Ultrasound Training Recommendations for Medical and Surgical Specialties

Transcription

1 Ultrasound Training Recommendations for Medical and Surgical Specialties Faculty of Clinical Radiology The Royal College of Radiologists

2 Ultrasound Training Recommendations for Medical and Surgical Specialties Faculty of Clinical Radiology The Royal College of Radiologists

3 The Royal College of Radiologists 38 Portland Place London W1B 1JQ Telephone Fax Citation details: Board of the Faculty of Clinical Radiology The Royal College of Radiologists (2004) Ultrasound Training Recommendations for Medical and Surgical Specialties Royal College of Radiologists, London. On publication this document will be made available on the College s web site: ISBN RCR Ref No BFCR(05)2 The Royal College of Radiologists, January 2005 This Publication is Copyright under the Berne Convention and the International Copyright Convention. All rights reserved. This booklet was prepared and published on behalf of the Royal College of Radiologists (RCR). Whilst every attempt has been made to provide accurate and useful information, neither the RCR, the members and Fellows of the RCR nor other persons contributing to the formation of the booklet make any warranty, express or implied, with regard to accuracy, omissions and usefulness of the information contained herein. Furthermore, the same parties do not assume any liability with respect to the use, or subsequent damages resulting from the use of the information contained in the booklet. Design and print:

4 Contents Foreword page 4 1 Introduction page 5 2 Aims and Principles page 6 3 Training Recommendations page Theoretical training page Practical training page 9 4 Continuing Medical Education and Professional Development page 11 Appendices Appendix 1: Recommended Theory Syllabus page 12 Appendix 2: Urological Ultrasound page 13 Appendix 3: Gynaecological Ultrasound page 18 Appendix 4: Gastrointestinal Ultrasound page 24 Appendix 5: Vascular Ultrasound page 28 Appendix 6: Breast Ultrasound page 32 Appendix 7: Thoracic Ultrasound page 36 Appendix 8: Cranial Ultrasound in Infants page 39 Appendix 9: Focused Emergency Ultrasound page 43 Appendix 10: Critical/Intensive Care Ultrasound page 47 Appendix 11: Musculoskeletal Ultrasound page 51

5 Foreword The Royal College of Radiologists (RCR) welcomes this document, recognising ultrasound as an evolving technology with wide application throughout medical and surgical practice. Equipment is becoming cheaper, more portable and more widely available, and it is inevitable and appropriate that medical practitioners other than clinical radiologists should seek to develop skills in the performance of ultrasound. The RCR is committed to the development of high quality imaging across the gamut of modalities, and to this end has prepared advice for training in ultrasound across the clinical specialities. It remains important that ultrasound is seen as part of a co-ordinated imaging service, and this document stresses continued communication with departments of clinical radiology and radiological mentors. The RCR hopes that through the provision of this advice, the access to ultrasound imaging will be significantly improved while maintaining the high quality of imaging services. We acknowledge that for most indications, ultrasound is an outpatient service, however it also contributes to diagnosis and management of patients presenting acutely and to the care of inpatients. It is important that as part of the continued liaison with departments of clinical radiology there is agreed provision for out-of-hours ultrasound imaging. I would like to thank David Lindsell for his work in leading the production of this advice and the following members of the working party for their contributions and advice. Dr Ian Beggs, Royal Infirmary, Edinburgh Dr Julie Cooke, Jarvis Breast Screening Centre, Guildford Dr Simon Elliott, Freeman Hospital, Newcastle upon Tyne Dr Fergus Gleeson, Churchill Hospital, Oxford Dr Henry Irving, St James University Hospital, Leeds Dr Kok-tee Khaw, St George s Hospital, London Dr David Lindsell, John Radcliffe Hospital, Oxford Professor Derrick Martin, Wythenshawe Hospital, Manchester Dr Alan Sprigg, Sheffield Children s Hospital, Sheffield Mr Peter K. Thompson, A&E Consultant, King s College Hospital, London Dr Michael Weston, St James University Hospital, Leeds The previous RCR advice Guidance for the Training in Ultrasound of Medical Non-Radiologists (BFCR(97)1) is now withdrawn. Dr Paul Dubbins Dean Faculty of Clinical Radiology 4 The Royal College of Radiologists

6 1 Introduction 1.1 High quality ultrasound services are provided by properly trained and committed practitioners using appropriate quality ultrasound equipment. In the UK, radiologists and sonographic practitioners have traditionally provided such a service from centralised departments of clinical radiology where equipment and manpower can be used cost-effectively. 1.2 However, there are increasing demands for ultrasound services to include direct access to facilitate immediate clinical decisions in areas such as one-stop clinics and, potentially, in the newly configured Independent Sector Treatment Centres. Departments of clinical radiology may have difficulty responding to these demands primarily because of the national shortages of radiologists and sonographic practitioners. It is therefore essential that alternative methods of service delivery are considered. These may include the involvement of other professional groups in addition to greater investment in clinical radiology departments. 1.3 Medical specialists other than radiologists are increasingly wishing to undertake ultrasound examinations on patients referred to them for their clinical opinion as a direct extension of their clinical examination. This may take place in the outpatient department, on the wards, and in the assessment of emergency patients. Clinicians are also using ultrasound to assist in practical procedures such as central line insertion. Additionally there is a demand by some European training boards to incorporate ultrasound experience into clinical training and accreditation where appropriate. 1.4 Radiologists have the skills, experience and commitment to provide guidelines for training of medical non-radiologists and hence influence the quality of service provided for the better. The College believes that this approach, of inter-disciplinary co-operation, serves the interests of patients best. 1.5 Training of medical non-radiologists should be adequately funded and planned so that there is no adverse impact on the service provided to patients and the ability of clinical radiology departments to train clinical radiologists and sonographic practitioners. 1.6 This document makes recommendations for ultrasound training in the following areas: urological ultrasound gynaecological ultrasound gastrointestinal ultrasound vascular ultrasound breast ultrasound thoracic ultrasound cranial ultrasound in infants focused emergency ultrasound intensive care ultrasound musculoskeletal ultrasound Ultrasound Training Recommendations for Medical and Surgical Specialties 5

