STANFORD UNIVERSITY MEDICAL CENTER



|Rotation: Ultrasound |Rotation Duration: 4 wks |Month(s): 3-4 |

|Institution: Stanford, VA |Call Responsibility: none |Night(s): covered by Night float |

|Responsible Faculty Member(s): |Location: |

|R. Brooke Jeffrey Jr., M.D. |Stanford hospital (2 months) |

|F. Graham Sommer, M.D. |VA DRC (1 month) |

|Terry Desser, M.D. |Johnson Perinatal Diagnostic Center, 3rd floor SUH |

|Bruce Daniel, M.D. |UCSF- optional fourth-year elective |

|Aya Kamaya, M.D. | |

|Juergen Willmann, MD PhD | |

|Lewis Shin, MD | |

|Ray Hsu, MD | |

|Richard Barth, M.D. (OB ultrasound) | |

| |Phone Numbers: |

| |Stanford Hospital: |

| |Ultrasound reading room: 498-2401, 723-3499 |

| |Ultrasound lab: 723-3498 |

| |OB ultrasound: 725-7030 |

| |VA Hospital: |

| |650-493-5000 ( +extension) |

| |front desk: 64489 |

| |Technologist: 63824, 63020 |

| |Reading room: 65250, 63886 |

|Technologists/Technical Staff: |Training Level: |

|Diane Orluck, RDMS, Chief Technologist |Stanford-years 1, 3 |

|Amber Gee, |VA-year 2 |

|Alex Karanany | |

|Amanada Nelson | |

|Carol Walters | |

|Christy Hill | |

|Ke Chen | |

|Lan Zhang | |

|Lillie Utley | |

|Marianne Johnson | |

|Rebecca Wong | |

|Pam Daniel, Sarah Brandon, Shirley Furuichi, Xin Yuan | |

|Goals & Objectives- |

|A note about goals and objectives- The goals and objectives outlined in this document are based upon the six core competencies as defined by the |

|ACGME. As residents gain experience and demonstrate growth in their ability to care for patients, they assume roles that permit them to exercise |

|those skills with greater independence. This concept—graded and progressive responsibility—is one of the core tenets of American graduate medical |

|education. This document should provide you a framework for the stepwise progression of your knowledge and skills. |

| |

| |

| |

|ROTATION 1: FIRST YEAR-Stanford Hospital Ultrasound |

| |

|This rotation involves interpretation of basic sonography of the abdomen, pelvis, thyroid, scrotum, and obstetrical cases. Also, introduction to |

|color and spectral Doppler studies of carotid arteries, upper and lower extremity and abdominal vasculature. Some ultrasound-guided aspirations and|

|biopsies will be performed on the ultrasound rotation and others on the interventional rotation. |

| |

|Patient Care |

| |

|Goal: |

| |

|Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the |

|promotion of health. Residents are expected to: |

| |

|Knowledge Objectives: |

| |

|Be familiar with all departmental US protocols found in reading room binder. |

|Know the key types of ultrasound examinations. |

|Understand indications, contraindications, and patient preparation for sonographically-guided procedures. |

|Demonstrate basic knowledge of EPIC, Nuance Radwhere voice recognition software, centricity RIS, GE centricity PACS, and the Siemens KinetDX |

|ultrasound workstation. |

|Become familiar with ultrasound machinery and transducers. |

|Become familiar with the use of Color Doppler and harmonics. |

|Learn the basics of ultrasound analysis. |

| |

|Skill Objectives: |

| |

|Become facile with scanning, using PACS and utilizing available information technology to manage patient information. |

|Observe and assist in US-guided aspirations and biopsies under direction of faculty or fellow. |

|Perform basic sonography with minimal assistance, including US of the chest, abdomen, pelvis, and lower extremities. |

|Procedure Log: Log at least 20 DVT cases, some of which should be upper extremity cases. |

|Coordinate activities in the reading room, including assisting the staff MD on providing direction for the technologists, consultation for other |

|clinicians, and answering the phone. |

|Gather clinical and radiological data on patients referred for ultrasound exam. |

|Develop diagnostic plan based on the clinical presentation and prior imaging. |

|Understand the clinical questions to be addressed by the study by calling the referring physician if necessary. |

|Review ultrasound requisitions to be sure that the correct type of study has been ordered to answer the clinical question. |

