American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, December 1, 2014

How can a physician learn echocardiography?

Last Spring I got a junk e-mail offering a free “Echo survival course” from the University of Vienna, in Austria. I just had to go to a website, enter my e-mail, and I would get 4 free modules on basic echocardiography. Cool, I thought. Free knowledge! I've wanted to know the deepest secrets of echocardiography since I was a wee medical student a quarter of a century ago.

But why, one might ask, would it be relevant for me to know echocardiography? I'm not a cardiologist after all. The usual routine is that someone like me, a general internist, or a family practitioner, orders an echocardiogram for a patient with a suspected heart problem. An ultrasonographer, a non-physician with expertise in performing ultrasounds of the heart, obtains images of the heart from various views, saves representative images, performs calculations of movements and sizes of structures and sends the whole file to a cardiologist, who interprets the data. The cardiologist then produces a document with various abstruse and arcane abbreviations and corresponding values which also, thankfully, contains a summary paragraph which says if the heart looked normal or not. This whole process can take up to a week from start to finish. The patient or the patient's insurance company will be charged $1,000 to $2,000, and at the return visit the patient's physician will likely say something like, “It looked pretty good” or “One of the valves is a little leaky so I'm going to have you see the cardiologist” or “It wasn't too bad for someone your age.”

I have been doing a rather quicker and more focused version of the echocardiogram as a bedside procedure for the last 3 years that frequently serves my purpose much better than the scenario I just described. It is possible to learn the basics of cardiac ultrasound through continuing medical education classes taught by emergency physicians, who have used bedside ultrasound for decades to more capably triage patients. Ultrasound machines have gotten smaller, more ubiquitous in hospitals (often you can find one nearby if you need it) and even affordable to own and carry around. Mine fits in a lab coat pocket and gets pretty good images from which I can make more informed decisions regarding my patients' diseases and appropriate treatment. It doesn't replace the full scale echocardiogram, except in cases where the details are unnecessary.

I have done thousands of focused echocardiograms, reviewed them with experts when that was appropriate, compared the results to full scale echocardiograms when those were done, and know much more about the normal and abnormal heart than I did during the first 2 decades of my internal medicine practice when I relied primarily on my stethoscope. My bedside echocardiograms tell me if the heart is weak, and how weak, if there is fluid around the heart, whether there is evidence of problems with the blood vessels in the lungs and if there is damage from long term high blood pressure. I can identify the moment of death quite accurately when attending the dying and can see if an acute heart attack is causing a patient's chest pain or breathing problems. I can avoid giving medications that the patient's heart will not tolerate.

When it comes down to it, though, a good cardiologist is better at interpreting an echocardiogram than I am. I am not qualified to take the images and arcane numbers produced by an echo technician and produce a succinct but exhaustive summary. I am an internist, which is a fine and noble job, but not a cardiologist. So, since I look at hearts at the bedside all the time with a small ultrasound, I would like to know more about the fine points of echocardiography.

I have looked around for years for a good way to learn echocardiography and found that, for someone already in medical practice, it is pretty tricky to get echocardiography training. There used to be a guy, an echo technician by training, who ran courses for internists and anesthesiologists in performing and reading echocardiograms, but he got old and pretty much stopped doing it. He also really did not approve of bedside ultrasound. His courses were expensive and weeks long. After completing a course, to be credentialed to read echocardiograms required shadowing a cardiologist for a period of time and then reading echocardiograms, which were over-read by a cardiologist. It would have been much easier if I had only known I would need this when I was still in training.

So it was very exciting when the offer of a free echocardiography course came to me in my e-mail. I followed the links and found that the 4 module free course was well taught and informative. I was still wary, but plunked down $757 for a full “master class” in echocardiography, which was self-paced and gave me 30 hours of training. I had 6 months to use the resource material. It was really pretty good. The faculty is all from the University of Vienna, in Austria, which is a real place, not like University of Phoenix or something. The faculty are real cardiologists, clearly interested in their material and their English is just fine, though spoken with Austrian accents. Both image acquisition and interpretation skills are taught and there is an emphasis on understanding not just the echocardiogram but the physiology of the heart and the underlying disease processes. There were 20 modules, with quizzes following each. The quizzes weren't particularly well written, but were detailed enough that it was necessary to really pay attention. There were exotic European spelling and grammar errors which did not distract from the material. I completed the course, got a certificate of completion and I feel pretty certain that I still am not qualified to read a full scale echocardiogram. I do, however, understand quite a few more subtleties than I did, and will continue to do bedside focused echocardiography with renewed appreciation.

I think this course is much more aimed at training physicians in resource poor settings where nearly all doctors are generalists, and having a physician who is able to read an echocardiogram, even without knowing the finer points, is life saving and really all that is available. Doctors in these situations will use a course like this to go from knowing close to nothing to being able to capably diagnose the majority of cardiac conditions, to their patients' great benefit. This was truly an educational niche that needed filling. The teachers also do in-person few-day courses in various locations, which I would love to attend at some point, not least of all to see what the student body is like. If they are fantastically successful (and I kind of think they are) perhaps there will be competition, and possibly even accessible education in the U.S. It has seemed like the lack of educational opportunities acted to protect a piece of lucrative turf claimed by cardiologists. The U.S. is not primarily made up of urban areas, though, and large portions of our geography, like where I practice, for instance, are not served by cardiology clinics. I am glad a resource like this exists, even though online training in something that is hands-on cannot expect to fully cover the educational needs of practitioners.

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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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.

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 Iowa City, IA, 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.

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.

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.

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).

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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