By: Michael Dolinger, MD MBA and Noa Krugliak Cleveland, MD
As the famous fictional chef Auguste Gusteau from the 2007 Disney Pixar movie *Ratatouille* says, “Anyone can cook, but only the fearless can be great.” Anyone can learn intestinal ultrasound. It is a non-invasive ultrasound of the abdomen that examines the large and small intestine for the presence or absence of inflammation. In this sense, it is a procedural skill. With proper training, time, and repetition, anyone can learn. There is no harm to patients in practicing this procedure, so the learner does not have to fear causing harm. While mastery of intestinal ultrasound takes more practice and experience, the journey to competency is achievable for anyone—from gastroenterologists to ultrasound technologists, and maybe even one day, patients themselves. Learning a new skill can be daunting, so we have created a 5-point approach to the mindset to make learning intestinal ultrasound as easy as possible.
1. It Takes a Motivated Team
Learning intestinal ultrasound requires time and practice. Support from your team to allow you the time needed to learn a new skill is invaluable. You must set aside time to attend formal training, which consists of introductory courses or longitudinal practice away from your “home” institution and patients for multiple weeks at a time. However, the unspoken part about learning intestinal ultrasound is that the most time needed is at “home” In your own clinic, where you may feel uncomfortable at first. The key to successfully learning this skill is to establish regularly scheduled practice time before you are certified and immediately after you have received your introductory course. We would recommend identifying a high-volume inflammatory bowel disease clinic session each week where your schedule is protected to practice intestinal ultrasound. You will be asking patients to volunteer their valuable time either before or after a visit with their doctor so you can practice, and you will be asking other doctors in your clinic to adjust their workflow in the same manner. Having this protected time for learning, without using intestinal ultrasound for clinical decision-making, is essential. Meet with your leadership, practice managers, and patient advisory councils to devise a plan for carving out practice time. I always say, you wouldn’t run a marathon without training. Therefore, you wouldn’t want to make decisions using intestinal ultrasound (the marathon) without at least a few months, if not more, of intensive training beforehand.
2. Plan for Your Specific Clinical Needs
Map out your clinic spaces. Identify the major areas where you envision utilizing intestinal ultrasound to improve care for your inflammatory bowel disease patients. From freestanding outpatient clinics to hospital-based clinics, from inpatient or emergency department consultations to the endoscopy unit, there is no one-size-fits-all model. Plan to meet the needs of your patients by identifying potential indications for intestinal ultrasound in your practice and discussing with leadership how you can address these needs. You will need to consider whether you will be the only provider or if you envision multiple providers learning to perform intestinal ultrasound within your care team. You will also need to think about whether you will use intestinal ultrasound for clinical care in your own patients, in multiple providers’ patients, and/or for research and clinical trials. All these factors should be considered ahead of time, creating a roadmap for bringing intestinal ultrasound to inflammatory bowel disease patients and changing care in your area. You may not have the perfect roadmap at the start, but beginning with a general direction and purpose to improve the lives of inflammatory bowel disease patients with non-invasive intestinal ultrasound as a diagnostic and monitoring tool is key.
3. Obtain the Right Ultrasound Machine for You
People always ask if a special ultrasound machine is needed to perform intestinal ultrasound. The answer is no. Most ultrasound machines are sufficient. You will want it dedicated to you for availability to practice when needed and to prevent delays in patient care. You don’t need the top-of-the-line machine to get started. We tell people it's better to start learning with a machine than to wait for a newer, more expensive model with all the bells and whistles. The key is starting with a machine capable of visualizing the intestines. You need just two probes: a mid-high frequency linear probe and a low-frequency convex probe. High-end ultrasound machines can cost as much as $150,000, but similar machines in the $70,000 to $100,000 range may provide sufficient or even superb image quality without all the futuristic research features and processing power of the top-of-the-line models. It’s similar (both in experience and price range) to buying a car. You may want that fancy sports car, but buying a reliable used car may be perfect when you are learning to drive and won’t care to bang it up a bit. Now, we wouldn’t recommend learning with a handheld ultrasound machine. The cost of a handheld in the $5,000 range may be attractive, but the technology is still limited. Image quality can be poor, and, more importantly, they are difficult to operate, especially for novices. Picture trying to learn ultrasound while holding a probe with one hand and using your other hand on a smartphone or device, pinching with your fingers, and squinting with your eyes. In theory, one day, this is likely to be the tool to bring intestinal ultrasound to all parts of the world, but the technology isn’t ready yet, particularly for beginners and their training.
There are many ultrasound machine manufacturers, so it is often best to discuss your options with other experts in the field and hear about their experiences—much like reading a movie review before deciding to watch a film! We actually caution against demoing machines in the beginning.You likely won’t have enough experience to understand or discern the differences between machines and your preferences. Others may disagree, but we would use the same car analogy as before: imagine trying to decide on the features you would need in a car without even knowing how to drive yet. Features that may seem attractive could be, for all intents and purposes, useless. This is where national training and educational courses can be helpful. Go explore a variety of machines from different manufacturers to find the best starting option for you.
4. Collaborate with Radiology Information Technology Services
If you are at a large hospital in the United States, chances are that you are not the first physician, and you may even be one of the last specialties to incorporate point-of-care ultrasound into clinical care. Ultimately, ultrasound images and video clips will need to “live” somewhere other than on the physical ultrasound machine's hard drive. Typically, this is done in a cloud-based storage system already licensed by your hospital and used in departments such as emergency medicine or a PACS system that is also used by radiology. This is an important step for billing and reimbursement, as ultrasound examinations must be retrievable for five years for auditing purposes by insurance companies. It is never too early to begin the conversation with your radiology IT department, collaborate with radiology leadership about your initiatives, or reach out to colleagues in other specialties at your hospital who are already performing point-of-care ultrasound to learn how they manage this, as each hospital may be a bit different, and learning from internal experiences is always beneficial.
5. A Global Standard for Intestinal Ultrasound Training and Certification
The International Bowel Ultrasound Group (IBUS) developed the training process for gastroenterologists to become certified in this skill. The IBUS training program consists of a three-module curriculum that includes an introductory hands-on Module 1, a longitudinal training program for four weeks at certified training hospitals for Module 2—often divided into two-week blocks—and a Module 3 certification examination. iUSCAN collaborates with IBUS to bring the IBUS training program to North America, beginning with Module 1. There are several certified Module 2 training centers in the United States and Canada. For more information on intestinal ultrasound training and how to apply, please see our events section and visit our post on training.
Ultimately, you will have many questions about learning intestinal ultrasound. Here’s our advice: learning a new skill is hard, and fighting against inertia to change care at your institution to enhance the lives of inflammatory bowel disease patients is even harder. It shouldn’t be this way, but that is the reality as it stands now. If it were easy, intestinal ultrasound would already be adopted everywhere in the United States. Please know that a large community supports you. For additional questions, please refer to our physician FAQ or you can email Michael Dolinger at Mike@iuscan.org or Noa Krugliak Cleveland at Noa@iuscan.org, and we would be happy to have a conversation and support you in any way we can.
