Abstract
When I graduated from sonography school in 1993, I looked forward to a long career of taking care of patients by finding out what ails them. Sonography appealed to me because medical school seemed too long and too expensive, and I loved the idea of “playing the role of detective” with ultrasound—you are given a set of clues and you have to find the cause. When I started my first sonography job in 1993, I could have never predicted that, in 2019, I would be debating whether it was impolite to have another piece of intestine from the hot pot in Chengdu, China, or should I wait for others to have their share? Or that I would “graduate” as a “level 2.5” in spicy food tolerance (this remains my highest honor). As an associate professor in Thomas Jefferson University’s Department of Medical Imaging and Radiation Sciences, I like to tell my students about my interesting career and how sonography as a profession can take paths you never expect.
In 2005, I left daily scanning life and started working as the Technical Coordinator for Dr Barry Goldberg in the Department of Radiology at Thomas Jefferson University Hospital. Jefferson was my alma mater, and it was good to be “home” again. Dr Goldberg had formed scholarly alliances with ultrasound programs around the world, including five in China, and one of my many roles in the position was to work with these educational programs on training their faculty using materials provided largely by Thomas Jefferson University Hospital. The training programs were all geared to physicians as these institutions were in countries without trained sonographers or programs for training sonographers. During my tenure in that role, I saw hundreds of sonologists trained using our protocols and educational materials. I had the fortune to meet many of the people who ran these programs when they came to Jefferson for visiting fellowships, and I enjoyed learning about their cultures and their students. Every year, a contingent from China visited us for 2 weeks and attended our Leading Edge in Ultrasound conference. Dr Ji-Bin “Jimmy” Liu was our liaison with the Chinese institutions, and he handled all their visas and compliance with our international visitor requirements. In 2008, I left my role at the hospital and became full-time faculty at Thomas Jefferson University. I still worked with Jimmy and other colleagues in the research area at Jefferson, so when they started talking about creating a new sonographer training program in Chengdu, China, I was very enthusiastic about helping. We had multi-organization virtual and in-person meetings regarding curriculum, faculty training, and certification. My first trip to China was in 2015 for a 2-week university immersion program at the Huaxi campus of Sichuan University featuring scholars across all areas of education. I was there specifically to teach ultrasound physics to the medical students at Huaxi Health Care Hospital, part of West China Medical Center of Sichuan University. The language barrier was significant, with some of the students having more English experience than others, and me having almost no Mandarin knowledge except to say 谢谢 (thank you) and 再见 (goodbye). Regardless of my lack of experience in speaking Mandarin, “intensity reflection coefficient” and “piezoelectric element” do not easily translate into any language. By the end of my visit, the students were very appreciative even though they struggled with the language differences. The hardest part of lecturing in China, or any country in which English does not predominate, is to speak very slowly. For a native Philadelphia speaker like myself, no matter how slowly I tried to speak, I kept hearing “slower, slower.” I, too, needed to learn some new things.
Why was China looking to train sonographers? Across the globe, there is a shortage of radiologists that existed before COVID pandemic but has gotten worse since 2020. In addition, the world population is aging, necessitating higher demand in a time of fewer radiology trainees. 1 China is no exception, with more than 1 billion people and too-few radiologists across the country. In addition, the resources are concentrated to major cities, with resources lacking in more rural areas. In 2017, Zhang reported that 80% of China’s medical resources are allocated to 20% of hospitals. 2 This lack of diversity leaves a dearth of resources in most areas across China. Ultrasound is an ideal modality in rural areas because it is portable and relatively inexpensive compared with magnetic resonance imaging (MRI) and computed tomography (CT). In China, physicians may scan more than 100 patients per day, with each examination targeted to a specific area of concern. The report is dictated during the study and the patient receives a printed report before they leave. Aside from the ergonomic implications of performing that many examinations in one day, even targeted examinations, there is little time for the role many sonographers play—that of the caregiver. Having sonographers in China allows for one physician radiologist to supervise many sonographers, modeled after the American model. In Huaxi Health Care Hospital, the employer of many of the graduates from Huaxi’s program, sonographers have different ratings, from “in training” to increasingly higher levels, each with more responsibility.
Professor Lan Yuo, MD, initiated the sonography program along with Professor Lu (“Jason”) Qiang, MD, the director of the program. The classes are taught in China by Huaxi faculty using the Jefferson sonography program model. Their program is a 4-year BS program with the first 2 years offering mandatory introductory coursework and the second 2 years providing their professional ultrasound training. I was asked to teach the ultrasound principles and instrumentation (physics) course remotely given my experience teaching the course. The 12-hour time difference made scheduling a challenge, but we found that 8 pm for me and 8 am for the students was not too bad. The initial class contained nine students, and each class subsequently grew larger. Given that the start of the training program occurred pre-Covid, remote learning was a new experience for all of us, with difficulties in audio and video compounded by bandwidth and distance issues. I taught the class in English, using an English language textbook, with a Chinese faculty counterpart to help with offline instruction and to help engage the class. One of the biggest differences between an American student class and a Chinese student class is that, in China, students are taught to sit quietly and listen to the teacher. In the United States, I try to have a more engaged, collaborative class, and I like my class noisy, with students working together on assignments. I had mixed results regarding my ability to have the students engage with each other and engage with me, with language issues only partly being responsible. The students and I adapted to the differences in learning cultures, and the students were always appreciative of my attempts to speak Mandarin. In 2018, I had a trip planned to China that took place during the term when I was teaching them physics. They did not know their class that day would be face-to-face. The look of pleasant surprise on their faces when I showed up in person was something I won’t forget.
From 2015 through 2019, I took several trips to China, visiting Beijing, Shanghai, Shenzhen, Hangzhou, Xi’an, and on multiple occasions, Chengdu (Figures 1 and 2). The trips were related to the Huaxi sonography program but also for summits geared to collaboration in ultrasound training and testing between China and The American National Standards Institute (ANSI), Inteleos, and Jefferson.
Traci with her students in Chengdu, China.
Traci teaching her students in Chengdu, China.
In 2020, I had three scheduled trips to China, including a trip in April to Wuhan. Unfortunately, there was no travel to China or anywhere else in 2020. The pandemic caused many changes to every country in the world and keeping up with those changes caused our relationships to be put on hold. I kept in touch with Jason and my friends TingTing and XaoFei over the past couple of years to see how they were handling the lockdowns. More recently, I asked Jason about the status of the sonography program, and he was proud to give me the following statistics:
Since 2016, the program has graduated 57 students and 54 are currently on campus
Most graduates are employed at tertiary hospitals
Jason finished with, . . . the curriculum of the sonography program could be established with a high standard and [graduates] could take the ARDMS exam after 1-year clinical rotation. Moreover, the daily working mode in the department of ultrasound of West China Hospital . . . set a good example of collaboration between sonographer and ultrasound physician in China.
Since establishing the sonography program in Chengdu, I also assisted with an ultrasound training program for medical students in Hangzhou, China.
I look back fondly on my time in China and my experiences with what I call “very” distant learning. I wonder where we would be if Covid and global politics hadn’t disrupted the whole world order? One thing I realized during my time with this program was that medicine transcends politics. When it comes to taking care of patients and making lives better, no one talks about what this government said or about saber rattling—it’s all just background noise. We just want to train sonographers and learn from each other. I miss my friends in China, and I miss the students there. I hope that there is a time when I can get back over to Chengdu and progress to “Level 3” spicy hotpot.