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Thursday, December 19, 2013

I'm now a certified ultrasonographer: passing the ARDMS test

I just finished taking an exam for the American Registry of Diagnostic Medical Sonography. Having passed it, I can now put RDMS after my name, standing for Registered Diagnostic Medical Sonographer. The RDMS is a credential that many ultrasound technicians carry, and occasional physicians, especially those who make ultrasound part of their practice. So now, should I ever be at loose ends, I can potentially get a job as an ultrasound tech.

To take the ARDMS qualifying test, one must first satisfy various requirements, which fit into categories meant to include ultrasonographers of great experience, ultrasonographers who have gone through a training program (usually 1-2 years) physicians who studied ultrasonography extensively during their medical school and residency training and physicians whose experience includes extensive review of hundreds of scans by experts. Proving experience requires letters from a supervising teacher. The exam is a proctored 5-hour test, 3 of which is in a specialty area and 2 of which tests knowledge of the physics and technology, with a special focus on safety. Due to the miracle of digital communication, I was able to take the test in my own time frame, in a “Pearson VUE” test site about 90 minutes from my home. The test site is in a little office space, but has a silent room with constant monitoring, manual pat downs, and rigorous identity checks. Apparently, Pearson VUE is part of a multinational company out of England which owns a large share of the Penguin publishing company and specializes in online learning. It was comfortable and low key. Short of having a cookie break and access to online resources, I can’t think of a better set up for success.

The exam is pretty specific. My ultrasound mentor recommended I take a review course which, in combination with quite a few hours of study, would probably result in me passing the test. The review course he recommended was by the company ESP ultrasound, taught by people who specialize in making sure students pass the exam. The course director is Sid Edelman, has been teaching for decades, and covers the ultrasound physics curriculum.

When I took the course, I thought that the level of trivia they taught could only have been due to some sort of collusion between the people who write the test and the people who taught the course. After taking the test, I realized that the test questions were not necessarily in the study guides for the exam, but that there was considerable overlap between what the course taught and what we were tested on. Much of the trivia that was taught was referred to in the exam questions, nevertheless, exam questions really required some knowledge of physics beyond what the course tested, and many of the questions were tricky, requiring deduction rather than straight memorization.

Preparing students to take standardized tests is a very big business in the U.S., so even in a narrow field such as ultrasound technology there are many choices, from Pegasus Lectures, providing on-site teaching in Atlanta and Tampa, and Burwin Institute which provides online material. Having a professor to emphasize the important information was really helpful to me. Without it I would have questioned the need to learn such a broad collection of detail, and would have found studying much more frustrating.

The physics part of the exam made me wish I had taken a real, in depth course on how ultrasound works, maybe something on a college level that lasted a semester and made me able to build my own basic ultrasound out of stuff I could buy at the hardware store. Since that was not possible, memory of my distant physics education and frequently consulting multiple sources to explain points that didn’t make sense helped me answer some of the more abstruse questions. Because the real physics of the complex machines we use now is beyond most people, what we learned did not truly represent reality. This was very disappointing to me, since I had hoped I would learn enough to be able to answer some questions about why the technology is so slow to develop. I wonder if the lack of detail also helped protect the companies whose livelihoods depend on producing a competitive product. I’m betting that is part of it, though that’s kind of creepy.

During the part of the course that taught me about ultrasound of the abdomen, thyroid and testicles, I developed awe for the knowledge most ultrasound technicians eventually have of 3 dimensional anatomy. Even at my very most knowledgeable, just after finishing my first year in medical school complete with cadaver dissection, I had nowhere near the depth of understanding of how the organs are packed into the body and served by so many named blood vessels. Ultrasound has repeatedly sent me back to my anatomy books to try to figure out how things lie in the human body. I will undoubtedly continue to improve, but there are many fresh faced young people with many less years of training, who make only a fraction of my salary, who will always be better at it than I am.

Passing the exam means that I know enough of the anatomy plus technical details and disease processes that I can pass the same exam as my technician colleagues, but our proficiency is in no way identical. I can’t compete with the exhaustive knowledge of anatomy a career ultrasonographer has, and he or she can’t possibly understand the level of implications of constellations of physical, laboratory and ultrasound findings and combine them with patients’ stories and priorities. It is good that this test has room for all of us. It could have been written so that either of us would routinely fail.

So why take this test? I’m not planning on a career change, after all. Being a doctor is plenty absorbing. I noticed that the ultrasound teachers who I work with usually have RDMS after their names. It is a recognition of competence that need not come with a long explanation. I have always been concerned that some group for whom I work will have extensive requirements for ultrasound credentialing. I envision myself happily examining all of my patients with ultrasound and being told that, no, that was not allowed. So far it hasn’t happened, but only because most places I work have no concept of bedside ultrasound, other than perhaps as a method of guiding procedures. It also seems likely that the credential will give both me and any employer some confidence in my ability to actually teach other people. I surely do not believe that an ARDMS test should be mandatory for physicians who employ bedside ultrasound because the requirements are way too cumbersome, but it will, for a few, be useful as a way of communicating competence in a variety of aspects of the practice.

I have been intermittently studying this stuff for about 6 months, including such questions as how fast ultrasound travels in soft tissue and the components of attenuation and how they relate to speed of the ultrasound beam and Snell’s law and how it might or might not affect real time ultrasound. I have not yet found a way to make this stuff help me, but I trust at some moment I will look back on my previous grasp of the material and wish I had learned it better.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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