Statement from the DEGUM board regarding the editorial entitled “Who’s Doing Your Scan? A European Perspective on Ultrasound Services.”

This editorial was published last year in the October issue of EJU (Ultraschall in Med 2017; 38: 479 – 482), a journal that is read by the members of various European ultrasound societies and especially by the members of DEGUM, ÖGUM and SGUM. In the editorial it states that approx. 80 % of ultrasound services in Great Britain are performed by specially trained sonographers, who provide in addition to the examination also a corresponding report on the examination. Of the remaining examinations, approx. 19 % are performed by the country’s radiologists. Only 1 % of examinations are performed by other physicians in private practice, with emergency physicians and fetal medicine specialists being named in this connection. The authors feel that the British system can be classified as a success and could serve as a model for the rest of Europe given the increasing demand for ultrasound examinations. They also mentions that elsewhere in Europe the British system has spawned so far only a few imitators. For that reason alone, a more appropriate title for the editorial would be “A British Perspective...” instead of “A European Perspective...”. There is a good reason why this system involving ultrasound services being performed by non-medical personnel is not practiced in many countries. Especially within DEGUM, one of the largest groups within EFSUMB, the delegation of ultrasound services to medical support staff is unpopular. After intensive discussion, a decision was made in 2011 by the extended DEGUM board that clearly states that ultrasound examinations and reporting are to be performed by physicians and cannot be delegated to support staff.

This view is primarily based on the fact that there is a completely different understanding of the importance of ultrasound in Germany than in some other countries, particularly in Anglo-American countries. While ultrasound is viewed in those countries first and foremost as an imaging method, it is accepted in Germany as an additional diagnostic method in the hands of the practising clinician. Ultrasound allows the treating physician to better interprete the personally acquired clinical findings and the physician receives within a very short time a working diagnosis that can be used as the basis for medical decisions. For the patients, this system has the enormous advantage that there are no long wait times for complex additional examinations and that other examinations, possibly involving exposure to radiation, are often unnecessary.

However, this also means that effective and high-quality use of ultrasound in the medical routine is only possible when combined with other medical tasks and activities. DEGUM recognized this fact early on. Therefore, in contrast to the figures cited by the authors from Great Britain, most ultrasound examinations in Germany are performed by the treating physician of the corresponding medical discipline, such as internists, gynecologists, fetal medicine specialists, abdominal surgeons, head and neck surgeons, urologists, neurologists, etc.

In Germany, the value of clinical ultrasound was recognized decades ago so that ultrasound has become part of the regulations for the specialist training in a wide range of medical disciplines.

From DEGUM’s standpoint, it is therefore unimaginable for ultrasound examinations to no longer be performed by a physician in the future and for examinations to be delegated to medical support staff simply because there are examinations that are supposedly simple or unpopular (e. g. residual urine determination or the like). Even with intensive training, a sonographer would not be capable of correctly interpreting clinical findings (including endoscopic findings) let alone acquiring them.

The comprehensive use of sonographers as described by the authors would result in a noticeable decline in ultrasound quality which would then lead to a decrease in the acceptance of ultrasound in the medical community. This would consequently lead to a major increase in the use of other diagnostic imaging methods, such as X-ray, CT, and MRI, resulting in unnecessary radiation exposure for patients. Moreover, major cost increases could be expected.

Ultrasound would be reduced to a pure “imaging modality”, without consideration of its true clinical value, namely as a real-time imaging tool in the clinician’s hands, allowing quick and highly accurate diagnosis.

DEGUM also cannot accept the argument that delegation of ultrasound services to medical support staff makes sense because the number of requests for ultrasound examinations is constantly increasing. Any increase in demand can be attributed to the continual improvements in ultrasound technology in recent years and the better training of ultrasound operators. As a result of both of these factors, more detailed information can be acquired from ultrasound examinations today and exact diagnoses can be made. The increase in the demand for ultrasound examinations must not lead to questioning of the basic principles of clinical ultrasound and to ultrasound being removed from the spectrum of diagnostic tools available to physicians. This would be a decisive step backward.

Therefore, from DEGUM’s standpoint, it would be inadvisable to jeopardize the quality of ultrasound by delegating examinations to medical support staff. We feel that the quality of ultrasound examinations must continue to increase with respect to patient care and this can only be achieved by developing and applying uniform standards. Quality should always go up not down. France provides proof that such concepts can work. For example, high-quality work using defined standards is being performed there in the field of gynecology and obstetrics, which should be an incentive for us to pursue similar concepts.

Even the continual repetition of the view that the introduction of sonographers for the implementation of ultrasound examinations cannot be stopped does not have the effect that the board of DEGUM will join the view of the editorial. In contrast, DEGUM stands for high quality in ultrasound as described above and this level of quality can only be preserved or improved if ultrasound continues to be viewed as a non-delegable service to be performed by physicians.

PD Dr. Kai – Sven Heling, Prof. Dr. Dirk Becker, Prof. Dr. Peter Jecker, Prof. Dr. Peter Kozlowski, Prof. Dr. Andreas Hagendorff, Dr. Siegfried Krishnabakdi, Prof. Dr. Markus Hahn as the DEGUM board