CON: Musculoskeletal Ultrasound Certification

By K. Bert Fields, MD and David Berkoff, MD

Is ultrasound the stethoscope of the 21st century? Three medical schools have answered this affirmatively – Wayne State, University of South Carolina and the Uniformed Services University of Health Sciences. Several residencies –obstetrics and gynecology, general surgery and emergency medicine – already consider this a standard part of residency training. Fellowships, including cardiology and rheumatology, incorporate this training in their core curriculum and offer advanced training to those who want special skills. None of these specialties require an examination. Why should sports medicine fellowships take a different approach?

Having taught ultrasound skills to medical students, residents, fellows and practicing physicians for the past six years, we have observed that learners can gain useful diagnostic skills with limited training. Plantar fasciitis, Achilles tendinosis, lateral epicondylitis and patellar tendinosis are examples of common clinical conditions that are easily accessible to ultrasound evaluation. Clinicians with basic skills can visualize these anatomical structures and use the information to confirm clinical diagnosis, monitor response to therapy and identify more serious structural injury that might require surgery. This allows physicians to have a clear diagnosis and plan at an initial visit and also reduces the need to use more expensive MRI. These simple scans improve patient satisfaction, clinical care and reduce medical expense. Should we ask these physicians who have basic ultrasound skills to stop using this technology because they have not demonstrated more advanced skills such as shoulder diagnosis or identification of nerve entrapments or passed an examination?

As a Fellowship Director, Dr. Fields certifies he has observed fellows care for patients, perform procedures and interpret diagnostic tests such as MRIs. There is a core group of clinical skills and necessary clinical experiences the RRC suggests each fellow should obtain. At the end of fellowship, we write a letter to document that the graduate is ready “to independently practice as a sports medicine physician.” Direct observation of clinical skill is the basis for board certification in all specialties and fellowships. Board certification examinations provide an independent check that graduates have the basic medical knowledge considered essential for the particular specialty. Board certification does not imply a graduate of any residency or fellowship is competent to perform certain procedures. Regulating agencies long ago recognized written tests could not determine competence in performing a clinical skill. This is the entire foundation for the supervision required in an accredited residency or fellowship and for the concept of hospital privileging.

Why then would we try to implement a static test to determine competence in a clinical skill? Ultrasound is dynamic and the physical examination determines where you should focus your probe placement and the type of scans you need to use. How strong is the correlation of the ability to interpret static images on a test with the ability to come to a correct clinical diagnosis utilizing both examination and scanning? Why should there be a certification test in musculoskeletal ultrasound? Is this to limit the use of this emerging technology so only those certified can utilize this in their practice? Is this to determine a group of sub-specialists in sports medicine/musculoskeletal ultrasound who can charge higher fees to insurers because of their unique skill set? Undoubtedly there are individuals with advanced skills that few in our discipline can match. There is already a path for those who want to have a practice as ultrasound specialists. Two of the world’s leading musculoskeletal ultrasound specialists are US physicians Levon Nazerian, MD, and Tony Bouffard, MD. These radiologists have helped develop new approaches and interventional techniques that advance the field.

The AMSSM needs to embrace the concept that musculoskeletal ultrasound is the new stethoscope for sports medicine physicians. Rather than seeking to exclude or limit the use of ultrasound among our members, we need to share our skills so all of us have basic competence. Individuals with basic ultrasound skills quickly improve with the experience of scanning patients in their practice, just as all of us improve our clinical skills with experience. As the technology improves and scans have much better resolution of anatomical structures, the learning curve will become shorter and less steep. We should become leaders in training our colleagues and have the goal that 100% of future sports medicine fellows will graduate with the basic skills to utilize musculoskeletal ultrasound in their practice.

The conclusions and opinions in this news article should not be interpreted as official statements of the American Medical Society for Sports Medicine.