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Ultrasound section questions
How many out there are in places where the ultrasound techs and the radiologists consult with one another? If the ultrasound techs don’t show cases to the radiologists often or ever, how do you treat the improvement aspect, so the techs know what they are looking at, don’t make mistakes continuously, improve, know how radiologists evaluate?
If the ultrasound techs are independent, what strategies are there to work with them to make their work better? Conversely, if they show cases all the time and don’t grow, what do people do? -
23 Replies
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I have been at both types of places, one where techs and rads are both onsite together, and are predominantly working together on the same cases, others where most ultrasound techs are just uploading the worksheet and images to PACS and the study gets read by someone who could be anywhere. One issue I think is that with the institution of combined reading lists, often ultrasound studies get read by rads at other sites even though there may be a physical rad on site where the study was performed. But, if there are say 8 different rads reading from 6 different sites, most likely you are not going to be reading from your own site probabilistically. Seems a shame since there are physical rads on site at most of the time. But, there is always a rad to answer questions by techs if the tech has any. Most of the time tho, techs would rather just do the study and send the patient out since its unlikely therell be a callback or complaint from some remote reader
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I have gone in with the tech to image the area of concern at lest a few times a month, especially with the newbies. The older techs are pro and I havent had issues with them.
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In training, I read from my main academic site, the VA, and a children’s hospital which all three had in-house US techs and in-house readers.
The only time it seemed helpful was at the children’s hospital, where US is by far more capable of finesse, and optimizing for that operator variability produced results. Radiologist-tech discourse for adult imaging at the other centers was either nitpicking that I surmise didn’t effect patient care or pleading for non-garbage that fell on deaf ears (the VA).
My practice has the techs shoot reports off to us without discussion and I think it’s fine. I don’t see much if any management-altering discrepancy when I have US-CT correlation. Maybe our Peds US could benefit from discourse but our current situation is fine.-
Ideally there is a robust feedback mechanism and/or monthly conferences to review tech issues. Realistically that doesn’t happen because everyone is so busy.
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Radcog: you say ideally, but the reality is that when the radiologists and ultrasound techs/department are separated by space, social, workflow–how does that workflow even work? When do the techs realize that they may not know something? I’m asking as we are in a new time of understaffed rads, understaffed techs, pressure to produce, and a seeming confusing workflow.
If the separation is there, what strategies are there to get anyone to care? Or is this just a waste of time?-
The variability in technologist quality is significant. If you dont know the techs, you are at a big disadvantage.
It takes time and effort to create an appropriate supervised environment for ultrasound.
Many practices I think have given up, and just pipe cases through Pacs with little quality control.
The concept of using sonography as a specific problem solving tool is rare to some academic practitioners, esp peds.
For most practices its a primitive screening tool. If there is any question, on to another more reproducible modality.
Ironically, even with the less sophisticated technology, ultrasound was practiced at a higher standard 30 years ago. Dont seeing ever going back because of manpower issues.
Lastly, the techs are overworked and abused by most everyone. The fist thing that has to be done is give them reasonable production goals with appropriate supervision and clerical support before anything else. Hospitals is particular are brutal managers. -
Quote from Midwest Eastern Rad
Radcog: you say ideally, but the reality is that when the radiologists and ultrasound techs/department are separated by space, social, workflow–how does that workflow even work? When do the techs realize that they may not know something? I’m asking as we are in a new time of understaffed rads, understaffed techs, pressure to produce, and a seeming confusing workflow.
If the separation is there, what strategies are there to get anyone to care? Or is this just a waste of time?
The techs do an exam, fill out a sheet of what they think is happening, upload it to PACS. You dictate the report. You can call them if you have a question like “why did you say no liver mass but measured a 6 cm liver mass” and they say “oh oops yay there was a 6 cm liver mass”.-
Does anyone here have a problem if rads lose ultrasound altogether to ER, surgery, vascular, OB? It sounds like none of the respondents here have any suggestions to improve the day to day workflow and no respect for ultrasound in general. Im gonna try to figure out where else to look for real discussions
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Quote from Midwest Eastern Rad
Does anyone here have a problem if rads lose ultrasound altogether to ER, surgery, vascular, OB? It sounds like none of the respondents here have any suggestions to improve the day to day workflow and no respect for ultrasound in general. Im gonna try to figure out where else to look for real discussions
I don’t think anyone would care if US went away from radiology but I don’t think anyone else would actually want it. ER might have POC US but they aren’t uploading images to PACS, dictating a formal exam, and billing AFAIK.-
OB already reads a lot of pregnancy ultrasound, but they generally want no part in the stuff that comes through the ED. Vascular surgery tends to like to read vascular ultrasound. Cardiology reads hearts.
