7 golden rules of echocardiography

1. Echo is an art, so practice! In order for you to become an expert, you need to practice, practice, practice. Scanning is a true art with a slow learning curve. As K.A. Ericsson described in his landmark studies, it takes around 10,000 hours of practice in order to become a true expert. So better start NOW. How do you know if you are becoming an expert? Well, Ericsson has described that genuine expertise must pass three tests:

  • It must lead to performance that is consistently superior to that of the expert’s peers: Your echocardiography reports should be more accurate than those of the “average” echocardiographer.
  • Real expertise produces concrete results: The patients’ care & health should improve because of your reports.
  • True expertise can be replicated and measured in the lab. As the British scientist Lord Kelvin stated “If you cannot measure it, you cannot improve it.”: Your echo reports have to be consistent and amenable to validation.

But how do you know if your reports are true and valid? This question takes us straight to the second rule…

2. Get a mentor to guide your way.

Mentors are important for two reasons: Firstly, they can correct and assist you in your clinical judgment. They are a form of validation. Secondly, they will guide your echo practice. Now what do we mean by that? As we have learned, it takes 10,000 hours of practice in order to become an expert. But it is essential to know what to practice (i.e. learning to optimize your gain-settings for 10,000 hours will not make you an expert). A good mentor will pinpoint the gaps in your knowledge and skill-set and will help you to focus your attention and time on these areas. If you cannot find a mentor, try to connect with knowledgeable peers (mini-mentors) who you can refer to. Having a hand full of mini-mentors around might be even more practical since they might be more accessible and available.

3. Be curious and always ask “why”.

Curiosity is one of the driving factors of successful diagnosticians. Imagine the following situation: You just examined a patient for dyspnea. You found left ventricular hypertrophy and a pseudonormal filling pattern. You think that diastolic dysfunction must be the cause of her complaints. However, the right ventricle also seems to be slightly enlarged with otherwise normal function and valves. If you send this patient back to the ward without closer evaluation of her right heart, odds are that you will miss an important and potentially reversible disorder. In this and other situations, always ask why…“Why is the ventricle enlarged?” - “Why is the jet eccentric?” - “Why is right ventricular function poor?” – “Might this be pulmonary embolism?” etc. Also: play around! Use abnormal views and see what happens when you manipulate the transducer. Discuss with your peers. This is just another way to get more practice and insights.

4. You are allowed to talk to the patient!

Many echocardiographers often forget this seemingly obvious rule. They rather rely on referrals. They are afraid that the patients won’t stop talking once they got them started. While this could be true, you have to consider that referrals are often incomplete. Often they are written by someone who does not know the patient very well or someone who is inexperienced. Ask the patients about their symptoms and heart conditions and you will be ahead of the crowd. In addition, this demeanor will ease the patient and make the exam more pleasant.

5. Study cardiology and cardiothoracic surgery.

Put yourself into the driving seat of patient management. Your echocardiogram is often key to the treatment strategy. What are the patient’s treatment options? What do you have to put into the report so that the treating physician can make the right decisions? You absolutely have to know the basic theory behind the diseases at hand. That’s where our course comes in handy. Most successful echocardiographers have spent some time in the operating room. So they know how pathologies, valves and malformations really look like. If you cannot manage to go over to the operating room or if you just don’t want to hang out with the surgeons, search for surgery-related videos on Youtube. They can be really instructive. Alternatively, go and attend autopsies that’s how Osler became one of the best physicians in history.

6. Measure and quantify but only trust reliable values.

Everybody likes facts and numbers to base decisions on. However, many studies have found that eyeballing performed by an experienced echocardiographer is just as good, if not better, as a measurement. Expert echocardiographers only believe measurements that are plausible from looking at the 2D or Doppler images. This is somehow contrary to most scientific disciplines where measurement should precede interpretation in order to avoid biased measurements. For us, that’s one of the reasons why we consider echocardiography to be a form of art.

7. Store digitally and compare with previous studies!

That’s what radiologist do all the time. You can easily miss subtle changes simply based on measurements, which have a large measurement error. Left ventricular function and pericardial effusion are good examples. The eye will give you a better appreciation.

If you can stick to these rules, your echo skills will significantly improve. We would be more than happy to read your opinions on our facebook page. Have a good day! Your 123sonography team.

Recommended articles:
Common Mistakes #2
Improving Your Scanning Skills
Echo Genius - Writing the Report (Part 1)

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