Wednesday, October 29, 2014
How does a non-cardiologist learn echocardiography? What's the deal with all of these ads for "123Sonography"?
But why, one might ask, would it be relevant for me to know echocardiography? I'm not a cardiologist after all. Cardiologists are the people who read most of the heart ultrasounds, or echocardiograms, that are performed in the US. The usual routine is that someone like me, a general internist, or a family practitioner, orders an echocardiogram for a patient with a suspected heart problem. An ultrasonographer, a non-physician with expertise in performing ultrasounds of the heart, obtains images of the heart from various views, saves representative images, performs calculations of movements and sizes of structures and sends the whole file to a cardiologist who interprets the data. The cardiologist then produces a document with various abstruse and arcane abbreviations and corresponding values which also, thankfully, contains a summary paragraph which says if the heart looked normal or not. This whole process can take up to a week from start to finish. The patient or the patient's insurance company will be charged one or two thousand dollars and at the return visit the patient's physician will likely say something like, "it looked pretty good" or "one of the valves is a little leaky so I'm going to have you see the cardiologist" or "it wasn't too bad for someone your age."
I have been doing a rather quicker and more focused version of the echocardiogram as a bedside procedure for the last 3 years which frequently serves my purpose much better than the scenario I just described. It is possible to learn the basics of cardiac ultrasound through continuing medical education classes taught by emergency physicians, who have used bedside ultrasound for decades to more capably triage patients. Ultrasound machines have gotten smaller, more ubiquitous in hospitals (often you can find one nearby if you need it) and even affordable to own and carry around. Mine fits in a lab coat pocket and gets pretty good images from which I can make more informed decisions regarding my patients' diseases and appropriate treatment. It doesn't replace the full scale echocardiogram, except in cases where the details are unnecessary. I have done thousands of focused echocardiograms, reviewed them with experts when that was appropriate, compared the results to full scale echocardiograms when those were done, and know much more about the normal and abnormal heart than I did during the first two decades of my internal medicine practice when I relied primarily on my stethoscope. My bedside echocardiograms tell me if the heart is weak, and how weak, if there is fluid around the heart, whether there is evidence of problems with the blood vessels in the lungs and if there is damage from long term high blood pressure. I can identify the moment of death quite accurately when attending the dying and can see if an acute heart attack is causing a patient's chest pain or breathing problems. I can avoid giving medications that the patient's heart will not tolerate.
When it comes down to it, though, a good cardiologist is better at interpreting an echocardiogram than I am. I am not qualified to take the images and arcane numbers produced by an echo technician and produce a succinct but exhaustive summary. I am an internist, which is a fine and noble job, but not a cardiologist. So, since I look at hearts at the bedside all the time with a small ultrasound, I would like to know more about the fine points of echocardiography.
I have looked around for years for a good way to learn echocardiography and found that, for someone already in medical practice, it is pretty tricky to get echocardiography training. There used to be a guy, an echo technician by training, who ran courses for internists and anesthesiologists in performing and reading echocardiograms, but he got old and pretty much stopped doing it. He also really did not approve of bedside ultrasound. His courses were expensive and weeks long. After completing a course, to be credentialed to read echocardiograms required shadowing a cardiologist for a period of time and then reading echocardiograms which were over-read by a cardiologist. It would have been much easier if I had only known I would need this when I was still in training.
So it was very exciting when the offer of a free echocardiography course came to me in my e-mail. I followed the links and found that the 4 module free course was well taught and informative. I was still wary, but plunked down $757 for a full "master class" in echocardiography which was self paced and gave me 30 hours of training. I had 6 months to use the resource material. It was really pretty good. The faculty is all from the University of Vienna, in Austria, which is a real place, not like University of Phoenix or something. The faculty are real cardiologists, clearly interested in their material and their English is just fine, though spoken with Austrian accents. Both image acquisition and interpretation skills are taught and there is an emphasis on understanding not just the echocardiogram but the physiology of the heart and the underlying disease processes. There were 20 modules, with quizzes following each. The quizzes weren't particularly well written, but were detailed enough that it was necessary to really pay attention. There were exotic European spelling and grammar errors which did not distract from the material. I completed the course, got a certificate of completion and I feel pretty certain that I still am not qualified to read a full scale echocardiogram. I do, however, understand quite a few more subtleties than I did, and will continue to do bedside focused echocardiography with renewed appreciation.
I think this course is much more aimed at training physicians in resource poor settings where nearly all doctors are generalists, and having a physician who is able to read an echocardiogram, even without knowing the finer points, is life saving and really all that is available. Doctors in these situations will use a course like this to go from knowing close to nothing to being able to capably diagnose the majority of cardiac conditions, to their patients' great benefit. This was truly an educational niche that needed filling. The teachers also do in-person few-day courses in various locations, which I would love to attend at some point, not least of all to see what the student body is like. If they are fantastically successful (and I kind of think they are) perhaps there will be competition, and possibly even accessible education in the US. It has seemed like the lack of educational opportunities acted to protect a piece of lucrative turf claimed by cardiologists. The US is not primarily made up of urban areas, though, and large portions of our geography, like where I practice, for instance, are not served by cardiology clinics. I am glad a resource like this exists, even though online training in something that is hands-on cannot expect to fully cover the educational needs of practitioners.