The World Health Organization (WHO) has recommended that there be at least one rheumatologist per 100,000 persons. In Latin America, there is an estimated need for 5000 specialists. The Pan-American League of Associations for Rheumatology (PANLAR) has about 2000 active members, not all of them rheumatologists. This number is well short of WHO recommendations.
In 1981, the International League Against Rheumatism (ILAR), in association with the WHO, initiated a program for the prevention and control of rheumatic diseases in diverse communities. The main goal of the Community-Oriented Program for the Control of Rheumatic Diseases (COPCORD), was to obtain reliable epidemiologic information from community-based studies.
Musculoskeletal Ultrasound
The numerous practical advantages of musculoskeletal ultrasound (MSKUS) over more expensive techniques such as magnetic resonance imaging make it the ideal technique for rheumatologists working in countries such as those of Latin America and the Caribbean region. Recognition of the value of ultrasound in the clinical practice of rheumatology has led to a challenge in terms of education and training, because an ever-increasing number of rheumatologists are oriented toward systematic use of ultrasound. Therefore, for the rheumatologist endeavoring to obtain the maximum benefit from ultrasound, it is essential to acquire adequate technical and cognitive skills. The first experience of training in ultrasound in Latin America and the Caribbean region was started in 2000 by two Mexican rheumatologists who decided to invest in MSKUS after being enthralled by lectures and practical demonstrations on MSKUS during national rheumatology and radiology congresses. Because of the lack of a specific MSKUS training program in Mexico in 2001, these specialists independently went abroad to receive training in MSKUS: one went to the Henry Ford Hospital Radiology Department in Detroit, Michigan, for an intensive, hospital-based, 3-month program. The second attended the course in MSKUS organized by the Spanish Society of Rheumatology ultrasound school (ECOSER) in Madrid and subsequently worked in the rheumatology departments of three Spanish hospitals performing practical training under the supervision of MSKUS rheumatologists, ECOSER members, and faculty from the European League Against Rheumatism (EULAR) sonography courses.
The experiences were extremely positive for both of these specialists, and in 2002, they decided to organize the first MSKUS course during the Annual Congress of the Mexican Society of Rheumatology, held in Mérida, Yucatan, to introduce ultrasound to Mexican rheumatologists. International radiologists were invited as speakers. The course was attended by 30 Mexican rheumatologists. In 2002, after the first MSKUS course and with the purpose of spreading knowledge of ultrasound among Mexican rheumatologists, a third rheumatologist decided to participate in a 3-month MSKUS course in Madrid.
Training
Since 2002, seven basic courses, three intermediate courses, one advanced-level course, and several symposia and conferences have been organized and presented in Mexico. In 2003, the three Mexican ultrasonographers who were enthusiastic about MSKUS founded the Mexican School of MSKUS of the Mexican College of Rheumatology, known as ECOMER (Escuela de Ecografía, Colegio Mexicano de Reumatologíía), with the intent of uniting efforts to launch MSKUS in Mexico.
The motto of ECOMER is Una imagen mas clara de la reumatología (“A clearer picture of rheumatology”). The main aims of ECOMER are to foster the training of rheumatologists interested in ultrasound and to promote research in the field of MSKUS imaging. To fulfill these aims, the school’s approach to ultrasound was standardized by adopting the EULAR guidelines for MSKUS in rheumatology as a reference for acquiring sonographic images. The ECOMER bylaws can be found at its Web site, www.ecomer.org.mx (accessed February 5, 2010). This Web site also provides a forum for case discussion, consultation, and imaging review.
In 2004, an intensive, intermediate-advanced course was organized, and for the first time, the course was endorsed by a local university, the Universidad Autónoma de Aguascalientes (UAA). After this course, five new members joined ECOMER. By 2006, a total of 150 rheumatologists, approximately 30% of the active members of the Mexican College of Rheumatology, had attended at least one basic MSKUS course.
