Ultrasound certificate

[BioNerd14]

Hey everyone! I'm an ER vet that is getting burnt out pretty quickly. I was curious if anyone had suggestions for abdominal ultrasound certifications? I'm not talking 1-2 days of CE, but an actual program to become very efficient. I have no interest in becoming boarded in radiology, I just want to become better trained with ultrasounds for a more thorough diagnostic work-up.
Dream job would be doing abdominal ultrasounds in a quiet room all day and giving the report to the DVM and then being on call for surgery like 2 days a week lol.
I have heard of the Academy of Veterinary Imaging through Sound, but the website is very vague and missing a lot of details.

Thanks for any advice/suggestions!

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[TheDogFather]

Both Sound and WAVE (We Are Veterinary Education) are located in Texas and offer in-depth training and certification. The catch is, while the training and certification can't help but make you a good sonographer, I don't believe those certificates are recognized as any sort of credential if that means anything to you. You are probably looking at $12,000-$14,000 (before travel, lodging, etc.) for the complete immersion courses, and they require case studies and follow-up reports. On top of that, you would probably want a machine a cut above what most general practices likely have. My machine, with five probes (three abdominal, two cardiac) set me back around $50,000. I've seriously considered one course or the other, but I've also taken an interest in orthopedics and the continuing education and equipment costs for that have been considerable and will continue to be so. Sonopath out of New Jersey also offers some sort of certificate but I don't think the courses are one week at a time, three times per class (abdominal/cardiac) like Sound or WAVE.

 

[allygator13]

Out of curiosity, how do you plan to become proficient at interpretation without having regular feedback on what you are seeing? Being able to image capture is one thing, correct interpretation is a whole other ball game.

 

[battie]

I'd like to add that you might honestly get priced out. Ultrasounds read out by a radiologist in my area (either a sonographer taking images and sending to radiologist or the radiologist coming in and doing the ultrasound) is about $350-400 in my ER (large metro area). Meanwhile my fast scan is $140. Why would I pay a non-boarded someone $250ish when I can do a quick scan for a decent idea of things that look weird for cheaper, or can have someone with a lot more knowledge than me for a little more?

Don't get me wrong, I love ultrasound and used to want to get more experience to do what you're thinking of doing. But it just doesn't make financial sense from a client perspective to me any more.

 

[allygator13]

I'd like to add that you might honestly get priced out. Ultrasounds read out by a radiologist in my area (either a sonographer taking images and sending to radiologist or the radiologist coming in and doing the ultrasound) is about $350-400 in my ER (large metro area). Meanwhile my fast scan is $140. Why would I pay a non-boarded someone $250ish when I can do a quick scan for a decent idea of things that look weird for cheaper, or can have someone with a lot more knowledge than me for a little more?

Don't get me wrong, I love ultrasound and used to want to get more experience to do what you're thinking of doing. But it just doesn't make financial sense from a client perspective to me any more.

Or someone who is not boarded and charging $500-600 for an ultrasound 🙃

 

[battie]

Or someone who is not boarded and charging $500-600 for an ultrasound 🙃

This was happening at my old hospital. Corporate jacked up the price to $550 when the local internist would do it for $500. Awkward.

 

[Minnerbelle]

This was happening at my old hospital. Corporate jacked up the price to $550 when the local internist would do it for $500. Awkward.

Omg that’s the saddest thing about corporate fee structure. I used to feel soooo embarrassed about how my charges were higher than specialists for a number of things. Like I charged more for an eye exam with stain, iop, and stt than an ophthalmologist only to end up saying I dunno why that eye is angry and pissed off, you really should go see an ophthalmologist! It was so embarrassing that if the client elected to go through the ER for emergency ophtho consult, I would sheepishly tell them I’m going to pretend none of this ever happened and charge only my PE fee.

OP, to be perfectly honest I don’t think I would ever choose to use your services for reasons stated above. I think that would be a tough niche to break into. Ultrasound is so operator dependent (and really doesn’t leave objective records to review/verify later like radiographs), that I would never waste client funds on a sonographer I didn’t fully trust. I’ve been burned even by some traveling internists who perform mobile ultrasounds. I also don’t like the trained scanners who then have DACVR review of images. I either need a strong relationship with an internist I trust or a DACVR to refer out for ultrasound.

