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Educational problems in echocardiography
EDITORIALS
Educational Problems in Echocardiography HARVEY
FEIGENBAUM,
MD,
FACC
Indianapolis, Indiana
The current interest in echocardiography has created several educational problems. As this diagnostic examination becomes increasingly accepted as a useful clinical tool, practicing cardiologists need to know more about the technique. They must know what the study can and cannot do so that they can order it appropriately. They should feel comfortable about examining echocardiograms so that they can intelligently read articles that draw on this technique. Eventually they will probably want to examine the echocardiograms obtained from their own patients. This educational need can be met fairly easily. Since these cardiologists will not be performing the study and will not be primarily responsible for its interpretation, they probably can get sufficient information from postgraduate courses of the lecture type, review articles or textbooks. Ideally they should have some opportunity to examine a patient or two just to know how the examination is performed, but this type of experience is not essential. A second major educational problem is keeping echocardiographers up to date with the latest information in a rapidly advancing field. Most of the significant developments in echocardiography are presented and discussed at the national cardiology meetings. Several postgraduate educational courses are being planned to help inform practicing echocardiographers of the current state of the art. Like all practicing physicians, echocardiographers must try to keep up with published data as best they can, but major echocardiographic papers may appear in several different journals. The American Institute of Ultrasound in Medicine has been compiling lists of as many articles as possible dealing with medical uses of ultrasound. Information is available from a few local organizations such as the Los Angeles Society for Ultrasound in Cardiology. This organization meets regularly, and the echocardiographers in the Los Angeles area have the opportunity to discuss mutual problems and interesting cases. Similar organizations may be developed in other parts of the country. Again, as in other areas of medicine, an increasing proportion of our educational effort in echocardiography probably will have to be used to update practicing echocardiographers. From the Hemodynamic Laboratory, Indiana University School of Medicine and Krannerf Institute of Cardiology, Indiinapolis, Ind. Address for reprints: Harvey Feigenbaum, MD, Hemodynamic Laboratory, Indiana University School of Medicine and Krannert Institute of Cardiology, 1100 W. Michigan St., Indianapolis, Ind. 46202.
Training
of
physician-echocardiographers:
Probably our biggest current educational problem in echocardiography is the increased demand by physicians who want this examination available for the management of their patients. Physicians and institutions have tried to meet this need in several ways. Frequently an echocardiographic laboratory is started by an institution’s purchase of an instrument. Then one or more physicians teach themselves how to perform and interpret echocardiograms with the aid of a few published articles. Or the instrument is given to a technician who tries to duplicate some of the published echograms; frequently this same technician is using the same ultrasonic equipment to examine other parts of the body. Both approaches are usually disastrous and lead only to poor quality echocardiography. Probably the best method of introducing echocardiography into an institution is to find a well trained physician and place him in charge of starting the laboratory. This physician should have been formally trained in an active echocardiographic laboratory for 3 or more months as part of a fellowship program in which his echocardiographic ability was verified by the echocardiographer in charge. He should then purchase the necessary echocardiographic equipment and will undoubtedly look for a technician who is suitably versed in cardiac anatomy and physiology and can be trained to perform echocardiography. Unfortunately, there are very few centers that sufficiently train physicians in echocardiography to meet the standards just stated. In addition, many practicing cardiologists want to perform echocardiography. The question is, Has echocardiography advanced to the point that one must undergo lengthy formal training before establishing a laboratory? This question has been answered in other areas. For example, a practicing cardiologist could not visit an active cardiac catheterization laboratory for a few days and learn the techniques sufficiently to start a laboratory on his own. Some workers in the field believe that the complexity of echocardiography has also reached the point where one cannot learn the technique in a few days or even in 1 or 2 weeks. They hold that an echocardiographic laboratory must be established by a trained physician even though an institution might have to wait 1 or 2 years before it finds a suitable physician. This point of view has a great deal of merit; however, I believe that physicians and institutions will
November 1974
The American Journal of CARDIOLOGY
Volume 34
741
EDITORIALS