|Perform exams responsibly and safely, assuring that the correct exam is ordered and performed. |

|Review images with the ultrasound technologists as studies are completed to insure that sufficient, diagnostic images have been obtained. Request |

|additional images as needed. |

|Develop hands-on scanning skills and learn the operation of the ultrasound instrument. |

|Demonstrate the ability to use the internet as an educational instrument: PubMed, RSNA site, Google, Stat DX. |

|Generate differential diagnoses based in imaging findings and clinical data. |

| |

| |

|Behavior and Attitude Objectives: |

| |

|Work with the health care team in a professional manner to provide patient-centered care. |

|Notify referring clinician for urgent, emergent, or unexpected findings, and document in dictation. |

|Active participation with faculty in patient workup. |

|Graduated responsibility in performing radiologic procedures. |

| |

|Medical Knowledge |

| |

|Goal: |

| |

|Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as |

|the application of this knowledge to patient care. Residents are expected to: |

| |

|Knowledge Objectives: |

| |

|Understand clinical application of ultrasound. |

|Identify relevant anatomic structures on US images. |

|Diagnose common pathologic conditions in the abdomen and pelvis and understand their pathophysiology. |

|Understand the elements of key ultrasound examinations including gallbladder, liver, renal, pelvic, FAST for ER, chest for fluid, extremity for |

|DVT. The goal at this level is to begin to understand the basics and what it takes to master them. |

|Learn the pathophysiology and diagnostic criteria of the diagnoses listed in appendix A. in preparation for a call |

| |

|Skill Objectives: |

| |

|Perform basic sonography with minimal assistance, including US of the chest for fluid, abdomen for gallbladder or liver disease, pelvis for |

|fibroids or ectopic, and lower extremities for thrombosis. |

|Demonstrate sufficient knowledge of medicine and its proper application to generate meaningful differential diagnoses. |

|Demonstrate a clinically appropriate diagnostic treatment plan. |

|Demonstrate the proper use of radiological equipment. |

| |

|Behavior and Attitude Objectives: |

| |

|Recognize limitations of personal competency and ask for guidance when appropriate. |

| |

|Practice-Based Learning and Improvement |

| |

|Goal: |

| |

|Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to |

|continuously improve patient care based on constant self-evaluation and lifelong learning. Residents are expected to develop skills and habits to |

|be able to: |

| |

|Knowledge Objectives: |

| |

|Assess US images for quality and suggest methods of improvement. |

| |

|Skill Objectives: |

| |

|Demonstrate independent self-study using various resources including texts, journals, teaching files, and other resources on the internet. |

|Facilitate the learning of students and other health care professionals. |

|Analyze and develop improvement plans in the clinical practice, including knowledge, observation, and procedural skills. |

|Keep a log of clinical and interpretive questions that arise during readout of cases, and research answers to at least 2 questions per week. |

|Demonstrate knowledge of and apply the principles of evidence-based medicine in practice. |

|Demonstrate critical assessment of the scientific literature. |

|Use internet and online and print resources to answer clinical questions. |

| |

|Behavior and Attitude Objectives: |

| |

|Incorporate formative feedback into daily practice. |

|Follow-up interesting or difficult cases without prompting and share this information with appropriate faculty and fellow residents. |

|Participation in body imaging journal club. |

|Preparation of cases for multi-disciplinary conferences. |

|Participation in ultrasound conference. |

|Demonstrate the ability to use all relevant information resources to acquire evidence-based data. |

|Demonstrate understanding of the principles of research project design and implementation. |

| |

|Systems Based Practice |

| |

|Goal: |

| |

|Residents must demonstrate an awareness of, and responsiveness to, the larger context and system of health care, as well as the ability to call |

|effectively on other resources in the system to provide optimal health care. Residents are expected to: |

| |

|Knowledge Objectives: |

| |

|Understand how their image interpretation affects patient care. |

|Demonstrate knowledge of funding sources for research and clinical care. |

|Demonstrate knowledge of reimbursement methods. |

|Demonstrate knowledge and sensitivity to workflow and resource utilization issues. |

|Demonstrate knowledge of the regulatory environment. |

|Demonstrate knowledge of basic management principles such as budgeting, record keeping, medical records, and the recruitment, hiring, supervision |

