|Year : 2014 | Volume
| Issue : 3 | Page : 284-288
Ultrasound training in surgical residency: Is it feasible?
Srihari Sridhara, Karan Vir Singh Rana, Satish Naware, Gurjit Singh, Ketak Nagare, Garima Gupta
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, India
|Date of Web Publication||18-Mar-2014|
Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune
Source of Support: None, Conflict of Interest: None
Purpose: Ultrasound training for the surgical residents is not a common practice in India. This study was undertaken to prepare a working model for surgical trainees and assess its effectiveness by training a single surgical resident. Materials and Methods: This was a prospective study of 238 patients with pain abdomen. Training was given in abdominal ultrasound for a period of 2 months. Ultrasound scans were performed independently by a radiology resident and surgery resident. Inter-rater agreement between both residents was assessed using Kappa coefficient. Ultrasound results were compared with clinical diagnosis and final diagnosis. Results: The kappa agreement was 0.53, 0.56, 0.8 and 1 for urolithiasis, appendicitis, pancreatitis and urinary tract infection, respectively. Almost all cases of cholelithiasis were identified by the surgery resident. There was improvement of 21%, 31% and 100% in patients of urolithiasis, acute appendicitis and liver abscess, respectively, in the second 10 months of the study. Conclusions: Ultrasound scans can be performed by a surgery resident with similar results as that of a radiology resident. Training of the surgery resident is possible with satisfactory results.
Keywords: Surgeon performed ultrasound, ultrasound training for surgery resident
|How to cite this article:|
Sridhara S, Rana KS, Naware S, Singh G, Nagare K, Gupta G. Ultrasound training in surgical residency: Is it feasible?. Med J DY Patil Univ 2014;7:284-8
|How to cite this URL:|
Sridhara S, Rana KS, Naware S, Singh G, Nagare K, Gupta G. Ultrasound training in surgical residency: Is it feasible?. Med J DY Patil Univ [serial online] 2014 [cited 2021 Dec 3];7:284-8. Available from: https://www.mjdrdypu.org/text.asp?2014/7/3/284/128954
| Introduction|| |
Ultrasonography (USG) as a diagnostic modality has continued to help the medical community for the past 50 years. In the initial years of ultrasound, the cardiologists and obstetricians evolved as innovators and the surgeons were the early adopters. The first surgeon to use USG was John Julian Wild (1946). He used ultrasound to image the bowel wall and breast and also described transrectal and transvaginal imaging. 
Surgeons are highly motivated to provide the best possible care for their patients, including the use of the latest technologic advances in diagnosis and treatment. Today, USG has its applications in the Intensive Care Unit, trauma center and during surgery, making it vital for the treating surgeon to exhibit proficiency in the same. However varied the applications are, the basics remain identical. Image interpretation in USG depends mainly on the knowledge of anatomy and the pathology of organ systems.
In Germany, since 1988, only surgical residents skilled in USG are qualified to sit for their National Board Examination. It is a part of surgical training in Japan, continental Europe and the USA. However, there is a lack of an ultrasound training program for residents of general surgery across India. In view of the above, this study was undertaken to analyze the achievability of USG training for surgery residents and its possible advantage in the evaluation of patients with pain abdomen.
| Materials and Methods|| |
Institutional Ethics Committee Clearance was obtained before start of the study. Informed consent was obtained from all the patients before inclusion in the study. The study prospectively looked at 238 patients with abdominal pain over a period of 20 months. Patients with penetrating trauma to the abdomen were excluded. The ultrasound machine used was Siemens - Acuson X300 with a linear probe (6-13 MHz) and a curvilinear probe (2-6 MHz).
The study was divided into four phases. The study outline is described in [Figure 1].
Training was given in the first two phases, the priming phase and the proctored phase.
The priming phase consisted of:
- Theory lectures: The surgery resident underwent 80 h of didactic and hands-on training in the Department of Radiology. Topics of the subject were covered in phased training sessions [Table 1].
- Attending certified ultrasound workshop: Completed a 3-day comprehensive course on the use of Critical Ultrasound in the practice of Emergency Medicine and Trauma organized by the Indo-US Academic Council for Emergency and Trauma.
- Observing USG examination: This included observing abdominal ultrasound examination being performed by radiology resident/professor. This was aimed at learning the techniques and practical aspects of performing USG. A total of 150 cases with 122 positive findings were covered during this session.
- Assessment: Competency assessment of the training was performed by both theoretical and practical evaluation. A minimum of 50% was set as qualifying marks and the eligibility for the next phase.
The proctored phase consisted of performing USG on cases with positive findings with an aim to reproduce the same results. One hundred patients of pain abdomen were evaluated under the guidance of the faculty of the radiology department. The next phase was performing USG independently. An equally trained radiology resident of the same batch was selected for comparison of results. All patients of pain abdomen were assessed initially by the surgery resident based on clinical history and examination. Relevant laboratory investigations were sent and provisional diagnosis was made. USG was performed on these cases by both the residents, and both were blinded from each others' reports. Any X ray taken was evaluated after the ultrasound scan. A positive scan was defined as an ultrasound scan that reports an expected abnormal finding or additional finding or any incidental finding other than a normal finding.
