How to Incorporate Musculoskeletal Sonography into Your Practice: A Personal Account - HD

Introduction

Hi, my name is Ryan Aler.

I'm a professor of radiology at New York University in New York.

I am a musculoskeletal radiologist, and I have a strong background in ultrasound.

And I wanted to share with you today my experience now in three different institutions in starting up a musculoskeletal ultrasound practice.

I think this is really important as tremendous amount of interest in musculoskeletal ultrasound.

And I think the experience that I bring from three different institutions may be a value, if that's if this is something you'd like to incorporate in your ongoing radiology practice.

Hi. So I'd like to speak to you today about incorporating musculoskeletal sonography into your practice.

And basically, I'd like to give you sort of my own personal account in terms of how I've been able to do this in three different institutions.

And hopefully that will serve as a guide for you in terms of the kinds of things that you may have to deal with in doing this.

As far as disclosures are concerned, I do have research and educational collaborations with Siemens Medical Systems.

So we're gonna talk about today several different areas.

First of all, is it doable? Is it, and the answer of course is yes.

And I'm gonna share my experience with you in terms of doing starting up these kinds of practices.

Why is it important for us as radiologists to do this?

Some common misconceptions as to why some people are reluctant to incorporate ultrasound into their musculoskeletal practice and finally, how to do it.

And there is a very nice article in the literature that I'd like to bring to your attention that describes this technique for those of you who like to go into this in a little more detail.

My Experience in Three Institutions

So where's my experience from?

Well, I've been at three different institutions.

Started at the University of Michigan.

This is there from 89 to 97, which is a large academic medical center, single, large hospital based practice.

Moved on from there at the hospital for special surgery.

Was there from 98 to 2012.

This is a different kind of setting.

It's an orthopedic subspecialty hospital.

Again, it's a hospital based practice, but a very specialized type of practice, basically dealing with musculoskeletal diseases.

And finally, now I'm at NYU Langone Medical Center, which again, is a large academic medical center, however, working in an outpatient setting for the most part, where we do the majority of our musculoskeletal ultrasound.

And although there is a hospital based practice associated with us as well, hospital for joint disease, which is the associated orthopedic hospital, but the large majority of ultrasound we do is in this outpatient center.

So let's go through that background to give you a sense of what the scenario was in these different types of situations.

And you also have to put in perspective that the time at which these practices occurred is very different.

So the view, the general view of people of musculoskeletal ultrasound back in the early nineties, late eighties, was very different from what it is currently.

So we have to put it in perspective of time as well as location.

So before 1989, when I was just beginning as faculty, musculoskeletal ultrasound was effectively non-existent within the university.

However, by 1997, we were actually doing 25 to 30 exams per week.

It was the examinations were done by the musculoskeletal interventional radiologists.

I had trained four technologists to perform diagnostic exams into system interventions.

And all these exams were basically performed in the main ultrasound lab in 1998.

When I moved on to the hospital for special surgery, the first year I was there, we did 1500 examinations.

And if you look at this breakdown over here, about 500 of those were musculoskeletal at that point.

But you could see over the past several following years that there was a rapid growth in musculoskeletal ultrasound.

By 2000, it was about a hundred percent increase.

By 2002, we're actually doing over 500 cases a month.

We had two high-end machines, and we had three techs at that point, and it was a proposed expansion.

And then finally, the last by the time I was leaving, we were actually doing over a thousand cases per month.

About 50% of those were all interventional.

We had four high-end machines, six technologists in four rooms.

And then finally, in my current experience, and this is in the environment where musculoskeletal ultrasound has really caught on fire in a not only in radiology, certainly, but in a number of different areas such as emergency medicine.

But even in that kind of setting, you could see that with, we have two high-end machines.

We have two technologists exams performed by the interventional radiologists.

And our numbers have increased significantly from when I started, about 200 to over 400 cases per month.

And that number is rapidly increasing.

So I think you could see that it's certainly very doable in different settings, in different scenarios.

So and I know everybody needs to individualize according to the place that they're at, but it certainly is a very doable thing.

Why Incorporate Musculoskeletal Ultrasound?

