The (Updated) History of Sonography: Education and Credentialing

Know from whence you came. If you know whence you came, there are absolutely no limitations to where you can go. —James Baldwin

As the above quote implies, knowledge of history can lead to continued future successful strategies for resolving issues, significant to sonographers and the overall sonography community, which are steadily looming on the horizon. In 2005, Joan Baker, ¹ MSR, FSDMS, provided an insightful commentary and historical overview of the evolution of sonography in celebration of the 50th anniversary of the American Institute of Ultrasound in Medicine (AIUM).

Since the Society of Diagnostic Medical Sonography (SDMS) is now approaching its 50th anniversary, it is appropriate to provide an update on how the world of sonography has advanced over the past 15 years. It is important to recognize a new generation has entered this fascinating field. Therefore, acknowledging the early entry conduits to diagnostic medical sonography (DMS) was a reflection of the role of those performing the examinations and relative to the surrounding circumstances at the time of beginning the occupation of sonography.

This article will reprise the progression of education for sonography and the continued forward movement of credentialing standards in this issue.

Evolution of Sonography Career Pathways

As indicated by Baker ² recently in her interview on International Sonography’s Podcast, the specific tasks assigned to a person working in the field of sonography grew as the technology developed over time. The changes in technology refer to progressing from A-mode data toward bistable capabilities to real-time imaging, as well as the impact of both continuous wave (CW) and pulsed wave (PW) Doppler. By the time color Doppler, 3D, and 4D applications arrived, the physician-sonographer roles were well established.

The collaborative proficiency between the person capturing the images and the interpreting physician led to successful diagnosis for patients. Baker ² noted,

We felt we had a different relationship with the physician. In ultrasound you have to be able to read the image just made in order to make the next image. That is not true in the other modalities, you produce films from a protocol and someone else decides if they are diagnostic or not, and that is the physician. But in our field that decision is made by the operator.

Still the increased utilization of sonography, in tandem with the additional essential expertise, created greater independence, which led to distinct specialty areas of practice.

Education and Standards

Historically, the avenue of entering the occupation of sonography was through on-the-job training (OJT) consisting of combined didactic information with a scanning apprenticeship using clinical application to determine findings. OJT was fundamentally the beginning of the various specialties of sonography at a time of true partnership between the physicians and technical staff. Formal “certificate programs” primarily offered an option for those seeking specific qualifications in sonography who already had education in other areas of medicine. These programs provided condensed learning of the necessary sonographic content in conjunction with clinical intern-style hours of experience.

Gradually, associate’s and bachelor’s degree programs in sonography were developed with blends of lecture hours and clinical options focusing on sonographic specialties such as cardiovascular or “general” sonography. Ultimately, the early luminaries recognized the critical need to determine an organized definition of the occupation and the correlating educational criteria.

Presently, the Commission on Accreditation of Allied Health Educational Programs’ (CAAHEP’s) all-encompassing purpose is to ensure oversight and due process to all programs participating in its system of accreditation. ³ The CAAHEP Board of Directors acts upon the recommendations of its joint review committees (JRCs), confirming that appropriate procedures and principles for accreditation are being followed and applied consistently and equitably when assessing educational programs seeking CAAHEP recognition.

Detailed standards and guidelines are defined by the specific disciplines, representing the nationally recognized minimum curriculum components to enter into a particular allied health occupation. However, it should be noted that this process of consistency among educational programs, of a precise discipline, does not guarantee clinical competency of students completing an accredited program.

JRC-DMS National Education Curriculum

The Joint Review Committee on Education in Diagnostic Medical Sonography (JRC-DMS) began in 1983 to “establish, maintain and promote quality standards for educational programs in Diagnostic Medical Sonography.” ⁴

In 2004, the SDMS held a comprehensive organizational strategic planning summit during which participants determined it was imperative for “Diagnostic Medical Sonography [to] have universally accepted and clearly defined standards for education and practice.” ⁵ An SDMS task force was created to develop a national education curriculum (NEC). Identifying the key building blocks of knowledge, skills, and abilities critical for an entry-level diagnostic medical sonographer was the initial step. The NEC is a series of curriculum outlines to be used as the foundation from which a comprehensive sonography education program may be built (K. Kuntz, personal communication, July 2017). Further achievement was the result of intense work involving 18 sonography-related stakeholder organizations at a NEC consensus conference. The final curriculum outcome concluded with successful endorsement of the document realized in 2008.