7 2 Aims and Principles 2.1 The medical use of ultrasound remains highly operator-dependent in spite of advances in technology, and the interests of the patient are best served by the provision of an ultrasound service which offers the maximum clinical benefit and optimal use of resources, i.e., with appropriately trained personnel using equipment of appropriate quality. 2.2 All who provide an ultrasound service are ethically and legally vulnerable if they have not been adequately trained. National Health Service (NHS) Trusts in the UK, which provide professional indemnity to practitioners, are unlikely to be able to mount any defence to an action brought against an untrained practitioner. Similarly, the professional defence organisations are unlikely to be successful in mounting a defence against a claim for negligence should an error of diagnosis be made by an untrained practitioner of ultrasound. Advisory guidelines for training in ultrasound provided by the RCR will establish the principles to allow appropriate bodies to provide professional indemnity by setting out training and continuing professional development (CPD) requirements. Trusts, purchasing commissioners and patients should be aware of the requirements for training. 2.3 An appropriate level of training in ultrasound is one that allows for the provision of a safe and effective ultrasound service. This may be a purely diagnostic, predominantly interventional, or a clinically focused service. Departments of clinical radiology would normally provide all of these services, but it would be expected that other medical practitioners would deliver only those aspects of ultrasound particularly relevant to their clinical practice. Nonetheless, the training for medical non-radiologists should be to the same standard as those for radiologists, albeit restricted to the relevant and particular area of their clinical expertise. Whereas radiological training provides for the practice of ultrasound across a broad range of medical and surgical specialties, NHS Trusts, purchasing commissioners and patients should be aware of the differences in the comparative depth and breadth of training, and hence ultrasound skills, between trained radiologists and trained medical non-radiologists. 2.4 The RCR has worked closely for many years with the Royal College of Obstetricians and Gynaecologists (RCOG) to ensure adequate training in obstetric ultrasound. The joint Diploma in Obstetric Ultrasound is currently being reviewed, and obstetric ultrasound is not covered in this publication. It is also recognised that the RCOG has its own special skills training module for ultrasound imaging in the management of gynaecological conditions and a number of radiologists act as preceptors for this. However a syllabus for gynaecological ultrasound has been included as there may be other groups (e.g., general practitioners) who might wish to train in this area. 2.5 The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) has proposed minimal training requirements for the practice of medical ultrasound in Europe. These are supported by the RCR and the British Medical Ultrasound Society. 2.6 Three levels of minimum training requirements are proposed in this document Level 1 Practice at this level would usually require the following abilities: to perform common examinations safely and accurately to recognise and differentiate normal anatomy and pathology to diagnose common abnormalities within certain organ systems to recognise when a referral for a second opinion is indicated to understand the relationship between ultrasound imaging and other diagnostic imaging techniques Within most medical specialties the training required for this level of practice would be gained during conventional postgraduate specialist training programmes. In the UK this level of training would equate to the end of basic training in ultrasound of radiology specialist registrars (SpRs) in year 3/4 of training. It would also be equivalent to a holder of, for example, the RCOG special skills training module in gynaecological ultrasound imaging. 6 The Royal College of Radiologists

