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UMDNJ-NJ Medical School Newark, NJ 07103
I wish to thank Dr. Hertzberg et al. for their thought-provoking article "Physician Training Requirements in Sonography: How Many Cases Are Needed for Competence?" [1]. I doubt that any radiologist with experience in sonography would disagree with the conclusion that involvement in 200 or fewer cases is not sufficient for a physician to develop competence in sonography. However, I wish to raise a few issues regarding the study.
The authors evaluated the sonography proficiency of first-year radiology residents at various stages of training by comparing studies performed by each resident with studies performed by both an experienced sonography technologist and an attending radiologist. However, in the methodology of the evaluation the deck appears to have been unfairly stacked against the residents.
First of all, was the study investigator who reviewed the images unaware of which image sets were produced by the trainees and which by the experienced sonographers? If not, this could introduce bias.
Second, each discrepancy between the resident and attending interpretation was automatically counted as resident error. Although unlikely, it is conceivable that in some cases the residents may have detected findings missed by the sonographer and attending physician. Was there any follow-up to ensure that this did not occur?
Third, and most significantly, resident performance in this study was not compared with that of a single individual (the attending radiologist) but, rather, was compared with the cumulative performance of an experienced sonography technologist and an attending physician on the same patient. To be fair, either the resident should have been supplied with a sonography technologist (which probably would have significantly improved "resident" performance), or the attending physician should have performed the studies without the help of a sonography technologist.
Although I doubt that any of these measures would have affected the conclusion of the investigation performed by Dr. Hertzberg et al. [1], when evaluating physician competence, especially for the purpose of making training recommendations, we should ensure that the methodology is sound (pun intended) to be as fair as possible to the trainees.
As a final point, we as radiologists may initially take delight in the results of these types of investigations because the implications for our turf battles are obvious. However, in the academic setting we may soon be called to practice what we preach. For example, at Dr. Hertzberg's institution, are first-year radiology residents allowed to perform or provide the initial interpretations for emergent sonographic studies, and if not, at what point in resident training does this occur? Because even the best scores attained by the trainees in this study were inadequate and there were pronounced differences between individual residents at the same level of training, should residents even be allowed to perform emergent sonographic studies until they have been deemed competent?
References
Duke University Medical Center Durham, NC 27710
We thank Dr. Maldjian for his interest in our recent article "Physician Training Requirements in Sonography: How Many Cases Are Needed for Competence?" [1]. His comments are interesting and thought-provoking. Dr. Maldjian raises the issue of fairness to the residents in the study design. The study was not intended to be a competition pitting residents against attendings or sonographers but, rather, was an attempt to measure the progress of resident education in sonography against the current standard of sonographic imaging available. The ultimate goal was not one of fairness to residents but, rather, one of fairness to patients, who expect and deserve to have high-quality sonographic examinations. The sonographer—sonologist team was chosen precisely because the considered opinion of this team is the standard for sonographic examinations performed at our institution.
In answer to Dr. Maldjian's other questions, all images in the study were reviewed on a digital display system. It was not feasible to blind the study investigator to the source of the image sets because the images obtained by the trainee were not an official part of the patient's medical record and, therefore, could not contain the true name or history number of the patient. Although we acknowledge this may have potentially introduced a source of bias to the study, it is important to emphasize Dr. Maldjian's point that any bias resulting from this was likely to have been minor and would not have significantly influenced the conclusions of the investigation. It is likewise highly unlikely that there were any cases in which residents made findings that were missed by the sonographer—attending team. All images generated by residents, including those from cases with false-positives, were closely reviewed. Resident false-positives could be explained by imaging artifact, unfavorable scan plane, and incorrect interpretation of sonographic patterns. Finally, in answer to Dr. Maldjian's question regarding the role of first-year radiology residents in providing emergent sonography services at our institution, our first-year residents do not perform or provide the initial interpretations for emergent sonographic studies by themselves at any point in their training; instead, they are always supported by trained sonographers, senior residents, and attending sonologists.
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