My opinion
 

By Prof. Syed A Gilani
Corresponding Author Prof. Syed A Gilani
Radiology, Nawaz Sharif Social Security Hospital, Multan Road, - Pakistan 56000
Submitting Author Prof. Syed A Gilani
RADIOLOGY

Ultrasound, Education, Research, Developing Countries

Gilani SA. Ultrasound Education & Research in Developing Countries. WebmedCentral RADIOLOGY 2011;2(3):WMC001753
doi: 10.9754/journal.wmc.2011.001753
No
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Submitted on: 12 Mar 2011 03:20:38 PM GMT
Published on: 14 Mar 2011 09:55:05 PM GMT

Introduction


Diagnostic ultrasound is an emerging imaging technology which is widely used in both industrialized as well as developing countries.Ultrasound has found widespread application in anatomical imaging, blood-flow measurement, and evaluation of physiology in almost all aspects of medicine.
DISCLAIMER
This discussion is based on my personal experience after visiting 64 countries of the world in last 12 years. I have selected 20 countries from developing world including all regions of the world, regardless of their regional or religious origins.
I hereby declare that I don't have any objective to degrade or insult any country or its experts in Ultrasound, rather I wish to see them better so their nation & ultimately the Humanity can get better standards of sonographic diagnosis leading to best health care.
OBJECTIVE
The main objective of this experience based discussion is to share my experiences with the reader of this article; and the authorities in ultrasound.
I hope the deficiencies pointed out shall be taken positively to upgrade the knowledge of ultrasound in these countries.
BACKGROUND
A WHO Study Group on Training in Diagnostic Ultrasound: Essentials, Principles and Standards met in Philadelphia, PA. USA, from 22 to 25th March 1999 to consider methods of improving the performance of physicians and allied health professionals who use ultrasound for diagnostic applications.
Training in Developing Countries
The need for adequate education and training in ultrasonopraphy exists in both industrialized and developing countries. Moreover, the challenge of providing adequate training in ultrasonography is made more difficult by the diversity of its utilization, since no single medical specialty has a monopoly on its use.
Current ultrasonography training
There are no detailed international recommendations or guidance for training those who are using or wish to use this imaging technique. It was partly for these reasons that WHO prepared the Manual of diagnostic ultrasound which provides guidance on the ultrasound diagnosis of a wide variety of common conditions at the primary and First-referral levels of health care. Worldwide, it is likely that much of the ultrasound currently performed is carried out by individuals with in fact little or no formal training.Further, the need for basic training is greater in developing than in developed countries.
Variations in training and practice
After completion of specialized training, many radiologists in the United States continue for an additional year of advanced ultrasound training. In other countries, ultrasound training requirements may be more (e.g. Israel), or less demanding (e.g. Turkey). In non-imaging specialties, training requirements also vary. Scandinavian countries require courses of 30 hours of ultrasound training for obstetrics. 20 hours for cardiology, and 24 hours for gastroenterology. Ultrasound training for German physicians forms part of their internship, and consists of theory and practice components, often directed towards the specialty they will practice. Post-training evaluation is rare, but the organization of training programs is well established. In Japan, the Japanese Society of Ultrasound Medicine has formed a group of teacher/physicians responsible for the training of doctors and other health professionals applying for accreditation in ultrasonography. This accreditation has not yet been accorded an official status. In Australia and New Zealand, the Australasian Society for Ultra­sound in Medicine (ASUM) in 1970 formally recognized the need for comprehensive education to ensure high quality practice in ultrasound. In addition, radiologists are trained only at centers accredited by the Royal College of Radiologists, which is also responsible for continuing medical education in the field. Joint programs with other Royal Colleges, such as the Royal College of Obstetricians and Gynecologists, are also being organized to provide advanced training in ultrasound. In Latin America, several different approaches to training exist. In some countries, ultrasound is taught during specialized medical training, and consequently reaches only newly qualified physicians. In China training schemes for both general and advanced ultrasound exist, and can he attended at various stages of the medical career (e.g. post-graduate, fellowship). Continuing education programs are currently being established. In the rest of the developing world, however, the situation is quite different. Diagnostic ultrasound services are often not available at all, or only at an inadequate level.
Many individuals are misusing it.
The equipment is often old or inadequate, because of a lack of funds. Consequently, it can be technically out of date, or suffer from poor maintenance and unavailability of spare parts.
There are very few formal training programs in ultrasound with the exception of some centers where radiologists are trained at university hospitals.
Radiological societies may organize short refresher courses, but in much of the developing world adequate ultrasound training or services are lacking.
The accreditation of users and the control of quality are also rare.
There are two names which can be mentioned for their international setups and collaborations for continuous medical education in medical diagnostic ultrasound.
1)  Professor Asim Kurjak
2)  Professor Barry B. Goldberg