 

[Trilt]

Or someone who is not boarded and charging $500-600 for an ultrasound 🙃

I also don’t like the trained scanners who then have DACVR review of images.

This is the price point and technique at my hospital and it drives me a bit ****oo.

Case example: took care of a kitty overnight a couple months ago who was supposed to get an ultrasound in the AM. I looked at her myself and found what looked like a splenic mass and small volume free fluid - tapped and it was just a lower PCV hemorrhagic effusion.

Ultrasonographer also thought it looked like a splenic mass, submitted report with it labeled as such and got back "suspect pancreas mislabeled as splenic mass" or some bull**** like that. I eventually explored that cat, and that's the one cat splenic hemangiosarcoma I've diagnosed (no thank you to that report, lol).

I personally can't interpret ultrasound for **** when I don't have the probe in my hand, so I definitely understand how hard it is to do remote read outs like that. I just wish there was easier access to an actual radiologist ultrasound that didn't require the pet to be hospitalized at the local blue pearl or vet school ($$$$ and only if they'll actually take them as a transfer). The BP used to have an outpatient ultrasound service (before it was a BP and before COVID insanity happened) and it really was a great resource, but alas those times are long gone.

Basically the end result of my ehhh feelings on our ultrasounds means I just trust my own interpretation up to a certain point, but unfortunately that certain point is almost exactly where I don't trust the service - GI evaluation, adrenals, when things just look weeeeiiiiiird (cancer/carcinomatosis cases come to mind) and the such.

BUT I also don't have a better available option for those cases. And other doctors I work with trust (and treat off) the reports much more than I do, so I find myself in weird spots where I'm pretty skeptical of a diagnosis but kind of have to stfu because it's already been accepted and someone with waaayy more letters than me called it.

It's frustrating.

 

[Trilt]

Yikes I did not realize I was writing a novel until I hit reply, sorry. I have strong feelings about this haha.

 

[allygator13]

This is the price point and technique at my hospital and it drives me a bit ****oo.

Case example: took care of a kitty overnight a couple months ago who was supposed to get an ultrasound in the AM. I looked at her myself and found what looked like a splenic mass and small volume free fluid - tapped and it was just a lower PCV hemorrhagic effusion.

Ultrasonographer also thought it looked like a splenic mass, submitted report with it labeled as such and got back "suspect pancreas mislabeled as splenic mass" or some bull**** like that. I eventually explored that cat, and that's the one cat splenic hemangiosarcoma I've diagnosed (no thank you to that report, lol).

I personally can't interpret ultrasound for **** when I don't have the probe in my hand, so I definitely understand how hard it is to do remote read outs like that. I just wish there was easier access to an actual radiologist ultrasound that didn't require the pet to be hospitalized at the local blue pearl or vet school ($$$$ and only if they'll actually take them as a transfer). The BP used to have an outpatient ultrasound service (before it was a BP and before COVID insanity happened) and it really was a great resource, but alas those times are long gone.

Basically the end result of my ehhh feelings on our ultrasounds means I just trust my own interpretation up to a certain point, but unfortunately that certain point is almost exactly where I don't trust the service - GI evaluation, adrenals, when things just look weeeeiiiiiird (cancer/carcinomatosis cases come to mind) and the such.

BUT I also don't have a better available option for those cases. And other doctors I work with trust (and treat off) the reports much more than I do, so I find myself in weird spots where I'm pretty skeptical of a diagnosis but kind of have to stfu because it's already been accepted and someone with waaayy more letters than me called it.

It's frustrating.

I definitely appreciate the strong feelings hahah. To a point, we are trained to interpret scans that are not performed by us. We have multiple ultrasound cases on our certifying board examination, where obviously we have not been the ones performing the scan, and we have to be able to use regional anatomy in the images/videos to know what we are looking at. However, again, those studies were likely performed by a radiology resident or radiologist, therefore the images/videos are decent quality. Honestly the best thing anybody can do who is performing a scan to be submitted is take images in at least two planes of every structure, and take tons of videos in multiple planes of any abnormalities. The more regional anatomy we can get in an image/video to orient us, the more helpful we can be. The biggest pitfalls that people encounter who are not specially trained in ultrasound is that they do not optimize the image (don't change depth, focal zone, gain, etc.), don't know how to optimize Doppler settings (if they use Doppler at all), or move through an abnormality too quickly or don't include enough regional anatomy to truly know what we are looking at. If you (or whoever is performing ultrasounds) haven't seen this yet, the ACVR and ECVDI put out a consensus statement on abdominal ultrasounds and what should and should not be included in the study, especially if being sent to a radiologist. Linked below.

