What does sonography look like in the future?

What will sonography look like in the future? – a question on everyone’s mind as we look ahead to the evolving landscape of sonography. Caterina Watson AFASA is a sessional academic at Edith Cowan University, and she shares her insights on point of care ultrasound (POCUS) and the opportunities and challenges it brings. She also discusses how the changes in technology affect sonography in both rural and metropolitan settings and how AI is impacting the sonography profession. Dr Mark Stieler, Director in Charge of Ultrasound at Exact Radiology Clinics, Queensland, discusses the sonographer’s full scope of practice, the role of general sonographers versus specialised sonographers, and the potential involvement of other allied health professionals in sonographic examinations.

Caterina Watson AFASA

Sessional Academic | Edith Cowan University

Caterina Watson is an obstetric and gynaecologic sonographer practising in Western Australia. She completed her Master of Medical Ultrasound, with distinction, at the University of Herefordshire in England. Caterina is the current chair of the ASA’s Emerging Technologies Special Interest Group committee and enjoys outreach teaching in the South Pacific nations. Caterina is employed as a sessional academic with Edith Cowan University where she is also enrolled as a PhD candidate. The project combines her special interests in fetal neurosonography and artificial intelligence.

As a sonographer working in POCUS, what opportunities does it bring?

The main opportunity is sharing knowledge and skills with allied health professionals. POCUS is performed by doctors in the ER and midwives in birthing suites. Teaching POCUS in outreach projects has enriched my clinical experience in terms of wider cultural etiquette and alternative medical practices. One of the Brisbane ASA Conference talks this year was: CQU students in VIETNAM ‘it’s not wrong, it’s different’. Exactly. Learning is a two-way process in POCUS work.

What are some of the challenges, if any?

I think the main challenges in outreach POCUS are equipment based. Machines are usually reconditioned and donated for outreach projects. This is a generous act but it is common to see rooms designated for the ultrasound graveyard. Here, well-intentioned equipment has been donated but has failed to keep operational after a short time. The support is not long term and programs for maintenance and infrastructure should be considered when donating ultrasound equipment. Another equipment challenge would be infection control, particularly with transvaginal probes. In rural & remote locations there is a shortage of probe covers, sterilisation methods, and gloves.

In terms of staff challenges, the end user of POCUS equipment should be correctly tutored in POCUS ultrasound, just as a sonographer is comprehensively trained in ultrasound. This includes the basics of ultrasound physics, instrumentation, and image interpretation. AI should not fill in all the gaps – there is a human in the loop and responsible for diagnostic output. Locally, I would like to see all Australasian POCUS staff regulated under ASAR, just as sonographers are. They should be certified by a recognised institution and required to demonstrate an appropriate CPD portfolio each triennium. This is difficult to implement on a global scale but can be benchmark practice in Australia and New Zealand.

How does POCUS affect how sonographers work in both metropolitan and rural/remote locations?

The target audience for teaching POCUS will change between metropolitan vs remote locations. Metropolitan POCUS training would provide role extension skills to ER clinicians and midwives/nurses. My experience of POCUS for rural/remote locations has been to provide education and training for 4th-year medical students and local sonographers. Local sonographers will have been working for significant periods of time without certified training. Many of them are keen to see how their skills align with Australian practices and they are interested in adopting Australian approaches for ultrasound assessment.

With greater demands on sonographer knowledge, increasing protocols, and decreasing scan time, do you see a benefit to sonographer specialisation, or will the general sonographer still be the mainstay of most departments?

It is in the interest of the patient to keep the general sonographer as the department mainstay. However, both are equally important to serve the healthcare model. Advances in AI will enable the general sonographer to perform more focused scanning techniques and perhaps be directed to achieve more accurate diagnostic images. This, in turn, will reduce scanning errors and improve the quality of patient care. For the future, I see little change in the ratio of general vs specialised sonographers. They are different players on the same football team.

The end user of POCUS equipment should be correctly tutored in POCUS ultrasound, just as a sonographer is comprehensively trained in ultrasound.

