Training in Perioperative Echocardiography: Time to Think Outside the Box

Feroze Mahmood, MD, FASE

Robina Matyal, MD

The use of ultrasound as an imaging technology has exponentially increased over the last decade. In the perioperative arena, it is used as a diagnostic aid, monitoring tool, and procedural adjunct. Transthoracic and transesophageal echocardiography (TTE, TEE) are two of the most common diagnostic modalities in the perioperative arena, but ultrasound is also used to guide placement of regional blocks, intravenous lines, and invasive monitors. The use of ultrasound is not exclusive to anesthesiologists, however, and multiple surgical specialties use it as a procedural adjunct. Various specialties have recognized the broad-based nature of this technology and have incorporated curriculum changes to introduce basic and advanced ultrasound education during residency training programs. Recognizing the value of echocardiography in the perioperative arena, the Society of Cardiovascular Anesthesiologists (SCA) has called for action to adopt a more comprehensive approach to ultrasound training for anesthesiologists.

Current echocardiography systems are advancing, with high image quality, faster processing, and multiple additional features (Doppler, strain, three-dimensional (3D) imaging), which have broadened the clinical applications of this technology. More recently, hand-held systems have become available, further expanding the use of echocardiography as a point-of-care imaging modality in everyday clinical practice. With these smaller echocardiography systems becoming more affordable, it is likely that their routine use will become an integral component of acute care medicine in the near future. Due to its increasing importance as a diagnostic and monitoring tool, medical schools in the United States have also initiated ultrasound education programs into their core curricula. Medical students are being trained in the basic principles and clinical applications of echocardiography in elective and emergency situations.

Introduction of a new technology without specific guidelines for its clinical use is always associated with regulatory challenges. Laparoscopy, robotic cardiac surgery, and endovascular procedures were all introduced into clinical practice prior to development of procedure-specific training. Perioperative use of ultrasound is in a similar situation, and perhaps more complicated and challenging due to its multiple applications that cross specialty lines. Training and certification procedures exist only for TTE and TEE, and for the most part deal with the ability to make formal diagnoses. There is significant variation in the quality of clinical training in using ultrasound for point-of-care (POC) treatment decisions. Despite the wide-spread use of POC echocardiography in the perioperative arena, there are no formal guidelines to establish levels of training and the scope of its use. While the American Board of Anesthesiology has increased the examination content relating to the use of perioperative echocardiography, proficiency in its use is not a mandated milestone of accredited anesthesia training.

Multiple anesthesia residency programs have recognized this deficiency in curriculum and have initiated echocardiography training programs to address this challenge. These educational initiatives are based on developing a fundamental understanding of ultrasound technology utilizing web-based didactics, coupled with simulator-based hands-on practice. These types of programs have shown evidence of clinical transferability and improved trainee performance. It is expected that such initiatives to facilitate fundamental understanding will facilitate acquisition of more advanced skills during specific specialty rotations. Such programs have been well received and ultrasound education and training curricula are being developed across the country. It is likely that in the very near future, proficiency in use of perioperative echocardiography will not simply be a desirable skill, but an expectation from graduating anesthesia residents.

While the aforementioned efforts are welcomed first steps, the current education model is the classic “top down” approach. Prior certification standards have been developed by expert users, with a poor understanding of the basic needs of POC users. Many of the formal echocardiography courses are considered “too advanced” and “not applicable” to the busy clinician who only wants to know if the heart is squeezing well or not. While there are various “beginner” web-based education resources, most lack quality controls and a review process that ensures a training standard can be obtained. Ideally, a base level of ultrasound education should be obtained in medical school and be nonspecific for any particular specialty.

The American Society of Echocardiography (ASE) has a history of providing collaborative leadership to a diverse group of healthcare providers. Cardiologists, anesthesiologists, surgeons, and sonographers are unified as a group with a common objective of promoting excellence in echocardiography. A major strategic goal of ASE is to “attract all users of cardiovascular ultrasound by creating quality and value.” It is important that ASE puts this ideal into action and include non-traditional users of echocardiography, who may not necessarily use ultrasound the same way as cardiologists or sonographers. The ASE has taken a first step toward embracing POC ultrasound users by creating a formal Task Force in this area. We hope this group remembers that the goal of POC echocardiography is not to create pretty pictures or obtain advanced hemodynamic measurements, but rather ensure the appropriate treatment is delivered to the patient. A “top-down” educational model is not going to engage the wide variety of POC users, which may push some educational leaders outside of their comfort zone. With such a broad base of potential users, we hope the ASE can think outside the box when it comes to educating them.

Apr 17, 2018 | Posted by in CARDIOLOGY | Comments Off on Training in Perioperative Echocardiography: Time to Think Outside the Box

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