Training in musculoskeletal ultrasound by UK rheumatologists: when is now, but how?

J. Cunnington1,2, G. Hide3 and D. Kane1,2

1 School of Clinical and Medical Sciences (Rheumatology), University of Newcastle-upon-Tyne, 2 Department of Rheumatology and 3 Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, UK

Correspondence to: D. Kane, School of Clinical and Medical Sciences (Rheumatology), Cookson Building, Framlington Place, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, NE2 4HH, UK. E-mail: d.j.kane{at}ncl.ac.uk

Musculoskeletal ultrasound (MSUS) is undeniably an excellent imaging tool for rheumatologists. It allows high resolution, multiplanar, anatomical images to be obtained in real time in a relatively inexpensive and patient-acceptable manner. Direct correlation of clinical and ultrasound findings can be made at the first consultation in a time-efficient manner. Over the last 5 yrs there has been an exponential increase in the number of publications regarding MSUS, which detail its ever-increasing applications [1, 2] and, most importantly, the positive impact it has on the clinical care of patients [3]. The work also represents the growing number of individuals and centres involved in MSUS. There is great enthusiasm among rheumatologists who would like to perform MSUS and provide a service. This is evidenced by the interest in MSUS documented by a survey at the European League against Rheumatism (EULAR) annual conference in Glasgow in 1999 [4], a report from the first British Society of Rheumatology (BSR) MSUS course in Cambridge in 2000 [5] and the oversubscription to all subsequent EULAR and BSR courses.

However, the road to becoming a rheumatologist sonographer is not without its challenges. MSUS is highly operator-dependent and training needs to be adequate if one is going to acquire the necessary knowledge and skills to be able to deliver a safe MSUS service. This requires a significant investment of time from the individual and finance for equipment and training from their department. Due to the lack of an internationally agreed training programme, there are huge differences in the way training is undertaken. The current experts in MSUS have trained using a variable combination of short courses, self-teaching and practice under expert guidance [6]. In this issue of Rheumatology, Taggart and colleagues document their practical approach to training in MSUS using currently available training resources, which largely reproduced how the original experts trained [7]. Although this is a valid and responsible method of training, a more structured approach may facilitate the training of rheumatologists and expedite the development of MSUS in the UK. Is there now sufficient information in the literature, interest among UK rheumatologists and clinical need for MSUS to develop a curriculum and training programme for rheumatologists that will provide a more consistent and superior standard of MSUS training?

Radiologists currently provide an MSUS service; their comprehensive training in all imaging modalities gives them excellent knowledge of cross-sectional anatomy and pathology to help them provide this service [8]. Rheumatologists can combine MSUS skills with clinical knowledge of rheumatic diseases to enhance their diagnostic skills and influence patient management immediately. Increasing demand for MSUS and other imaging by rheumatologists and a national shortage of musculoskeletal radiologists has led to increasing waiting times for imaging studies and the impetus driving clinician-led MSUS is the need to reduce time to diagnosis and treatment for patients. The Royal College of Radiologists (RCR) has recognized the demand for non-radiologist-operated ultrasound and has produced guidelines for physicians and surgeons in 10 separate specialties who wish to undertake training [9]. The guidelines for MSUS recognize that within the field there is a wide range of potential examinations and pathologies and suggest that training should be addressed in a modular approach to meet the needs of the individual trainee. A rheumatologist, for example, would not be likely to wish to train in MSUS of orthopaedic pathology, hernias and other non-rheumatological pathology listed in the competency assessment sheet. The guidelines document the knowledge base, including the physics and technology of ultrasound, sectional and ultrasound anatomy and pathology in relation to ultrasound, that needs to be taught. They suggest that training should be supervised by an experienced musculoskeletal sonographer and that this should take place in weekly sessions for a minimum of 3–6 months, in which time 250 scans should have been done. A logbook should be kept listing the type and number of examinations undertaken and the endpoint of training should be judged by mentor assessment of competencies listed in the guidelines. The guidelines also advise how a competent individual should carry on maintaining their skills. These guidelines are useful but it is not clear if radiologists would provide the training and how practical it would be for practising rheumatologists to commit to lengthy periods of training in a radiology department.

The EULAR Working Group for MSUS in Rheumatology is a group of rheumatologists with expertise in MSUS and who teach on the EULAR MSUS practical courses. They have produced a set of guidelines [10] with an accompanying website resource for image acquisition of peripheral joints by MSUS (www.doctor33.it/eular/index.asp). The guidelines include information regarding technical equipment, methods of training, a standard set of image planes required for scanning each joint region, and the MSUS-detectable pathology that should be taught. The standard set of image planes and the website resource have been successfully used for training by a single well-motivated trainee rheumatologist as part of an intensive self-teaching MSUS programme [11]; however, training limited to a self-teaching approach is not ideal. These guidelines give no indication of the volume of work that would need to be done or the standard that should be reached to achieve competence in MSUS.

A four-stage Delphi analysis of a panel of worldwide rheumatology and radiology experts in MSUS has produced recommendations for rheumatologists performing MSUS that may be used to design a training curriculum [12]. These detail the indications, anatomical areas and knowledge and skills that are deemed appropriate for rheumatologists training in MSUS but do not provide detail on the means of acquiring or assessing these skills. Though a majority consensus was reached between rheumatologists and radiologists in most areas, there were a number of significant differences of opinion between radiologists and rheumatologists concerning the anatomical areas and indications relevant to rheumatologists performing MSUS. This may represent the rheumatologists’ enthusiasm for training in MSUS and how they feel it will benefit their practice and the radiologists’ reservations and their knowledge of the appropriateness of other imaging modalities for specific musculoskeletal pathologies. The differing opinions are important and reinforce the need for both specialties to engage in training development. It is interesting to note that this approach to developing a curriculum for MSUS training has drawn similar conclusions to that of the expert consensus from the RCR and the EULAR Working Group for MSUS. These recommendations provide a sound basis on which to agree a MSUS training curriculum for rheumatologists in the UK, though it will be important to retain the emphasis on modular and flexible training in order to make it accessible to all rheumatologists seeking to train.

