MONTREAL - Ultrasound’s low equipment and maintenance costs, immaculate safety profile, and wide range of applications have made it critical to healthcare programs of developing nations. For much of the world’s population, ultrasound represents the only hope of receiving an imaging exam, and with it a chance to avoid exploratory surgeries, "blind" biopsies, and missed opportunities for diagnosis and treatment.
Fulfilling these hopes is a tall order indeed. For all of its usefulness, ultrasound is an operator-dependent modality that requires extensive training, follow-up, and retraining of enough providers to satisfy surging global demand. On Monday at the International Congress of Radiology, Dr. Barry Goldberg, director of diagnostic ultrasound at Thomas Jefferson University Hospital in Philadelphia, talked about the state of ultrasound education in the world, and the steps being taken to fulfill the vast need for medical imaging services. in Philadelphia talked about the state of ultrasound education in the world, and the steps being taken to fulfill the vast need for medical imaging services.
In the years since 1988, when the World Health Organization (WHO) issued its first ultrasound education manual, ultrasound teaching programs have spread rapidly around the world, but not rapidly enough, Goldberg said.
"Education has not kept up with the needs, and while there are efforts in developed countries, unfortunately in the impoverished nations of the world there’s really inadequate infrastructure, a lack of trained physicians, and other medical professionals," he said. "And so there are tremendous opportunities for international education...but also challenges."
Developed countries around the world have made efforts to set standards for ultrasound use and training, "some of which radiology approves of and some of which it does not," he said. In some European countries and in Korea, only physicians can practice ultrasound. In many Asian and Scandinavian countries, non-physicians such as radiographers and clinical lab technologists are permitted to practice ultrasound. In Norway, midwives can interpret ultrasound exams.
"Where established non-physician ultrasound training programs exist, they are typically comprehensive, requiring high standards of knowledge and practice," typically requiring one or two years of dedicated training, Goldberg said. "In some respects the nonphysicians in many countries have more training than the physicians."
The World Health Organization recommends ultrasound training for all physicians, and Europe has responded by initiating a new initiative to develop curricula for basic (level 1) and advanced (levels 2 and 3) ultrasound training for physicians, Goldberg said. According to WHO, the highest skill levels should enable physicians to perform competent ultrasound exams using the most sophisticated ultrasound equipment and the most advanced imaging techniques.
In Japan no formal legal accreditation is required, but the industry is self-regulated, and the country has formed a society of teachers and physicians responsible for ultrasound training. Some countries in Latin America provide training only to newly qualified physicians, he said.
It’s a different story in China, where programs exist for general and advanced ultrasound education at various stages of the medical career, and physician specialists called sonologists often lead their own ultrasound departments in hospitals, medical centers, and clinics nationwide, Goldberg said. Among myriad graduate and postgraduate offerings, the country has developed five-year ultrasound residencies. China has some 150,000 physicians practicing ultrasound, and approximately 100,000 ultrasound scanners. The average ultrasound unit is used on about 40-50 cases a day at a cost of $2-$30 per exam, he said.
"Some of those may be only grayscale (scanners)," he said, but "more and more sophisticated equipment from the United States and other places is entering China, and so we’re seeing a rapid increase in the quality of their equipment."
Thomas Jefferson University
Under Goldberg’s leadership, Thomas Jefferson University in Philadelphia established a division of diagnostic ultrasound training in 1977. In 1978 the Veterans Administration and the National Science Foundation gave the center a $750,000 grant to develop an intensive ultrasound training program to benefit the VA system and the U.S. armed forces.
The Jefferson Ultrasound Research and Educational Institute (JUREI) was founded in 1992 in an effort to consolidate and strengthen the university’s ultrasound training programs, and in 1993 the center was designated as a WHO collaborating center for continuing and general ultrasound education, Goldberg said.
The university provided the space but no funds, so those who can afford to pay do pay, he said, and the rest of the money comes from grants.
"On average every year we train about 1,000 physicians, physicists, and paramedical personnel from around the world, and now our training centers around the world...have trained more than 2,000 physicians," he said. Much of the center’s training now takes place in the developing countries where the physicians will serve, he said; simple economics dictated that bringing everyone to the U.S. for training wasn’t the most cost-effective way to place skilled ultrasound physicians around the world.
