Expert consensus panel urges all rheumatology residents to learn basic ultrasound skills
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SAN DIEGO — Establishing mandatory competencies for musculoskeletal ultrasound is necessary to improve its use in both rheumatology residency programs and clinical practice, a speaker said at ACR Convergence 2023.
“There are many advantages to musculoskeletal ultrasound in rheumatology,” Maria Powell, MD, of the University of Calgary, told attendees. “From a clinical perspective, it can help with the diagnosis and treatment of many conditions. From an educational standpoint, it can help teach anatomy and physical exam skills.”
Musculoskeletal ultrasound can also offer novel and useful outcomes for clinical research, she added.
Despite these potential advantages, Powell noted there is currently no curriculum for incorporating musculoskeletal ultrasound in clinical practice or residency training in Canada. In addition, educational programs for this approach are variable around Canada, according to Powell.
“Furthermore, 40% of programs actually don’t teach any ultrasound to their residents currently,” she said.
Barriers include limited resources, such as the availability of machines and teachers to instruct students on how to use them. There is also limited time to teach ultrasound techniques.
“All of these barriers are inter-related and we cannot address all of them at once,” Powell said.
To establish expert consensus around this imaging modality, to be used in Canadian rheumatology residency training programs, Powell and colleagues first invited 13 musculoskeletal ultrasound experts to define necessary competencies. The next stage included a working group of 18 experts, residents and rheumatology program directors to further define techniques and parameters. The third stage featured an additional group of external experts to review the competencies.
The first stage yielded a prioritized list of 45 competencies. In the second stage, after three rounds of surveys, the group achieved consensus that 42 items — from a total of 86 derived from the list of prioritized competences — should be mandatory, while 39 can be optional.
“On average, our experts had more than 10 years of experience using musculoskeletal ultrasound in clinical context,” Powell said. “Eighty percent had education leadership roles within the residency training program.”
According to the resulting guidelines, all Canadian rheumatology residents should learn basic ultrasound skills. They should also learn how to perform a focused musculoskeletal ultrasound of the hands, wrists and feet for features of inflammatory arthritis, such as effusion and synovitis. They should understand the difference between bone erosion and osteophyte, as well as how to detect tenosynovitis. Limited musculoskeletal ultrasound of the knee and ankle to identify joint effusion is also recommended.
According to Powell, two themes for musculoskeletal ultrasound use in rheumatology emerged from the process: “clinical utility and learnability.”
Ultrasound competencies that enhance clinical assessment of patients were prioritized for clinical utility.
“For learnability, things like managing learner cognitive load, learner characteristics, required resources, and opportunities to practice these skills throughout educational training were prioritized,” Powell said.
Moreover, the recommendations offer insight on what skills and competencies are necessary prior to a scan, during a scan and after a scan.
“For example, they should know the indications and limitations of the exam they are about to perform,” Powell said. “They should know how to probe appropriately to obtain an acceptable image and then integrate those findings into the patient management.”
Powell concluded that the findings contain “expert consensus recommendations” for the minimum musculoskeletal ultrasound training in Canadian rheumatology residency programs.
“We started with a very comprehensive list of competencies and through a robust three-stage consensus design we were able to refine this list to what is predicted to be the most clinically useful and learnable for rheumatology residents,” she said.
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Powell M, et al. Abstract 726. Presented at: ACR Convergence 2023; Nov. 10-15, 2023; San Diego.
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