I also inadvertently went on a rant haha

ACVR and ECVDI consensus statement for the standardization of the abdominal ultrasound examination - PubMed

This consensus statement is designed to provide a standard of care document and describes the ACVR and ECVDI definition for performing a standard abdominal ultrasound examination in dogs and cats. The ACVR and ECVDI define a standard abdominal ultrasonographic examination as a complete exam of...

pubmed.ncbi.nlm.nih.gov

 

[battie]

We have three options for inpatient/outpatient ultrasound: ultrasonographers that get extra training for veterinary ultrasounds, and they exclusively do veterinary now, a boarded radiologist that travels in the area, or a married pair of internists. Which we pick comes down to that case essentially and schedule.

We've had issues and great experiences across all three. For the ultrasonographers, they take 100+ images to send and take their time. Each ultrasound is 20-30 minutes long. But the radiologist read out have missed some things (such as a foreign body). They're available during the day essentially any day of the year, including major holidays.

The radiologist and internist pair have the awesome advantage of being present and can give commentary. The radiologist diagnoses pancreatitis on 90% of his cases though 🤣 They are obviously not as readily available though.

I personally considered the non-traditional residency route (a traditional residency of any kind is not an option for the foreseeable future). But the radiologist is an interesting man and not sure if I could personally spend that much time with him 😅

 

[TheDogFather]

Omg that’s the saddest thing about corporate fee structure. I used to feel soooo embarrassed about how my charges were higher than specialists for a number of things. Like I charged more for an eye exam with stain, iop, and stt than an ophthalmologist only to end up saying I dunno why that eye is angry and pissed off, you really should go see an ophthalmologist! It was so embarrassing that if the client elected to go through the ER for emergency ophtho consult, I would sheepishly tell them I’m going to pretend none of this ever happened and charge only my PE fee.

That is so true of so many areas of general practice. Corporate prices or not, emergency consults or not. I often read about the unrealistic expectations that our clients have. I'm hardly surprised that many do. After all, we're smarter than physicians because real doctors treat more than one species. Our training leaves so much practical information on the table and the top end of the profession has raised "standards" so high (without discussion of the associated costs) that in all but the most basic cases general practice is a fifth wheel. Red eyes? I did all the tests of which I am capable. I don't have the answer. Referral. Your dog is limping? He needs a TPLO. Referral. Your dog is not responding to a food trial/Apoquel/Cytopoint? Referral. Back to the original post. I'd love to have the skills to be that "in-between" sonographer that offers more than "that looks weird" and and expensive full-blown radiologist scan and interpretation. That sort of thing should be somewhere in the vet school curriculum vs. "find a mentor" or spend another year's tuition on something that will be of questionable long-term usefulness.

 

[allygator13]

That is so true of so many areas of general practice. Corporate prices or not, emergency consults or not. I often read about the unrealistic expectations that our clients have. I'm hardly surprised that many do. After all, we're smarter than physicians because real doctors treat more than one species. Our training leaves so much practical information on the table and the top end of the profession has raised "standards" so high (without discussion of the associated costs) that in all but the most basic cases general practice is a fifth wheel. Red eyes? I did all the tests of which I am capable. I don't have the answer. Referral. Your dog is limping? He needs a TPLO. Referral. Your dog is not responding to a food trial/Apoquel/Cytopoint? Referral. Back to the original post. I'd love to have the skills to be that "in-between" sonographer that offers more than "that looks weird" and and expensive full-blown radiologist scan and interpretation. That sort of thing should be somewhere in the vet school curriculum vs. "find a mentor" or spend another year's tuition on something that will be of questionable long-term usefulness.

