(c) Ultrasound Training Solutions -Suean Pascoe€¦ · Introduce Ultrasound Training Solutions and...

1(c) Ultrasound Training Solutions - Suean Pascoe

Sonographers teaching doctors: the Aussie experience

Objectives:

1. Introduce Ultrasound Training Solutions and discuss why do we do what we do

2. Provide brief insight into how Ultrasound Training Solutions does things differently

3. Discuss what we have learned over the ten years we have been teaching point-of-

care ultrasound (POCUS)


Disclosures

• Co-owner and Director of Ultrasound Training Solutions

• UTS is a small family business

• We specialise in teaching POCUS to physicians and allied health professional

across many disciplines of medicine

• While it may be a commercial venture it is founded first and foremost on

passion

• All programs are developed on the basis of solid academically established

education principles

• Secretary - Australasian Society for Ultrasound in Medicine (ASUM)


Why do we do what we do?


Why do we do what we do?

Once upon a time…

• There were two general sonographers – myself and Oriana Tolo – who were both

tired of grinding away in a dark room of an imaging practice

• Disillusioned with corporate radiology culture, we both were seeking a new challenge

• As we both loved teaching we began throwing ideas around about how we might be

able to pursue this passion

At the time I was teaching on a consulting basis along the eastern coast of Australia, and

knew that there was a growing demand for a structured approach to ultrasound training

from an increasing number clinicians outside of radiology, particularly as portable

machines were making the modality cheaper and more accessible.

In a sliding doors moment of synchronicity, I was approached to teach an emergency

physician who wanted to pursue a formal ultrasound qualification who – after two years

of advocacy – had secured approval for protected training.

Unfortunately – and for reasons yet to be determined – this training was cancelled after

two hours.

Two hours! I’ve had parties at McDonalds last longer.

His despair was palpable – and over the ensuing few days I continued to pester him:

• How are you going get your skills?

• Who is going to teach you?

As it transpired at the time – there weren’t a whole lot of options in Australia for any

physicians wanting to learn ultrasound…


So the idea was born - lets start a school!

• We started first with emergency medicine courses, and got going with

• A borrowed point-of-care system machine

• Some pull-up banners as privacy screens

• A few massage table which we packed into a self-haul trailer and towed to

the venue to set up and pull down each day.

• Brothers, sisters, aunties, uncles and their neighbours who we convinced into

being patient models.

After about 18 months of this we moved into more permanent rented premises.

With growing demand we then developed additional courses and added to our

repertoire as requested

• First for intensivists

• Then anaesthetists

• Sports medicine and musculoskeletal applications grew

• Followed in quick succession by emergency courses tailored to advanced and rural

and remote emergency applications

• Obstetrics and gynaecology was next off the rank – which added a whole level of

logistic considerations in recruiting and managing pregnant models

• Rehab physicians soon joined the cohort

• And most recently nurses, midwives and podiatrists

Now – where in our first year we did 21 days of teaching in total – we provide in excess

of 21 days per month.

We have grown to the point now where we have

• 31 different courses spanning a range of medical disciplines

• 29 physicians contracted to provide clinical input

• 6 part-time sonographers who we have trained in POCUS specific applications

• 4 administrative staff to help keep us on the straight and narrow

And to top it all off in September we celebrated our ten year anniversary – a milestone

we are incredibly proud to have reached.

So based on our path to date we think we have gained relevant and valuable insight into

what works – and what doesn’t work – when it comes to sonographers teaching doctors.


How do we do it differently?


The influence of an accidental hero

• Seeking guidance at a time when POCUS was emerging from the dark in Australia we

initially rang the college of emergency medicine for suggestions of key opinion

leaders that we could discuss our idea with

• Reflective of the time – where the relevance of ultrasound in the emergency

department was not commonly accepted – meant that an enquiry made by two

sonographers was received with scepticism

I remember to this day the phone call where the accidental hero of our story

was adamant that “sonographers shouldn’t be teaching doctors”

Because

“all you do is teach them how to become sonographers and that

wasn’t what they needed. They need to be able to use

ultrasound in the emergency room. For god’s sake don’t turn the

lights down when you teach

Knowing no better, we very much took this advice to heart and thought our

endeavours were all over before we started!

• Now I mention accidental hero because in the long run this advice – unbeknownst to

the individual concerned – set us on a very different path to other education

providers

We conscientiously and exhaustively developed programs to combine the best

of both worlds, where

• Sonographers taught the technical expertise, and

• Clinicians taught the clinical utility and integration of ultrasound in clinical

management

Consequently, while the programs we developed were not the cheapest

available, we knew we were providing ultrasound training that reflected best

practice from a clinical and educational standpoint.

• We spent considerable time double checking that our presentations were

pitched at the right level

• We didn’t want to be too much like a sonographer but we also didn’t want to

simplify the program too much

This is where our foundation clinician consultants helped out enormously.

We also spent a great deal of time in the emergency department to understand

and appreciate the application of ultrasound – benefits AND limitations – in an

emergency context

And to this day, whenever we teach the lights have remained on!


Sonographers can teach

• As we have come to appreciate, sonographers are appropriately qualified to teach

physicians the technical expertise required to get the most out of ultrasound

• Understanding the buttons – and the physics that let them do what they do – is

crucial for making good pictures

• Without a good picture – you can’t make a good diagnosis!

