recognised this utility, and begun to use laptop-sized US units which are able to achieve an image quality that is satisfac- tory for examining MSK systems as long as high-frequency (1012 MHz) probes are utilised. The more recent availabil- ity of truly hand-held units has gener- ated even greater interest in sonographic augmentation of the physical examina- tion, although currently these ultraport- able machines are used mainly for basic assessment of, for example, free uid in the abdomen in trauma cases, and are not designated by the vendors for MSK use. Other advantages of US, such as a lack of ionising radiation, ability to perform a dynamic examination, high spatial reso- lution and ability to guide intervention, further exemplify this modalitys impor- tant role in diagnosis and management of MSK conditions. education for sports medicine fellows. 1
It is also advantageous in that it is based on the existing American Institute for Ultrasound in Medicine (AIUM) curricu- lum, as this agency has a wealth of experi- ence in sports medicine. As radiologists, we are acutely aware of the great value of sonographic assess- ment of musculoskeletal (MSK) injuries. Non-radiologist clinicians have also The paper by Finnoff et al (see page 1144) is an important rst step in formalising a detailed curriculum for ultrasound (US) Musculoskeletal ultrasound: changing times, changing practice? Bruce B Forster, Mark Cresswell Department of Radiology, Vancouver General and St Pauls Hospital, Vancouver, Canada Correspondence to Bruce B Forster MD FRCPC, Professor and Head, UBC Department of Radiology, Room 3350-950 West 10th Avenue, Vancouver BC, Canada V5Z 4E3; bruce.forster@vch.ca 03_bjsports80796 & 80986.indd 1136 11/18/2010 7:45:56 PM group.bmj.com on December 15, 2011 - Published by bjsm.bmj.com Downloaded from Editorial Br J Sports Med December 2010 Vol 44 No 16 1137 professional development credits per 2-year cycle to maintain competency in US in emergency medicine. Other pro- grammes such as monitoring of diag- nostic accuracy compared with surgical gold standards where appropriate, or other imaging modalities, would also ensure ongoing best practice. Field-of-play/bedside US: these exam- 7. inations, reported in the linked paper by James et al (see page 1149), will in the future involve ultra-portable units, and raise additional questions, such as image storage and reporting. 4 So, although the article by Finnoff et al 1
helps to establish some specic curricular objectives, there do remain unresolved details, which would be essential to ensure quality performance and interpretation of MSK US examinations. As multimodality imaging experts, radiologists can assist our colleagues in sports medicine in reaching some of these important quality targets, whether through performance of addi- tional US examinations in difcult cases, interpretation of other imaging modali- ties such as CT or MRI to aid sonographic diagnosis, curriculum design or through suggestions to ensure competency. As long as quality patient care is achieved, we are all winners. Competing interests None. Provenance and peer review Not commissioned; not externally peer reviewed. Accepted 25 October 2010 Br J Sports Med 2010;44:11361137. doi:10.1136/bjsm.2010.080986 REFERENCES 1. Finnoff JT, Lavallee ME, Smith J. Musculoskeletal ultrasound education for sports medicine fellows: a suggested/potential curriculum by the American Medical Society for Sports Medicine. Br J Sports Med 2010;44:11441148. 2. Budoff MJ, Cohen MC, Garcia MJ, et al. ACCF/AHA clinical competence statement on cardiac imaging with computed tomography and magnetic resonance. J Am Coll Cardiol 2005;46:383402. 3. American College of Emergency Physicians Policy Statement on Emergency Ultrasound Guidelines. Guidelines approved by ACEP Board or Directors, October 2008. Page ranges: 138. http://www.acep.org/WorkArea/DownloadAsset. aspx?id=32878 (accessed Oct 20, 2010). 