Doppler Dilemmas

April 22, 2016
Eric Postal, MD

Sometimes image quality is just plain bad.

I’ve had the good fortune to receive more than halfway decent training in Doppler sonography. One of my attendings during fellowship, in particular, gave a lecture series and had published a textbook on the topic.

With the benefit of hindsight, I now suppose it was more likely than not that, upon leaving academic environments for the…let’s say more pragmatic…world of outpatient imaging centers, I would see less textbook-worthy ultrasound imaging presented for my dictated reporting.

It was, instead, more of a rude awakening for me at the time. What I had learned to be diagnostic quality Doppler imaging (spectral, in particular) turned out to be vanishingly rare in the “real world.” Indeed, my knee-jerk reaction was that more than a few of the images I was being given were downright lousy. By issuing reports on them, would I not be complicit in a sort of fraud? Leading patients and referrers to believe that a meaningful diagnostic test had been performed when, in truth, it really hadn’t?

Had it been an isolated case here and there, or one or two sono techs in particular, it wouldn’t have given me much pause. Even under ivory tower conditions, one learns that some patients have body types, mental statuses, etc. less conducive to pristine imaging. One also learns that some techs have phenomenal skills at image acquisition, while others…not so much.

But this was case after case, and more techs than not. My next thought was that, maybe, the outpatient imaging centers employing me (and especially some referring clinicians who employed their own sono techs to do in-house carotid screenings, for us to report) just weren’t spending the time, effort, or moolah to get the quality of techs I had been fortunate to work with in hospitals.[[{"type":"media","view_mode":"media_crop","fid":"47958","attributes":{"alt":"Doppler dilemmas","class":"media-image media-image-right","id":"media_crop_6202976427112","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5700","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 166px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©James Steidl/Shutterstock.com","typeof":"foaf:Image"}}]]

And then I started reading for hospitals again, and an awful lot of the Doppler studies I got were, ah, suboptimal too. I’m trying to be charitable with my terms, here. But really…a DVT study giving arterial waveforms to prove patency? A study to investigate potential carotid stenosis with scattered annotated peak-systolic velocity measurements in the 30s (not with a parvus/tardus waveform, lest some wiseacre comment on the possibility), intermingled with measurements in the 60s and up? I mean, I wasn’t just quibbling about the lack of a well-depicted dicrotic notch in each and every waveform.

I’d tried to consider that perhaps I’d just been spoiled with good images in the past, and was now bristling at adjusting my approach to the real world. Eventually, I concluded that the problem was not me, but a pandemic of Doppler studies that weren’t being done as well as most folks might have assumed. I wasn’t so much a caviar and petit four aficionado, now sneering when offered cocktail weenies, as a healthful food fan balking when proposed a 24-7-365 diet of McD’s.

The question, ultimately, was what to do about it all? Back in fellowship, the fallback option would have been to grab the transducer and get diagnostic quality Doppler pix oneself. Don’t have the skills for it? Learn ‘em, if you want to be the ultrasound guy! (Perhaps while making plans to beseech the local hierarchy to recruit sono techs with better skills, or to send current staff to a refresher course.)

Not a realistic plan for most of us, any of that. First, in my particular situation of reading studies offsite for hundreds of different facilities, I physically can’t stroll into the sono suite to scan anybody. Some would say this is a reason why teleradiology is a Very Bad Thing…regardless, chances are that my skills have atrophied to the point that I could probably wield a transducer as capably as would a macaque.

Moving beyond my own particular circumstances, though, it’s unrealistic for most working rads, who might be willing to read Doppler studies as a matter of providing coverage but are far from experts on the matter. Heck, many of them probably don’t recognize the technical issues I routinely see, and wince...for them, the less-than-diagnostic aspects of the Dopplers they report are the “unknown unknown.”

In our times of ever-tightening budgets, good luck getting someone holding the purse-strings to unclench for better Doppler -tech recruitment, or training…unless the string-holder happens to be one of the rads in the position of reporting such cases, and putting his professional life on the line in the process.

So…what to do? Go ahead and read out the sub-par Doppler studies we see multiple times per day, letting patients and referrers think they got a better diagnostic test than they actually did? Comment in each report about how the studies could have been better, running the risk of ticking people off in the process? Exempt (or ban) nonexpert rads and techs from participating, even if that means we wind up with 1% of the manpower needed to perform the vast number of Dopplers ordered every day?

If there’s a simple solution, I’ve yet to hear it.