8 2.6.2 Level 2 Practice at this level would usually require most or all of the following abilities: to accept and manage referrals from Level 1 practitioners to recognise and correctly diagnose almost all conditions within the relevant organ system and to have sufficient understanding of ultrasound depiction of pathology to optimise the referral of the patient if the condition falls outwith the practitioner s skills to perform common non-complex ultrasound guided invasive procedures to teach ultrasound to trainees and Level 1 practitioners to conduct some research in ultrasound The training required for this level of practice would be gained during a period of subspecialty training which may either be within or after the completion of a specialist training programme. This would equate to the level of training in radiology at the time of acquiring the CCST, assuming that part of the fifth year of subspecialty training had involved ultrasound Level 3 This is an advanced level of practice, which includes some or all of the following abilities: to accept tertiary referrals from Level 1 and Level 2 practitioners to perform specialised ultrasound examinations to perform advanced ultrasound-guided invasive procedures to conduct substantial research in ultrasound to teach ultrasound at all levels to be aware of and to pursue developments in ultrasound In the UK this would equate to a consultant radiologist with a subspecialty practice which includes a significant commitment to ultrasound. 2.7 The boundaries between the three levels are difficult to define precisely and the above should only be regarded as a guide to different levels of competence and experience. In the detailed syllabuses attached to this document in Appendices 2 10 an attempt is made to indicate more specifically the type of experience required for each level of training. Training in musculoskeletal ultrasound does not lend itself easily to levels of training and instead a modular approach is recommended (Appendix 11). 2.8 The training of medical non-radiologists should foster relationships between radiological and non-radiological medical practitioners so that mutual support continues beyond the initial training period. Ideally a radiologist would continue to act as a mentor for a medical non-radiologist undertaking ultrasound after their training is completed. In addition regular clinico-radiological meetings should continue in order to ensure an integrated approach to any further imaging that may be required. 2.9 A system for recording the results of any ultrasound examination in the patients record is mandatory. The permanent recording of images, where appropriate, is desirable for the purposes of correlative imaging, future comparison and audit Knowledge of the appropriate use and integration of other imaging techniques, as well as the clinical and economic impact of ultrasound on the demand for other imaging, should be required The requirement to deliver training for medical non-radiologists must acknowledge the time commitment of the trainer and trainee, the provision of funding, the content and practicability of the syllabus and the availability of trainers and training courses. It is essential that there should be no adverse effects on trainees in radiology and sonography. It must be recognised that training requires additional time, space and equipment. Training should be properly costed and funded Training should be related to the specialist requirements of the trainee, i.e., training should be modular. Within any one level of training it may be appropriate for a trainee to become proficient in some but not all of the individual modules and only undertake ultrasound practice in this /these areas. Ultrasound Training Recommendations for Medical and Surgical Specialties 7

9 2.13 Training should be given in departments which have a multidisciplinary (medical, surgical, radiological etc.) philosophy, an adequate throughput of work, a radiologist or sonographic practitioner with experience and an interest in training in the module required, appropriate equipment and an active audit process. The role of sonographic practitioners in delivering some or all of this modular training should be formally recognised and agreed Regular appraisal should take place during the training period. It must be recognised that not all trainees have the aptitude to undertake ultrasound scanning and that, some, despite undergoing training, may not acquire the appropriate skills ever to practise independently. At the end of a period of training a competency assessment form should be completed for each trainee, which will determine the area or areas in which they can practise independently (see Section 3). The responsibility to be adequately trained and to maintain those skills lies with the individual practising ultrasound. An assessment of competence is a reflection on the position at the time the assessment is undertaken and no more. If sonographic practitioners are involved with competence assessment then they should be fully supported in this respect by a responsible radiologist experienced in ultrasound or other ultrasound trained medical practitioner Following training, regular and relevant continuing medical education (CME/CPD) should be undertaken and documented. It is the responsibility of the trainee to ensure that their practical skills are maintained by ensuring that regular ultrasound sessions are undertaken and that there is an adequate range of pathology seen in their ultrasound practice. 8 The Royal College of Radiologists

10 3 Training Recommendations Training should consist of both theoretical and practical syllabuses. 3.1 Theoretical training Preliminary theoretical training should cover the physics of ultrasound, levels and sophistication of equipment, image recording, reporting, artefacts and the relevance of other imaging modalities to ultrasound. This element of training may be best delivered by linking with some of the excellent courses run by university departments accredited by the Consortium for the Accreditation of Sonographic Education (CASE) The theoretical syllabus is set out in Appendix Practical training A syllabus for each area of ultrasound specialisation structured into the three levels of training has been developed incorporating theoretical training on anatomy and pathology and a practical syllabus listing conditions which should be included in the experience of the trainee (Appendices 2 10). A modular anatomical approach is recommended for musculoskeletal ultrasound (e.g., a trainee may become proficient in shoulder ultrasound alone), as set out in Appendix 11. In other areas of ultrasound specialisation, in appropriate circumstances, a limited anatomical or modular approach may also be acceptable if full competence in that area is demonstrated and future clinical practice is confined to that area alone Practical experience should be gained under the guidance of a named supervisor trained in ultrasound within a training department. In the context of advice from the RCR, this would normally be in a department of clinical radiology. There may be some areas of ultrasound practice which are not covered by these modules such as intra-operative ultrasound and transcranial Doppler ultrasound. Where required, training modules based on similar principles should be developed for any area of ultrasound practice not covered in this publication The syllabuses set out in Appendices 2 11 include a competency assessment sheet for training. This should be completed during the course of training as it will help to determine in which areas(s) the trainee can practise independently (see section 2.14) The requirements for the different levels of training are as follows: Level Level 2 Different trainees will acquire the necessary skills at different rates and the endpoint of the training programme should be judged by an assessment of practical competence. Examinations should encompass the full range of pathological conditions listed in the syllabuses. A logbook listing the number and type of examinations undertaken by the trainee themselves should be kept. An illustrated logbook of specific normal and abnormal findings may be appropriate for some syllabuses. Training should usually be supervised by a Level 2 practitioner. In certain circumstances it may be appropriate to delegate some or most of this supervision to a Level 1 practitioner with at least 2 years experience of Level 1 practice. This usually requires at least 1 year of experience at Level 1, with the equivalent of at least one session per week. Ultrasound Training Recommendations for Medical and Surgical Specialties 9

