Hashimoto, Beverly E. MD*; Kasales, Claudia MD†; Wall, Darci MD‡; McDowell, Jennifer RDMS, RVT§; Lee, Marie MD∥; Hamper, Ulrike M. MD, MBA¶
For more than 15 years, educators have recognized the need to teach medical professionalism. A recent review article identified more than 200 articles dedicated to teaching medical professionalism between 1999 and 2009.1 Although many definitions of professionalism have been proposed, the most universally accepted definitions are based on behaviors because behaviors are more easily measured. Using this behavioral definition of professionalism, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Radiology2 (ABR) have defined professionalism as 12 behavioral milestones to be achieved by radiology residents2 (Table 1).
Although many professional aspects of sonography are similar to the rest of radiology, the relationship between the radiologist and the sonographer is a feature unique to ultrasound. This relationship results from the significant operator dependence of current sonographic technology. Unlike magnetic resonance imaging and computed tomography, most sonographic examinations are not rigidly standardized. Although certain prescribed imaging protocols are followed for any given examination, operators have a significant leeway in the final documentation because of the numerous imaging angles and approaches that are possible for each patient. Furthermore, differences in body habitus, patient mobility, equipment, and sonographic technical parameters contribute significantly to the final documentation. In most laboratories, this important operator feature belongs to the sonographer. Because the sonographer controls the quality of the examination, radiologists must trust and value their sonographers. Thus, building a radiologist-sonographer relationship is critical to the optimal performance of an ultrasound laboratory.
Teamwork is a well-recognized attribute of medical professionalism.3–6 For those who perform ultrasound regularly, having a good radiologist-sonographer relationship seems obvious but difficult to quantitate. However, the importance of this relationship was highlighted in a study, which compared the accuracy of radiology interpretations of examinations performed at a remote location with those performed with radiologist on-site. The authors noted that the accuracy between these 2 situations was comparable but highly dependent on good communication between radiologists and sonographers.7
If having a constructive relationship with sonographers is important for high-quality ultrasound, then instructing radiology residents to develop skills to obtain such a relationship should be part of the ultrasound professionalism–teaching curriculum. But how does one teach this principle? Unlike other areas of professionalism such as patient confidentiality, teaching a resident the importance and value of the sonographer is not a lesson, which is effectively transmitted in a formal lecture. British authors reported that their medical students favored learning professionalism by observing physicians rather than listening to formal lectures.3 Teaching residents about optimal radiologist-sonographer relationships is probably best done by observation and role modeling.
The nature of educational sonographic training complicates the teaching of radiologist-sonographer professionalism because the resident-sonographer relationship changes because the resident masters the factual sonographic material. Early in ultrasound training, the resident is highly dependent on the sonographer as a teacher. Residents learn scanning techniques and how to use and optimize sonographic equipment. As residents progress, they transition into more of a clinician leadership role. Optimally, this role will mimic the relationship expert attending physicians have attained with their sonographer staff. The transition from being completely dependent to becoming a leader is not easy and requires active guidance from expert radiologists as well as the cooperative participation by experienced sonographers. Supervising radiologists should clearly identify the behaviors expected of residents because they transition through their training. Sonographers should be interested in teaching residents and should be comfortable with experiencing the transition of residents from dependent learners to leaders of the clinical team. To have a successful program, sonographer teaching should be reinforced because the sonographers transition from student to junior, then senior or supervising positions.
DESCRIPTION OF RESIDENCY LEARNING PROCESS
The following proposed ultrasound training program incorporates the residency professionalism milestones published by the ACGME and the ABR2 (Table 1), and the general ultrasound milestones suggested by the Society of Radiologists in Ultrasound8 (Table 2). Using this format, the ultrasound resident-sonographer professionalism training program may be described by the following levels:
Level 1 (beginner) residents learn level 1 professional values and ethics listed by the ACGME and the ABR. Residents should practice these behaviors because they are introduced to sonographer roles.