Currently, practical sources of training in the UK are mostly available in the form of BSR introductory MSUS training courses. These courses are run over two or three consecutive days and cover a large curriculum; with limited time for hands-on scanning, the courses have the potential to be overintensive. Their aim is to introduce concepts, aid understanding of MSUS and provide basics in using MSUS equipment and image acquisition. These courses are oversubscribed, have high attendee satisfaction and have been shown to increase participants’ knowledge and skills in the short term [13]. Although such courses give initial valuable guidance in MSUS training, there are limits on what can be achieved in such short periods of time. They currently provide no structure for continued training or methods of assessment of standards of competency. Despite this, such courses are the current foundation for training in the UK, as demonstrated by the attendance of Taggart and colleagues at BSR and EULAR courses throughout their training. Short courses can be successfully used as part of a structured training programme, as demonstrated by the Ultrasound School of the Spanish Society of Rheumatology. They have, however, expanded on the introductory course and offer beginners’, intermediate and advanced courses with certification at each level, an additional learning resource in the form of a CD and a final pathology logbook for assessment [14].

Five years ago Taggart and colleagues recognized the potential MSUS could have in their rheumatological practice [7]. Lacking a school of MSUS or other such training infrastructure, they initiated a responsible training mechanism and later designed a unique competency assessment to ensure adequate training was received. The Belfast group's initial steps were to attend introductory courses in MSUS and purchase MSUS equipment. This is a common step to take, as evidenced by the increasing number of rheumatology units in the UK who send staff to the BSR MSUS course and who are intent on purchasing MSUS equipment. However, in the absence of a defined curriculum, training programme and mentor/experienced sonographer, these units will struggle to establish a clinical service. The Belfast group initially overcame these obstacles by attending several introductory MSUS courses each and by obtaining some local tuition from a radiologist. This approach required a significant amount of time (5 yr), particularly as these introductory courses are not designed to be a continuous source of training or support. Taggart and colleagues recognized that to progress they needed regular expert supervision and mentoring. They were fortunate to develop a training partnership with Professor Walter Grassi—an internationally renowned expert in MSUS in rheumatology—and his department in Italy. In this way MSUS training was done under direct expert supervision, initially in Italy and later under the supervision of Dr Filippucci in Belfast.

Access to a mentor is pivotal to training in MSUS but very few units in the UK have experienced rheumatologist sonographers and there are limitations on the abilities of musculoskeletal radiologists to perform this role. Some radiologists will feel that MSUS is more appropriately performed by radiologists [8] and others will be supportive but prioritize their limited training time to address the training of musculoskeletal radiologists [9], while those that are interested in providing training to rheumatologists require support in this era of tightly regulated job planning. Taggart and colleagues spent in excess of £250 000 on training seven rheumatologists in 5 yr, the majority of this being on equipment and an unspecified lesser amount on courses. The cost of mentoring by their radiologist and Professor Grassi and Dr Filippucci is not specified. Any attempt to develop MSUS training for rheumatologists in the UK needs to realistically address the issue of how this will be funded. Financial support for trainees attending short courses is usually accessed from postgraduate sources of study leave funding, but provision of funding for mentors is more complex. The Spanish Society for Rheumatology addressed this by funding the training of a core group of MSUS trainers who developed a series of training programmes and acted as mentors [14]. This approach has resulted in the training of 450 rheumatologists in 10 yr. The funding was obtained from the same sources as those the Belfast group accessed—pharmaceutical companies, charities and health-care trusts.

Integral to the successful development of MSUS in rheumatology is the assessment of competency. The RCR guidelines anticipate that this will be through a logbook and mentor assessment of competency, as is currently used in the training of radiologists [9]. Taggart and colleagues developed a unique, comprehensive assessment tool with the aid of their Italian colleagues. This was in the form of a written multiple-choice question paper and a practical assessment of their MSUS examination skills in healthy patients and patients with rheumatic conditions. Though there is much to commend in a formal assessment of competency, this approach will require a considerable resource in personnel and time compared with the logbook/mentor approach. It is important to ensure that any assessment of competency in MSUS retains flexibility, so that trainees are not obliged to achieve competency in areas that they do not intend using in their clinical practice.

For the time being, rheumatologists in the UK interested in MSUS will continue to attend introductory MSUS courses, purchase equipment and begin to perform MSUS. Equipped with these rudimentary skills and hardware, but without the benefit of an MSUS curriculum, training programme and mentors, they will continue to be challenged in developing skills and providing an adequate clinical service. It is clear from the Belfast experience that this can be ultimately successful but that a more structured approach to training would be advantageous. There is now sufficient expert consensus on an MSUS curriculum for training, sufficient interest among UK rheumatologists for MSUS training and sufficient clinical need for MSUS to develop a MSUS training programme for rheumatologists in the UK that will provide a more consistent and superior standard of MSUS training. In December 2005 the Arthritis Research Campaign is funding a Musculoskeletal Education workshop following the 4th BSR MSUS course in Newcastle. This will bring together experts and trainees in MSUS from rheumatology and radiology both from the UK and Europe. It is hoped that at this meeting progress will be made in the development of a training programme that will advance the practice of MSUS in the UK.

J.C. is funded by the Arthritis Research Campaign and D.K. is Arthritis Research Campaign Clinical Senior Lecturer in Rheumatology.

The authors have declared no conflicts of interest.

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