We have the "that sort of thing should be somewhere in the vet school curriculum" discussion with 4th year students rotating through our ultrasound service often. The problem is that they are already cramming so much information into the vet school curriculum, it is very challenging to fit this in as well. Especially when not everyone is going to use ultrasound anyway. Unfortunately, with the amount of time spent on radiology and radiograph interpretation, many veterinarians are still not good at radiographic interpretation (not meaning to cause offense, but with some of the things we get referred for interpretation with their initial, very incorrect interpretation, it is concerning). How do you expect ultrasound to be any different? Especially with how user-dependent it is. It's not just image interpretation, and it's not just image capture, it's both. There is pretty much no time to incorporate that sort of training/education into the 4 years of vet school that is already jam-packed with everything else.

 

[battie]

Unfortunately, with the amount of time spent on radiology and radiograph interpretation, many veterinarians are still not good at radiographic interpretation (not meaning to cause offense, but with some of the things we get referred for interpretation with their initial, very incorrect interpretation, it is concerning).

Prior to COVID, our imaging rotation was more focused on teaching position rather than interpretation because we didnt have a radiologist (along with 10 or 12 other schools at the time). Any imaging you were taught was taught on the service in question getting the imaging. Add in the fact that some interns and residents aren't great at teaching or working with students, imaging was a rough thing to learn across the board.

If we're going to dedicate resources to imaging in vet school, it should 100% go to actually teaching radiology for radiographic interpretation. Almost all clinics have x rays. Not nearly the same has ultrasound.

 

[allygator13]

Prior to COVID, our imaging rotation was more focused on teaching position rather than interpretation because we didnt have a radiologist (along with 10 or 12 other schools at the time). Any imaging you were taught was taught on the service in question getting the imaging. Add in the fact that some interns and residents aren't great at teaching or working with students, imaging was a rough thing to learn across the board.

If we're going to dedicate resources to imaging in vet school, it should 100% go to actually teaching radiology for radiographic interpretation. Almost all clinics have x rays. Not nearly the same has ultrasound.

Totally. And it's crazy how much this differs between institutions. Where I went for 4th year, our radiology rotation was split pretty evenly between learning how to position and learning interpretation. We had daily rounds with the radiology resident focusing on interpretation, and for the final exam for the rotation, we were basically writing mini radiology reports and had to be proficient at interpretation of those studies. However I've been to many other institutions now over the course of my training, and some places purely focus on positioning and "tech" duties on the rotation, while others have a mix, exams are multiple choice, etc. And everywhere I've been have had true radiology departments with radiologists, so even that does not mean you are necessarily getting a good education in interpretation.

 

[TheDogFather]

We have the "that sort of thing should be somewhere in the vet school curriculum" discussion with 4th year students rotating through our ultrasound service often. The problem is that they are already cramming so much information into the vet school curriculum, it is very challenging to fit this in as well. Especially when not everyone is going to use ultrasound anyway. Unfortunately, with the amount of time spent on radiology and radiograph interpretation, many veterinarians are still not good at radiographic interpretation (not meaning to cause offense, but with some of the things we get referred for interpretation with their initial, very incorrect interpretation, it is concerning). How do you expect ultrasound to be any different? Especially with how user-dependent it is. It's not just image interpretation, and it's not just image capture, it's both. There is pretty much no time to incorporate that sort of training/education into the 4 years of vet school that is already jam-packed with everything else.

If one of the criterion for including or excluding topics from a veterinary curriculum was "not everyone is going to use X" we could all be out of there in two years and hardly miss a beat. One of the many already shopworn vetmed cliches' I see and hear is "the days of James Herriot are over. We can't be everything to everybody." Then why do veterinary educators persist in doing just that? Yes, the problem is that they are already cramming so much information (much of it useless, quickly forgotten, or both) that it is difficulty to teach anything more. How about un-cluttering the training? Certain thing, like virtually all aspects of radiology, surgery, most ophthalomology, and a good bit of dermatology have to be taught, and not memorized. All of the "-ologies" that are pretty much all-you-can-eat PowerPoint presentations for which we tediously prepare for by making stacks of flash cards, pages of tables, and convoluted mnemonics and charts are the subjects that need to be worked in on a case-by-case basis, not the practical aspects of the curriculum. I recall that when I was in vet school and someone brought up the topic of expanding dentistry training (we did have a good program, and I was lucky enough to get in the course--but relatively few students were that fortunate). With a straight face, some administrator literally said just what you did, "the curriculum is so full that we don't have time to teach it as it is". Dentistry? Supposedly the most common affliction of our pets? How about teaching fewer things better than pretending that we need to be crammed full of minutiae on everything--which in the end serves next to nothing?

