A review of musculoskeletal ultrasound training guidelines and recommendations for sport and exercise medicine physicians

The General Medical Council define a ‘Good Doctor’ as follows: ¹

Good doctors make the care of their patients their first concern; they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity.

Another statement of note is that all doctors have a duty to ‘recognise and work within the limits of your competence’. ¹

Competence (or competency) is defined as the ability of an individual to perform a job properly. A competency is a set of behaviours that provide a structured guide, enabling the identification, evaluation and development of the behaviours in individual employees. ² When this is translated into clinical competency, then all doctors must demonstrate that they have the appropriate training and experience in a procedure to safely perform this on a patient and interpret the findings. This ranges from performing a simple blood test, to diagnostic investigations and complex surgical operations.

Medical training for doctors was historically time-based, adopting the ‘see one, do one’ principle of training, with subjective assessments from senior doctors and consultants at the end of each time served post. Now all postgraduate training follows a competency based framework of achieving outcomes and forward progress is attained on the basis of achieving these outcomes. This has the advantages of standardizing training and increasing the medical profession's public accountability. However, the main disadvantage is that trainees may concentrate on purely achieving competency outcomes at the expense of clinical experience, in essence, performing a ‘tick box exercise’. ³

Sport and exercise medicine (SEM) specialist training in the UK, similar to other medical specialties, follows a curriculum-based competency framework. The curriculum was devised jointly by the Faculty of Sport & Exercise Medicine, the Joint Royal Colleges of Physicians’ Training Board and the Postgraduate Medical Education and Training Board (now part of the General Medical Council). It is composed of a number of competencies that each trainee doctor must attain in the different separate components that form the curriculum. This is achieved through a combination of various work-based assessments with a supervisor and confirmed annually by an independent panel of clinical representatives, appointed by the local medical deanery. Following their recommendation that a trainee has achieved all the competencies, the trainee is then conferred specialist recognition by the Postgraduate Medical Education and Training Board and is eligible to apply for consultant posts. ⁴

Many SEM clinicians, specialists or those with a special interest, perform musculoskeletal ultrasound (MSK US) within their clinical practice. As yet, there is no formal training competency required to practice MSK US in the SEM setting. For trainees, all the training curriculum requires is a basic understanding of the ‘principles and techniques of musculoskeletal ultrasonography’ with clinical practice or a formal course in MSK US being an optional component. SEM clinicians can attend one or two day MSK US courses or clinical workshops and gain a certificate of attendance and continuing professional development points. But is this enough to claim clinical competency in the practice of MSK US and use on patients?

Debate currently exists within the SEM setting as to the practice of MSK US. Should this be regulated? Who practices this – doctors or physiotherapists? Are these courses or workshops enough for clinical competency? If not, what are the standards that we should set for clinical competency for the practice of MSK US? And who should set these standards?

In order to define what standards and competencies are required, it is prudent to determine what other specialties or governing bodies, within the UK and abroad, have set minimum standards of competency in MSK US.

MSK US training standards – UK

In the UK, current formal training in ultrasound is at postgraduate level for radiographers or midwives wishing to specialize in specific components of ultrasound. Courses leading to formal qualifications at universities are accredited by the Consortium for the Accreditation of Sonographic Education (CASE), a group formed by five organizations with the aim of ensuring the highest standards of sonographic education and training. ⁵ Sonographers may belong to the professional body, the British Medical Ultrasound Society (BMUS). ⁶ However, the BMUS does not set standards for training. They are founder members of CASE and also recommend the guidance set out in a document published by the medical body, The Royal College of Radiologists; ‘Ultrasound Training Recommendations for Medical & Surgical Specialties’. ⁷

The Royal College of Radiologists (RCR) is the governing body in the UK for radiologists and is responsible for setting training standards and maintaining these standards in all aspects of radiology, ranging from X-ray interpretation, ultrasound, computed tomography to magnetic resonance imaging. The training recommendations document was developed in response to an increasing number of medical non-radiologists performing ultrasound diagnosis in their clinical work and aimed to develop a set of training guidelines for all branches of ultrasound. By developing these guidelines, the Royal College of Radiologists set a minimum requirement of training required to gain competency in this field and practice safely for radiologists and medical non-radiologists and provided a framework for sonographers to base their training. ⁷

They advocate that basic theoretical training is a prerequisite to any practical training in ultrasound. This is composed of two main areas: physics and instrumentation (basic ultrasound physics and how to use the ultrasound machine correctly) and ultrasound techniques (examination and scanning techniques). This is achieved by attending a theoretical course and reading appropriate textbooks and literature. No formal examination is required.