So why is it important for us as radiologists to do it?

Well, there is of course, increased in clinical demand, and we'll talk about that a little more about that in a minute.

Non radiologists will do it and are doing it.

And so if we don't do it, then we're it's really one of those areas that we will lose as imagers.

It does provide a new revenue source if you don't already have it incorporated in your practice.

I think it is in keeping with our expertise as multidisciplinary or multi-modality imagers, where we really have tremendous expertise in a variety of different imaging areas as well as ultrasound.

And it, I think probably most importantly, it makes us a visible member of the clinical team.

And we'll talk about that more in a few minutes. Okay.

Increased Clinical Demand

Well, there is tremendous increased clinical men for doing musculoskeletal ultrasound.

One way we've been able to adapt to this is by incorporating same day add-ons in our practice.

When I was at hospital for special surgery, this amounted to taking as many as 10 to 20 cases on per day.

It's something we can do fairly easily in ultrasound, whereas if you're going to a schedule for something like an mr, sometimes it could be a several week waiting list.

So that so these are exams that we can do, and we can often oftentimes offer same day service to the patients, see them and treat them in the same day, which is quite significant.

At NYU, that number is about four to eight today in our current experience, although that seems to be increasing as well.

And there are a variety of different clinical services that are really impacted by our offering this service.

In my experience, the I basically have dealt with all these types of clinical services, probably orthopedic surgeons, non-surgical sports medicine, rheumatology probably among the largest of these groups, but certainly have dealt with all these individuals.

And once you offer that service to them, they will be more than happy to oblige you by giving you referrals.

Non-Radiologists Performing Ultrasound

Now, as I mentioned before, there has been increasing interests by non radiologists in performing ultrasound.

And just a quote from a article, and this is back in 2001, that appeared in the rheumatology literature by an Italian rheumatologist, no less.

Ultrasound is a safe, cheap and powerful tool for evaluating soft tissue involvement in rheumatic diseases, and should be regarded as an extension of the bedside clinical examination, which is certainly one reason that non radiologists are interested in performing it.

And then of course, the follow up statement, the simplicity and reliability of the technique might warn rheumatologists to undergo sonographic training.

So this is really the lead into the non non radiologists doing this type of imaging.

I have on the right here a slide or a graph that was in an article that actually Dr. Nazarian was a co-author on in the Journal of American College of Radiology.

This is in 2012.

And it looks at trends of utilization for ultrasound, for dust diagnostic purposes.

And you can see among radiologists is top blue curve over here.

It's rapidly increasing, but if you look at non radiologists, it's also significantly increasing.

In fact, if you look at if you were to look at the total numbers of non radiologists doing over relative to radiologists, their numbers actually exceed the num number of exams performed by radiologists.

So we see it's there's clearly a lot of interest for non radiologists in doing it.

And as a result of that musculoskeletal ultrasound performed by non non radiologists is in fact here to say.

And so it is something we have to deal with in the future.

So the question is how can we work in that type of environment?

I think there are a number of reasons for this interest.

Of course, there, as I indicated before with the with the Italian radiologists, rheumatologists, excuse me, there was already precedent set outside of the United States for non radiologists performing ultrasound.

There has been, in recent years, a proliferation of inexpensive portable, relatively high quality ultrasound scanners, so-called laptop scanners.

And so it's become much less much more affordable for these individuals to obtain ultrasound equipment and really obtain relatively high quality images.

It's of course, a new source of revenue, which is something we all think about.

There are numerous courses out there, websites and so forth that are available to non radiologists.

I know I've had as far as observers non radiologists come to our institution at HSS and I know some of my colleagues have had the same experience as well.

And it and of course, it's been integrated into part of their fellowship training such as an emergency emergency medicine and rheumatology for are two good examples of that.

So they're really it's really incorporated into their training currently.

So the bottom line is, if we're not doing it, then we will lose it because there's certainly a lot of interest in others by others to do it as well.

Revenue Enhancement

Well, as I mentioned before, there is enhanced revenue.

And as we all know, procedures pay, and I would say the large percentage of the exams that we do are in fact interventional.

