Got ultrasound?

Pitfalls emerge as general practitioners take on diagnostic imaging

October 8, 2008 (published)
By Jennifer Fiala

Merced, Calif. — When it comes to ultrasonography, Dr. Jon Klingborg knows his limitations: ID bladder stones and not much more, the general practitioner from California says.

That’s because although Klingborg’s practice once spent a small fortune to acquire a now-outdated machine, handling it and interpreting the images are two hurdles he says no weekend manufacturer’s course will serve to improve his competency. Even with 40 patients a day, his ultrasound caseload is so small that the lack of practice fails to raise his proficiency, grouping him with general practitioners from the estimated 20 percent of U.S. practices that have dust collecting on their ultrasound machines.

“As a profession, we’ve railed against weekend chiropractic and acupuncture classes, so why should this be any different?” he asks. “It takes a tremendous amount of practice just to drive the machine, which makes it extremely challenging here, because I don’t know that we have one case a day that would call for ultrasonography.”

Critical foundation
That’s where Seth Wallack, DVM, Dipl. DACVR, comes in to play. He thinks all general practitioners should feel comfortable using ultrasound to recognize and diagnose conditions like chronic peritonitis and go further to tap the abdomen and put fluid on a slide to look for bacteria. So the radiologist and part owner of the Veterinary Imaging Center of San Diego, with the help of several colleagues, has devised an ultrasonography short course designed to teach practitioners to recognize and treat the most critical emergency conditions that plague small-animal patients.

It’s a change to the established, vendor-driven teaching model that might provide decent ultrasound overviews but offers little to bring about long-term competency that only comes with years of study and practice, Wallack says. His advice: Forget about finding adrenal glands and bowel disease. At a minimum, general practitioners should be able to recognize critical illnesses in their ultrasound patients.

“There are animals dying out there because a lot of general practitioners don’t know what they’re seeing when they’re looking at ultrasound,” he says. “These veterinarians are the first line in critical cases, and we’re talking about things that will kill an animal in four hours. They might recognize a problem, but that’s only part of it. The other parts are management and stabilization, and they should not have to rely on a me or another specialist to feel comfortable in emergency situations.”

The $1,675 program, launched last month, involves two days of intensive, hands-on training followed by online reading material and an online exam. A score of 70 percent or better earns the program’s certification, which Wallack hopes will one day be viewed as legitimate as standards put forth by the American Animal Hospital Association.

“As a profession, we’re at a similar place to where we once were with X-ray machines; the prices are coming down and veterinarians are getting excited to invest in ultrasound,” he says. “But weekend education, in the past, has led people to buy machines and not use them. These practitioners are not going to find a centimeter of disease in a bowel. That’s something that a you learn after three to four years in residency.”

Vendor perspective
While Dr. Marty Henderson agrees ultrasound proficiency takes time and dedication, the general practitioner teaches ultrasound short courses for Sound Technologies on weekends off from his mobile ultrasound practice in San Antonio, Texas. He says the two-day training packages he offers are “extremely in-depth and very well done” and provide users a solid understanding of the value of ultrasound technology.

“That being said, the bigger issue in my mind is that most of the time people aren’t going to go home and reproduce what they learned, because they’re not going to get enough cases or have enough time to get good at it,” he says.

Henderson, who carries no board certification, spent four years in general practice before honing in on ultrasound. He says that it took 1,500 cases before he felt competent practicing what he calls “a completely experience-driven modality.”

“It would take most general practitioners 10 years to get that kind of experience,” he contends. “There’s a small set of practitioners who have a machine and use it, but for the most part, they go through a honeymoon phase after their first year, and then the machine starts to collect dust. The good thing is that even though they’ve spent the money and aren’t using the machines to their capacity, they’re recognizing that there are so many things they could be doing, so the medicine is better and so is patient care if they refer out or call in someone with experience."

That idea has helped push ultrasound to become a standard of care in veterinary medicine, Henderson says. “It’s no longer a pie-in-the-sky kind of exam. It’s cheaper, it’s easier to get and everyone knows they need to offer it in their practice, although not everyone has access to someone who’s good at it.”

And every machine is different, he adds.

“The kids getting out of school think it’s a must-have to do good medicine. They want to know that the place where they’re working has a machine, but usually it’s not the $300,000 piece of equipment with a resident running it that they’re used to having access to,” Henderson says.

Proficiency takes dedication
Tod Drost, DVM, Dipl. ACVR echoes that sentiment. As an associate professor in The Ohio State University’s (OSU) Department of Clinical Sciences and president of the American College of Veterinary Radiology (ACVR), he contends that scanning all weekend, eight hours a day will never amount to adequate ultrasound training. The weekend ultrasound courses provided by vendors rarely feature real cases with sick animals, he says. And the certifications these courses provide amount to nothing more than marketing tools used to sell machines because there’s no concrete definition for “certification.” Without a governing body policing the term, handing out such documents waters down all certification processes, including the recognition of specialists, Drost contends.

“For the most part, the public doesn’t know the difference between a weekend course and a residency program. All they see are documents on the wall,” he says.

Furthermore, when it comes to practical use, each scan is a 30-minute to 45-minute procedure that many veterinarians find challenging to devote to while in general private practice. Ultrasound is in a league of its own in terms of developing competency, he says.

“You can teach 100 students to interpret radiograph films, and they’ll be proficient after a semester. Those same 100 students are not going to learn ultrasound adequately. That’s because ultrasound involves using the machine, identifying what you’re looking at and going from there. It’s much more difficult,” Drost says.

To drive that message home, ACVR requires residents to complete at least six months of concentrated clinical training in diagnostic ultrasound. And this month, the American College of Veterinary Internal Medicine reportedly is expected to vote on adding 40 hours of ultrasound training to its residency requirements.

At OSU’s teaching hospital, Drost says that of the 15,000 imaging cases that come through each year, a handful stem from missed and incorrect diagnoses made by private practitioners who misinterpret their own ultrasound examinations.

“Can any DVM become proficient in ultrasound? I think they can. The thing they need is the time to do the training and someone to help guide them in practice. The deck is really stacked against private practitioners. They can’t be all of us rolled into one. That’s just not realistic,” Drost says.



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