Building focused cardiac ultrasound capacity in a lower middle-income country: a single centre study to assess training impact

Background: In low- and middle-income countries (LMICs) where echocardiography experts are in short supply, training non-cardiologists to perform Focused Cardiac Ultrasound (FoCUS) could minimise diagnostic delays in time-critical emergencies. Despite advocacy for FoCUS training however, opportunities in LMICs are limited, and the impact of existing curricula uncertain. The aim of this study was to assess the impact of FoCUS training based on the Focus Assessed Transthoracic Echocardiography (FATE) curriculum. Our primary objective was to assess knowledge gain. Secondary objectives were to evaluate novice FoCUS image quality, assess inter-rater agree-ment between expert and novice FoCUS and identify barriers to the establishment of a FoCUS training pro-gramme locally. Methods: This was a pre-post quasi-experimental study at a tertiary hospital in Nairobi, Kenya. Twelve novices without prior echocardiography training underwent FATE training, and their knowledge and skills were as-sessed. Pre- and post-test scores were compared using the Wilcoxon signed-rank test to establish whether the median of the difference was different than zero. Inter-rater agreement between expert and novice scans was assessed, with a Cohen's kappa > 0.6 indicative of good inter-rater agreement. Results: Knowledge gain was 37.7%, with a statistically significant difference between pre-and post-test scores (z = 2.934, p = 0.001). Specificity of novice FoCUS was higher than sensitivity, with substantial agreement between novice and expert scans for most FoCUS target conditions. Overall, 65.4% of novice images were of poor quality. Post-workshop supervised practice was limited due to scheduling difficulties. Conclusions: Although knowledge gain is high following a brief training in FoCUS, image quality is poor and sensitivity low without adequate supervised practice. Substantial agreement between novice and expert scans occurs even with insufficient practice when the prevalence of pathology is low. Supervised FoCUS practice is challenging to achieve in a real-world setting in LMICs, undermining the effectiveness of training initiatives

Breast disease programs in obstetrics and gynecology: a plea for training in mammography.

Obstetrics and gynecology residency programs have started to integrate structured breast disease teaching programs into the curricula. I suggest that mammography training should be the cornerstone of programs on the diagnosis of breast diseases. The implementation of such a program into a teaching department is described in an attempt to facilitate similar efforts elsewhere.

Diagnostic ultrasound in general practice.

A three-year diagnostic ultrasound training project for generalists is described. Specific applications and a rationale for the use of ultrasound by general physicians are presented. The current status of training programmes, credentialing strategies, and desirable equipment characteristics are also discussed. Finally, benefits, liabilities and controversies in diagnostic ultrasound imaging are reviewed.

Obstetric ultrasound training for family physicians. Results from a multi-site study.

A practical program to train family physicians in obstetric ultrasound was tested with 13 family physicians. Each physician completed 6.5 days of course work and ultrasound laboratory apprenticeship prior to beginning a clinical preceptorship of approximately 14 months' duration. During the clinical preceptorship the physicians performed ultrasound studies in their own offices. All studies were reviewed by a local consultant radiologist utilizing examination data sheets and videotapes. At the conclusion of the training program, the physicians took a combined practical and written proficiency examination administered by an independent sonographer. Eight physicians completed the training, performing during the preceptorship an average of 78 examinations. The rated performance of the physicians improved markedly over the course of the preceptorship. During the last segment of the preceptorship the radiologist preceptors rated 94 percent of the ultrasound studies as acceptable, compared with 79 percent rated acceptable at the beginning of the preceptorship. Seven of the eight physicians completing the protocol took the proficiency examination: all passed. This study can provide a blueprint for an individual family physician to design his own training, or it can guide an academic department of family medicine in developing and evaluating ultrasound training programs for residents and practicing physicians.

The accuracy of measurements of ovarian follicular scanning by inexperienced observers using real-time sector scanning.

Three inexperienced operators (2 midwives and one obstetric registrar) were given ten sessions of training in ovarian follicular scanning. During each session, five patients were examined jointly. Once the inexperienced observers had received sufficient training the prospective study was started. Twenty measurements by each inexperienced observer were compared to measurements made by an experienced observer. In 17% of measurements the error was greater than 3 mm, the errors being evenly distributed among the three observers. After a further five sessions of instructions, another set of sixty measurements was generated: 93% of these measurements correlated exactly among the inexperienced operators and between the inexperienced and the experienced operator. This study suggests that after a supervised training of 15 sessions, obstetricians and midwives with prior obstetric scanning experience can produce reliable ovarian follicular measurements.