Specifically within MSK US, a modular approach may be best, due to the wide remit of MSK US and that it is unlikely all clinicians will cover the full range. The RCR recommend a minimum of 250 examinations over a 3–6-month period. A logbook should be kept recording all the examinations and pathologies seen. Training should be supervised by an experienced MSK US mentor. The endpoint of the training is judged by an assessment of competencies.

Interestingly, in order to maintain skills and competence, RCR recommend performing at least 200 MSK US examinations per year and including MSK US as part of continuing professional development/education.

MSK US training standards – Europe

Assessing MSK US training in Europe is complex, with many countries having their own organizations and different languages. Perhaps the most efficient method of assessing European training standards is to review guidelines set by pan European associations, of which many individual European country associations, if any, will be a member of.

The European Society of Musculoskeletal Radiology (ESSR) produces excellent guidelines on MSK US, but these are technical guidelines for the clinical practice of MSK US, and not training guidelines. The ESSR awards a diploma in MSK radiology, of which MSK US is a component, but this is reflective of CPD over a five-year period, and, as is disclaimed on the website, not a certificate of competence. ⁸

The European Federation of Societies for Ultrasound in Medicine and Biology, of which the BMUS is a member association, produces a set of minimum training requirements for the practice of medical ultrasound in Europe. These are similar in nature to the recommendations of the RCR and are competency based. They are composed of a theoretical module and practical training. The number of examinations they require is 300 per year, supported by a clinical logbook, once again with competency being assessed by a suitably qualified mentor. They differ in advocating three levels of training, each level reflecting further levels of clinical experience in MSK US. However, competency for each level must be attained prior to progression to a higher level. ⁹

MSK US training standards – USA and worldwide

In the USA, the American Institute of Ultrasound in Medicine (AIUM) approved new training guidelines for MSK US in 2009. This opened the door for sports physicians to practice MSK US. Prior to this, only qualified radiologists were approved to perform MSK US. Medical non-radiologists could perform MSK US providing they had attended a training programme in MSK US inclusive of 150 MSK examinations. This was to be supervised over a period up to 36 months. ¹⁰

The American Medical Society for Sports Medicine (AMSSM) developed a curriculum so that sports medicine doctors could obtain adequate training in MSK US during their sports medicine training, in order to meet the requirements of competency outlined by the AIUM. This curriculum is similar in content to the RCR curriculum, with theoretical components, didactic clinical examinations, mentored examinations, clinical logbook and competency approval from qualified mentors. ¹¹

The Canadian Association of Radiologists (CAR) has a standard of performance for MSK US but no defined training programme. CAR requires physicians practising MSK US to be a qualified diagnostic radiologist with a qualification from the Royal College of Physicians and Surgeons of Canada in radiology, similar to the previous system in the USA. There is no mention of medical non-radiologists. ¹² In Australia, the Royal Australian and New Zealand College of Radiologists have a generic competency-based logbook programme for radiology trainees in general medical ultrasound, but not specifically related to MSK US. Likewise the needs of medical non-radiologists are not addressed. ¹³ The Australian College of Sports Physicians, often seen as the trailblazers in the sports medicine world, also have no formal guidelines on training or practice in MSK US. ¹⁴

Discussion

The topic of MSK US practice is a subject of current debate within the SEM community. These concerns include whether the content and teaching provided on a variety of courses produce a competent MSK US SEM physician, or are these courses merely income generators for commercial providers. With physiotherapists also providing MSK US services, is this situation of training being market driven versus competency driven?