And great interventional procedures are greater than 50% of our current musculoskeletal ultrasound service, which is an out which are predominantly performed as outpatient exams.

There are a variety of different procedures that we do in terms of aspirations and injections.

We inject an aspirated inject a number of different substances.

I would say the majority of about RR grams that I do.

And probably half of the MRR grams that we do in our department are perform injected under ultrasound guidance and a variety of other newer procedures that are very minimal to ultrasounds, such as tenotomy, platelet-rich plasma therapy, stem cell injections, and so forth.

As well as as well as other procedures that are very conducive to ultrasound guided.

Radiologists' Expertise

Now we are as radiologists the imaging experts or and we have experience in multiple different areas, it's we can go across easily from boundaries from areas such as magnetic resonance imaging to ultrasound and really need to utilize that expertise.

And we do utilize that expert expertise when we form a variety of examinations.

And musculoskeletal ultrasound is no different.

People come out with fellowship training and with a deep, now with a sense of knowledge in musculoskeletal anatomy and pathology.

We have multimodality expertise or many fellowship programs, or certainly substantially increased number of fellowship programs that incorporate both ultrasound and MR in their training.

We know how to optimize our images.

We develop learn scan techniques, and we're also trained to do a variety of inter image-guided interventions.

And so it's very much in keeping with us as radiologists that we be doing both ultrasound as well as other modalities that we normally incorporate into our practice.

Unique Capabilities of Ultrasound

And of course, we need to keep in mind that ultrasound in and of itself has a series of unique imaging capabilities.

We can perform provocative maneuvers as in this particular case where a patient comes in with an ulnar neuropathy, and we can see that this with provocative maneuvers this triceps muscle over here is pushing the ulnar nerve over the medial epicondyle.

And so we can understand why he has his ulnar neuropathy.

And this type of prerogative test is really unique to ultrasound.

And of course, when we dupe ultrasound guided procedures, we can have direct visualization of the needle and the injected material as in this particular case where we have a needle in a ganglion cyst along the dorsal aspect of the ankle.

And we're looking at the injected material as it goes in, so we know we're getting in the right area.

So there are a variety of reasons why ultrasound really would play a unique role in our imaging capabilities in and of itself.

And finally, it avoids imaging that may be pro prohibitive or simply overkill.

Patient comes in with a bump in the dors back of his wrist or a bump in his elbow.

And the question is, is there a ganglion cyst or some other type of soft tissue swelling?

This is a simple target examination, doesn't necessarily require that the patient go on for more advanced imaging.

So here we have an example of a patient that had soft tissue swelling over his elbow.

If you are looking in a subcutaneous fat, you see this well encapsulated echogenic mass over here.

And this is fairly typical for a subcutaneous lipoma.

And this is a five minute examination, fairly easy determination to make.

Or we can see pathology in the setting of indwelling hardware, which may be difficult to evaluate with other types of imaging modalities, such as CT or mr, where there's either streak artifact or susceptibility artifact, where in this case, we have a patient that had a had had a wrist fracture, has a volar plate, and we can see a threaded screw projecting through the po posterior cortex of the radius, impinging on one of the extensor tendons of the wrist as being the source of the wrist pain.

So this is a determination that would be difficult to make any other way.

And of course, we were all aware of the fact that not everybody is amenable to having Mrs.

Or cts particularly Mr in the case of a lot of soft tissue abnormalities if there's a pacemaker aneurysm cliff and so forth.

So ultrasound really serves a purpose of an additional modality to address some of these issues.

Visibility as a Clinical Team Member

I think most importantly, the radiologist becomes a visible member of the clinical team.

I think there's an altered perception of by the patient as well as the clinicians in terms of how they view the radiologist, the radiologist, not simply someone who sits in the reading room with the lights turned off and just looking at reading his film, reading his films allows us direct hands on contact with the patients.

The patients will review the radiologist as being one of the people who are helping to treat their pain.

I think it promotes a much higher level of visibility for radiologists within both the hospital as well as the community.

And so the ultrasound person becomes part of the clinical, ultrasound then becomes part of the clinical algorithm in treating a number of problems.

