely scan the groin as distinct from the hip joint, usually in the context of a sporting injury or hernia assessment. Also, a relatively large number of rheumatologists scan the shoulder, which is widely regarded as one of the most difficult structures to examine with MUS. Ascertaining the appropriateness of the indication or anatomic area examined with MUS was beyond the scope of this study.

Almost our entire expert panel had received at least 100 hours of training, implying that this may be the global standard that is required. The median number of hours of training received by radiologists was slightly greater than rheumatologists (>100 versus 91–100), but this difference was not statistically significant. As regards methods of training, most radiologists described themselves as self taught, which may reflect the fact that they trained at a time when other methods of teaching, e.g., courses, were not available. Almost all rheumatologists had attended at least 1 training course, in contrast to radiologists who attended relatively fewer. Rheumatologists also undertook self teaching as well as working with an expert, who in many cases was a radiologist. Many radiologists and some rheumatologists are now tutors at training courses. Interestingly, even among the radiologists, there were large differences in the format of training. Although radiologists traditionally undertake an apprenticeship of specialty training (although only 45% of our radiology experts actually confirmed this) prior to specialization in musculoskeletal imaging including ultrasound, their training thereafter appears similarly nonformalized to that of a rheumatologist. Therefore, there appears to be no standard radiology approach on which to base the training of a rheumatologist in MUS. However, this study was not designed to evaluate the quality of training by whatever method.

Of particular note is the fact that only 12 members of our expert panel had ever taken part in any form of competency assessment. Even in this small group, the content of the assessments was variable and was formalized in only a limited number of centers. No mechanisms to facilitate lifelong learning and no processes of ongoing appraisal or revalidation were reported.

This study provides a unique insight into an important and developing specialty. It draws attention to differences in practice between experts in MUS, but more particularly highlights important issues of training and assessment. Despite increasing numbers of rheumatologists performing MUS examinations, there remains no unified approach to training and competency assessment. There is a clear need to develop a standardized educational program for rheumatologists performing this imaging technique that can be applied throughout the world. The development of such a program will form the subsequent stages of this ongoing project.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES

We would like to acknowledge the contribution of our panel of experts for their assistance with this project.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. Acknowledgements
  8. REFERENCES