Similar concerns also exist in the physiotherapy community regarding training standards of physiotherapists practising MSK US. ¹⁵ The physiotherapy group composed of MSK US practitioners is aware of these concerns and recommends, not enforces, that their members should follow a training curriculum endorsed by the BMUS. ¹⁶

More debate is required in the SEM and physiotherapy communities regarding the potential medicolegal aspects of providing a clinical service that competency cannot be demonstrated in. A surgeon would not perform an operation on a patient unless they had been trained and demonstrated competency, normally over a period of several years, and the patient would expect the surgeon to fulfil these criteria. Thus, practising MSK US on a patient having only attended a non-regulated commercial course opens a significant area for litigation should an adverse incident in patient management occur. Unfortunately, as is often seen, it may require a significant adverse incident to occur before regulation is introduced.

There is an issue with lack of available mentors who practice MSK US on a regular basis. Mentorship is an accepted part of learning and their advice and supervision is invaluable in enabling a novice to develop a methodical clinical approach. Anecdotally, there are a reasonable number of SEM physicians practising MSK US, but no hard evidence of actual numbers and how much of their clinical practice this entails. Novices find it hard to find mentors either due to the lack of availability or possibly a reluctance to be involved in training others if there is a lack of confidence in their own clinical ability or competency with MSK US.

The Faculty of Sport & Exercise Medicine (FSEM), the governing body for SEM in the UK, is aware of these concerns regarding training, competency and potential medicolegal issues. An article in the British Journal of Sports Medicine, which stimulated lively debate, suggested that we adopt the training guidelines produced by the AMSSM. ¹¹ However, the FSEM recently announced that they have entered into discussions with the RCR regarding the development of a training curriculum and appraisal for the practice of MSK US and hope to produce a document during 2012. ¹⁷

A similar situation existed in Rheumatology in the last decade, with the increasing popularity of MSK US use. Concern was raised over training, content of courses and competency of practitioners.^18–21 Following research and debate, competency based training guidelines were issued, following a similar line of theoretical knowledge and mentored clinical competencies as proposed by other UK and international bodies.^22,23 Discussions with rheumatology governing bodies or associations would be of benefit for the FSEM, as this is an analogous situation for SEM, a decade further on.

How do you assess competency? Historically, medical knowledge has been assessed by a written examination. These are standardized, reliable and reproducible. Examinations have been shown to be a reliable method of assessing MSK US theoretical knowledge and clinical competency.^24,25 Training in both the UK and worldwide is moving towards a competency-based assessment system involving clinical demonstrations, mentoring and logbooks. Both these methods should be incorporated into assessing MSK US competency.

Recommendations

Using current evidence-based guidelines from the UK, Europe and worldwide, MSK US competency should be assessed upon the following recommendations:

Formal course or examination or both in theoretical knowledge on the principles and practice of ultrasound;

Clinical practice of MSK US for a minimum of 150 hours;

Clinical logbook of all MSK US examinations;

Training should be focused and tailored to each individual's needs and can be expanded with clinical experience;

Supervision by an experienced mentor;

Clinical competency MSK US examinations/assessments by mentor and/or an independent assessor;

All of the above leading to a formal qualification in MSK US;

Continuing clinical practice of MSK US demonstrated by logbook and / or CPD.

Formal post graduate training in MSK US is offered by several CASE accredited universities in the UK leading from postgraduate certificate to masters level; Glasgow Caledonian University, University of Cumbria, University of Leeds, University of Teeside and Bournemouth University, with curricula encompassing the above. Promotion of these courses to SEM physicians will enable the sports medicine community to achieve formal MSK US competency.

Conclusion

It is the duty of all doctors to be competent in the areas of medicine that they practice and a right of all patients to expect their doctor to be so. To attain competency in the practice of MSK US, SEM physicians require to be adequately trained and to have demonstrated competency through a formal qualification or training programme, mentored by an experienced practitioner, and must maintain these skills through continuing clinical practice and CPD. The Faculty of Sport & Exercise Medicine has a governing body responsibility to issue formal guidelines for the training, practice and demonstration of competency in MSK US for SEM physicians in the UK.