And that's been my general experience at all the institutions I've been at.

Common Misconceptions

So there have been some common misconceptions, I mean, from way back when that I remembered discussing this with various people as to why we should be doing ultrasound.

One of them, of course, it negatively impacts our MR volume.

It may take a long time to do it's operator dependent, therefore, it's unreliable.

It can be hard to learn, and the images may be difficult for clinicians to relate to.

Well, let's look at some of these.

In my experience, this has not been the case as far as negatively impacting mr.

When I was at special surgery, our MR volume in 2001 had actually grown 65%.

There was a hospital approval to expand to a higher, a larger number of high field strength systems.

By the time I was leaving in 2012, we had actually had 10 high field strength magnets in doing appro approximately 2,400 examinations per month at N NYU, even in the setting of hurricane Sandy that I'm sure many of you're familiar with, we're still doing about 2000 exams per month, which is basically back to our pre hurricane limit numbers.

And there's really been no significant impact on our R volume, certainly by the presence of doing musculoskeletal ultrasound.

So it's really had no negative impact, at least in my experience, in terms of our or in terms of our MR volume.

Time Required

Now, does it take a long time to do well, the time it takes really varies in the type of examination.

Many of the types of exams we do in ultrasound or clearly targeted examination, so such as evaluation of soft tissue swelling in the wrist, for instance, many of these exams can be done in five minutes or less.

Some of the exams can be done by a technologist with either minimal or no involvement by the radiologist at all.

You simply look at the images, and if it's fairly straightforward, oftentimes you could simply sit down and dictate a report based on that.

And there are there clearly are exams where the radiologists must get involved.

For instance, when we do shoulder ultrasounds, those are somewhat more extensive.

But even in those situations, a lot of the preliminary scanning can be done by a technologist, and the radiologist can then perhaps go in and post scan the patient the in a more targeted fashion and not have to necessarily spend a lot of time.

And I know in my situation, I generally don't spend more than about five minutes with these patients after I've gotten an initial study from my from my tech.

And one thing that's generally true is once I'm in there scanning the patient, I've usually pretty much come to decision as to what the pathology is.

And so it's you can almost dictate these exams on the fly when you're doing them.

Now, interventions can take a somewhat longer time to do the majority of of the interventions we do.

We generally pa put these patients in a 30 minute time slot.

There are certain exceptions that can take longer cryoablation, PRPs, but these are really exams that some of these interventions are fairly unique to ultrasound and would be difficult to do almost any other way except perhaps using, for instance, computer tomography.

In certain instances of many cases we do interventions in addition to either diagnostic ultrasound or some other diagnostic examination.

So we're doing it usually as in conjunction with some other types of diagnostic imaging that's already been done.

There are various things you can do to help facilitate these procedures.

You can have dedicated interventional rooms and you really I really encourage you to work closely with your with your technologists, your nurses and really trying to optimize and facilitate these procedures to be done.

In many situations, the actual radiologist involvement can be reduced significantly.

In some cases, the down to as little as five to 10 minutes, depending on what type of procedure you're doing.

Operator Dependence

Now, we've all heard the all heard the comments that musculoskeletal ultrasound is very operator dependent.

And I would actually put forth that basically all imaging is operator dependent.

We've all had the experience of seeing poorly performed Mrs.

Cts arthrograms and so forth.

It really depends on how those exams are being performed.

All all imaging requires training in terms of doing it appropriately.

And of course, in the right setting with the right amount of training.

We know there are already numerous publications out there that show that can be high levels of inter and intra observer reliability for musculoskeletal ultrasound, just there as there is in other types of imaging.

So it once you once you have adequate training, there's no question that you can do it well, and there's a lot of evidence to support that.

Learning Curve

So how is is it hard to learn?

Can you can you teach a tech to do it?

Well, I think one of the things that's helpful is it's always helpful since there is a lot of expertise out there in the current environment.

Most people with expertise are very very happy to consult with others who are looking to start their practices.

I think with the number of fellowship trained MSK radiologists coming out of various training programs, there's certainly the opportunity to hire people with experience already.