Recently, the NEC was updated in September 2016, appropriately adjusting for essential changes in the specialty areas. New content reflects current clinical practice resulting from innovations in technology and new discoveries in medicine affecting required subject matter for programs. As more clinical practice specialization develops, it becomes more and more challenging to define “entry-to-practice” educational standards. Entry level in 2005 is very different from that in 2017, commented Katie Kuntz, MEd, RT(R), RDMS, RVT, FSDMS, current vice president of CAAHEP and an original member of the NEC Task Force (K. Kuntz, personal communication, July 2017).

Joint Review Committee on Education in Cardiovascular Technology

Another CAAHEP working group is the Joint Review Committee on Education in Cardiovascular Technology (JRC-CVT), launched in 1985. ⁶ Preceding this expansion of CAAHEP, the American Medical Association’s Council on Education, a mixture of professional associations and educational institutions, began work in December 1982 on the development of the Essentials and Guidelines of an Accredited Educational Program in Cardiovascular Technology with consensus and adoption reached in September 1983. The ultimate purpose was providing the initial resource document for educational institutions seeking accreditation of their cardiovascular technology curriculum.

As a further progressive strategy, currently JRC-CVT is collecting data from programs regarding “best practices” relative to their experiences with the accreditation process.

An additional instance of continuous quality improvement by JRC-CVT can be found in the changes made to the cardiac sonographic academic framework. It became indispensable to be more inclusive of congenital heart disease within the pediatric and fetal educational content. Since fetal subject material is covered by both the JRC-DMS and the JRC-CVT, it is important to have consistent arrangement of program components for comparing student outcomes. Also within the cardiac section, formulas and values have been removed, since these can be dynamic numbers over time based on up-to-date published guideline documents. The intent is to ensure education is congruent with clinical practice and certification examinations.

Availability of Clinical Sites

An indispensable aspect of learning sonography is the student’s clinical internship experience, which can be a complex organizational issue for educators. Dale Cyr, MBA, CAE, FSDMS, who is the executive director for Inteleos, noted, “In today’s healthcare environment, there is a definite lack of clinical sites to meet today’s demand for training, let alone future increases in sonographer opportunities” (D. Cyr, personal communication, July 2017). Programs cannot accept more students than proportionately available clinical internship spaces. Providing the required medical understanding is fundamental for students to develop their clinical competency. The lack of capacity starts a vicious circle of less internship sites, fewer students being accepted into programs, and decreasing returns offered to maintain educational resources, which ultimately can lead to specific workforce shortages for optimal patient care. This is where professional societies and individuals can actively encourage clinical locations to support the future of sonography. Becoming an approved clinical site for an accredited ultrasound program can be mutually beneficial for the student and the internship site. “In my opinion, if employers want to be able to hire well-educated, competent new graduates, then they need to share in the responsibility and open their doors and accept more students,” explained Kuntz (personal communication, July 2017).

Refinement of the field continues to progress. Entwined to overall educational programs and specific responsibilities within clinical specialties is the description of the Scope of Practice, Clinical Standards and Guidelines for the Diagnostic Medical Sonography, and significant developments in credentialing.

The original Scope of Practice for the Diagnostic Sonographer was first published in 1993 ⁷ with an update in 2000 entitled the Scope of Practice for the Diagnostic Ultrasound Professional, ⁸ which was accepted by members of the Sonography Coalition (ARDMS, ASE, CCI, SDMS, the Society for Vascular Surgery [SVS], and the Society for Vascular Ultrasound [SVU]). The most recent revision of the Scope of Practice began in 2013 with representatives of JRC-DMS and JRC-CVT, in conjunction with 16 other medical ultrasound-related organizations, involved in the modification process. Clinical standards were included with endorsement of the documents achieved in 2015. ⁹

Certification

As the needed educational components continue to increase, due to expanded clinical roles within the sonography specialties, the certifying bodies have tightened the eligibility requirements for certification examination applications to ensure the quality of successful candidates. The benefits of certification include demonstration of knowledge, skills, and abilities through educational achievement; validation of clinical experience to prospective employers; and a clear, competitive edge over noncertified candidates. Those aspects also contribute to reassurance of safety to the public.

