Background
Ultrasound is a simple, inexpensive, non-invasive, easily repeatable, and portable technique used to explore internal structures, that can be performed at the patient’s bedside or in medical offices, unlike Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI), which require the presence of a specialist in radiology and of non-portable equipment installed in specific rooms. Ultrasonography can be performed for diagnostic purposes by any physician with adequate competence, regardless of the presence and type of specialization and this is one reason why ultrasound can be broadly defined as “medical,” as its execution is allowed simply with a medical degree or, limitedly to a few Countries, with a specific technical training.
Despite this very large applicability, unfortunately, there is still no official mandatory ultrasound teaching in the core curriculum of the Medical and Surgical Degree programs in many Countries either in Europe [1] or worldwide, despite several experts and scientific societies were publicly in favor of introducing it [2]
[3]. At present, adequate ultrasound training is provided by Radiology and a few other Schools of Specialization, such as for instance Internal Medicine, Gastroenterology, Endocrinology, Obstetrics and Gynecology, Pediatrics, Radiology, General Surgery, Cardiology, Vascular Surgery, Thoracic Surgery, etc. [4]. Training courses to become a General Practitioner offer such training. However, not any given local Specialty or General Practitioner Course offer adequate training in Ultrasound or any training at all, even in the above-mentioned disciplines.
In a few fields this choice is logical, as for instance a psychiatrist is unlikely to need specific knowledge in ultrasound, where in almost any other one an ultrasound competence would be needed.
Indeed, ultrasound requires specific operator competence, like any medical procedure, which is why dedicated courses and training environments independent of Medical Specialization Schools or General Medicine courses are necessary and continuously held. Indeed, EFSUMB itself has always paid great attention to Education, even at the undergraduate level in conjunction with its national societies [1]
[2]
[3]. This will definitively translate into a much more widespread daily use of ultrasound to support most medical diagnoses for in- and out-patients at any level.
Ultrasound in Clinical Environments
Considering that ultrasound has become an integral part of patient assessment and examination in many specialized branches, there is an increasing opportunity for specialists themselves to perform ultrasound examinations for their patients, based on their specific competence and varying degrees of exam complexity.
One might wonder if performing the ultrasound examination personally is simply a matter of saving time, avoiding writing requests, waiting for an appointment date, and being able to read the results directly instead of waiting. The answer is certainly “no”!
The immediate advantage perceived is that ultrasound performed by the physician who is responsible for the patient, a condition that can be defined as “clinical ultrasound,” offers multiple advantages, integrating physical and medical examination. Many synonyms have been used up to now (POCUS, bed side sonography, Sonography-Assisted Medical Examination – SAME –). In many scenarios, like in the Emergency Rooms, in general practitioner offices, or in Clinical wards, the aim of ultrasound use is to complete the clinical physical examination trying to answer specific questions, potentially without the need to fill in a structured report. The operator must be a qualified physician in these situations, able to perform sonography. This will allow the physician to verify the correspondence between the classic semeiological signs (e.g, suspicion of pleural of peritoneal effusion, organ enlargements, Giordano, Mc Burney or Murphy signs, etc.) and the corresponding expected ultrasound findings. SAME must therefore always be performed according to the patient’s clinical needs and it will constitute an integral part of the medical examination for the purpose of assisting the physician in the diagnostic and therapeutic process [5].
The main advantage is that the execution of the examination by the medical staff who manages the patient maximizes the diagnostic value of the ultrasound exam. Firstly, the patient is seen by a doctor who does not need to rely on limited medical history data, that could be at risk of lacking important details necessary for interpreting the images, possibly simply due to time constraints when setting the request. The doctor responsible for the patient is instead well acquainted with the entire medical history and the clinical question(s) for which the investigation is requested. Additionally, medical ultrasound benefits from the fact that sometimes ultrasound may not provide the answer to the clinical question triggering the US scanning, but may reveal unexpected findings of uncertain relevance. In the “anatomical” ultrasound approach, this situation often leads to a phrase often read in reports, “to be interpreted in the clinical context”. This would not be a mistake, since it is understandable that an operator who is not familiar with the patient’s complete clinical picture may not correctly interpret certain image findings out of the clinical context. However, the written report of findings of uncertain relevance, expecially not well fitting in the clinical context, easily leads to situations difficult to be explained to the patient and his/her relatives and often triggers new, often poorly useful diagnostic investigations.
At variance from anatomical ultrasound, this phrase would instead disappear in clinical ultrasound, because it is the clinician who interprets and evaluates the examination. He/she will decide the value to assign to each ultrasound finding, leaving no room for uncertain interpretation or for subsequent reconsideration by others. Furthermore, dynamism is always present and the physician performing a medical ultrasound can extend the examination as he/she deems necessary. For instance, when the initially planned examination findings are insufficient to fully clarify the clinical picture or if the ultrasound findings suggest other potential diagnostic avenues, there is no need to request an additional or different ultrasound examination, because, if within the specific competence, it can be performed immediately by the clinician conducting the ultrasound scan as soon as the idea arises.
