Ultrasound standard around the world
By: Steve Ramsey Phd
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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.
This discussion is based on my personal experience after visiting many countries of the world in many years of my experience .
I have selected few countries from developing world including all regions of the world, regardless of their regional or religious origins.
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 ultrasonopraphy 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 attend 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, and they are
1) Professor Asim Kurjak, 2) Professor Barry B. Goldberg, 3) Dr Ted Lions .
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.
Things are improving after USA and MOH in Afghanistan exchange training programs.
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 many chances for up gradation 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. Doctors and radiologists work very hard and eager to learn new modalities and techniques and they ask anybody with skill in the field of sonography to volunteer and go train others
4) BRUNEI DARULSALAM
Clinical Ultrasound– Generally good in Private clinic, Excellent in the jerudong royal medical centre where I used to work for 7 years. Poor in RIPAS hospital as they depend on ill trained radiologists and OBG/gyn to do the ultrasound procedures . In 7 years I found more than 1200 missed diagnostic from other hospital. Some were very serious like calling a 6 years old live fetus, fetal demise and almost sent to abort. They do BPP and call it detail scan. In some clinics you have to take your shoes off and work in bare foot or wear a slipper .
No teaching setup in governmental & Private sector. I offered to teach and open a small teaching centre, I never hear any feedback for the last 10 years not even a thank you we will update you!
Most of the good sonologists and sonographers are foreigners.
Circumstances are favorable for teaching but lack of interest is noticed in most of the departments of Radiology. I presented more than 12 lectures and single handedly organized a one day 8 hours seminar for 1000 doctors, nurses, midwifes, and technologists.
No radiology/ultrasound society exists. They belonged to Singapore, Malaysia or Australia Ultrasound societies. I am still interested to open a small institute or college to teach Ultrasound, X-ray, MRI, Ct scan and MSK ultrasound If anybody are interested please email me so we can make proposal to the Ministry of education and ministry of health in Brunei. It might take 10 years to get an answer same as I found in the Middle East and gulf region for some reason paper work moves at snail paste and turtle speed.
5) EGYPT
Clinical Ultrasound– Generally very poor , Better in private rich clinics .
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. Same in France and most Scandinavian countries
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. I tried to help and volunteer teaching once , some corrupt individual stole our equipment and supplies so we didn’t go.
8) MACEDONIA
Clinical Ultrasound– Excellent. It is my mother back round country what I say
There are few teaching setup in governmental sector which are of good standards like in Skopje.
Circumstances are favourable for teaching. Excellent in Private clinics
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 Circumstances are very much favorable for teaching.
10) INDIA
Clinical Ultrasound– Generally good. Need quality work as the quantity over run the quality most of the time.
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 ultrasonopraphy.
Circumstances are very much favorable 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. Many financial scandals
Few individuals are of international fame.
There is no authority to regulate the things relevant to ultrasound. Some buy their degrees.
12) NEPAL
Clinical Ultrasound– Generally satisfactory.
There are teaching setups in governmental sector but no on Private sector.
Circumstances are not favourable for teaching. They ask for volunteer so if you are keen to teach you can e mail the MOH or other clinic and offer your help they will love to have you.
Radiology society of Nepal is dealing with Ultrasound too.
13) IRAN
Clinical Ultrasound– satisfactory. Sonographers not allowed to do the exam!
There are teaching setups in governmental sector only.
Many private hospitals arrange meetings for CME in ultrasound.
Only Radiologists are allowed to scan. As it is the case in most of the Arabic countries like Syria , Iraq, etc
Radiology society exists and is very active.
14) MALAYSIA
Clinical Ultrasound– Generally good
There are few teaching setups in governmental sector but just one in Private sector working with collaboration of ASUM.
Some private hospital occasionally arranges 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 satisfactory.
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. The only Country beside UK offers a credited PhD in Medical Ultrasound. The other places that offer PhD in med-Ultrasound run in Pakistan and Switzerland are mill PhD and unaccredited waste of time and money despite the good course materials.