The certifying agencies include the American Registry of Diagnostic Medical Sonography (ARDMS), Cardiovascular Credentialing International, and the American Registry of Radiologic Technologists (ARRT).

ARDMS recently restructured its relationship with the Alliance for Physician Certification & Advancement (APCA) to form Inteleos, which is streamlining each organization’s pursuit of quality certification requirements.

APCA uniquely provides an avenue for physicians to confirm their interpretive capabilities through physician-based examination assessment. The specific ultrasound-related examinations are Registered in Musculoskeletal Sonography (RMSK) and Registered Physician in Vascular Interpretation (RPVI), which moved from oversight by ARDMS to APCA on July 1, 2017. ¹⁰ APCA also provides tests regarding interpretation of nuclear cardiology, cardiovascular computed tomography, and magnetic resonance.

The Inteleos Board of Directors feels strongly that anyone who is using ultrasound equipment should demonstrate appropriate levels of proficiency commensurate with their particular area of clinical practice. The ultimate objective of all the examinations of Inteleos is establishing high standards, consistency, and uniformity to the practice of ultrasound, in over 70 countries worldwide, among those persons performing ultrasound examinations and interpretation, explained Cyr (personal communication, July 2017).

Technology has further influenced aspects of Inteleos operations, according to Cyr (personal communication, July 2017). It should be recognized that developments in technical science have largely driven how sonography is used with increasing abilities to obtain a much broader scope of diagnostic information that can be applied to more clinical settings. The increases in sonographic capabilities provide distinct challenges in credentialing individuals who practice with an extensive variety of clinical content, further explained Cyr (personal communication, July 2017).

Within more traditional credentialing, ARDMS is managing testing for nurse midwives and other specific focused examination-type usage. Another more recent specialty examination being offered is musculoskeletal sonography (RMSKS). Often these assessments are performed by personnel in less common clinic environments such as orthopedic surgeons or physiatrists rather than the more traditional radiology suite.

As Inteleos continues to expand for physicians, Cyr stated, “I see the sonographer profession growing by obtaining employment into non-traditional sonography clinical settings” (D. Cyr, personal communication, July 2017). Examples of this type of sonographer employment areas could be within family practice, internal medicine, and anesthesiology groups, to identify a few. For clarification, sonographers working in nontraditional medical locations does not imply they are not providing high-quality ultrasound examinations. As always, sonographers are delivering streamlined patient services in new places while consistently meeting the established responsibilities and standards of care confirmed by their certification and reinforced by teamwork with the overseeing physician. The broadened change reflects the depth of immersion for ultrasound technology in such diverse specialties of medicine positively affecting patient outcome.

Furthermore, Cyr continued, “I do not see physician Point of Care Ultrasonography^11,12 (POCUS) imaging curtailing sonographer employment. There will always be a need for experienced sonographic imaging. Through antidotal conversations and community knowledge it is well understood that new clinical services using ultrasound often increase referral patterns to the institutional ultrasound experts as questions often arise with sonographic findings when non-traditional users engage in ultrasound practice” (D. Cyr, personal communication, June 17, 2019).

Cyr also postulated that the varieties of clinical context for POCUS may lead to further usage and expansion of employment opportunities for the emerging generations of sonographers who have the knowledge, skills, and abilities to confirm the findings of a POCUS examination.

POCUS terminology arose in the early 2000s; recognizing specific patient circumstances required more immediate information rather than scheduling a sonogram on another day offsite delaying essential intervention, thus the application of POCUS. The concept of POCUS, combined with the miniaturization of ultrasound devices, brought about this modern “stethoscope” in the office, at the patient’s bedside, in the emergency department, or in other critical care settings. A well-known more historic application of sonography is providing procedure guidance. The broader capability of POCUS is now into other subspecialties of medicine beyond the original radiology or obstetrics department.

