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

Importance of Education in Musculoskeletal Ultrasound

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
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.

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

Relating to Ultrasound Images

And are the images difficult to relate to?

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.

They get used to looking at the ultrasound anatomy
in respect to other type, the,
the same anatomy seen in other imaging modalities.

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

I always encourage people to scan meticulously,
particularly with a musculoskeletal ultrasound
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 very helpful
because it gives you sort
of a nice geal view of the anatomy.

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.

Just using some of these different features when you're trying to present ultrasound, a musculoskeletal ultrasound to an audience can be very helpful.

Starting a Musculoskeletal Ultrasound Practice

So how do we start a musculoskeletal ultrasound practice?

I've alluded to education as being one of those 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 very importantly,
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,
how do you promote it within your
local hospital setting and so forth.

Ultrasound of the Month Initiative

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 our regular or a local intranet.

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

It presents an interesting clinical scenario,
along with the corresponding ultrasound images as well,
as well as the diagnosis,
so they really get a sense of what we can do.

Educating Colleagues

Educating your colleagues is very important.

One way to do this is to attend staff conferences,
educate your radiology colleagues
within the context of your clinical 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 what's important to them.

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

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

And once you start offering the service
to them, they'll actually start utilizing you
quite a bit more whenever you have an opportunity
to talk at the clinical conferences, to showcase,
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.

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

Setting Up Websites and Educational Tools

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've had experience doing both of these.

And there are a number
of good websites out there already 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 webpage,
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 clinicians within the institution.

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

Logistics and Administrative Setup

Now finally, logistics become very important.

Once you have the interest, obviously you have to do the administer.

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

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 can be very important.

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

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

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

Common CPT Codes

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

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.

Promoting the Practice

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 means,
such as ultrasound
of the month, for instance.

You can have brochures that you distribute,
available within your practice when patients come in 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 the same day.

For certain types of procedures,
it's important to stress the complementary role
of ultrasound with other types of imaging modalities.

So that your colleagues know when they're ordering an MR scan,
what types of examinations might be appropriate to refer
for ultrasound guided.

For instance, in this case, there's a patient
with a meniscal cyst on
a magnetic resonance imaging.

And this was very conducive
to an ultrasound guided aspiration and injection.

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.

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

Conclusion

We've spoken about a number of things in terms
of setting 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.

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

And you'll notice that
once you start getting some confidence,
you can expand the more complex types of procedures.

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

I can't stress that enough.

People know what it is you're doing.

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

And 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 clinical team.

There's no time to lose.

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

Thank you very much.