The reports of both the residents were compared with each other and with the discharge diagnosis. The final diagnosis was made based on either or all of the following: USG reporting performed by a radiology faculty, laboratory investigations, other radiological investigations, operative finding and histopathological diagnosis. The inter-rater agreement between the two residents was assessed using the kappa coefficient as statistical test.
| Results|| |
The indications for requesting USG are recorded in [Figure 2]. The age distribution, the positive scans and the concordance with the final diagnosis are listed in [Table 2]. The improvement shown by the surgery resident in the second 10 months of the study is computed in [Figure 3].
|Figure 2: Clinical impression requesting ultrasound Others - Liver abscess, obstructed hernia, operated case of cholecystectomy, pyonephrosis|
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The scan concordance with the final diagnosis was high in the age group of 30-39 years. Lindelius et al. in their study published in 2010 observed that the diagnostic accuracy is high in the age group of 30-59 years. 
|Table 2: Age distribution, positive ultrasound scans and concordance with final diagnosis|
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For urolithiasis, the sensitivity and specificity of the surgery resident were 66.67% and 100%, respectively. There were 15% positive scans in cases with renal colic in the study performed by Raman et al.  Renal cases had a sensitivity of 89.5% and a specificity of 98.5% in a study performed by Mandavia et al.  The kappa agreement between the surgery resident and the radiology resident was 0.53.
For acute appendicitis, almost half (46%) of the appendicitis were not picked up in the ultrasound scans. The surgery resident had a sensitivity of 41% and a specificity of 83.33%. The radiology resident had a sensitivity of 61% and a specificity of 80%. The kappa agreement was 0.56.
For cholelithiasis, the sensitivity and specificity of the surgery resident was 96% and 100%, respectively. The agreement between the results of the scan performed by the surgery and radiology residents was more than 95%.
The kappa agreement in cases of pancreatitis was 0.8. The cases of urinary tract infection had the maximum kappa agreement of 1. The cases of abdominal mass/malignancy were identified with the ultrasound, but a more definite diagnosis was given by the computed tomography scan. The ultrasound scan was not conclusive in seven cases of perforation.
There were 17 additional findings that were identified by the surgery resident as accurate as the radiology resident in 88% of the cases. One case of hypernephroma kidney was identified only by the surgery resident. However, the cases related to the female genital system could not be identified by the surgery resident.
Ultrasound was changing the clinical impression and the management in 17.6% of the cases. In a research performed by Aristomenis et al. published in 2008,  they found out that after USG, the management changed in 14-27% of the cases. Ultrasound increased concordance with final diagnosis by 10%, without any other investigating modality. Allenmann et al. found a 13% increase in the diagnosis with the use of ultrasound. 
In a pilot study by Christopher et al. reviewing 122 training programs, 19% of the programs provided less than 10 h of didactic instruction and 22% provided more than 40 h of instruction.  Majority of these training programs were for the emergency physicians. Therefore, to achieve a higher level of proficiency, 80 h of training was taken as a standard in our study.
| Discussion|| |
A study by Zielke et al. concluded that surgical residents trained in USG can achieve results comparable to those of "expert" sonographers.  Sajjad et al. concluded that surgeons can identify gallstones as accurately as the radiologists.  The number of positive scans in the biliary system was about 81% in the study done by Raman et al. 
Although ultrasound scans could identify the free fluid in the abdomen in case of perforations, X-ray abdomen was relied upon more for the diagnosis of perforation. The identification of free fluid in the abdomen is one of the first things to be learnt by trainees. 
The basic principle of any ultrasound training program is to ensure an efficient training of non-radiologists in the field of diagnostic ultrasound. , The widely accepted training guidelines , mandate an instructor, theory lessons, certified course in ultrasound and proctored training.
However, it must be taken into consideration that different trainees will acquire the knowledge at different rates and the level of training should be assessed at the end of the training session, like in our study.
The priming phase also included observing elective and emergency abdominal ultrasound examination being performed by radiology residents/professors. This part of the training is not needed if the trainee is already accustomed with the ultrasound machine and its usage. This was essential in our study because of the fact that, as undergraduate students, the exposure to ultrasound usage is very minimal in the current training curriculum followed in India. There are some studies published recently analyzing the effect of ultrasound training for undergraduates. , It must also be noted that each ultrasound examination involves routine scanning of all organs of the abdomen apart from the organ of interest. This improves the number of images seen by the surgery resident and thereby improves the image-retaining capacity.
The value of proctored training sessions has been greatly emphasized in the available literature. , The literature reports that proctored cases were less than 25 cases in 16% of the programs and more than 150 cases in 39% of the programs.  The Australasian College of Emergency Medicine allows trainees to perform as many cases in the training period till such time the trainee gains comfort, competency and technique.
The challenges met during the training include the time allocation and the accessibility to the equipment. Maintaining a cordial relationship with the radiology colleagues forms a vital part of such study. It has happened sometimes that the co-operation extended by the radiology faculty and some residents was not reflected by all.
Rozycki and Shackford found out that many of the obstacles can be addressed by incorporating the ultrasound curriculum into the surgical training.  With the implementation of such a course, it will be easy to plan and implement training classes for a group of residents rather than a single person, like in our study. The non-cooperation may be explained by the fear of invasion of practice domains. 
The time taken for performing an ultrasound scan by the surgery resident is an important aspect. This should be less according to the literature.  However, this factor could not be assessed in our study due to the non-availability of the machine all the time. This may be attributed to the strict norms followed with respect to prenatal diagnostics. This is a limitation of our study apart from inclination of the surgery resident to focus the examination on areas of clinical interest.
| Conclusions|| |
The comparability of the results achieved stand as a testimony for the level of training provided. Although the measure of agreement is valid in our study, it must be remembered that different trainees will achieve the necessary skills at different levels. But, the results of this study, where a single resident was trained in diagnostic abdominal USG, are promising.
Training of surgical residents in ultrasound forms the foundation for implementation of its principles in various clinical settings. This will also improve ultrasound application in various fields of surgery in the years to come. The use of intraoperative ultrasound and further advancements in the field of ultrasound can be easily learnt and applied with a strong foundation.
Also, if the treating surgeon sees inside the patient before operating on him, it is nothing less than a reassurance, both for the patient and for the surgeon. The impact of such a modality can never be understated.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]