• Who better to teach you these buttons than the experts


Sonographers are experts

• Sonographers are experts at optimising images

• Sonographers are expert window getters!!

Present us with a difficult body habitus or mobile ‘target’ and we will work our tricks

and doggedly pursue the image – we know what to do precisely because we have

practised the art and science for years

We’re experts as in Australia we undertake a two year post graduate diploma to gain our

ultrasound qualification having already generally completed an applied science degree

and/or come from an allied health background – for example radiography or nursing

So by the time we complete our training we are already half way to reaching the

commonly accepted benchmark that it takes 10000 hours to become an expert in

whatever application you are seeking – or approximately five years of full time

employment


Skills deconstruction

Our Aussie experience has led us to teach the different elements of ultrasound quite

separately

We break the training down into very small chunks of information and reinforce with

practical sessions.

Anatomy

Scan planes

Probe manipulation

Windows

Image optimisation

Pattern recognition

Documentation

Integration into clinical management


We don’t assume knowledge

• Experience has taught us that clinician ultrasound educators tend to make the

mistake of glossing over the basics of POCUS

• WE are all guilty of overestimating our abilities

• However, strong skills are built on solid foundations

If you don’t master the basics then you can’t achieve true expertise.

• Imagine yourself climbing this ladder over a crevasse

If you miss any rungs of the ladder then things are going to get scary

If you don’t anchor this to the glacier well – that is provide good support and

foundation – then things are going to get scary

We have many stories where the basics have been assumed and folk have really

struggled until they are taught how to use the machine

Do not miss any of the rungs – this is truly a case of less haste = more speed


What have we learned?

Heaps


POCUS lesson 1: Do not assume doctors know their anatomy

• We made the mistake initially of assuming that doctors knew their anatomy

• To use an Australian colloquialism – you sure know your arse from your elbow – but

the three spatial awareness of anatomical relationships in quite another matter

• So after a few years we revised all of our programs to incorporate teaching anatomy

• The result has been a faster uptake of ultrasound skills


POCUS lesson 2: Sonographers underestimate the #POCUS learning curve too - teaching

the teachers takes time an investment

POCUS tips everything you know as a sonographer on its head and you are forced to

look at things from a very different perspective

Consequently, the clinical sonography skills that our team has when they start with us

represents about 30% of the knowledge they need to be a good sonographer educator

in POCUS

A sonographer is trained as a photojournalist – they take a photojournalistic essay

driven by protocol

A POC sonographer shines a flashlight and takes a quick look to answer a specific

question

As a sonographer you have to learn and understand the clinical questions first and then

appreciate how the ultrasound findings will change the clinical management of the

patient to be effective

Despite recent moves in Australia to encourage the appointment of sonographers

educators in the emergency department, our experience suggests that both

sonographers and clinicians underestimate the learning curve associated with the

transition from radiology to clinical ultrasound

I worry that sonographers think that pursuing a POCUS position is a easy supervisory

role suitable as a retirement option

However, a POCUS sonographer in fact should be recognised as an entirely distinct new

sub-speciality of ultrasound

Some of the specific challenges that the sonographer educators we have trained have

faced include:

1. Getting used to being respected and having our opinion valued. With that comes a

pride and understanding of seeing the benefits of ultrasound immediately

Ordinarily we don’t really see the impact of our scans – they are in and out of the

department and we move on to the next case

2. Taking accountability for the scan

3. Traditional medical tribalism, which instils in us a “know your place’ attitude

In a POCUS role we are suddenly required to oversee doctors and tell them what to

do from a technical perspective regarding

This authority – and the associated imposter syndrome – takes a while to overcome

4. Teaching doctors is different – you make different mistakes

We need to anticipate the mistakes that you are going to make in your clinical

context

An example – having the depth set too deep is not ideal but it is diagnostic!

Having it set to shallow can be dangerous.

As a friend of mine so rightly points out - the enemy of good is perfect!


POCUS lesson 3: Sonographers moving to #POCUS must develop additional clinical

knowledge - closing the gap takes teamwork

The gap in clinical knowledge presents a number of challenges – not insurmountable

The challenge is in closing the gap, specifically in such applications as:

• Needle guidance techniques

• Lung ultrasound – remember radiology still doesn’t quite believe lung ultrasound

exists

• Echo - we have found it much easier to train general sonographers in the POCUS

application of echo because traditional echocardiographers struggle with the

abbreviated nature of the POCUS scan

Some of them plain struggle with scanning from the other side of the bed

It takes time to develop the skills required to become a proficient and knowledgeable

POCUS educator and fully make the transition

In our experience the timeframe required is approximately 12 months full time or 2

years part time in an in-house training program


POCUS lesson 4: Transitioning from technical expert to educator is hard

The other challenge facing our POCUS educators is one that all educators face – it is the

challenge of transitioning from technical expert to educator

Just because you are good at your job doesn’t mean you can teach it

Just as training to be an expert in ultrasound may take 10000 hours, so too does training

to be an educator

But the investment is worth it


My final thought echoes that of Osler – by practice alone you can become expert

I’m sure Osler would have loved POCUS


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