|and management of staff. |

|Learn about the AIUM accreditation standards for Ultrasound laboratories. |

| |

|Skill Objectives: |

| |

|Provide accurate and timely interpretations to decrease length of hospital and emergency department stay. |

|Appropriately notify the referring clinician if there are urgent or unexpected findings and document such without being prompted. |

|Practice cost-effective use of time and support personnel. |

|Demonstrate ability to design cost-effective care plans. |

|Review of literature, including ACR Appropriateness Criteria. |

| |

|Behavior and Attitude Objectives: |

| |

|Advocate for quality patient care in a professional manner, particularly concerning imaging utilization issues. |

|Attendance and participation in multi-disciplinary conference. |

|Interaction with department administrators. |

|Membership and participation in local and national radiological societies. |

| |

|Professionalism |

| |

|Goal: |

| |

|Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are |

|expected to demonstrate: |

| |

|Knowledge Objectives: |

| |

|Understanding of the need for respect for patient privacy and autonomy. |

|Understanding of their responsibility for the patient and the service, including arriving in the reading room promptly each day, promptly returning|

|to the reading room after conferences, completing the work in a timely fashion, and not leaving at the end of the day until all work is complete. |

|If the resident will be away from a service (for time off, meeting, board review, etc.), this must be arranged in advance with the appropriate |

|faculty and/or fellow. |

|Demonstrate knowledge of issues of impairment. |

| |

|Skill Objectives: |

| |

|Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, |

|disabilities, and sexual orientation. |

|Professionalism and compassion while obtaining informed consent in all patients undergoing US-guided procedure. |

| |

|Behavior and Attitude Objectives: |

| |

|Respect, compassion, integrity, and responsiveness to patient care needs that supersede self-interest. |

|Demonstrate excellence: perform responsibilities at the highest level and continue active learning throughout one's career. |

|Demonstrate honesty with patients and staff. |

|Demonstrate honor and integrity: avoid conflict of interests when accepting gifts from patients and vendors. |

|Demonstrate positive work habits, including punctuality and professional appearance. |

| |

|Interpersonal and Communication Skills |

| |

|Goal: |

| |

|Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, |

|their families, and professional associates. Residents are expected to: |

| |

|Knowledge Objectives: |

| |

|Know the importance of accurate, timely, and professional communication. |

| |

|Skill Objectives: |

| |

|Produce concise and accurate reports on most examinations, provide a clear report based on standard radiologic terminology. |

|Communicate effectively with physicians, other health professionals. |

|Obtain informed consent with the utmost professionalism. |

|Obtain pertinent clinical information and clear understanding of diagnostic question to be answered by communicating directly with clinicians if |

|necessary. |

|Communicate relevant clinical history to ultrasound technologists. |

|Provide direct communication to referring physicians, and documenting communication in report for all significant positive findings. |

|Demonstrate skills in obtaining informed consent, including effective communication to patients of the procedure, alternatives, and possible |

|complications. |

|Demonstrate the verbal and non-verbal skills necessary for face to face listening and speaking to physicians, families, and support personnel. |

|Demonstrate findings to clinicians when they come to ultrasound department to review study. |

| |

|Behavior and Attitude Objectives: |

| |

|Work effectively as a member of the patient care team. |

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|ROTATION 2: Second Year- VA |

| |

|This rotation involves interpretation of intermediate sonography of the abdomen, pelvis, thyroid, scrotum, and obstetrical cases. Also, |

|introduction to color and spectral Doppler studies of carotid arteries, upper and lower extremity and abdominal vasculature. Some ultrasound-guided|

|aspirations and biopsies will be performed on the ultrasound rotation and others on the interventional rotation. |

| |

|Patient Care |

| |

|Goal: |

| |

|Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the |

|promotion of health. Residents are expected to: |

| |

|Knowledge Objectives: |

| |

|Be increasingly familiar with all departmental US protocols. |

|Know the majority of types of ultrasound examinations, see below. |

|Understand indications, contraindications, and patient preparation for sonographically-guided procedures. |

|Increased familiarity with machines and transducers: optimizing Doppler settings. |

| |

|Skill Objectives: |

| |

|Demonstrate advanced knowledge of EPIC. |

|Become increasingly facile with Scanning, using PACS and utilizing available information technology to manage patient information. |

|Perform intermediate sonography with minimal assistance, including US of the chest, abdomen, pelvis, and lower extremities. |