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 setup 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 good in most hospital , excellent in Aramco and hospital who hired western sonographers. Many Asian Sonographers work in Private clinics with normal standard protocols and lots of miss pathologies. Now days more Saudi Sonographers with BSc and some with MSc degrees are in the market and provide excellent exam and some are super in their work .
There are variables due to different type of foreign trained sonographers, sonologists and radiologists having different training and educational backgrounds ,some poor and some standard .
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. Jealousy is seen when Syrian or other Arabic doctors sees a good western sonographer do the job so they always try to stop them from doing the job, or delay them and increase their stress level in the already stressed working internment that base quantity over quality in most of local hospitals but not in the national guards and specialist hospitals that run by good train western team.
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 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 used to write and publish papers with Sultan Qaboos University, Muscat, Oman . I was impressed by their standards and working relations. I didn’t find any society of radiologists or sonologists.
Circumstances are very much favorable for teaching but in governmental sector. They use UK protocols
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 centers 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 favorable 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. Once a college in shariah wanted to start an ultrasound program so they asked me and it took me 9 months to make a BSc and MSc model program and send it to them , they stole it and later the dean left and my project taken , they didn’t pay me single cent , and at the end they only have certificate program small course in the BSc in diagnostic imaging and the program run by Radiographer who obtained Burwins certificate from Canada and call it post graduate diploma!!!! Lol this is an open book exam with no control over the exam and 2 to 4 months correspondence course , it is an excellent course but it is not diploma and defiantly not post graduate diploma.
20) YEMEN
Clinical Ultrasound– Generally very poor. especially now days after the influence of Iranian terrorists who support the separatist with money and weapons to destroy the country as they did in Syria ,Iraq and Lebanon causing the migration of many radiologists and the brain drain of those countries.
No teaching setup in governmental & Private sector.
Circumstances are not favorable 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.
I had an offer from the Netherland to run the health science program , health science college for Ultrasound, X-ray , Lab etc. I supposed to be the dean of the college and the imaging director, when the college almost built the terrorists destroy it and burned it to the ground! So I lost yet another opportunity to shine, make living, teach what I learned .That’s why I hate terrorists in Iraq, Syria, Iran, Yemen, Lebanon and everywhere as they can destroy the fabric of the society .
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 ultrasonopraphy should pursue continuing education through “refresher” courses and conferences, as well as those offering updates on new technology and practice.
Regional (international) centers
Regional centers 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.
Same problem found in Iraq and Syria. There are no ultrasound training programs, and no ultrasound societies exist, it run by the radiology union. The sonographers are not allowed to do the exams! Many who sent abroad to be trained never come back .Many hospitals are ill managed at this time after the death of Saddam the country went down to drain, corruption and thefts everywhere. Killing of doctors and specialist are the norm. The Majority of the health care is poor now days after it was one of the best in the best in the world in Saddam time. North Iraq of the State of Kurdistan are more stable place with very good radiologists and sonologists but no sonographers yet. I offered to teach and train them but no body return the call or the emails , I dont know if that is the normal culture for them.
You can read more of my notes about many other cities and places in Japan, South Korea, Singapore which have the excellent sonography program, students, workers and radiologists to Australia and south east Asia and many other cities in Canada that I wrote about in my article Ultrasound the world in 30 years here in LinkedIn .You can read ll the previous articles. Don’t forget also to visit my new blog www.moleopedia.com
Conclusion ; It’s 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 15 to 20 % 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.
otherwise a separate council/committee must be established to register and accredit the sonologists followed by sonographers if they are nor ARDMS certified.
. USA and Canada must aim at MSc in medical ultrasound and start from now to create the ultrasound practitioner program for MSc in medical ultrasound degree holders who can do the report as they do in UK. Again that will not happen for the next 100 years due to envy and jealousy in the field and from those sonographers who do not hold the degrees that vote against it or not bother to push for it.
It is about 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.
Thank you for reading
Steve Ramsey, PhD.