11 Level 3 A significant further number of examinations should have been undertaken in order to encompass the full range of conditions and procedures encountered in each module. A logbook listing the numbers and types of examinations undertaken by the trainee should be maintained. An illustrated logbook of specific normal and abnormal findings may be appropriate for some syllabuses. Supervision of training should be undertaken by someone who has achieved at least Level 2 competence and has had at least 2 years experience at that Level. This requires practitioners to spend a significant part of their time undertaking ultrasound examinations, teaching, research and development. They will have spent a continuous period of sub-specialist training in which ultrasound will have been a significant component. They will be able to perform specialised examinations at the leading edge of ultrasound practice such as the use of intravascular ultrasound contrast agents and the performance of advanced ultrasound-guided invasive procedures The syllabuses for each area of ultrasound specialisation are outlined in Appendices The Royal College of Radiologists

12 4 Continuing Medical Education and Professional Development 4.1 The minimum amount of on-going experience in ultrasound as outlined in each syllabus should be maintained. 4.2 CME/CPD should be undertaken which incorporates elements of ultrasound practice. 4.3 Regular audit of the individual s ultrasound practice should be undertaken to demonstrate that the indications, performance and diagnostic quality of the service are all satisfactory. Approved by the Board of the Faculty of Clinical Radiology: 2 July 2004 Approved by Council: 23 July 2004 Ultrasound Training Recommendations for Medical and Surgical Specialties 11

13 Appendix 1: Recommended Theory Syllabus This basic theoretical training is a prerequisite to any practical training in ultrasound. Physics and instrumentation The basic components of an ultrasound system. Types of transducer and the production of ultrasound, with an emphasis on operator controlled variables. Use of ultrasound controls. An understanding of the frequencies used in medical ultrasound and the effect on image quality and penetration. The interaction of ultrasound with tissue including biological effects. The safety of ultrasound and of ultrasound contrast agents. The basic principles of real time and Doppler ultrasound including colour flow and power Doppler. The recognition and explanation of common artefacts. Image recording systems. Ultrasound techniques Patient information and preparation. Indications for examinations. Relevance of ultrasound to other imaging modalities. The influence of ultrasound results on the need for other imaging. Scanning techniques including the use of spectral Doppler and colour Doppler. Administration Image recording. Image storing and filing. Reporting. Medico-legal aspects outlining the responsibility to practise within specific levels of competence and the requirements for training. Consent. The value and role of departmental protocols. The resource implications of ultrasound use. 12 The Royal College of Radiologists

14 Appendix 2: Urological Ultrasound Level 1: Training and Practice Practical training should involve at least one ultrasound list per week over a period of 3 6 months, with approximately 5 10 examinations performed by the trainee (under supervision) per session. A minimum of 250 examinations should be undertaken. However, different trainees will acquire the necessary skills at different rates, and the end point of the training programme should be judged by an assessment of competencies. Examinations should encompass the full range of pathological conditions listed below. A logbook listing the types of examinations undertaken should be kept. Training should be supervised either by someone who has obtained at least Level 2 competence in urological ultrasound or by a Level 1 practitioner with at least two 2 years experience of Level 1 practice. Trainees should attend an appropriate theoretical course and should read appropriate textbooks and literature. During the course of training the competency assessment sheet should be completed as this will determine in which area or areas the trainee can practise independently. Level 1: Knowledge Base Physics and technology, ultrasound techniques and administration (see Appendix 1) Sectional and ultrasonic anatomy kidneys ureters other retro-peritoneal structures (adrenals, aorta, i.v.c.) bladder seminal vesicles prostate scrotal contents other pelvic structures (uterus, ovaries, lymph nodes, vessels, bowel) Pathology in relation to ultrasound kidneys: congenital anomalies, cysts, tumours (benign and malignant), stones, collecting system dilatation, renal and peri-renal abscesses, trauma, diffuse renal diseases ureters: dilatation, obstruction bladder: tumours, diverticula, wall thickening, calculi, volume estimation prostate: zonal anatomy, infection, hyperplasia, tumours scrotal contents: testicular tumours, cysts, torsion, hydrocele, inflammatory problems, trauma Level 1: Competencies to be Acquired Kidneys perform a thorough ultrasound examination of the kidneys in different planes recognise normal renal ultrasonic anatomy and common normal variants measure renal length and assess variation from normality recognise and assess the degree of collecting system dilatation recognise and diagnose simple cysts recognise complex cysts and refer for appropriate further investigation recognise renal tumours and refer for appropriate further investigation recognise and diagnose renal stones recognise peri-renal abnormalities and refer for appropriate further investigation recognise abnormalities which need referral for scanning by a more experienced ultrasonologist and/or further investigation Ultrasound Training Recommendations for Medical and Surgical Specialties 13