not wait this long, and the practicing physician who wants to perform echocardiography is probably going to do so whether or not training is available. He probably will attend one or two postgraduate courses where echocardiography is discussed. He might get some superficial training from one of the commercial companies, and he will proceed to set up a laboratory. Realizing this fact, we have tried to help practicing physicians who want to use echocardiography. For several years we permitted physicians to visit our laboratory for 1 to 2 weeks at a time. Approximately 200 physicians took advantage of this invitation. Some of the best echocardiographers in the country were among this group, but I also know of several participants who are either not active in the field or, worse, are performing very poor quality echocardiography. This type of training is extremely time-consuming and disruptive to an echocardiographic laboratory. It is particularly disadvantageous to the cardiology fellows who are receiving more formal instruction in echocardiography. Since these fellows should be the best trained and are our primary responsibility, any program that jeopardizes their training is obviously not the best. As a result we have had to curtail severely the number of visitors permitted to receive individual training in echocardiography. During the past year, with the cooperation of the American College of Cardiology, we have presented a series of echocardiographic workshops. Each workshop lasts 3 l/2 days. There are 3 half-day sessions of lectures and 4 half-day sessions involving the examination of patients and the interpretation of echocardiograms. The program has been very popular, and most of the physicians who have taken the course have enjoyed it. However there is an obvious question as to how much training a physician can obtain in 3 l/2 days. I can guarantee that none of the physicians who finish the course feel confident that they know all there is to know about echocardiography. We go to great pains to instill humility and caution in the use of the technique. We try to impress upon participants that this course represents merely an initiation into the field, and that their expertise will come only with a great deal of practice at their home institutions. They are encouraged to examine patients who are undergoing cardiac catheterization or cardiac surgery in order to receive as much information on their diagnoses as possible. In this way they can build up their own confidence in their ability to use echocardiography to make proper diagnoses. Only time will tell whether or not these workshops have been of value in starting high quality echocardiographic laboratories. In any case, I look upon these programs as merely stop-gap measures to meet the demand temporarily. In’the long run, the laboratories should be started and managed by physicians who have been more formally trained. Training of technicians: The next question is, How can a technician be trained? It is well known that technicians can perform the actual echocardiographic examination. In fact, they frequently obtain better quality echocardiograms than do physicians. 742
November 1074
The American Journal 06CARDIOLOGY
Furthermore, the fee schedule for echocardiography is based on performance of the examination by a technician. Thus, many physicians want to start a laboratory by merely having a technician trained to take the echocardiograms. This is not the proper approach for many reasons. (1) A technician can function only as an assistant to the physician in charge. In a proper physician-technician relation, the technician knows that he can turn to the physician with any problem, including a particularly difficult echocardiographic examination. In fact, the technician usually works best when he has been trained by the physician with whom he works. (2) It is difficult for a technician to keep up with all the advances in echocardiography since he does not have access to the medical publications or the medical meetings. (3) A physician who is totally dependent on a technician could be in legal difficulty if an improper echogram led to an erroneous diagnosis and mismanagement of a patient. Thus, a physician who wants to manage an echocardiographic laboratory must be trained in all aspects of echocardiography and, in particular, must know how to perform a good echocardiographic examination. Once a physician is trained in echocardiography, either through a formal training course or after sufficient personal experience, then he can recruit and train a technician. As I have indicated, technicians usually learn the technique best if they already have some familiarity with cardiac anatomy or physiology. If they have a little training in electrocardiography and have some understanding of hemodynamics, they tend to learn the technique faster than others. The best technicians seem to come from cardiac catheterization or phonocardiographic laboratories. Today, the burden of training technicians is on the individual physician. I know of no good echocardiographic laboratory that has a training program for echocardiographic technicians. There are several programs that attempt to train technicians to perform all diagnostic ultrasound examinations, but the cardiac aspects of these programs are usually quite weak. Moreover, I am not in favor of the concept of the general diagnostic ultrasound laboratory, and these technicians are being trained for such a purpose. There is undoubtedly a need for a more formalized training of technicians in echocardiography, and this need will have to be met in due course. If in our haste to start echocardiographic laboratories we let a lot of poorly trained or untrained people perform echocardiography, there is a good chance that the quality will drop to the point where the entire technique may be discredited. The popularity of echocardiography will persist only if the quality is maintained. As long as we continue to emphasize quality rather than quantity, there is no question that eventually there will be a sufficient number of well trained echocardiographers. Then we can concentrate on ways to keep these echocardiographers up to date and the referring clinicians well informed as to how echocardiography can help them manage their patients. Volume 34
