MSK U/S elective

[ahussain9]

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Hey all,

I was wondering if anyone knows of a place offering electives to residents for a hands on MSK U/S rotation including diagnostic and injection techniques. I know a number of residents, myself included, who would be interesting in participating in such an elective. You can PM me or let us all know on the forum.

thanks! 🙂

 

[MedBronc23]

At Mayo we get 6 months of MSK US didactics, and 1-2 months of clinical MSK US, but not sure if you can just come for an elective. Worth looking into. Where are u at?

 

[MedBronc23]

You could also look into coming to hands on AIUM US course in Rochester, MN. Or John Finnoff (formerly at Mayo) is hosting US course via AAPMR.

Those are well taught, and would give you a good start.

IMHO you probably won't get really good at diagnostic or interventional MSK US in residency or fellowship unless you attend a program where it is intimately embedded into your training. You would not think someone proficient in EMG after a one month rotation, hence the stringent requirements for min 200 EMGs ect. this is one of the main reasons why I chose to train where I did, and I feel blessed that my choice matched up with the program's. That said I have performed well over 200 US guided injections with staff supervision and I am still learning and getting comfortable.

As MSK US becomes more universally integrated into physiatry training, this will improve. And some exposure is better than none.

Anyone have differing opinions or perspective

 

[Louisville04]

You could also look into coming to hands on AIUM US course in Rochester, MN. Or John Finnoff (formerly at Mayo) is hosting US course via AAPMR.

Those are well taught, and would give you a good start.

IMHO you probably won't get really good at diagnostic or interventional MSK US in residency or fellowship unless you attend a program where it is intimately embedded into your training. You would not think someone proficient in EMG after a one month rotation, hence the stringent requirements for min 200 EMGs ect. this is one of the main reasons why I chose to train where I did, and I feel blessed that my choice matched up with the program's. That said I have performed well over 200 US guided injections with staff supervision and I am still learning and getting comfortable.

As MSK US becomes more universally integrated into physiatry training, this will improve. And some exposure is better than none.

Anyone have differing opinions or perspective

What are the top three ultrasound guided injections you do?

 

[DOctorJay]

The top three are probably subacromial subdeltoid bursa, knee, and a tie between hip and glenohumeral joint.

 

[MedBronc23]

Thanks Doctor Jay. I agree with that consensus.

 

[ahussain9]

I'm at Hopkins. We have a couple of attendings who do diagnostic and/or Injections. We also have regular access to U/S workshops as well as a weekly U/S practice with each other (residents). However, I'd like to dedicate a full month to it, as that would be the best usage of my elective time. Preferably a location without other residents/fellows, or enough volume that that won't be an issue. I'm well aware of the U/S course at Mayo. I may consider going next year.

thanks!

 

[DocHappy]

To add on the original post, I am interested in doing a full month elective of U/S guided procedures + EMG in southern California, where my family is. Ideally, I don't have to compete with other residents/fellows for hands on experience. Private practice setting is fine. Any information is appreciated.

 

[RUOkie]

To add on the original post, I am interested in doing a full month elective of U/S guided procedures + EMG in southern California, where my family is. Ideally, I don't have to compete with other residents/fellows for hands on experience. Private practice setting is fine. Any information is appreciated.

FWIW, I won't let any med student/resident who comes to my clinic handle a needle on any of my patients. When I was in academic medicine I was VERY different, but I ain't trusting a resident to do a procedure in my solo practice.

 

[bedrock]

To add on the original post, I am interested in doing a full month elective of U/S guided procedures + EMG in southern California, where my family is. Ideally, I don't have to compete with other residents/fellows for hands on experience. Private practice setting is fine. Any information is appreciated.

You're asking for a lot. This is why academic department exist.......to train you, particularly in procedures, which require time, oversight, and risk.

No PP guy will let you do procedures on their patients. If you're lucky you can find an academic place that will let you see a lot of MSK US, but you're not going to get significant hands-on time.

Sorry but that's why you have be selective about where you do residency and fellowship.

Some academic departments will let you observe, but no one will take on the extra time and risk of supervising your procedures unless you are one of their residents/fellows

 

[MedBronc23]

Ahussain9 do y'all get to injections with staff supervision at Hopkins?

 

[ahussain9]

Yep. We do all joint injections (i.e. shoulder, knees, hips, SI joint etc.), tendon sheath injections, axial injections under fluoro including ILESI, TFESI, MBB, and RFA. We get very good training in spasticity management including botox, phenol, baclofen pump refills and investigation under flouro and with CT evaluation.

