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

Common Misconceptions About Musculoskeletal Ultrasound

There have been some common misconceptions from way back when that I remember 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 operated dependent, therefore it's unreliable.

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

Let's look at some of these.

Negative Impact on MR Volume

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 a doing approximately 2,400 examinations per month at 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 MR 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, in terms of our MR volume.

Time Required for Examinations

Now, does it take a long time to do 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, 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 radiologist 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, and post scan the patient, the, in a more targeted fashion and, and not have to necessarily spend a lot of time.

And I know in my, 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 techs.

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, when you're doing them.

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

We generally 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, 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, 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, in many situations, the actual radiologist involvement can be reduced significantly in some cases down to as little as five to 10 minutes, depending on what type of procedure you're doing.

Operator Dependency

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, 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 there 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 and Training

So how is, is it hard to learn?

Can you, can you teach a tech to do it?

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, who are looking to start their practices.

I think, with the number of fellowship trained, MSK radiologists coming out of, 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, is to establish small group training sessions.

And basically what I mean by that is, you know, meeting on a weekly basis or, 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, 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, to function quite well.

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

So it's certainly very doable.