PANLAR is an umbrella organization founded in 1943, with the purpose of stimulating and promoting the development of awareness, knowledge, and the means of prevention, treatment, rehabilitation, and relief of rheumatic diseases. PANLAR fosters cooperation between the 22 countries in the geographic area: North, Central, Caribbean, Andean and South America.
PANLAR gathers the national rheumatology societies of the countries that are affiliated to it, fostering cooperation between them and increasing its collaboration to similar leagues such as EULAR, ILAR, and APLAR.
The PANLAR Ultrasound Study Group was created in 2002. Since then and along with the national societies of rheumatology and with the valuable collaboration of distinguished members of the EULAR/OMERACT Ultrasound Working Group, a number of introductory, basic, intermediate, and advanced teaching courses have been given in Latin America, including Argentina, Bolivia, Brazil, Colombia, Cuba, Costa Rica, Dominican Republic, Ecuador, Guatemala, Honduras, Chile, Mexico, Nicaragua, Peru, and Venezuela. In some Latin American countries such as Colombia, Mexico, and Venezuela, the ultrasound courses have been endorsed by national universities, in the case of Colombia by Universidad de la Sabana, in Mexico by Universidad Nacional Autonoma de Mexico, and in Venezuela by Universidad de los Andes.
In addition, the PANLAR Ultrasound Study Group, using a consensus-based questionnaire (Delphi method), has developed recommendations for the content and conduct of PANLAR MSKUS courses.
Competency Assessment
In the absence of an internationally recognized model to acquire basic competency in MSKUS, ECOMER members decided to follow the experience described in a paper written by rheumatologists from Belfast, Northern Ireland. Study results for the Mexican experience have been reported.
According to the geography of country and to facilitate course attendance by rheumatologists in Mexico, an itinerant introductory MSKUS course, called ECOTOUR, was carried out during 2007. Course presenters visited seven different cities around Mexico. The ultrasound course level was introductory-basic, with 2 days of clinical sessions and hands-on workshops with healthy subjects. ECOTOUR was designed to provide participants with a thorough understanding of the role and limitations of MSKUS in the clinical practice of rheumatology and to provide attendees with practical knowledge of musculoskeletal MSKUS anatomy and pathology. This itinerant course was attended by a total of 98 rheumatologists.
Approximately 830 rheumatologists throughout Latin America and the Caribbean have attended MSKUS courses offered from introductory to advanced levels in which ECOMER members have participated as faculty or organizers.
Regarding certification and accreditation, the PANLAR Ultrasound Study Group considered MSKUS certification or accreditation necessary, but given the numerous legislative factors to meet in order to acquire this—different for each country, health legislation, and educational institution—it was recommended that practicing MSKUS rheumatologists pursue the regulatory conditions in their own institution and country for obtaining certification or accreditation in MSKUS.
Survey Results for Musculoskeletal Ultrasound Training Courses
After the Mexican experience, interest in MSKUS in Latin America and the Caribbean region has grown steadily, as evidenced by the increasing number of MSKUS training courses organized by national rheumatology societies and the number of conferences and abstracts presented at diverse local and regional rheumatology congresses and meetings. To document the profile of Latin American rheumatologists interested in performing MSKUS, an exchange-of-ideas forum was organized by electronic mail to develop a questionnaire on MSKUS. Participants were ECOMER faculty members, EULAR sonography course teachers, and MSKUS course organizers from diverse national rheumatology societies.
Spanish-language questionnaires were distributed to 120 randomly selected participants who attended the first PANLAR MSKUS training course during the 15th PANLAR 2008 congress in Guatemala City and an MSKUS training course organized by ECOMER in Veracruz, Mexico, in 2008 ( Table 25E-1 ). Ninety-six rheumatologists responded to the questionnaire, representing 96 centers from 15 Latin American countries. None of the respondents were trained in ultrasound in medical school. Forty-two (46%) of 96 rheumatologists had attended at least one MSKUS training course; of these, 27 (64%) were actively performing MSKUS scans within their own departments. Initial instruction in MSKUS was obtained from a radiologist by 29 (30%), from a rheumatologist by 14 (15%), and from diverse specialists by 12 (13%) of rheumatologists.
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