4. James P, Barbour T, Stone I. The match day use of ultrasound during professional football nals matches. Br J Sports Med 2010;44:11491152. covered. Finnoff et al 1 propose that fellows attempt to meet the AIUM guidelines of 150 cases performed, interpreted and reported, and 40 h of category 1 American Medical Associations Physicians Recognition Award credits, unless within 2 years of a fellowship which has accredited US content. It would not be acceptable to have a voluntary standard; all fel- lows in such a programme should be mandated to meet these requirements in order to practise, and furthermore, all fellows should be required to sub- mit proof of their experience to their facility prior to practising within the modality. Ideally, such records would be required by a credentialling body such as the AIUM or the American Medical Society of Sports Medicine, which would then issue a certicate of competence. Requirement for hands-on experience: 3. although many forms of sonographic training exist, such as video, web-based learning, DVDs etc, quality US train- ing is distinguished by hands-on image acquisition, for which there is no sub- stitute. Radiologists in teaching insti- tutions have extensive experience in resident hands-on training and in ensur- ing competence in US examination, and would be an important resource for development of programmes such as that suggested by Finnoff et al. 1 Advanced levels of competence: com- 4. petency criteria could be two-tiered, with one level for purely diagnostic studies, and a second tier for sono- graphically guided intervention, the lat- ter requiring added, mentored training. Determination of competency: as well 5. as proof of training and experience as outlined above, competency could be ascertained by observation of skill in image acquisition, video review of cases, over-reading of cases by experts, simulator training or traditional exam- ination, all of which are suggested as reasonable methods by the American College of Emergency Physicians (ACEP) policy statement in their Emergency Ultrasound Guidelines. 3 Ongoing quality assurance: the ACEP 6. suggests at least 10 h of continuing BENCHMARKING ESSENTIAL HANDS-ON EXPERTISE US requires hands-on expertise more than any other imaging modality. Canadian radiology residency programmes require a minimum of 6 months of US experience, albeit in all body systems, in order to prac- tise in Canada. The MSK system is widely considered to be one of the more difcult body systems to master, and additional training, over and above the 6 months of residency experience, is often offered by MSK imaging fellowship programmes. However, there are too few radiologists or US technologists to meet the needs of our patients, whether at the eld-of-play, in the hospital or in the ofce. Thus, in the interest of optimising patient care, it is rea- sonable for sports medicine physicians and fellows to be offered training. However, in order to ensure quality outcomes, several benchmarks must be considered: Collaboration with related special- 1. ties: in a competence statement on cardiac CT and MR 2 the American College of Cardiology Foundation and the American Heart Association con- sulted with the American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Atherosclerotic Imaging, Society for Cardiovascular Intervention and the Society for Cardiovascular MR, all of which include cardiology and imaging specialist members. Such wide discus- sion increases the likelihood of a com- prehensive programme and improves buy-in from multiple disciplines. The scenario of cardiologists performing coronary CT angiography, when the vast majority had never formally been involved in this modality before, is not unlike the current scenario with sports medicine clinicians and US. Minimum education, training and 2. experience, specied and veried: it is vital that trainees undertake MSK US training within programmes that are accredited, and that a minimum number of cases performed by the candidate under expert supervision be specied. Furthermore, if the intent is for the candidate to perform general MSK US, then all anatomical regions within the MSK system should be 03_bjsports80796 & 80986.indd 1137 11/18/2010 7:45:56 PM group.bmj.com on December 15, 2011 - Published by bjsm.bmj.com Downloaded from doi: 10.1136/bjsm.2010.080986 2010 44: 1136-1137 Br J Sports Med Bruce B Forster and Mark Cresswell times, changing practice? Musculoskeletal ultrasound: changing http://bjsm.bmj.com/content/44/16/1136.full.html Updated information and services can be found at: These include: References http://bjsm.bmj.com/content/44/16/1136.full.html#ref-list-1 This article cites 3 articles, 3 of which can be accessed free at: service Email alerting the box at the top right corner of the online article. Receive free email alerts when new articles cite this article. Sign up in Notes http://group.bmj.com/group/rights-licensing/permissions To request permissions go to: http://journals.bmj.com/cgi/reprintform To order reprints go to: http://group.bmj.com/subscribe/ To subscribe to BMJ go to: group.bmj.com on December 15, 2011 - Published by bjsm.bmj.com Downloaded from