Teleradiology has been marketed to veteriarians as a way to speed up the ultrasound education process or (in some cases) replace all the hours needed to learn ultrasound. Unfortunately, find that ultrasound teleradiology does not live up to expectations and veterinarians lament that their teleradiology reports are “wishy washy” or claim “all they [teleradiologists] are doing is covering their butts.” It is clear that the expectations of teleradiology are out of line with the reality of using teleradiology for ultrasound. Perhaps looking at teleradiology from the other side will help explain why our opinion is that in unexperienced hands ultrasond teleradiology is largely a fake.
Ultrasound is a dynamic imaging modality – an analogy
Unlike radiographs, CT, or MRI, ultrasound is incredibly dependant on the user and it takes years and hundreds of cases to learn all of the skills needed to perform an ultrasound examination. If the teleradiologist is not confident in the skills of the person sending the images, there will always be doubts about whether a lesion was overlooked. To put things in perspective, try this analogy.
Question: please tell me what is going on in this movie? I would like to know the plot and a summary of the cast of all characters.
Answer: that was a stupid question. There is no way I can tell what that movie was about.
Some might respond that if they saw the whole movie, they would be able to pick out important frames that would tell the whole story. Unfortunately, in this analogy, you do not even speak the language of the movie. This movie was written in Swahili and you only had a 2 day short course in Swahili. Sorry.
Sending ultrasound images for review (if you are an inexperienced sonographer) is the same thing as asking what a movie is about if given only a few frames of the movie. Someone could comment on what is in those frames (I see a pair of glasses) and tell you what might be going on but do not expect them to commit and make it seem like they have a good handle on things. There is no way for them to know if important frames were omitted from the study. This uncertainty is the origin of wishy washy ultrasound teleradiology reports.
It does not stop there:
Obtaining ultrasound images takes skill and it is very easy to make normal anatomy look like pathology. Furthermore, many veterinarians use ultrasound machines inappropriately. Some entry level machines that are best used in emergency situations (for example to identify the presence or absence of fluid in the abdomen) are inappropriately used for a full abdominal evaluation.
Getting back to our analogy, the inappropriate use of ultrasound or inability to obtain diagnostic images is the same as presenting movie reviewers with the following images:
Yuk! Even more uncertainty in the ultrasound report.
But – ultrasound teleradiology is not all bad
The previous discourse hopes to establish that ultrasound teleradiology is not a good way to learn ultrasound and if a novice sonographer chooses to send images for teleradiology review they should not expect too much. The situation changes when an experienced sonographer uses teleradiology. This is the case in human medicine where RDMS certified sonographers have completed an extensive training program (not a short course) and scan hundreds of patients before getting “set free.”
When an experienced sonographer uses teleradiology, they speak the language of ultrasound so they are able to pick out the important frames to present to the reviewer. They also understand the limitations of their ultrasound machine and are skilled in how to appropriately acquire an image. As stated previously, this takes time and experience (i.e. hundreds of cases and not a weekend short course).
When experienced sonographers utilize teleradiology they do not ask “what is wrong with this animal” or “did I do a good job” because they know they did a good job and they are confident that all of the necessary information is present on the images. They are asking the reviewer to tell them what about what is present on the images and the images they present to the reviewer are diagnostic. Because the reviewer is confident in the skill of the experienced sonographer, they are able to commit to a diagnosis, as they know there is no information that is not present on the images that would affect the interpretation.
Bottom line: learning ultrasound is difficult. Teleradiology is not a stand in for the hours needed to learn ultrasound. Teleradiology can be used in ultrasound education but do not expect too much. Set the bar very low as it is impossible to learn ultrasound through teleradiology (how do you know what you missed?). Conversely, when used in experienced hands, teleradiology can be a powerful tool to deliver advanced imaging to pets around the world.