Educational Problems in Echocardiography HARVEY
FEIGENBAUM,
MD,
FACC
Indianapolis, Indiana
The current interest in echocardiography has created several educational problems. As this diagnostic examination becomes increasingly accepted as a useful clinical tool, practicing cardiologists need to know more about the technique. They must know what the study can and cannot do so that they can order it appropriately. They should feel comfortable about examining echocardiograms so that they can intelligently read articles that draw on this technique. Eventually they will probably want to examine the echocardiograms obtained from their own patients. This educational need can be met fairly easily. Since these cardiologists will not be performing the study and will not be primarily responsible for its interpretation, they probably can get sufficient information from postgraduate courses of the lecture type, review articles or textbooks. Ideally they should have some opportunity to examine a patient or two just to know how the examination is performed, but this type of experience is not essential. A second major educational problem is keeping echocardiographers up to date with the latest information in a rapidly advancing field. Most of the significant developments in echocardiography are presented and discussed at the national cardiology meetings. Several postgraduate educational courses are being planned to help inform practicing echocardiographers of the current state of the art. Like all practicing physicians, echocardiographers must try to keep up with published data as best they can, but major echocardiographic papers may appear in several different journals. The American Institute of Ultrasound in Medicine has been compiling lists of as many articles as possible dealing with medical uses of ultrasound. Information is available from a few local organizations such as the Los Angeles Society for Ultrasound in Cardiology. This organization meets regularly, and the echocardiographers in the Los Angeles area have the opportunity to discuss mutual problems and interesting cases. Similar organizations may be developed in other parts of the country. Again, as in other areas of medicine, an increasing proportion of our educational effort in echocardiography probably will have to be used to update practicing echocardiographers. From the Hemodynamic Laboratory, Indiana University School of Medicine and Krannerf Institute of Cardiology, Indiinapolis, Ind. Address for reprints: Harvey Feigenbaum, MD, Hemodynamic Laboratory, Indiana University School of Medicine and Krannert Institute of Cardiology, 1100 W. Michigan St., Indianapolis, Ind. 46202.
Training
of
physician-echocardiographers:
Probably our biggest current educational problem in echocardiography is the increased demand by physicians who want this examination available for the management of their patients. Physicians and institutions have tried to meet this need in several ways. Frequently an echocardiographic laboratory is started by an institution’s purchase of an instrument. Then one or more physicians teach themselves how to perform and interpret echocardiograms with the aid of a few published articles. Or the instrument is given to a technician who tries to duplicate some of the published echograms; frequently this same technician is using the same ultrasonic equipment to examine other parts of the body. Both approaches are usually disastrous and lead only to poor quality echocardiography. Probably the best method of introducing echocardiography into an institution is to find a well trained physician and place him in charge of starting the laboratory. This physician should have been formally trained in an active echocardiographic laboratory for 3 or more months as part of a fellowship program in which his echocardiographic ability was verified by the echocardiographer in charge. He should then purchase the necessary echocardiographic equipment and will undoubtedly look for a technician who is suitably versed in cardiac anatomy and physiology and can be trained to perform echocardiography. Unfortunately, there are very few centers that sufficiently train physicians in echocardiography to meet the standards just stated. In addition, many practicing cardiologists want to perform echocardiography. The question is, Has echocardiography advanced to the point that one must undergo lengthy formal training before establishing a laboratory? This question has been answered in other areas. For example, a practicing cardiologist could not visit an active cardiac catheterization laboratory for a few days and learn the techniques sufficiently to start a laboratory on his own. Some workers in the field believe that the complexity of echocardiography has also reached the point where one cannot learn the technique in a few days or even in 1 or 2 weeks. They hold that an echocardiographic laboratory must be established by a trained physician even though an institution might have to wait 1 or 2 years before it finds a suitable physician. This point of view has a great deal of merit; however, I believe that physicians and institutions will
November 1974
The American Journal of CARDIOLOGY
Volume 34
741
EDITORIALS