This Study


It is based on critical analysis of different aspects like Standards of clinical ultrasound in different hospitals of a country. Educational setups in universities and hospitals of that country
Role of health ministries in up-gradation of standards of ultrasound.
CME programs
National society/association.
Radiologists vs. non radiologist controversies
Private sector
Ultrasound education setups.
Guidelines & protocols.
The 20 countries included in this survey are
1) AFGHANISTAN
Clinical Ultrasound– Generally very poor.
No teaching setup in governmental & Private sector.
One private hospital arranged a meeting few years back.
Circumstances are not favourable for teaching.
No radiology/ultrasound society exists.
2) BAHRAIN; Salmaniya Hospital,Manama,Bahrain
Police hospital BAHRAIN
Standards of clinical Ultrasound are variable.
Generally are not very satisfactory for a rich country.
Govt. spends money on training and CME programs but most of the physicians least bother about learning.
Radiologists have influence therefore sonographers and sonologists don't have much chances for upgradation of their skills.
3) BANGLADESH
Clinical Ultrasound– Generally below satisfactory level, few individuals meet international standards else are very poor.
No teaching setup on governmental sector whereas there are three to four institute in private sector most of which are mishandled and disorganized.
One training institute offers few programs of better standards in Dhaka city.
Ultrasound society is one man show for last 15-20 years.
4) BRUNEI DARUL SALAM
Clinical Ultrasound– Generally good.
No teaching setup in governmental & Private sector.
Most of the good sonologists and sonographers are foreigners.
Circumstances are favourable for teaching but lack of interest is noticed in most of the departments of Radiology.
No radiology/ultrasound society exists.
5) EGYPT
Clinical Ultrasound– Generally very poor.
Few teaching setups in governmental & Private sector.
Circumstances are favourable for teaching but again few people have control.
Radiology AND Ultrasound society exists and are improving the standards of ultrasound in the country.
6) GEORGIA
Clinical Ultrasound– Generally poor.
Few teaching setups  in governmental but no setup in private sector.
Circumstances are favourable for teaching.
There is Radiology society which also deals with ultrasound.
Most of the people who scan are radiologists.
7) GHANA
Clinical Ultrasound– Generally very poor.
No teaching setup on governmental & Private sector.
Circumstances are not favourable for teaching in most of the areas.
A medical society deals with radiology and ultrasound.
8) MACEDONIA
Clinical Ultrasound– Generally good.
There are few teaching setup in governmental sector which are of good standards like in Skopje.
Circumstances are favourable for teaching.
A radiology society exists.
9) Republic of KOSOVO
Clinical Ultrasound– Generally very good. Physicians are keen to learn.
No proper teaching setup on governmental & Private sector.
Ultrasound society was very active for five year due to personal efforts of one of the sonologists who was trained by Prof.Asim kurjak.
Circumstances are very much favourable for teaching.
10) INDIA
Clinical Ultrasound– Generally good.
There are multiple teaching setups in governmental & Private sector.
The Indian federation of Ultrasound is very active and well disciplined.
Many courses/seminars and workshops are arranged on district and national levels. Few individuals are extra-ordinary in skills of ultrasonogrpahy.
Circumstances are very much favourable for teaching.
11) PAKISTAN
Clinical Ultrasound– Generally good.
Multiple teaching setup in governmental & Private sector.
Circumstances are very much favourable for teaching.
Ultrasound society of Pakistan exists but is just one man show and is not serving the ultrasound community appropriately.
Few individuals are of international fame.
There is no authority to regulate the things relevant to ultrasound.
12) NEPAL
Clinical Ultrasound– Generally satisfactory.
There are teaching setups in governmental sector but no on Private sector.
Circumstances are not favourable for teaching.
Radiology society of Nepal is dealing with Ultrasound too.
13) IRAN
Clinical Ultrasound– Extra-ordinary.
There are teaching setups in governmental sector only.
Many private hospitals arrange a meetings for CME in ultrasound.
Only Radiologists are allowed to scan.
Radiology society exists and is very active.
14) MALAYSIA
Clinical Ultrasound– Generally satisfactory.
There are few teaching setups in governmental sector but just one in Private sector working with collaboration of ASUM.
Some private hospital occasionally arrange meetings on ultrasound.
Circumstances are favourable for teaching.
There is Radiology society and an ultrasound society but not very active.
15) SUDAN
Clinical Ultrasound– Generally poor.
There are many teaching setups in governmental & Private sectors.
One private setup is working on international standards.
Some gynaecologists like Prof.Abdel Latif Ashmaig are working hard to established high standards of Obgyn ultrasound in the country.
Circumstances are very much favourable for teaching.
There is a radiology society but no ultrasound society exists.
16) NIGERIA
Clinical Ultrasound– Generally poor.
There are few teaching setup on governmental & just one private septup which is struggling for standards.
One private hospital arranged few Ultrasound CME meetings in last few years.
Late Dr Iseko Lee was one of my friends in Abuja who established a recognized training institute at Limi Hospital. Otherwise standards are variable.
Circumstances are very much favourable for teaching.
A Radiology society exists.
17) Kingdom of Saudi Arabia
Clinical Ultrasound– Generally satisfactory but variable due to different type of foreign trained sonographers, sonologists and radiologists having different training and educational backgrounds.
The general impression is good but when we deal with individual centres the situation is very bad,most of the people working in ultrasound are least bothered to train others and most of the local physicians are not interested to learn. No teaching setup in governmental & Private sector.
One private hospital arranged a meeting few years back.
Circumstances are not favourable for teaching as their hospitals and ministries arrange CME programs.
There is radiology society which has good standards as it mostly depends on foreigners working in the kingdom or coming as visiting lecturers.
18) OMAN
Clinical Ultrasound– Generally very good.
There is proper training and CME setup for locals and foreigners working in the state which is providing an ideal situation for the sonologists,sonographers and radiologists.
The atmosphere between these radiologists, sonologists and sonographers is ideal.I visited Sultan Qaboos University, Muscat,Oman to conduct a one week workshop on vascular ultrasound. I was impressed by their standards and working relations. I didn’t find any society of radiologists or sonologists.
Circumstances are very much favourable for teaching but in governmental sector.
19) UAE
Clinical Ultrasound– Generally satisfactory but variable due to different type of foreign trained sonographers, sonologists and radiologists having different training and educational backgrounds.
The general impression is good but when we deal with individual centres the situation is not satisfactory.
Most of the people working in ultrasound are least bothered to train others and most of the local physicians are not interested to learn. No teaching setup in governmental & Private sector.
Circumstances are not favourable for teaching as their hospitals and ministries arrange CME programs. And if any foreign society arranges any CME people are not mostly attracted.
No radiology/ultrasound society exists.
20) YEMEN
Clinical Ultrasound– Generally very poor.
No teaching setup in governmental & Private sector.
Circumstances are not favourable for teaching.
No radiology/ultrasound society exists.
We conducted three annual courses in 2004-06 at Thora Hospital and Military Hospital Sana'a, Yemen and found physicians to be interested in learning but the teaching atmosphere was not comfortable.
The Need of training programs
The development and implementation of intensive training programs specifically for ultrasound instructors is desirable and has been established practice for many years in some countries (e.g. Germany).
Models of such programs have been developed at the Jefferson Ultrasound Research and Education Institute in the United States.
Licensing and accreditation
Licensing and accreditation of ultrasound practitioners and teachers are the responsibility of local, national, or regional governmental authorities, professional societies, or other recognized organizations.
Continuing education
Regardless of the level of expertise acquired, all instructors and practitioners of ultrasonography should pursue continuing education through "refresher" courses and conferences, as well as those offering updates on new technology and practice.
Regional (international) centres
Regional centres should be established with the collaboration of all countries in a region, and preferably with the assistance of international professional organizations.
Equipment
Training centers should have adequate equipment and should be responsible for the implementation of educational programs.
Access to patients
Training centers should have access to patients presenting a range of conditions appropriate for the areas taught.