Level 2 (advanced beginner) residents demonstrate behaviors of level 1 and are effective health care team members. Residents become less dependent on sonographers and develop effective dialogue with sonographers about cases, which are normal or which have basic abnormalities.
Level 3 (competent) residents demonstrate behaviors of levels 1 and 2 and are effective health care team leaders. Residents begin to develop leadership style, which engages the sonographer in clinical case discussions to help craft optimal sonographic documentation.
Level 4 (proficient) residents demonstrate behaviors of levels 1 to 3 and serve as a role model for professional behavior. Residents exhibit an optimal clinical leadership style regarding complex cases and involve sonographers in organizing and aiding patient management.
Level 5 (expert) residents participate in local and national organizations to promote professionalism and ethics and mentor others in these areas. Residents are a source for educating sonographers about advanced scanning techniques and developing clinical research or quality improvement projects involving sonographers.
When reviewing the medical professionalism literature, the 3 main themes necessary for effective teaching are reinforced; these are as follows: (1) possession of medical knowledge is needed to exhibit medical professionalism; (2) professionalism is best transmitted in the clinical setting as an apprenticeship; and (3) students exhibit appropriate professionalism only after long-term and repetitive behavioral reinforcement. The exhibition of medical professionalism is inherently bound to and a critical element in the practice of medicine. Therefore, to optimally demonstrate professionalism, it is imperative that one should possess adequate medical knowledge. This intuitive link is demonstrated by a survey of third year British medical students, in which medical knowledge was voted the most important element of professionalism.3 Medical knowledge is part of the reason why physicians are trusted, and trust is a key component to ideal relationships. Relationships mean more and bring “the best in both parties when it is grounded in mutual trust.”9
In sonography, trust is a critical component in the professional relationships between radiologists and sonographers. Sonographers express concern when they cannot trust the sonographic expertise of radiologists.10 Radiologists in turn must be able to trust the sonographer’s skills to obtain the correct images and hence make the right diagnosis. However, although medical knowledge is essential for professionalism, having knowledge alone does not mean that the student exhibits acceptable professionalism. Therefore, professionalism needs to be taught in parallel with medical knowledge.
Most authors advocate that medical professionalism is best taught in the clinical setting (as opposed to formal lecture method). Sociocognitive psychologists have found that behavior is more likely to be influenced by the individual’s surrounding situation rather than by underlying attitudes.11,12 Therefore, experienced medical instructors have advocated that behavioral education should be associated with clinical training. Ideally, teaching of professionalism should be taught by expert teachers who demonstrate sound professionalism in their daily work. The principles of professionalism can be further reinforced through case-based learning.11,13 This style of teaching has been described as an apprenticeship.14 The apprenticeship method is particularly applicable to ultrasound training because residents need to not only learn academic medical facts but also manual techniques. Sonographic medical knowledge can be taught in parallel with sonographic professionalism.
Besides having role models, researchers have found that professional behaviors need to be consistently reinforced throughout the medical program.15 The general attitudes of the medical training program are more powerful than intermittent or spotty exposure to professionalism training.1 Wear and Zarconi16 reported that their medical students cited the clinical environment as the place “where negative cues influenced students’ conceptions of altruism, compassion, and respect.” Efficiency, not empathy, is valued in a busy clinical environment. Ultrasound radiologists are commonly faced with accommodating increasing examination volumes while at the same time teaching residents. This clinical pressure increases the difficulty in providing consistently sound professional role models.
Therefore, to develop a successful ultrasound professional teaching program, the curriculum should include all of the previously mentioned features. That is, the sonographic knowledge should be taught in conjunction with ultrasound professionalism. The teaching method should involve clinical practice and role modeling, and finally, the resident should be consistently exposed to professional teaching throughout their training period. Because every radiology residency has different educational resources, educational goals rather than specific teaching methods have greater practical application for a broad range of programs. However, educational goals alone do not provide guidance on implementation; therefore, discussion of possible teaching scenarios may clarify how a program may carry out this training.