And it's usually good to assign that individual if you if you hire such a person as a point person to really help promote the instruction of musculal ultrasound within your own within your own practice.

One of the things that I find helpful is to establish small group training sessions.

And basically what I mean by that is meeting on a weekly basis or biweekly basis where you meet with a group of people, either technologists or people working with you, other radiologists, and basically practice on one another, having someone demonstrate the normal techniques for scanning, and then allowing people to practice on one another so they really get a comfort level in terms of doing these types of examination.

And in my experience, as I mentioned before, when I was at U of M, we I was able to train four techs to function quite well.

HSSI trained six techs and now at NYU already have two technologists trained.

So it's certainly very doable.

I can't stress the importance of education.

And in the current environment, there are many different opportunities to receive either a didactic as well as hands-on education through a number of organizations.

Observerships are available at a number of institutions where that have well-established musculoskeletal ultrasound programs.

Currently, there are a number of good textbooks and publications out there.

There are well, web-based learning tools, as well as a number of published guidelines for performing musculoskeletal ultrasound that are out in the literature.

So I would strongly encourage everybody to access some of these resources.

Image Relatability

And are the images difficult to relate to?

Well, if we think of ultrasound as just being a small field of view, image of obscure part of anatomy, then maybe that's the case.

But I think there are a number of things you can do to help clarify what the ultrasound images look like.

I think part of it has to do with educating yourself and your colleagues correlating whenever possible with MR and ct.

So they get used to looking at the ultrasound anatomy in respect to other type the same anatomy seen on other imaging modalities.

It's good to integrate the this into your clinical conferences as much as possible.

I always encourage people to scan meticulously particularly with a musculoskeletal ultrasound where the where knowledge of the anatomy is very important.

Label your images so people know what you're looking at.

And I think extended field view imaging, particularly in this setting, is it can be very helpful because it gives you sort of a nice gesell view of the anatomy.

So in some sense, it's sort of looking like looking at an MR scan and I find clinicians can relate to these types of images much more easily.

So again, you know, just using some of these different features when you're whenever you're trying to present ultrasound, a musculal ultrasound to an audience can be can be very helpful.

How to Start a Musculoskeletal Ultrasound Practice

So how do we start a musculoskeletal ultrasound practice?

Well, I've alluded to education as being one of those one of the factors that are involved.

We'll talk more about that in a minute.

Logistics, of course, in terms of how you set it up, people you speak to.

And I think very importantly, and something we don't do well as radiologists, but something we need to do, particularly in the current environment, is advertise ourselves.

Basically, how do you promote it within the literature and how you promote it within your local hospital setting and so forth.

This is an example of one of the things that I started at HSS and we're continuing at NYU is a so-called ultrasound of the month, something that we have out there, either in the intranet or in the in our regular or a local intranet.

And this basically as much as an of an educational tool for various people as well as for clinicians, basically to indicate to them of what we are capable of doing in ultrasound.

So it presents a an interest in clinical scenario along with a corresponding ultrasound images that as well, as well as the diagnosis, so they really get a sense of what we can do.

So educating your colleagues is very important.

One way to do this is to attend staff conferences, educate your radiology con colleagues within the context of your clinical your your your um local conferences.

Talk to clinicians, attend their conferences as much as possible.

Let them know what you can do, determine their specific interests, where their interests lie, so you can get a sense as to what's important to them and where you might be able to add to their pro to what's important to them.

In terms of ultrasound, as I mentioned several times already, offering to take an on patients can be very important.

Really pr improves the quality of the the quality of medical care that they can offer.

And I think once you start offering the service to them, they'll they'll actually start utilizing you quite a bit more whenever you have an opportunity to talk at the clinical conferences or showcases, so people can get a sense as to what the various types of pathology looks like.

And you can see the kinds of things that you can do.

And at least in my own experience for those of you who work in academic institutions, research collaborations can be very helpful.

When you start such collaboration, oftentimes you bring clinicians in, they begin to see what you can do.

And then next thing you find out is that they're actually starting to make referrals of various types of clinical exams for you as well.

So that's actually one one handy way to to to get a set of referrals.

Promotion and Advertising

So as I mentioned before, in educating your colleagues, setting up a website can be very helpful.

