Musculoskeletal ultrasound (MSKUS) is a popular and important disease assessment tool among rheumatologists. Consequently, many rheumatologists are seeking opportunities to learn how to perform this imaging technique themselves and to integrate ultrasound as a key element of their clinical practice. This has resulted in the establishment of a number of training initiatives for rheumatologists, particularly teaching courses. While the scientific research agenda continues to advance, progress in developing an educational infrastructure continues at a relatively slower pace, despite increasing demand for training from members of the rheumatology community. Establishment of a solid basis for learning and teaching is a fundamental requirement if ultrasound is to become integral to rheumatology practice and practitioners are to attain competency in performing this user-dependent imaging technique.
Educational Challenges for Rheumatologists Performing Ultrasound
The fact that an increasing number of rheumatologists are performing ultrasound has important educational implications, particularly with regard to initial and ongoing training and assessment of competency, and represents a challenge that still needs to be addressed by the rheumatology and radiology communities. Although rheumatology ultrasound is an expanding area, the published information on training is limited. Relatively little information is available regarding approaches to teaching or assessment of competency, and there is no unified agreement regarding an educational curriculum or certification. This situation is reflected in the wide variety of approaches to MSKUS taken by rheumatologists and was confirmed in a European League Against Rheumatism (EULAR) survey. Most respondents reported training undertaken at a postgraduate level (87%), with attendance at a training course (46%) and informal training from an experienced colleague (51%), usually a rheumatologist or a radiologist, being the most common approaches.
The Need for an Educational Structure
The importance of training in MSKUS for rheumatologists was recognized by EULAR with the establishment of The Working Group for Musculoskeletal Ultrasonography in Rheumatology and by the British Society of Skeletal Radiologists (BSSR) and Royal College of Radiologists, both of which have developed guidelines on image acquisition, equipment, and practice standards. Similar groups have been established in countries around the world, including the Outcome Measures in Rheumatology Clinical Trials (OMERACT) and British Society of Rheumatology (BSR) special interest groups in MSKUS and an American College of Rheumatology (ACR) study group in MSKUS, all of which have taken an interest in education. There has been a growing acceptance of the need for a training framework for nonradiologists in the radiology literature.
Rheumatology Ultrasound Training Literature
The EULAR Working Group for MSKUS has produced some technical guidelines for MSKUS in rheumatology. These provide advice on ultrasound equipment, brief guidance on teaching and training, and a suggested technique for image acquisition that includes standard scans, positioning of the patient, and ultrasound-detectable pathology for a variety of anatomic regions. Using these guidelines, together with pictorial references on the associated EULAR Web site, an accompanying CD-ROM, and one-on-one teaching from an experienced ultrasonographer, a rheumatologist without prior ultrasound experience was able to achieve an acceptable standard of ultrasound image acquisition. This judgment was made by comparing the quality of ultrasound images produced by the trainee with those of an expert in eight joint regions. The duration of training required to attain this standard was 24 hours of nonconsecutive scanning, encompassing 30 scanning sessions with 14 patients and 5 healthy volunteers. The total time commitment from the tutor was 500 minutes, which comprised an initial 2-hour general tutorial focusing on machine orientation and more specific teaching as part of each scanning session. This study demonstrated an effective training approach that resulted in the production of ultrasound images of acceptable quality. However, it was limited in that it focused only on techniques of image acquisition and not on image interpretation; further training would be required to produce an ultrasonographer competent in diagnostic MSKUS. It is likely that these figures represent a significant underestimate of what is required to achieve competency. No direct assessment was made of scanning technique.
A similar approach was used to assess the reproducibility of ultrasound assessment of the hip joint. The distance from the femoral neck to the iliofemoral ligament was measured by a novice ultrasonographer, who had received 3 hours of training in hip ultrasound, and compared with similar measurements by an experienced ultrasonographer. After 132 examinations of 22 hips and 20 phantom examinations, images of acceptable quality were recorded with relatively small interobserver variation. This study demonstrated that rheumatologists could be trained to produce images of acceptable quality with accurate anatomic measurement within a relatively short period. However, the resultant level of expertise described in this study is likely to fall well below that of an independent diagnostic ultrasound practitioner.
Taggart and coworkers described an informal program of MSKUS training extending over a 5-year period. Participants attended training courses, visited an established MSKUS unit, and were taught by an external MSKUS tutor. They were then able to demonstrate basic competency in MSKUS at a formal examination. However, few details were reported as to the exact nature of the educational approach, the content was unclear, and there was little information on how the training was delivered, methods of teaching, or the amount of training each subject received. The assessment included written questions and completion of a report after scanning of a single joint in a normal subject and in a patient with musculoskeletal disease. There was no assessment of practical performance in the real-time scanning situation. A thorough practical assessment is mandatory for such a hands-on imaging technique to demonstrate achievement of the required standard. This study demonstrated that, with enthusiasm, persistence, and practice, rheumatologists can use MSKUS to identify normal anatomy and pathology. However, it revealed very little about the nature of the training (e.g., content areas), the educational process, teaching, or assessment.