15 Appendix 2: Urological Ultrasound continued Bladder perform a thorough ultrasound examination of the bladder in different planes recognise normal ultrasonic anatomy of the bladder and common normal variants measure bladder volume recognise and diagnose bladder diverticula recognise and assess bladder tumours recognise bladder calculi use colour Doppler to assess ureteric jets recognise abnormalities which need referral to a more experienced ultrasonologist and/or for further investigation Scrotum perform a thorough ultrasound examination of the scrotal contents in different planes recognise normal ultrasonic anatomy of the testes and epididymi and common normal variants recognise and diagnose epididymal cysts recognise and diagnose varicoceles use Doppler to help differentiate torsion/inflammatory problems recognise and assess intra-scrotal and intra-testicular calcifications recognise and assess testicular tumours recognise inflammatory changes in testes and epididymides recognise abnormalities which need referral to a more experienced ultrasonologist and/or for further investigation Prostate recognise normal ultrasonic anatomy and common normal variants perform trans-rectal ultrasound measure prostatic volume identify abnormal focal lesions perform a standardised technique of trans-rectal prostatic biopsy recognise abnormalities which need referral to a more experienced ultrasonologist and/or for further investigation Other To be able to recognise and, where appropriate, refer for further investigation: normal aorta and aortic aneurysm normal liver and liver masses normal uterus and ovaries and gynaecological masses To be able to use ultrasound in the assessment of patients presenting with: haematuria loin pain/renal colic loin mass lower urinary tract symptoms recurrent urinary tract infections supra-pubic mass palpable masses in the scrotum scrotal pain Level 2: Training and Practice Practical training should involve at least 1 year of experience at level 1 with a minimum of one session per week. A further 600 examinations should have been undertaken in order to encompass the full range of conditions and procedures referred to below. A logbook listing all examinations undertaken should be kept. Supervision of training should be undertaken by someone who has achieved at least Level 2 competence in urological ultrasound, has had at least 2 years experience at that Level, and who would normally be of consultant status. A Level 2 practitioner will be able to accept referrals from Level 1 practitioners. 14 The Royal College of Radiologists

16 Appendix 2: Urological Ultrasound continued Level 2: Knowledge Base Physics and technology in-depth knowledge and understanding of the physics of ultrasound in-depth knowledge and understanding of the technology of ultrasound equipment Ultrasound techniques the advanced use of Doppler ultrasound, including spectral, colour and power Doppler the use of ultrasound for guiding interventional procedures further applications of trans-abdominal ultrasound further application of endo-cavity ultrasound (e.g., trans-vaginal ultrasound) intra-operative ultrasound Sectional and ultrasonic anatomy the normal renal and pelvic vasculature, including an understanding of the Doppler signals obtained from these vessels more detailed knowledge of structures outside the urinary tract in the abdomen and pelvis ultrasound anatomy of the penis and female genital organs Level 2: Competencies to be Acquired Competencies will have been gained during training for Level 1 practice, and then refined during a period of clinical practice. Kidneys, bladder, prostate, scrotal contents recognise all pathology affecting the urinary tract and provide an accurate diagnosis in almost all cases recognise abnormalities which are out with his/her experience and refer on appropriately perform ultrasound-guided invasive procedures, including cyst aspiration, abscess drainage, renal biopsy, percutaneous nephrostomy and supra-pubic bladder catheter insertion perform Doppler ultrasound studies relevant to the urinary tract recognise abnormalities elsewhere in the abdomen and pelvis which need referral for scanning by another ultrasonologist and/or further investigation Level 3: Training and Practice A Level 3 practitioner is likely to spend the majority of their time undertaking urological ultrasound, teaching, research and development and will be an expert in this area. He/she will have spent a continuous period of specialist training in urological ultrasound. He/she will perform specialised examinations at the leading edge of ultrasound practice. He/she will accept tertiary referrals from Level 1 and Level 2 practitioners and will perform specialised examinations (e.g., the use of intravascular ultrasound agents in evaluating possible malignancy) as well as performing advanced ultrasound-guided invasive procedures. Maintenance of Skills: All Levels Having been assessed as competent to practise there will be a need for CPD and maintenance of practical skills. A specialist registrar will need to continue to perform ultrasound scans throughout the remainder of their training programme. Such further ultrasound practice may be intermittent, but no more than 3 months should elapse without trainees using their ultrasound skills, and at least 100 examinations should be performed per year. A medical practitioner performing Level 1 ultrasound should continue to perform at least 250 ultrasound examinations per year on a regular basis, should have regular meetings with radiological colleagues and should have a named radiologist as an ultrasound mentor. Practitioners should: include ultrasound in their ongoing CME audit their practice participate in multidisciplinary meetings keep up to date with relevant literature Approved by the British Association of Urological Surgeons. Ultrasound Training Recommendations for Medical and Surgical Specialties 15

17 Appendix 2: Urological Ultrasound Training Competency Assessment Sheet Core Knowledge Base Level 1 Trainee Trainer Physics and technology Practical instrumentation/use of ultrasound controls Ultrasound techniques Administration Sectional and ultrasonic anatomy Pathology in relation to ultrasound Competencies/Skills to be Acquired Level 1 To be competent to perform/diagnose the following: Kidneys ultrasound examination in different planes ultrasonic anatomy and common normal variants renal length and variation from normality collecting system dilatation simple cysts complex cysts tumours stones peri-renal abnormalities Bladder ultrasound examination in different planes ultrasonic anatomy and common normal variants bladder volume diverticula tumours calculi use colour Doppler to assess ureteric jets Prostate ultrasonic anatomy and common normal variants trans-rectal ultrasound prostatic volume abnormal focal lesions trans-rectal prostatic biopsy Scrotum ultrasound examination in different planes ultrasonic anatomy and common normal variants epididymal cysts varicoceles intra-scrotal and intra-testicular calcifications tumours inflammatory changes in testes and epididymides use Doppler to help differentiate torsion/inflammatory problems Other to be able to recognise: normal aorta and aortic aneurysm normal liver and liver masses normal uterus and ovaries and gynaecological masses use ultrasound in the assessment of patients presenting with: haematuria loin pain/renal colic loin mass lower urinary tract symptoms recurrent urinary tract infection supra-pubic mass palpable scrotal masses scrotal pain know when to refer to a more expert ultrasonologist 16 The Royal College of Radiologists