Level 1 residents have not had any previous ultrasound training. Although they may learn sonographic anatomy by reading, reviewing patient cases with attending physicians, and listening to lectures, resident exposure to scanning allows them to appreciate the pitfalls and challenges associated with the operator dependence of ultrasound. When in the scanning room, the resident is first introduced to the role of the sonographer. If sonographers are used in the educational process, the resident-sonographer interaction may include observing sonographers’ scan, resident hands-on scanning observed by sonographers, and sonographer instructing residents about equipment. During this process, the resident is dependent on the sonographer for information.
When developing the ultrasound residency teaching process, the residency director should include sonographer leadership in developing educational goals and designing optimal teaching methods. Once this structure has been instituted, the uniformity of resident experience can be established by optimizing sonographer training. Sonographers may have variable educational backgrounds. Before working with residents, sonographers should be evaluated for their medical knowledge and technical expertise. This evaluation can be performed in conjunction with the laboratory’s usual performance assessment program.
Once the sonographer demonstrates adequate sonographic knowledge, they should receive specific instruction concerning their role in residency training. Inexperienced sonographers may initially observe experienced teaching sonographers interact with residents. During their training period, these new sonographers should be actively coached by experienced sonographers and radiologists. Before being involved in resident teaching, the new sonographer should be evaluated by these teaching sonographers and/or radiology attending physicians. Any inadequacies should be addressed before allowing a sonographer to participate in training radiology residents.
Although sonographer performance is an important factor in an optimal sonographer-resident relationship, the resident should expect to be an active participant in this process. Besides exhibiting the ACGME and ABR milestone behaviors, the successful resident should also exhibit self-motivation for learning and express gratitude for sonographer’s instructions. Unfortunately, although residents may exhibit these behaviors to attending radiologists, they may not necessarily demonstrate these qualities to sonographers. Lack of resident interest or signs of disrespect will commonly reduce the sonographer’s willingness to aid them. One of the author’s previous residents announced in the sonography room early in his first ultrasound rotation that he wasn’t interested in ultrasound because he was going into interventional radiology. Later in his residency, a sonographer remarked that this attitude was ironic because he needed their help when doing ultrasound-guided biopsies.
Level 2 residents have mastered normal sonographic anatomy and basic pathology, so they can begin to independently evaluate and interpret cases. During the level 2 preparation, the resident’s training transitions from the scanning room into the reading room. The development of picture archiving and communication systems (PACS) has greatly changed ultrasound workflow. Although highly advantageous in streamlining ultrasound images, PACS has been cited as a barrier for developing effective teamwork between radiologists and other health care workers.17 Mistakes have been attributed to poor communication between radiologists and sonographers when using PACS systems.2 In this role, residents should recognize their interdependence with the sonographer in optimally understanding each case. Because residents have not mastered sophisticated pathologies, they also observe how expert ultrasound radiologists interact with sonographers. These observations will form the model for their behavior as they progress through their training.
Level 3 residents are learning more advanced sonographic techniques such as vascular ultrasound. During this process, they should begin to develop clinical leadership skills when handling an ultrasound case. They should be able to integrate the sonographer’s information while viewing patient images. The resident should lead the discussion by asking questions about pertinent clinical history or puzzling images and recognize when additional sonographic imaging is required to clarify findings. While leading the discussion, the resident should learn communication techniques that engage the sonographer. The effective leader recognizes that physician-sonographer teamwork is critical in obtaining optimal information to aid the patient. Residents can learn these skills by modeling senior attending physicians, active coaching from observant expert physicians, and by daily practice handling real-patient cases. During this stage of resident training, the sonographers present the case to the resident, and the attending physician observes the interaction of the resident with the sonographer. After the sonographer has left the reading room, the attending physician discusses any communication issues with the resident in private.
Level 4 residents are comfortable handling difficult pathologies and have mastered the leadership skills necessary to develop teamwork with sonographers. Sonographers have confidence in the clinical judgment of this resident. When requested to obtain specific images, sonographers are motivated to produce images, which otherwise may have been difficult to obtain. The consistent professional behavior of these residents can serve as role models for other residents.