A further study aimed to assess the ultrasound learning curve of three rheumatologists in evaluating synovitis in the small joints of the hands and feet in patients with rheumatoid arthritis. Each trainee underwent an initial 5 hours of didactic instruction by an experienced rheumatologist ultrasonographer which focused on ultrasound examination of finger and toe joints. Over an unspecified time period, each trainee then received seven additional training sessions in which they observed their tutor conducting ultrasound examinations on five patients and were asked to interpret the presence or absence of synovitis. The trainees were then required to perform an independent ultrasound assessment of two patients themselves and to record their findings. The trainee and tutor results were compared to give a measure of accuracy and plotted over time to give an estimate of the learning curve. The number of patients and joints evaluated by the trainees is difficult to precisely ascertain from the paper, although the study authors stated that 70 patient examinations resulted in accurate assessment of synovitis. However, the accuracy of this figure could be questioned, because it appears that a large part of this training involved observation, and there was relatively little hands-on practice, which is thought to be essential when learning such a practical, user-dependent skill. There was no quantification of the duration of training or the overall length of this process. Nevertheless, this article demonstrated that rheumatologists are capable of achieving an acceptable standard in ultrasound, after a period of training, for a particularly clinically relevant indication such as the assessment of synovitis.
Other studies have attempted to ascertain the number of ultrasound cases required to achieve competency. The American College of Radiologists (ACRad) and the American Institute of Ultrasound in Medicine (AIUM) have suggested that between 300 and 500 scans are required. The Society for Academic Emergency Medicine in the United States has adopted an ultrasound training curriculum that requires involvement in 150 examinations, of which 50% can be of healthy subjects. The evidence on which such specific case numbers are based is unclear. In a study assessing physician competence among radiology residents for a variety of ultrasound indications (MSKUS was not included), involvement in 200 cases during training produced a corresponding improvement in skill levels, but the standard achieved fell below what was considered to be an acceptable level of competency. The majority of trainees still made interpretation errors and were unable to acquire images of satisfactory quality, implying that involvement in 200 ultrasound examinations is insufficient to achieve competency.
This concept of the minimum number of cases required to achieve competency merits further study. It should be appreciated that the learning curve is likely to be different for individual trainees, as is the number of ultrasound examinations needed to achieve the required standard. An alternative method would be to establish a minimum acceptable standard and devise an assessment to measure when that standard is reached. This may provide a more accurate method of ensuring competency, accounting for the variation in individual learning curves and reducing the need to publish a specific generic quantitative requirement, which would inevitably provoke debate and disagreement and might be inaccurate.
Brown and colleagues performed an extensive situational analysis, the purpose of which was to precisely establish what infrastructure was already in place to facilitate education in MSKUS. As part of this exercise, a cross-sectional evaluation study was conducted among international expert rheumatologist and radiologist ultrasonographers to provide more information regarding practice, training, and assessment in MSKUS and to seek opinions regarding a proposed training pathway for rheumatologists. Expert musculoskeletal ultrasonographers were defined according to specific criteria. The study highlighted variations in practice among experts and identified similarities and differences among individuals from the specialty backgrounds of rheumatology and radiology. For example, radiologists have been performing MSKUS longer than rheumatologists. Radiologists tend to scan more patients at a single sitting, but rheumatologists scan more joints in individual patients, and on average, both specialties perform the same number of MSKUS sessions per week. Indications for scanning were broadly similar. Radiologists performed a greater number of scans for muscle or ligament injury, nerve lesions, and soft tissue masses, although the number of rheumatologists scanning soft tissue masses was probably higher than expected, and it could be argued that this is an inappropriate indication for primary ultrasound assessment by a rheumatologist. Rheumatologists scanned proportionately more patients for diagnosis and monitoring of inflammatory arthritis, guided aspiration, or guided injection. Anatomic sites scanned by all experts were similar, except that significantly more radiologists routinely scanned the groin as distinct from the hip joint, usually in the context of a sporting injury or hernia assessment, and a relatively large number of rheumatologists scanned the shoulder, which is widely regarded as one of the most difficult structures to examine competently with ultrasound.
Training and assessment data were also interesting, with almost the entire expert panel having received at least 100 hours of training, perhaps implying that this may be the global standard that is required. Training appeared similarly nonformalized, regardless of specialty. Most radiologists described themselves as self-taught, and only one half of respondents reported having undertaken the traditional radiology apprenticeship of specialty training before specialization in musculoskeletal imaging, including ultrasound. In contrast, almost all rheumatologists had attended at least one training course, and they also undertook self-teaching and working with an expert, who often was a radiologist. Only a relatively small number of respondents had taken part in any form of competency assessment; such assessments varied in content and were formalized in only a limited number of centers. No mechanisms to facilitate lifelong learning and no processes of ongoing appraisal or revalidation were reported. Most respondents identified participation in a formal training program and a period of working with an expert practitioner as the most appropriate system of future training.
In summary, despite a number of laudable and ongoing educational initiatives and some published training guidelines, the data confirm the absence of a unified approach to training or assessment and the lack of a common educational curriculum for rheumatology ultrasound.