18 Appendix 2: Urological Ultrasound Training Competency Assessment Sheet continued Core Knowledge Base Level 2 Trainee Trainer Physics and technology Ultrasound techniques Sectional and ultrasonic anatomy Competencies/Skills to be Acquired Level 2 To be competent to perform/recognise the following: pathology affecting the urinary tract and provide an accurate diagnosis in almost all cases abnormalities which are out with personal experience and refer on appropriately ultrasound-guided invasive procedures, including cyst aspiration, abscess drainage, renal biopsy, percutaneous nephrostomy and supra-pubic bladder catheter insertion Doppler ultrasound studies relevant to the urinary tract abnormalities elsewhere in the abdomen and pelvis which need referral for scanning by another ultrasonologist and/or further investigation Ultrasound Training Recommendations for Medical and Surgical Specialties 17

19 Appendix 3: Gynaecological Ultrasound Level 1: Training and Practice Practical training should involve at least 30 ultrasound sessions within a period of 6 months with approximately 5 10 examinations performed by the trainee (under supervision) per session. However, different trainees will acquire the necessary skills at different rates and the end point of the training programme should be judged by an assessment of competencies. Examinations should encompass the full range of pathological conditions listed below. A logbook listing the type of examinations undertaken should be kept. Training should be supervised either by someone who has obtained at least Level 2 competence in gynaecological ultrasound, or by a Level 1 practitioner with at least 2 years experience of Level 1 practice. Trainees should attend an appropriate theoretical course and should read appropriate textbooks and literature. During the course of training the competency assessment sheet should be completed as this will determine in which area or areas the trainee can practise independently. Level 1: Knowledge Base Physics and technology, ultrasound techniques and administration (see Appendix 1) The techniques of transabdominal and transvaginal scanning are essential. A full understanding of the issues relating to the performance of intimate examinations and the importance of informed consent for the procedures is emphasised. Sectional and ultrasonic anatomy uterus (including physiological changes with age and cycle) ovaries (including physiological changes with age and cycle) cervix and vagina first trimester gestation appearances kidneys bladder and urethra lymph nodes associated structures; omentum and peritoneal fluid Pathology in relation to ultrasound uterus: fibroids, adenomyosis, intra-uterine contraceptive devices (IUCDs), endometrial hyperplasia, polyps and tumours ovaries: cysts and their complications, torsion, endometrioma, tumours, inflammation and infection, polycystic and hyperstimulated ovaries fallopian tubes: hydro/pyo-salpinges cervix and vagina: congenital lesions, cysts, tumour, retained foreign bodies first trimester: dating, counting, chorionicity, haemorrhage, signs of non-viability, retained products of conception, ectopic pregnancy kidneys: hydronephrosis, stones, tumour bladder and urethra: tumours, diverticula, wall thickening, calculi, volume estimation, periurethral cysts and abscesses other pelvic pathology: lymph nodes, bowel masses, vascular anomalies 18 The Royal College of Radiologists

20 Appendix 3: Gynaecological Ultrasound continued Level 1: Competencies to be Acquired Early pregnancy date pregnancy recognise signs of non-viability identify multiple pregnancy and chorionicity recognise signs of haemorrhage recognise signs of retained products of conception recognise signs of ectopic pregnancy Abnormal vaginal bleeding To be able to recognise: features of fibroids and their localisation appearances of IUCDs and their localisation normal and abnormal endometrial thickness the features of atrophic and hyperplastic endometrium the features of endometrial polyps when further investigation is required and what to ask for Pelvic pain To be able to recognise: the features of ovarian cyst torsion, rupture or haemorrhage the features of endometrioma appearances of hydrosalpinges the features of pelvic inflammatory disease non-gynaecological causes of pelvic pain Pelvic mass To be able to recognise: typical appearances of uterine and ovarian masses features indicating benign or malignant pathology non-gynaecological causes of a pelvic mass Reproductive medicine To be able to recognise: features of the endometrium at different stages of the menstrual cycle features of the ovary at different stages of the menstrual cycle features of a stimulated and hyperstimulated ovary features of a polycystic ovary Kidneys perform a thorough ultrasound examination of the kidneys in different scan planes recognise normal renal ultrasonic anatomy and common normal variants measure renal length and assess variation from normality recognise and assess the degree of collecting system dilatation recognise renal cysts recognise renal tumours recognise renal stones recognise abnormalities which need referral to a more experienced ultrasonologist and/or for further investigation Ultrasound Training Recommendations for Medical and Surgical Specialties 19