not wait this long, and the practicing physician who wants to perform echocardiography is probably going to do so whether or not training is available. He probably will attend one or two postgraduate courses where echocardiography is discussed. He might get some superficial training from one of the commercial companies, and he will proceed to set up a laboratory. Realizing this fact, we have tried to help practicing physicians who want to use echocardiography. For several years we permitted physicians to visit our laboratory for 1 to 2 weeks at a time. Approximately 200 physicians took advantage of this invitation. Some of the best echocardiographers in the country were among this group, but I also know of several participants who are either not active in the field or, worse, are performing very poor quality echocardiography. This type of training is extremely time-consuming and disruptive to an echocardiographic laboratory. It is particularly disadvantageous to the cardiology fellows who are receiving more formal instruction in echocardiography. Since these fellows should be the best trained and are our primary responsibility, any program that jeopardizes their training is obviously not the best. As a result we have had to curtail severely the number of visitors permitted to receive individual training in echocardiography. During the past year, with the cooperation of the American College of Cardiology, we have presented a series of echocardiographic workshops. Each workshop lasts 3 l/2 days. There are 3 half-day sessions of lectures and 4 half-day sessions involving the examination of patients and the interpretation of echocardiograms. The program has been very popular, and most of the physicians who have taken the course have enjoyed it. However there is an obvious question as to how much training a physician can obtain in 3 l/2 days. I can guarantee that none of the physicians who finish the course feel confident that they know all there is to know about echocardiography. We go to great pains to instill humility and caution in the use of the technique. We try to impress upon participants that this course represents merely an initiation into the field, and that their expertise will come only with a great deal of practice at their home institutions. They are encouraged to examine patients who are undergoing cardiac catheterization or cardiac surgery in order to receive as much information on their diagnoses as possible. In this way they can build up their own confidence in their ability to use echocardiography to make proper diagnoses. Only time will tell whether or not these workshops have been of value in starting high quality echocardiographic laboratories. In any case, I look upon these programs as merely stop-gap measures to meet the demand temporarily. In’the long run, the laboratories should be started and managed by physicians who have been more formally trained. Training of technicians: The next question is, How can a technician be trained? It is well known that technicians can perform the actual echocardiographic examination. In fact, they frequently obtain better quality echocardiograms than do physicians. 742
November 1074
The American Journal 06CARDIOLOGY
Furthermore, the fee schedule for echocardiography is based on performance of the examination by a technician. Thus, many physicians want to start a laboratory by merely having a technician trained to take the echocardiograms. This is not the proper approach for many reasons. (1) A technician can function only as an assistant to the physician in charge. In a proper physician-technician relation, the technician knows that he can turn to the physician with any problem, including a particularly difficult echocardiographic examination. In fact, the technician usually works best when he has been trained by the physician with whom he works. (2) It is difficult for a technician to keep up with all the advances in echocardiography since he does not have access to the medical publications or the medical meetings. (3) A physician who is totally dependent on a technician could be in legal difficulty if an improper echogram led to an erroneous diagnosis and mismanagement of a patient. Thus, a physician who wants to manage an echocardiographic laboratory must be trained in all aspects of echocardiography and, in particular, must know how to perform a good echocardiographic examination. Once a physician is trained in echocardiography, either through a formal training course or after sufficient personal experience, then he can recruit and train a technician. As I have indicated, technicians usually learn the technique best if they already have some familiarity with cardiac anatomy or physiology. If they have a little training in electrocardiography and have some understanding of hemodynamics, they tend to learn the technique faster than others. The best technicians seem to come from cardiac catheterization or phonocardiographic laboratories. Today, the burden of training technicians is on the individual physician. I know of no good echocardiographic laboratory that has a training program for echocardiographic technicians. There are several programs that attempt to train technicians to perform all diagnostic ultrasound examinations, but the cardiac aspects of these programs are usually quite weak. Moreover, I am not in favor of the concept of the general diagnostic ultrasound laboratory, and these technicians are being trained for such a purpose. There is undoubtedly a need for a more formalized training of technicians in echocardiography, and this need will have to be met in due course. If in our haste to start echocardiographic laboratories we let a lot of poorly trained or untrained people perform echocardiography, there is a good chance that the quality will drop to the point where the entire technique may be discredited. The popularity of echocardiography will persist only if the quality is maintained. As long as we continue to emphasize quality rather than quantity, there is no question that eventually there will be a sufficient number of well trained echocardiographers. Then we can concentrate on ways to keep these echocardiographers up to date and the referring clinicians well informed as to how echocardiography can help them manage their patients. Volume 34