Essential Steps in Defining a Rheumatology Ultrasound Curriculum
What should be considered in developing a universal curriculum for rheumatology ultrasound? Harden cited 10 key questions that should be answered when planning any curriculum ( Table 25A-1 ). This approach represents a useful framework for applying the existing data regarding education and training in rheumatology ultrasound and provides an opportunity to identify and discuss any apparent deficiencies and areas for further work. This should inform the curriculum development process and also the research agenda in MSKUS education. A modified version of this framework is used in this chapter to provide suggestions about how these elements may apply to rheumatology ultrasound.
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Statement of Intent
The aim of this educational program should be to train a rheumatologist to perform MSKUS to a predetermined standard of competency. What is that predetermined standard of competency?
Background and Need
The need for a more formalized program of learning and teaching for rheumatologists in MSKUS has been outlined. Increasing numbers of rheumatologists are applying ultrasound to musculoskeletal problems they encounter in their daily practice, and they are increasingly likely to perform routine MSKUS assessments themselves, rather than relying on the traditional service provided by the radiologist. However, at present there is little educational infrastructure to facilitate training and no system of assessment of competency or quality assurance. A coordinated educational program is required to ensure competency in rheumatologist ultrasonographers.
Content
The precise role of a rheumatologist ultrasonographer remains unclear. Given the lack of comprehensive published standards to act as a starting point for developing a system of teaching and assessment, it is difficult to plan an informed training program. To construct a program of education, it is fundamental to know what should be taught and subsequently measured by assessment; that is, the program usually must be designed to deliver a specific set of educational standards or outcomes. But what are these outcomes?
Much of the research in this area has been carried out by Brown and colleagues and involved a series of iterative exercises using expert practitioners, as summarized here. The first stage sought to establish a consensus regarding those indications and anatomic areas that would be appropriate (or inappropriate) for scanning by a rheumatologist and the knowledge and skills that would be required to be deemed competent in MSKUS. To do this, a panel of international experts in MSKUS was recruited. All of the panelists met specific selection criteria that included regular MSKUS practice, a track record of research and teaching, and peer acknowledgment of their expert standing. Given the lack of published data and established training models, it was assumed that this group of experienced professionals would be able to provide the most informed insights into the practice and training of rheumatologists in MSKUS and that they could most appropriately address issues of competency and standard setting that would be raised during the course of this project. The result was the identification of a set of best practice recommendations specific to rheumatologists performing MSKUS.
An educational program needs to include skills that are useful for the daily practice of rheumatologists and skills that they would be motivated to learn. A study of rheumatologists was conducted to assess the clinical utility of and motivation for acquiring the skills deemed important by imaging experts. These data were incorporated into the educational outcomes to take into account the practice requirements of rheumatologists. In this way, the clinical needs of rheumatologists and the competency standards of imaging experts have been acknowledged and important stakeholders have been engaged in the curriculum-defining process.
A final validation phase was conducted in which the evolving educational outcomes were returned to the imaging experts for further reflection and comment. Final modifications based on their critical appraisal completed the development of this competency-based framework. The resulting set of definitive competency-based educational outcomes provides an accurate, evidence-based blueprint for the training and assessment of rheumatologist ultrasonographers.
Other literature to be considered includes the Royal College of Radiologists (RCR) publication, Ultrasound Training Recommendations for Medical and Surgical Specialties, and the EULAR Working Group on Musculoskeletal Ultrasound’s Guidelines for Musculoskeletal Ultrasound Training in Rheumatology.
These data suggest that there is relevant published, evidence-based information to define educational content and appropriate outcomes for rheumatology MSKUS that can be used as the foundation to develop a formal curriculum.
Competency Outcomes for Musculoskeletal Ultrasound by Rheumatologists
Based on the aforementioned evidence, Brown and colleagues proposed the development of competency-based educational outcomes (generic and pathology-related) in which levels of knowledge and skills are divided into specific categories, termed competency designations ( Tables 25A-2 through 25A-5 ). This approach could be applied to the development of a standardized competency-based curriculum for rheumatologist-performed MSKUS, with the outcomes providing the educational blueprint to plan teaching and assessment. These proposals comprise a list of 10 generic standards that each rheumatologist ultrasonographer should achieve (see Table 25A-3 ) and a group of rheumatology-specific MSKUS pathology competency outcomes. A rheumatologist ultrasonographer should be able to correctly identify, demonstrate, and interpret these pathologies using ultrasound and, where appropriate, use ultrasound to guide aspiration and injection (see Table 25A-4 ). Of particular importance is the identification of specific areas of caution for which liaison with other specialists should be strongly considered and primary, routine MSKUS by rheumatologists is probably less appropriate (see Table 25A-5 ). One of the advantages of the clear evidence-based methodology used to formulate these outcomes is that the definition of each competency designation (Core, Option A: Intermediate, and Option B: Advanced) (see Table 25A-2 ) represents a practical hierarchy combining clinical utility assigned by rheumatologists with competency standards determined by imaging experts.
Core Competency: fundamental knowledge and skills required by all rheumatologist sonographers
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Competency Options : areas in which certain rheumatologists may wish to perform MSKUS to address specific questions within areas of interest that will require a proportional additional level of expertise
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