21 Appendix 3: Gynaecological Ultrasound continued Bladder perform a thorough ultrasound examination of the bladder in different planes recognise normal ultrasonic anatomy of the bladder and common normal variants measure bladder volume recognise and diagnose bladder diverticula recognise bladder tumours recognise bladder calculi recognise abnormalities which need referral for scanning by a more experienced ultrasonologist and/or further investigation Level 2: Training and Practice Practical training should include at least 1 year of experience at Level 1 with a minimum of the equivalent of one session per week. A further 600 examinations should have been undertaken in order to encompass the full range of conditions and procedures referred to below. A logbook listing all examinations undertaken should be kept. Supervision of training should be undertaken by someone who has achieved at least Level 2 competence in gynaecological ultrasound, has had at least 2 years experience at that level, and who would normally be of consultant status. A Level 2 practitioner will be able to accept referrals from Level 1 practitioners. Level 2: Knowledge Base Physics and technology in-depth knowledge and understanding of the physics of ultrasound in-depth knowledge and understanding of the technology of ultrasound equipment Ultrasound techniques the advanced use of Doppler ultrasound, including spectral, colour and power Doppler the use of ultrasound for guiding interventional procedures further applications of trans-abdominal ultrasound further applications of trans-vaginal ultrasound: saline infusion hysterography (SIH), HyCoSy Sectional and ultrasonic anatomy The normal pelvic and gynaecological organ vasculature, including an understanding of the Doppler signals obtained from these vessels More detailed knowledge of structures outside the female reproductive tract in the abdomen and pelvis Level 2: Competencies to be Acquired Competencies will have been gained during training for Level 1 practice, and then refined during a period of clinical practice. Female reproductive tract recognise and correctly diagnose almost all pathology affecting the female genito-urinary tract perform ultrasound-guided invasive procedures, including ascitic drainage, omental biopsy, pelvic mass biopsy (TA or TV), lymph node aspiration, SIH and HyCoSy perform Doppler ultrasound studies relevant to the uterus and ovaries recognise abnormalities elsewhere in the abdomen and pelvis which need referral for scanning by another ultrasonologist and/or further investigation stage ovarian and uterine tumours 20 The Royal College of Radiologists

22 Appendix 3: Gynaecological Ultrasound continued In addition specifically to be able to recognise and evaluate: causes of an abnormal Doppler waveform. changes associated with precocious puberty, thelarche, adrenarche and virilisation congenital anomalies features of lymph nodes in the inguinal and iliac chains Bartholin s cysts, abscesses and peri-urethral lesions features of haematocolpos features of adenomyosis non-ovarian endometriosis non-gynaecological causes of pelvic pain and how to diagnose appendicitis, inflammatory bowel disease, bowel cancer, hernias, aneurysms and bladder disease different types of complex ovarian masses malignant disease of the omentum, peritoneum and the rest of the abdomen features of pleural effusions common sites and features of tumours that metastasise to the pelvis the principles of oocyte collection by transvaginal ultrasound guided aspiration of follicles Level 3: Training and Practice A Level 3 practitioner is likely to spend the majority of their time undertaking gynaecological ultrasound, teaching, research and development. He/she will have spent a continuous period of specialist training in gynaecological ultrasound. He/she will accept tertiary referrals from Level 1 and 2 practitioners. He/she will perform specialised examinations at the leading edge of ultrasound practice. Maintenance of Skills: All Levels Having been assessed as competent to practise there will be a need for CPD and maintenance of practical skills. A specialist registrar will need to continue to perform ultrasound throughout the remainder of his/her training programme. Such further ultrasound practice may be intermittent, but no more than 3 months should elapse without the trainee using his/her scanning skills, and at least 100 scans should be performed per year. A medical practitioner performing Level 1 ultrasound should continue to perform at least 250 ultrasound examinations per year on a regular basis, should have regular meetings with radiological colleagues and should have a named radiologist as an ultrasound mentor. Practitioners should: include ultrasound in their ongoing CME audit their practice participate in multidisciplinary meetings keep up to date with relevant literature Ultrasound Training Recommendations for Medical and Surgical Specialties 21

23 Appendix 3: Gynaecological Ultrasound Training Competency Assessment Sheet Core Knowledge Base Level 1 Trainee Trainer Physics and technology Practical instrumentation/use of ultrasound controls Ultrasound techniques Administration Techniques of transabdominal and transvaginal scanning Issues regarding intimate examinations and informed consent Sectional and ultrasonic anatomy Pathology in relation to ultrasound Competencies/Skills to be Acquired Level 1 To be competent to perform/diagnose the following: Early pregnancy dating pregnancy signs of non-viability multiple pregnancy and chorionicity haemorrhage retained products of conception ectopic pregnancy Vaginal bleeding fibroids and their localisation IUCDs and their localisation normal and abnormal endometrial thickness atrophic and hyperplastic endometrium endometrial polyps Pelvic pain ovarian cyst complications endometriosis pelvic inflammatory disease non-gynaecological causes of pain Pelvic mass identification organ of origin of mass benign versus malignant features Reproductive medicine endometrial changes with menstrual cycle ovarian changes with menstrual cycle polycystic ovaries stimulated and hyperstimulated ovaries Kidneys ultrasound examination in different scan planes ultrasonic anatomy and common normal variants renal length collecting system dilatation cysts tumours stones Bladder ultrasound examination in different planes ultrasonic anatomy and common normal variants bladder volume bladder diverticula tumours calculi General know when to refer to a more expert ultrasonologist 22 The Royal College of Radiologists