The defining characteristics of POCUS are slightly variable. POCUS infers learning the specific sonographic task technique is easily accomplished. The performance implies a quick, focused examination at the patient’s bedside, which is done for a well-defined indication. In addition, the assessment findings are easily identifiable with the direct goal of improving patient outcome. ¹³ An alternative definition designates POCUS as used by either the examining or interpreting clinician, incorporating the image findings into direct clinical decisions for patient care. ¹⁴ Consistent with their philosophy, Inteleos piloted the first POCUS Assessments in October 2013 (J. Rockett, personal communication, September, 2019). The decision-based clinical exams offered certification from the POCUS Academy in May 2017. ¹⁵

Presently, certification boards in general are evaluating the approach to recertification processes. In March 2019, ARDMS communicated to the registrants that the anticipated implementation of the tentatively proposed recertification procedure has been put on “pause.” ARDMS recognizes the ultrasound community is anxious to know the definitive details of the recertification concept. According to Cyr and McKonkey, “We are working diligently with sonography volunteer leaders to evaluate new and innovative re-certifications program ideas that:

• Reinforce the high professionals’ standards associated with ARDMS Registrants;

• Strengthen the sonography profession;

• Reconfirm current-day knowledge;

• Sustain the value of the credentials; and

• Uphold the sonographer commitment to quality care and patient safety. An update about recertification is expected June 2019” (D. Cyr and P. McConkey, personal communication, April 2019).

American Registry of Radiologic Technology (ARRT)

ARRT first launched its sonography examination in 2000. This action was based on the primary recognition by ARRT leadership that it is not uncommon to start in radiologic technology before obtaining additional training in diagnostic medical sonography.

Additional rationale was based on the observation that a number of sonographers seem to be certified in one specialty area of sonography yet working in another. ARRT realized that this misalignment between practice patterns and credentials opened an opportunity for ARRT, as a niche for an examination that would cover multiple specialty areas of ultrasound (abdomen and OB/Gyn), along with the vital physics and instrumentation components of sonography, explained Jerry Reid, PhD, executive director for ARRT (J. Reid, personal communication, July 2017). An examination focusing on vascular sonography was added in 2001, with the most recent addition for breast ultrasound in 2004.

As of 2018, there are now almost 1100 candidates who have met requirements and passed the ARRT ultrasound examinations. ¹⁶ According to Reid, “While we anticipate that the number holding the R.T. (S) credential will continue to increase, we are happy that even with no sustained, targeted marketing efforts the number has topped 1,000” (J. Reid, personal communication, July 2017).

For the immediate future, ARRT continues to look for ways to enhance the value of its credentials in all disciplines. Every five years, the ARRT Board of Trustees reviews clinical components and content specifics based on task analysis data resulting in updates to the examinations. The most recent revisions were approved with implementation effective January 1, 2019.

Cardiovascular Credentialing International

Cardiovascular Credentialing International (CCI) was incorporated in 1968, ¹⁷ providing examinations in 10 cardiovascular noninvasive and invasive specialties. Once someone is certified in at least one ultrasound specialty, CCI requires continuing education units of 36 every three years. Thirty of the credits must be specific to cardiovascular subject material. CCI advocates that its current process of continuing education ensures maintenance of competency for those holding CCI credentials. According to Jerel Noel, CAE, executive director, presently CCI is not planning on implementing recertification examination strategies at this time (J. Noel, personal communication, August 2017).

According to Jeff Hill, APS, BSBA, RDCS, FASE, the most substantial change within the field of cardiovascular sonography is the implementation of an examination for advanced credentialing by CCI ancillary to verified data analytics specific to the required tasks and responsibilities of cardiac sonographers within a cardiology practice (J. Hill, personal communication, July 2017). Hill went on to explain that appropriately identifying the importance of the significant expanded roles of some cardiovascular sonographers triggered CCI to develop the Advanced Cardiac Sonographer (ACS) exam operative in February 2018. ¹⁸ Now that the breadth and expectations of the ACS have been defined, the diversified result is streamlining the diagnosis of patients.