Its not even a fight we can win. If another service wants it, they are going to get it.-
Quote from RoleCall
OB already reads a lot of pregnancy ultrasound, but they generally want no part in the stuff that comes through the ED. Vascular surgery tends to like to read vascular ultrasound. Cardiology reads hearts.
Its not even a fight we can win. If another service wants it, they are going to get it.
if endocrinology ever takes thyroid US my life will be complete -
Quote from RadCog
if endocrinology ever takes thyroid US my life will be complete
LOL same here
I wonder if the original TI-RADS rads regret pushing it. They get a bunch of papers but I wonder if they get mean looks at conferences.
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Quote from W24
Quote from RadCog
if endocrinology ever takes thyroid US my life will be complete
LOL same here
I wonder if the original TI-RADS rads regret pushing it. They get a bunch of papers but I wonder if they get mean looks at conferences.
I actually really like TI-Rads because it doesn’t incorporate interval growth so I rarely do any comparison these days to prior exams. -
It does incorporate growth. 20% in 2 dimensions is considered growth
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Quote from RoleCall
It does incorporate growth. 20% in 2 dimensions is considered growth
Can you provide a source? I have looked at many charts on TIRADS and none of it contians anyting about growth. I think you are mistaken
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You should read the whole white paper before you continue using TIRADS.
[link=https://www.jacr.org/article/S1546-1440(17)30186-2/pdf.]https://www.jacr.org/arti…(17)30186-2/pdf. [/link]
Link won’t post. Google “tirads white paper” -
People also seem to have glossed over the lymph node section of the paper. Its not about size, its morphology:
“Abnormal findings suggestive of cervical lymph node metastasis include a globular shape, loss of the normal echogenic hilum, presence of peripheral rather than hilar flow, heterogeneity with cystic components, and punctate echogenic foci that may represent microcalcifications.” -
TIRADS mentions growth but it doesnt affect management recommendations which are based on size and features. A TR4 nodule could double in size from 6mm to 12mm and would still not meet criteria for FNa
I have found the ATA guidelines to be much better though often more confusing to find out what their actual guidance is. But generally they biopsy early, get a single follow up study (with time interval depending on features) then usually let them go if no change. It would result in substantially less diag ultrasounds but substantially more FNAs. From a purely selfish radiologist standpoint, if the endo people are doing the FNAs, you should go with ATA guidelines
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Growth does affect management, in some situations. Growth can shorten follow-up from 2 years to 1 year. It can also require a nodule to be followed for more than 5 years
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Quote from RoleCall
Growth does affect management, in some situations. Growth can shorten follow-up from 2 years to 1 year. It can also require a nodule to be followed for more than 5 years
those guidelines are not part of TI-RADS. maybe you are thinking of something in the endocrine literature? -
Nope, its TI-RADS. The pictures and tables in the literature are a good reference, but you really need to read everything before you use TI-RADS
“Careful comparison with any prior images helps determine if there has been threshold growth, which is defined as enlargement by 20% and 2 mm in two dimensions or a 50% increase in the volume of the nodule. If there is evidence that the TR category has increased but the nodule still does not warrant biopsy because of size criteria, then follow-up in 1 year is needed, and the prior surveillance recommendations are superseded.”
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Quote from RoleCall
Nope, its TI-RADS. The pictures and tables in the literature are a good reference, but you really need to read everything before you use TI-RADS
“Careful comparison with any prior images helps determine if there has been threshold growth, which is defined as enlargement by 20% and 2 mm in two dimensions or a 50% increase in the volume of the nodule. If there is evidence that the TR category has increased but the nodule still does not warrant biopsy because of size criteria, then follow-up in 1 year is needed, and the prior surveillance recommendations are superseded.”
good to know and thanks for sharing.
at my institution the doctors order yearly exams for every single patient so I don’t really think about followup frequency TBH. just biopsy vs FU
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Quote from Midwest Eastern Rad
Does anyone here have a problem if rads lose ultrasound altogether to ER, surgery, vascular, OB?
I would object. US is good money when you can do them back to back.
Now, I would gladly give thyroid US to endocrine. Because those are painful 😉
Quote from RadCog
I don’t think anyone would care if US went away from radiology but I don’t think anyone else would actually want it. ER might have POC US but they aren’t uploading images to PACS, dictating a formal exam, and billing AFAIK.
We have some ER docs who do. They image everything, whether it needs it or not and their US are never definitive. There is no need for a ‘formal exam’ on abdominal limited or pelvic limited. You document some pictures and what you saw.
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