These can be cases of the month, as I mentioned before.

They can be how to manuals in terms of how to do various types of scans such as shoulder, elbow and so forth.

They can be interventional type of webpages.

And we we've had experience doing both of these.

And there are there are a number of good websites out there already from various from various institutions such as University of Michigan, for instance, that really have a lot of information in terms of doing musculoskeletal ultrasound.

You can set images up on your local webs page, which is the ultrasound of the month, as I mentioned before, which offers a clinical synopsis and a few relevant images to help educate not only your colleagues, but also the the clinicians within the institution.

So they can see the kinds of things that you can do with ultrasound.

Now finally, logistics become very important.

So once you have the interest, obviously you have to you have to do the administer.

You have to know where you can set up such a such a how you can incorporate this easily into your practice.

And one way to do that is working with your administrative staff to know how best to schedule these types of examinations, how to code them, and how to bill for them in order to incorporate them into your practice.

Working with your clinical colleagues and nurses and technologists, as I said, are it can be very important.

It sort of you can help determine the types of exams you can do, the necessary workspace that that you will require it in order to perform ultrasound, where the where the where the workspace should be located, and get a sense of how it will work into your your existing workflow.

And as I mentioned, since there is a lot of expertise out there already, it's most people are very amenable to as I am, for instance, to be contacted either by email or by by phone.

And you can certainly ask some questions in terms of since you already have an established practice you know, kinds of things that would be very helpful for you to consider when you want to incorporate it into your own practice.

I've indicated in this slide a number of common CPT codes that we use for for both diagnostic and interventional examinations.

And just these are some of the numbers, some of the CPT codes that we find very useful and that we're currently using for billing these examinations.

And finally, it's very important once you want to set up a practice, is to learn how to promote it.

And of course, conferences is one way to do it, but advertising can be very helpful.

This could be advertising through web-based through web-based means such as ultrasound of the month, for instance.

You can have brochures that you distribute both available within at at your within your practice when patients come in that that they can access or brochures that you mail out.

We've sent out letters to referring clinicians to let them know the kinds of services that we offer, including ultrasound.

And as I mentioned before, being available to take add-on cases can be very helpful.

'cause one way of promoting the service.

And at the same time, letting clinicians know you're out there and you can take their patients on on the same day for certain types of procedures.

You it's important to stress the complementary role of ultrasound with other types of imaging modalities.

So that and part of this is so that your colleagues know when they're ringing an MR scan, what types of examinations might be appropriate to refer for ultrasound guided.

So for instance, in this case, as a patient with a meniscal cyst, you on magnetic resonance imaging, and this was very conducive to an ultrasound guided aspiration and injection.

So once you see this, then you know that this can follow.

And it's a very nice way to treat these examinations.

And as I mentioned before, there are examinations that necessarily aren't conducive to either MR or ct.

So be aware of this. When you discuss ways of dealing with various types of abnormalities with clinicians, you can keep that in mind and know which patients would be appropriate to go on for ultrasound examination.

And so that's another way to help build up a referral basis.

Conclusion

So we've spoken about a number of things in terms of studying up your ultrasound practice.

What I'd like to stress is that a musculoskeletal ultrasound is an important service to offer for a variety of reasons, as we've discussed.

And importantly, if we don't do it, we will lose it.

It is doable.

Just educate yourself and your colleagues so they know what's appropriate and they can sort of relate to these images.

If need be, starts simple.

Think of the kinds of things that you feel comfortable doing in terms of starting out with.

But and I think you'll you'll notice that once you start getting some confidence, you can expand to more complex types of procedures.

I think being available to take on add-ons can be very helpful and very importantly, advertise.

I can't stress that enough.

So people know what it is you're doing.

I think you once you've done this, you'll find that musculoskeletal ultrasound will enhance your radiology practice.

And I think you you'll be surprised to see what kind of impact you have on medicine, how it's done in an institution, and you become a more valued member of the of the clinical team.

So, I'd like to leave you with this.

There's no time to lose.

Call and find out about starting your musculoskeletal ultrasound practice today.

Thank you very much.