With that, JUREI’s "Teaching the Teachers" program was born, in which doctors learn how to set up and run ultrasound training programs in their own countries and regions. The first years of funding came from the U.S. government, which sought to improve the quality of life in the newly independent Eastern European nations, as well as from the Open Society Institute (formerly George Soros Foundation), Goldberg said. Then three years ago, the RSNA provided a research and educational grant for a similar program in sub-Saharan Africa, which ends this month.
"And we’ll begin on July 1 to do the same thing in the Caribbean, Central, and South America," he said. Applications are now being accepted from physicians in this part of the world for training to begin in January 2005, he said. The selections will be made in August 2004. A free newsletter chronicling the group’s activities is available at: http://jeffline.tju.edu.
"What is the concept? It is to train physician leaders in ultrasound," Goldberg said. "They are not residents, they are not physicians from small villages, but in the developing countries (these are) people who can teach in their countries, in their region." So far more than 90% of those selected have been radiologists, he said.
They are brought to Philadelphia for 12 weeks of intensive training, both in ultrasound and in teaching ultrasound. Those chosen to be center leaders return for a four-week follow-up visit after the initial phase, to retest skills and provide further training in ultrasound education. Passing the program requires successful completion of a difficult 100-question "uncued" final exam -- translated when necessary -- to remove any possible advantage in picking the pathology from a list of multiple choices.
The test is a breeze for test writers, who don’t have to think of five differential diagnoses, but it’s hard for the students, he said.
To help them muddle through, a team of program coordinators, radiologists, mentors, and even translators are available to provide teaching and support services in even the most advanced aspects of ultrasound such as 3D and 4D imaging, and ultrasound-guided interventional techniques including biopsy. Thus, the students are prepared for the future as well as the present, and are taught to provide a full range of services, Goldberg said. And because they are expected to teach, the physicians are trained and critiqued in teaching and presentation skills. They learn about administration and management, and the care and maintenance of ultrasound equipment.
"In the developed countries where many of us are from, we just make a phone call and a serviceman appears. That is rarely the case in other parts of the world," he said.
Overall, 4% of the students elected not to return to their home countries after training, and as a result, in recent years more attention has been paid to background checks. There is also more reliance on recommendations from regional advisors and committees in the target countries, which has eliminated the problem, Goldberg said.
"As a result of this program we now have 63 affiliated ultrasound centers around the world in some 46 countries,"he said. Among them, Ireland, Italy, Austria, and Switzerland have joined an alphabet of developing nations from Afghanistan, Albania, Armenia, Bangladesh, Brazil, and Bosnia-Herzegovina -- to Indonesia and Kazakhstan, Malaysia, Mongolia, Nepal, and Pakistan -- to Romania, Sierra Leone, Venezuela, and Uzbekistan, as affiliated training centers.
The growing global effort now relies on assistance from a number of other organizations, including free educational materials from SonoWorld, the RSNA and the Radiology Outreach Foundation, the efforts of the nonprofit International Certification and Educational Accreditation Foundation (ICEAF), and organizations such as Carelift International that are able to deliver ultrasound equipment wherever it is needed.
Equipment
Through its nonprofit Global Ultrasound Equipment Donation Foundation, the Philadelphia group also provides ultrasound equipment in cases where it can be sure there are adequate trained staff and a secure place to deliver systems. Siemens Medical Solutions of Malvern, PA, and GE Healthcare of Waukesha, WI, have donated hundreds of ultrasound scanners, Goldberg said, adding that he continues to solicit other vendors to assist in the effort.
Of course, sending a scanner to a developing country is no guarantee it will arrive at its intended destination; Goldberg said he has been very pleased with the group’s 100% equipment delivery success rate so far.
Things got dicey in one African country, for example, when Goldberg’s group decided to deliver a donated machine even though the country had no affiliated training center -- because trained sonographers were available at a hospital there that had no scanner, he said.
"We ended up delivering a machine that went into the port and wouldn’t come out of the port," Goldberg said. "I had sent one of my technologists there to provide them training, and he had to go to the minister of health because the minister of ports apparently had a brother who owned a hospital elsewhere, and threatened to take everything. And within 24 hours the equipment was released."
Goldberg’s next slide showed hundreds of people lined up outside of the hospital where the scanner was being installed. They had heard that an ultrasound machine was coming, he said.
By Eric BarnesAuntMinnie.com staff writer
June 29, 2004
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