In what ways do you anticipate AI impacting sonography?

AI is another tool in the diagnostic package. As AI develops in sophistication, I imagine reduced sonographer MSK injury, and greater assistance for examination diagnosis. The future might include robotic scanning and augmented reality equipment operation. Far from replacing the sonographer, I see AI enabling the sonographer to work independently from the radiology clinic hub. Generative AI can also impact our sonography workload and facilitate sonographer autonomy. This year, radiology conference material includes discussion of ChatGPT and report writing. These same issues are also of interest to the ultrasound community.

How will the current education model and sonographers need to adapt to use AI in the diagnostic medical imaging space?

Medical AI is an area of intense research which continues to impact sonographer working environments. Sonographers should be educated in AI to the same depth of knowledge as radiologists. In both Australia and United States, training radiologists learn about defining the quality of AI data, pre-processing & post-processing AI data methods, computer science metrics for algorithm evaluation, and the clinical validation. They can appreciate how generative AI has been used to create synthetic data to test machine learning algorithms. For sonographers, the same impetus exists to understand these technical subjects. Through focused AI education at the tertiary and postgraduate level, higher levels of sonographer engagement with AI can produce more significant research in ultrasound.

Dr Mark Stieler

Director in Charge of Ultrasound | Exact Radiology Clinics, Queensland

Mark has been heavily involved in musculoskeletal ultrasound for 30 years and in more recent years has been performing a wide range of ultrasound-guided interventions. He is committed to extending his knowledge in sonography and has acquired extensive educational qualifications including a Post-graduate Diploma in Diagnostic Medical Ultrasound, a Master of Applied Science in Medical Ultrasound, a PhD, a Post-graduate Diploma in Cardiac Ultrasound and a Postgraduate Certificate of Ultrasound-Guided Interventions.

Are sonographers currently meeting their full scope of practice?

I think many sonographers are currently able to fully satisfy their professional goals within the current framework. However, there is still more that we as a profession can accomplish in this regard. There are two main areas where this can occur. The first area is in the performance of ultrasound-guided interventions, particularly steroid injections. The second area is that of sonographer-issued reports. In both areas, as a profession, we need to ensure that only those sonographers with a sufficient level of expertise enter these areas of expanded scope of practice to ensure the highest standards are maintained.

From your perspective, does the role of the general sonographer have longevity?

Given the generally low population density in Australia, there will always be a large number of ‘sole practitioner’ sites where there is no option other than a single sonographer performing the entire range of scans that present to the practice. However, these sonographers must be able to recognise when situations arise that require the attention of someone with more specialised skills and patients must be on-referred when necessary. It is detrimental to the patient, and the sonography profession in general, if a sonographer performs a procedure that is beyond their level of knowledge or expertise.

It is likely the ‘specialist’ sonographers will eventually outnumber the generalists, particularly in major urban areas. DR MARK STIELE

Do you think sonographers with subspecialties will eventually outweigh general?

The field of sonography has become so large and diverse that it is simply not possible for any sonographer to be an expert in everything. It is both desirable and inevitable that sonographers focus their attention on their fields of interest. For this reason, it is likely the ‘specialist’ sonographers will eventually outnumber the generalists, particularly in major urban areas.

We are seeing a trend in overseas models where other professions are currently performing modified sonographic examinations. Do you think we should embrace the training of other professions or try to maintain our own professional skills?

There is no single answer to this question! There are numerous situations where the use of diagnostic ultrasound by other health professionals is crucial to patient management (e.g. emergency physicians and anaesthetists). However, there are also many situations where certain health professionals perform ultrasound examinations for purely financial reasons. This will often be done with little or no proper training and at appalling levels of technical and diagnostic proficiency. As a profession, we should certainly be prepared to be actively involved in the training and support of those professionals who require the use of diagnostic ultrasound for the management of their patients, but we should also be prepared to actively oppose the ‘cowboys’ that are pursuing financial gain and have little regard for the diagnostic quality of the scans they perform. •