The one area we are weak in is MSK U/S. Previously, some of our residents would rotate with Dr. Ebrahim at NRH (who now left) and one in particular trained all her free time with him. She now does all MSK U/S at a local ortho group. We've started rotating with her for that training. We also have a new attending who does U/S guided joint injections...so hopefully that will pick up.

We don't have a sports attending on board so we rotate with the Hopkins orthopedic group. They are awesome and open to any PM&R resident who wants more exposure including game coverage with the Orioles. Some of our previous residents have done quite well with sports fellowships including Erik Brand who trained at Spaulding for fellowship...now he's in Seattle with a group out there (non-acgme MSK/SPORTS fellowship available there btw). Another is doing fellowship in San Diego and interviewed at Hopkins for a joint appointment with ortho and pm&r to give us some more dedicated training in sports/msk.

I'm more interested in pain but would like to get more training in MSK U/S during residency as I'm not sure how much of that is available with current pain fellowships. I'm starting to think a observational rotation would be equally helpful as we already do some blind injections...it's more important to become comfortable with U/S anatomy and technique. Would you agree?

 

[DOctorJay]

Agree the anatomy is the most important piece but developing the skill to keep the probe stable and advance the needle inplane within a mm slice is difficult to master and will take some time. Much different on a live moving pt than a cadaver or phantom.

 

[Louisville04]

The top three are probably subacromial subdeltoid bursa, knee, and a tie between hip and glenohumeral joint.

Do you do facet joint injections with ultrasound?

 

[MedBronc23]

Yes at least many of our pain docs at my training institution can do facets with US. DOctor Jay can attest more.

 

[lobelsteve]

Yes at least many of our pain docs at my training institution can do facets with US. DOctor Jay can attest more.

That sounds good, but the data is +/- for this. But more importantly, you MUST use fluoro or CT scan or you can not bill it as a facet injection.

It works great for cadavers, especially the skinny ones. 🙂

 

[DOctorJay]

We are not doing US facets currently but there are a couple consultants here and one at Mayo Jax who could easily do them. Narouze apparently prefers US for cervical facets and his technique is detailed in his text.

 

[bedrock]

We are not doing US facets currently but there are a couple consultants here and one at Mayo Jax who could easily do them. Narouze apparently prefers US for cervical facets and his technique is detailed in his text.

I admire the US skill of the Mayo docs, (who are some of the best in the country with US), but being so US focused may cloud their perspective. All techniques have limits. Cervical facet injections can be tricky even with fluoro and I've never seen an ultrasound technique superior to fluoro for that procedure.

And as steve mentioned you won't get paid with US, so no reason to use an inferior and challenging facet injection technique, and work for free to boot.

(I do think US is fantastic for many peripheral joint injection, tendon injections, and various nerve blocks)

 

[DOctorJay]

I admire the US skill of the Mayo docs, (who are some of the best in the country with US), but being so US focused may cloud their perspective. All techniques have limits. Cervical facet injections can be tricky even with fluoro and I've never seen an ultrasound technique superior to fluoro for that procedure.

And as steve mentioned you won't get paid with US, so no reason to use an inferior and challenging facet injection technique, and work for free to boot.

(I do think US is fantastic for many peripheral joint injection, tendon injections, and various nerve blocks)

I agree with you. Just because you can doesn't mean you should. This is why we don't do it. There would need to be an extremely compelling reason to do it with US here.

 

[Louisville04]

The top three are probably subacromial subdeltoid bursa, knee, and a tie between hip and glenohumeral joint.

At your facility are all knee and subacromial bursa injections done with ultrasound guidance?

I was reading a topic on ultrasound machines on phyzforum and came upon this

"From an ROI perspective, remember that your source of income is almost if not completely bankrupt and printing money to pay you. If you think that CMS is going to continue to pay for US guidance on most injections you are mistaken. CMS has already decided that they do not want to pay for US guidance on joint injections. If you bill for US guidance on all injections and do not justify in your documentation what issues made US guidance necessary, you are likely going to be meeting RAC auditors at your door in due time"

 

[DOctorJay]

Nope. We usually see patients after they've failed a palpatory guided injection. We always dictate the specific reason for guidance as well - typically it's a BMI issue. No problem getting it covered especially when we're injecting viscosupplement into a knee or doing an intraarticular hip.

 

[lobelsteve]

Nope. We usually see patients after they've failed a palpatory guided injection. We always dictate the specific reason for guidance as well - typically it's a BMI issue. No problem getting it covered especially when we're injecting viscosupplement into a knee or doing an intraarticular hip.

All hips need imaging.

 

[DOctorJay]

All hips need imaging.

true, bad example