24 Appendix 3: Gynaecological Ultrasound Training Competency Assessment Sheet continued Core Knowledge Base Level 2 Trainee Trainer Physics and technology Ultrasound techniques Sectional and ultrasonic anatomy Competencies/Skills to be Acquired Level 2 To be competent to perform/recognise/diagnose/evaluate the following: Female reproductive tract almost all pathology affecting the female genito-urinary tract ultrasound-guided invasive procedures, including ascitic drainage, omental biopsy, pelvic mass biopsy (TA or TV), lymph node aspiration, SIH and HyCoSy Doppler ultrasound studies relevant to the uterus and ovaries abnormalities elsewhere in the abdomen and pelvis which need referral for scanning by another ultrasonologist and/or further investigation stage ovarian and uterine tumours Other causes of an abnormal Doppler waveform changes associated with precocious puberty, thelarche, adrenarche and virilisation congenital anomalies features of lymph nodes in the inguinal and iliac chains Bartholin s cysts, abscesses and peri-urethral lesions features of haematocolpos features of adenomyosis non-ovarian endometriosis non-gynaecological causes of pelvic pain and how to diagnose appendicitis, inflammatory bowel disease, bowel cancer, hernias, aneurysms and bladder disease different types of complex ovarian masses malignant disease of the omentum, peritoneum and the rest of the abdomen features of pleural effusions common sites and features of tumours that metastasise to the pelvis the principles of oocyte collection by transvaginal ultrasound guided aspiration of follicles Ultrasound Training Recommendations for Medical and Surgical Specialties 23

25 Appendix 4: Gastrointestinal Ultrasound Level 1: Training and Practice Practical training should involve at least one ultrasound list per week over 3 6 months with approximately 5 10 examinations performed by the trainee (under supervision) per session. A minimum of 250 examinations should be undertaken. However different trainees will acquire the necessary skills at different rates and the end point of the training programme should be judged by an assessment of competencies. Examinations should encompass the full range of pathological conditions listed below. A logbook listing the types of examinations undertaken should be kept. Training should be supervised either by someone who has obtained at least Level 2 competence in gastrointestinal ultrasound or by a Level 1 practitioner with at least 2 years experience of Level 1 practice. Trainees should attend an appropriate theoretical course and should read appropriate textbooks and literature. During the course of training the competency assessment sheet should be completed as this will determine in which area or areas the trainee can practise independently. Level 1: Knowledge Base Physics and technology, ultrasound techniques and administration (see Appendix 1) Sectional and ultrasonic anatomy liver gallbladder bile ducts pancreas spleen kidneys other structures (uterus, ovaries, lymph nodes, vessels, bowel) Pathology in relation to ultrasound liver: cysts, benign and malignant tumours, metastatic disease, fatty change, cirrhosis biliary system: gallbladder stones, acute and chronic cholecystitis, gallbladder tumours, bile duct obstruction including level of obstruction, intra hepatic duct gas and stones pancreas: pancreatitis, duct stones, duct dilatation, pancreatic tumours portal venous system and spleen: splenic enlargement, portal venous distention, varices, thrombosis, ascites other structures: renal masses and urinary tract obstruction (hydronephrosis), ovarian and uterine masses including cysts, tumours, fibroids and unexpected pregnancy Level 1: Competencies to be Acquired Liver perform a thorough ultrasound examination of the liver in different scan planes recognise normal hepatic anatomy and variants recognise normal and abnormal liver texture, such as fatty change, cirrhosis, atrophy and hypertrophy recognise focal lesions, particularly cysts and benign lesions, and be able to detect possible malignant lesions requiring further investigation recognise normal hepatic and portal venous anatomy within the liver 24 The Royal College of Radiologists

26 Appendix 4: Gastrointestinal Ultrasound continued recognise abnormalities of the hepatic and portal venous system e.g., thrombosis perform ultrasound controlled biopsy for the evaluation of parenchymal liver disease Biliary system perform a thorough evaluation of the biliary system recognise normal ultrasonic anatomy of the biliary system and its frequent normal variants recognise abnormalities of the gallbladder wall recognise gallbladder stones recognise features of acute and chronic cholecystitis assess bile duct dilatation at intra hepatic and extra hepatic levels and determine level of obstruction Pancreas perform a thorough examination of the pancreas recognising normal anatomy recognise the limitations of pancreatic ultrasound because of bowel gas recognise solid and cystic tumours within the head and body of the pancreas recognise pancreatic duct dilatation and pancreatic duct stones recognise the features of acute and chronic pancreatitis and their complications Portal venous system and spleen evaluate the size of the spleen and recognise focal lesions and evidence of trauma evaluate the portal vein and its diameter and the presence of portal venous thrombosis recognise cavernous transformation of the portal vein and varices Bowel recognise normal stomach, small and large bowel recognise focal intestinal abnormality and understand the principles of further investigation recognise small bowel obstruction Other recognise abdominal aortic aneurysm recognise hydronephrosis recognise normal kidneys, uterus and ovaries recognise renal and gynaecological masses Level 2: Training and Practice Practical training should involve at least 1 year of experience at Level 1 with a minimum of one session per week. A further 500 examinations should have been undertaken in order to encompass the full range of conditions and procedures listed below. A logbook listing all examinations undertaken should be kept. Supervision of training should be undertaken by someone who has achieved Level 2 competence in gastrointestinal ultrasound, has had at least 2 years experience at that level and who would normally be of consultant status. A Level 2 practitioner will be able to accept referrals from Level 1 practitioners. Ultrasound Training Recommendations for Medical and Surgical Specialties 25