Level 5 residents have mastered professional ultrasound skills and are involved in promoting this topic in local or national meetings. These residents not only work well with clinical sonographers but also partner with sonographer leaders in educating others about professionalism. Clinically, these residents may also engage sonographers in research or in developing new examination protocols or quality improvement projects. These residents can mentor other residents and sonographers about professional behavior.
Each of the previously described 5 levels is designed to develop radiologists who can ultimately function as effective imaging partners in the radiologist-sonographer relationship. If residents do not fulfill these milestones, then they will face some limitation in this role. The use of each milestone is best understood by reviewing the effect of not reaching each level. What type of radiologists do they become? Level 1 radiologists are completely dependent on their sonographers. They may not even review the images, and their dictations may mimic their sonographer’s notes. This radiologist may not have had any scanning experience and does not comprehend the role of the sonographer in the section or fully appreciate the skills of the sonographer. Lack of understanding sonographer role is one of the strongest complaints expressed by sonographers.10
Radiologists who only master level 2 are also highly dependent on sonographers. Although they are familiar with common pathologies, this radiologist will make interpretive mistakes with less common abnormalities, particularly if the sonographer does not identify the correct diagnosis. This relationship between radiologist and sonographer fosters ill will among sonographers who feel that they should be paid to be the interpreter of the study.10
Radiologists who master only level 3 have difficulty integrating complex sonographic cases. They are insecure interpreting sonographic studies and tend to recommend other cross-sectional modalities rather than confidently identifying and evaluating the problem with ultrasound. This insecurity can lead to their identifying phantom sonographic abnormalities from normal findings and inappropriately sending sonographers back to retake multiple images. Sonographers commonly do not trust the clinical judgment of these radiologists and resent the extra work, which may not aid in the patient’s care.
Radiologists who master level 4 intelligently interact with their sonographers, asking appropriate questions about imaging findings. These radiologists are commonly excellent sonography teachers. When the sonographer has a question about a potential lesion, the radiologist can analyze the images and determine management. These radiologists recognize when additional ultrasound imaging is necessary but some times may not be able to describe the optimal sonographic technique necessary to solve the problem. These imagers may be dependent on having experienced senior sonographers who can translate their request into appropriate sonographic imaging.
Radiologists who master level 5 are engaged with their sonographers in producing optimal examinations. Sonographers use them as teachers. Furthermore, these radiologists not only view the examination for diagnostic purposes, but they also critically evaluate the technique of the sonographer. Growth and maintenance of sonographer scanning skill are important for this radiologist because he/she is aware of the integral role the sonographers play in maintaining high-quality ultrasound. If the radiologist has a question about a finding, this radiologist can articulate the problem and recommend a sonographic technique, which may clarify the issue. The radiologist is not completely dependent on the sonographer to determine the best method. However, optimally, this radiologist is open to dialogue if the sonographer has other suggestions. For optimal radiologist-sonographer teamwork, all radiologists in an ultrasound laboratory will master level 4 milestones and at least 1 will attain level 5 training.
Optimal evaluation of professionalism is both longitudinal in time and multidimensional in technique and observers. Longitudinal evaluation is important because professionalism is a set of behaviors, which should not only be attained but also maintained. This process necessarily requires regular feedback and opportunity for individual reflection and behavioral change. Furthermore, because professionalism is a complex entity, evaluation should be multidimensional in methods and sources. Methods proposed for medical professional evaluation include observed clinical encounters, collated views of coworkers, record of individual incidents of lapses, simulations, article-based essay tests, and self-administered examinations.11 Increasing the number of methods and the number of observers increases the reliability of the results.11 The types of methods and numbers of observers are limited by the resources of the residency program.
In conclusion, radiology resident ultrasound training programs should include training of professionalism throughout their curriculum. This training is highly beneficial in promoting teamwork between radiologists and sonographers, which in turn optimizes patient care and fosters a productive and respected imaging section.
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