Conclusion


Its the time when ultrasound has proved that it is one of the major diagnostic tools in almost all modalities of medical sciences, we must work hard to recognize it as a separate imaging specialty -- not a part or sub-specialty of radiology.
We don’t have any objection on radiologists they can use ultrasound but after proper training programs during their radiology educational or residency programs.
I have come to conclusion that just less than 10-15% of radiologists are good in ultrasound and the reason is that they have special interest in it or are pushed by the department to perform ultrasound. Whereas most of the best ultrasound specialists are sonologists (physicians who can perform ultrasound).I can prove it in any country, in any system and at any platform.
All societies of ultrasound around the world have to take it seriously. Anyone radiologists or non-radiologists must have proper ultrasound training under supervision of qualified and registered senior people in ultrasound.
For instance in developing countries most of Radiologists are DMRD diploma holder and they are not taught ultrasound properly whereas those radiologists who hold degrees of MD RADIOLOGY and FCPS/FRCR or diplomat of American board of radiology are better.
Therefore those having DMRD must have at least 6 month full time training in ultrasound.
Similarly those who did their diplomat American board or Fellowship in radiology till 1985 must have CMES or at least three months training in ultrasound.
Whereas a non radiologist physician must have at least one year full time training in ultrasound relevant to his/her specialty, regardless of the diploma/degree he/she gets after one year.
There must be a specialty of ultrasound recognized by concerned authorities like PAKISTAN MEDICAL AND DENTAL COUNCIL in my country and similarly by authorities of all countries.
otherwise a separate council/committee must be established to register and accredit the sonologists followed by sonographers if they are nor ARDMS certified.
Its time to start working on this project.Make a system in which all physicians can use ultrasound but after proper training and they can be assisted by sonographers, who are again creating problems in the system by writing reports which obviously doubts the accuracy of ultrasound.

Source(s) of Funding


Afro-Asian Institute of Medical Sciences, Lahore, Pakisthan

Competing Interests


Nil

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Variation in Ultrasound Education World Wide
Posted by Dr. Thomas F Heston on 20 May 2011 07:09:35 PM GMT

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