It is also worth reminding the ease of performing the examination directly in the ward for inpatients ([Fig. 1]) or in the visit room for outpatients, avoiding the need to move beds or wheelchairs. This not only saves time and costs, but also eliminates some risks for fragile patients, who, when hospitalized, would otherwise have to navigate through different and possibly distant environments from his/her ward of admission [6].
Fig. 1 Medical Ultrasound (bedside) performed with a transportable device.
The latter advantage is the result of technological improvements. In the early days of ultrasonography, high-quality devices were heavy, bulky, and required a constant electrical connection. They were not always suitable to be moved or would suffer a risk of being damaged during transportation, making their availability limited. Ultrasound machines have become smaller today ([Fig. 1]), but nonetheless maintain the possibility of good image resolution and even of more advanced functions than simple Doppler ultrasound, such as elastography or contrast-enhanced ultrasound (depending on the equipment and software). Pocket-sized ultrasound scanners with Doppler US are also widely available ([Fig. 2]). All these devices can work without being connected to the electrical grid, are compact in size, easily transportable to the patientʼs bedside. Many also include the ability to remotely store images in centralized DICOM archives and all have accessible costs for healthcare facilities. This transition has definitively opened the doors to the dissemination and implementation of clinical ultrasound.
Fig. 2 Medical ultrasound (bedside) with pocket-size device.
Not without reason, this type of ultrasound, performed at the location where the patient’s medical examination takes place, is also called “bedside” ultrasound, meaning it is performed at the patient’s bedside by an operator who is working in the clinical unit. This coincides with the definition of “clinical” ultrasound, where the meaning is precisely that of an examination carried out by someone who is regularly at the patient’s bedside. This is indeed reminded by the etymology of the word itself, as the etymology of “clinical” derives from the ancient Greek word meaning “bed,” making it synonymous with the current English term “bedside.”
Clinical ultrasound also will start from anatomical areas, similarly to “anatomic” or “district” ultrasound, but its boundaries will be determined by attempting to provide the best explanation for the clinical question rather than solely examining a specific anatomical district, also taking account of recent laboratory or instrumental findings.
Consequently, the technology used will correspond to the question at hand. If the question is basic and requires a binary yes/no response (e. g., Is there fluid in the peritoneum? Is the aorta dilated?), the examination can be performed using so-called “palm-sized” or “pocket-sized” ultrasound devices [7]
[8]. In this case, ultrasound becomes an extension of the patient’s physical examination and is also referred to as “bedside ultrasound” or “point-of-care ultrasound” (POCUS) or “echoscopy”. The advantages of this approach are evident: speed, simplicity, and above all, easy repeatability to monitor the progress of certain therapeutic interventions. The present article is not the place to provide an exhaustive list, but a few examples are immediately apparent: if a patient is not urinating and has hypogastric pain, POCUS can accurately determine whether there is a distended bladder and can confirm the correct placement of a urinary catheter when this had become necessary. Or, if instead the starting sign of lack of urination was due to dehydration occurring because of another hypogastric issue causing pain and lack of eating and drinking, POCUS could be used not only to rule out obstructive cases of anuria, but could be utilized to assess the caliber of the inferior vena cava supporting the achievement of adequate rehydration.
If, following a first level ultrasound examination, the clinical question proves particularly complex, the patient can be referred to specialized units equipped with high-quality ultrasound scanners and a multiparametric assessment, and the involvement of other imaging techniques might be recommended [9]
[10]. This high-level ultrasound care can still maintain a medical/clinical approach, but becomes performed in Radiology departments or clinical specialized centers equipped with high level machines by operators who have the depth of expertise required to perform these investigations or procedures (including contrast enhanced investigations and organ biopsies guided by ultrasound). In the highly specialized centers, it is easier to choose the best next imaging technology among computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), or scintigraphy when the ultrasound examination does not provide a conclusive answer to the clinical question, but, most of all, the operator can better provide a multiparametric integration of ultrasound with all previously executed imaging techniques, fostering the possibility to achieve the correct imaging diagnosis.
In any of the listed clinical scenarios and environments, the quality of the delivered examination must always remain high and medical ultrasound is different in terms of approach, but not in terms of experience of the operator. A report which is perfect from a formal point of view can be the best medico-legal guarantee. Reporting and performance of the examination cannot be separated from each other in the sonographic medical act, as sonography is a dynamic examination summarized in the report, based on a set of considerations not limited to the evaluation of the images. An extremely basic knowledge can be acceptable only for very focused echoscopy questions at the bedside, as an extension of the physical examination. EFSUMB, as Federation of multidisciplinary ultrasound societies, welcomes specialists from all branches aiming to maximize ultrasound education of medical students, medical doctors of different specialties, as recently shown in the recent successful EUROSON congress held in Riga in May 2023. The society will continue promoting common high level standards for ultrasound practice, organizing courses, textbooks, renovating the website and producing new and updated guidelines and position papers as the soon to arrive on multiparametric thyroid, breast or testis ultrasound currently in preparation.
