Who's doing your scan? A European perspective on ultrasound services

Traditionally, in many countries in Europe, ultrasound practice and delivery of service is physician based. In some English-speaking countries around the world, notably Canada, Australia and the United States of America (USA), ultrasound is performed often by technicians or sonographers but reported by physicians, mainly radiologists. In the United Kingdom (UK) a third situation exists; that of predominantly sonographer-led ultrasound services. A sonographer is typically a radiographer who has now specialised entirely in ultrasound after a designated period of formal training (postgraduate qualification in ultrasound), mostly working within radiology departments as part of a team of radiographers and radiologists. This article explores the processes behind the differences and discusses the underlying rationale and prejudices involved. The reasons behind the inexorable rise in ultrasound examinations throughout Europe are well understood but when it comes to investigating who is providing these examinations, and to what level, the findings are remarkably inconsistent [ 1 ]. It is difficult to obtain accurate data but, in some European countries ultrasound is practised almost exclusively by medically trained practitioners, normally in general practice or within a subspecialty such as urology, gynaecology or cardiovascular surgery. Ultrasound is used as an adjunct to their practice and the services of a radiologist or sonographer are not sought [ 2 ]. In the National Health Service (NHS) in the UK, the largest provider of ultrasound services, it is suggested that around 80 % of ultrasound examinations are performed and reported independently by sonographers. The remaining ultrasound examinations are performed by radiologists (19 %), with less than 1 % performed by other medically trained practitioners, which includes urologists, emergency physicians and fetal medicine specialists. This model has proved to be successful and safe in the UK environment [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] for well over 20 years but as yet is not replicated elsewhere in Europe. There may be several reasons for this different approach to ultrasound service provision. Hospitals and clinics on mainland Europe are often smaller than those in the UK and there are more medically trained practitioners per head of population; the UK doctor has always been “time-starved”. This allows the doctor outside the UK sufficient time to be able to retain ultrasound examinations as part of their own practice and have had no need to consider delegating this task to others. In the right hands, ultrasound is a rewarding, powerful diagnostic tool and is a very satisfying part of medical practice. There is no desire to relinquish this aspect of practice. In some European countries outside the UK, including Ireland, Denmark, Sweden, Norway and the Netherlands sonographers are performing many of the ultrasound examinations. All are well-established groups and have been practising in some cases for more than 20 years. Many also write a provisional opinion but the overseeing medically trained practitioner always takes responsibility for the final report even if they make no changes to the sonographer's initial findings. In the UK it is recommended that the person performing the examination produces the report since, due to the dynamic and transient nature of ultrasound, it is deemed safest and best practice [ 8 ]. Static “snapshots” are a poor substitute for the wealth of information gleaned from the real-time study. Probable reasons behind sonographers not issuing reports independently in countries other than the UK include training and remuneration combined with tradition and medically trained practitioner dominance, a situation that prevails in the USA. Medically trained practitioners in countries that do not have sonographers issuing reports sustain this on the grounds of the explicit lack of medical knowledge of sonographers required to interpret and manage ultrasound findings. This was debated recently at a session dedicated to this topic at the 2017 European Congress of Radiology, Vienna. The evolution of clinical demand for ultrasound services has, however, made a number of medically trained practitioners consider ways to overcome these real and perceived barriers; the struggle to meet demand is evident with one or two centres outside the UK now looking at new ways of working and piloting independent reporting by sonographers [ 9 ] [ 10 ]. Ultrasound training for both sonographers and medically trained practitioners across Europe is variable [ 1 ] [ 2 ]. Some sonographers need have no prior background in healthcare, learning ad-hoc and “on the job” and may work only for a specific medical specialist in a narrow area. Others may already have a radiographic background and may not practise until they have gained formal postgraduate qualifications and passed rigorous competence tests across a range of clinical areas, as in the UK [ 10 ]. Similarly, some medically trained practitioners undergo robust lengthy ultrasound training ending with some type of competence assessment, as recommended by the European Federation of Societies for Ultrasound in Medicine and Biology [ 11 ]. Others only have to perform a minimum number of supervised and unsupervised ultrasound examinations, or show evidence of practice for relatively few hours. Others purchase an ultrasound machine for use within their own practice but seek no training at all. This diverse nature of ultrasound training indicates that the likely best practitioner is the fully trained practitioner; either a properly trained sonographer or medical practitioner. Both are very likely safer than a physician without training despite the advantage of medical knowledge to interpret scan findings. Ultrasound technique and interpretation are skills acquired slowly over time and cannot be learnt in a day. Several studies have conducted audit and “double reporting” by both sonographer and radiologist as a means of initially investigating sonographers’ reliability to detect, interpret and report. Results over the years indicate sonographers and radiologists have a similar accuracy [ 3 ] [ 4 ] [ 6 ] [ 7 ] [ 9 ]. Should the route of increasing sonographer scanning and reporting be contemplated, many hurdles are present. Creating a cohort of independent ultrasound practitioners requires more than just robust training, assessment and a period of dual reporting. It is vital that sonographers learn and practise within departments with a multidisciplinary philosophy [ 11 ]. Furthermore, legislation in many countries would need amendment; regulatory organisations will need to consider changes in guidelines for delegation of tasks. New local protocols to define scope of practice will need to be developed and sonographers will have to ensure they are protected with appropriate indemnity cover. As a consequence, sonographers' salaries may well rise but, assuming the level of remuneration reflects that of the UK workforce already in place, sonographers will still be more economical than a medical practitioner. Standardised training and education offered as undergraduate and/or postgraduate university-based courses would allow sonographers freedom of movement to practise, but this should always remain in an interactive environment. In larger centres of ultrasound practice, the sonographer forms part of a team, with overall responsibility for the integrity assumed by the department lead. When ultrasound is performed in an isolated medical practice, employing a sonographer assumes delegation and responsibility, which lies with the practice lead. As stated by the Society of Diagnostic Medical Sonography (USA); “The diagnostic medical sonographer functions as a delegated agent of the physician and does not practice independently” [ 12 ]. The sonographer is therefore unlikely to ever achieve a truly independent status, a point still debatable even in the UK, and would require considerable legislation change in a number of countries to be fully independent. However, with the right education and support, non-medical autonomous sonographers, albeit a small but growing group, across Europe and beyond would likely be a reliable resource within imaging teams in hospitals and clinics. Sonographers undertaking routine ultrasound services, as in the UK, would free radiologists to engage with more complex conditions requiring interventional procedures and multimodality imaging. The general practice based medical practitioner may be less needing of sonographer support currently, but the rapid changes of healthcare costs may necessitate this in the future. Currently, if you have an ultrasound examination in the UK, it will almost certainly be performed and reported by a suitably qualified highly trained sonographer but this is not the same for the rest of Europe, where it may be done by one of a raft of practitioners but who is not necessarily an imaging specialist. Does this matter? Possibly not, so long as you can guarantee they have completed appropriate training and assessment. However, demand for ultrasound services is increasing at a rate at which some European clinicians are finding difficult to keep apace, and may precipitate delegation and autonomy to non-medical practitioners. Should this be contemplated, the UK model of robust training has stood the test of time to result in a predominantly hospital sonographer delivered service, from which lessons may be learned. The ability to be a truly independent reporting sonographer will still be resisted by many, but this may eventually be driven by healthcare costs. There is already change in some European countries but this practice remains far more accepted in the UK, USA, Canada and Australia with the UK the only country so far that is reliant on independent sonographer reporting. Hazel M. Edwards Paul S. Sidhu

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