 

[allygator13]

If one of the criterion for including or excluding topics from a veterinary curriculum was "not everyone is going to use X" we could all be out of there in two years and hardly miss a beat. One of the many already shopworn vetmed cliches' I see and hear is "the days of James Herriot are over. We can't be everything to everybody." Then why do veterinary educators persist in doing just that? Yes, the problem is that they are already cramming so much information (much of it useless, quickly forgotten, or both) that it is difficulty to teach anything more. How about un-cluttering the training? Certain thing, like virtually all aspects of radiology, surgery, most ophthalomology, and a good bit of dermatology have to be taught, and not memorized. All of the "-ologies" that are pretty much all-you-can-eat PowerPoint presentations for which we tediously prepare for by making stacks of flash cards, pages of tables, and convoluted mnemonics and charts are the subjects that need to be worked in on a case-by-case basis, not the practical aspects of the curriculum. I recall that when I was in vet school and someone brought up the topic of expanding dentistry training (we did have a good program, and I was lucky enough to get in the course--but relatively few students were that fortunate). With a straight face, some administrator literally said just what you did, "the curriculum is so full that we don't have time to teach it as it is". Dentistry? Supposedly the most common affliction of our pets? How about teaching fewer things better than pretending that we need to be crammed full of minutiae on everything--which in the end serves next to nothing?

You're not wrong and I do not disagree, but the way it stands now, there is no time. Also most people don't want to stay in academia anymore to try to make these changes 🤷‍♀️

 

[BioNerd14]

Thanks for all the replies!
1. I guess from my perspective, I work in a huge metro area and we only have 1 place that has a boarded radiologist that does ultrasounds and they book about a month in advance. So moreso, was looking into it from a perspective of pancreatitis, GB mucocele, etc. Nothing as in-depth as a boarded US. It's my clinic's policy that we are ONLY allowed to do AFAST/TFAST and it's even questionable to be like, "Hey....I see a giant splenic mass on AFAST"
2. I appreciate all the feedback though! I'm just grasping at straws doing ER medicine as a new grad and getting burnt out, especially with the amount of economic euthanasias. I'm in a huge metro area, but very low income. I average about 3-7 economic euths a shift. We work with over 20 shelters/rescues but nobody will take blocked cats, parvo pups, etc. Just wishful thinking I could get out of it 🥲

 

[battie]

As an ER doc who is only two years out:

t's my clinic's policy that we are ONLY allowed to do AFAST/TFAST and it's even questionable to be like, "Hey....I see a giant splenic mass on AFAST"

Things like masses come with time and practice with FAST scans. But you can definitely find them and they matter when you do, especially if there is blood or other fluid in the abdomen. At this point, I have no problem telling people there is fluid in the abdomen (and what type if I successfully tapped it) and a mass where I think it is and what organ I think I found it attached to.

doing ER medicine as a new grad and getting burnt out, especially with the amount of economic euthanasias

When you say new grad, do you mean 2023? If so, leave. You're worth your weight in gold right now. If you're willing to move, your options are literally endless.

Unfortunately, I don't think the increased radiology skills will save you in this job. 😔

1 place that has a boarded radiologist that does ultrasounds and they book about a month in advance. So moreso, was looking into it from a perspective of pancreatitis, GB mucocele, etc

Do you guys have a mobile option? There are only two radiologists in my metro area, but one sonography group does the scan, then sends it to a radiologist. We've already touched on quality of that and such above, but it might be a decent alternative.

Likewise, this is what my old hospital would do. The problem I had with it was the fact it cost just as much or more as a specialist doing it. If further experience is something you'd like to be able to get more info, then it doesn't hurt by any means taking the courses. But don't expect to get a ton of takers if you're charging high amounts.