|Procedure Log: Log at least 10 abdomen and 10 pelvis cases. |

|Coordinate activities in the reading room, including assisting the staff MD on providing direction for the technologists, consultation for other |

|clinicians, and answering the phone. |

|Gather clinical and radiological data on patients referred for ultrasound exam. |

|Develop diagnostic plan based on the clinical presentation and prior imaging. |

|Understand the clinical questions to be addressed by the study by calling the referring physician if necessary. |

|Review ultrasound requisitions to be sure that the correct type of study has been ordered to answer the clinical question. |

|Perform exams responsibly and safely, assuring that the correct exam is ordered and performed. |

|Review images with the ultrasound technologists as studies are completed to insure that sufficient, diagnostic images have been obtained. Request |

|additional images as needed. |

|Develop hands-on scanning skills and learn the operation of the ultrasound instrument |

|Demonstrate the ability to use the internet as an educational instrument: PubMed, RSNA site, Google, Stat DX. |

|Generate differential diagnoses based in imaging findings and clinical data. |

|Endovaginal and transabdominal scans of the pelvis: Second and third year residents should learn the techniques for performing these examinations, |

|and should learn how to set up the endovaginal probe. They should also learn the proper technique for disinfecting the probe between studies. |

|Abdominal ultrasound: Second and third year residents should learn to perform emergency scans of the abdomen for indications such as suspected |

|cholecystitis. |

|Learn to perform imaging of the acute scrotum for suspected torsion and epididymitis. |

| |

| |

|Behavior and Attitude Objectives: |

| |

|Work with the health care team in a professional manner to provide patient-centered care. |

|Notify referring clinician for urgent, emergent, or unexpected findings, and document in dictation. |

|Active participation with faculty in patient work-up. |

|Graduated responsibility in performing radiologic procedures. |

| |

|Medical Knowledge |

| |

|Goal: |

| |

|Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as |

|the application of this knowledge to patient care. Residents are expected to: |

| |

|Knowledge Objectives: |

| |

|Understand clinical application of ultrasound. |

|Identify relevant anatomic structures on US images. |

|Diagnose common and uncommon pathologic conditions in the abdomen and pelvis and understand their pathophysiology. |

|Understand the elements of key ultrasound examinations including gallbladder, liver, renal, pelvic, FAST for ER, chest for fluid, extremity for |

|DVT. |

|Learn to analyze and diagnose IUP, ectopic pregnancy, adnexal mass, pancreatic mass, liver mass, spleen mass, kidney mass, bladder mass, and |

|ovarian mass. |

|Learn appropriate differential diagnoses and methods for further analysis. |

|Learn to analyze and diagnose ultrasound studies of the neck and scrotum, carotid duplex studies. |

|Review and understand at least half of the diagnoses listed in appendix B. |

| |

|Skill Objectives: |

| |

|Perform intermediate sonography with minimal assistance, including US of the chest for fluid, abdomen for gallbladder or liver disease, pelvis for |

|fibroids or ectopic, and lower extremities for thrombosis. |

|Demonstrate sufficient knowledge of medicine and its proper application to generate meaningful differential diagnoses. |

|Demonstrate progress during subsequent rotations. |

|Demonstrate a clinically appropriate diagnostic treatment plan. |

|Demonstrate the proper use of radiological equipment. |

| |

|Behavior and Attitude Objectives: |

| |

|Recognize limitations of personal competency and ask for guidance when appropriate. |

| |

|Practice-Based Learning and Improvement |

| |

|Goal: |

| |

|Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to |

|continuously improve patient care based on constant self-evaluation and lifelong learning. Residents are expected to develop skills and habits to |

|be able to: |

| |

|Knowledge Objectives: |

| |

|Assess US images for quality and suggest methods of improvement. |

| |

|Skill Objectives: |

| |

|Demonstrate independent self-study using various resources including texts, journals, teaching files, and other resources on the internet. |

|Facilitate the learning of students and other health care professionals. |

|Analyze and develop improvement plans in the clinical practice, including knowledge, observation, and procedural skills. |

|Keep a log of clinical and interpretive questions that arise during readout of cases, and research answers to at least 2 questions per week. |

|Demonstrate knowledge of and apply the principles of evidence-based medicine in practice. |

|Demonstrate critical assessment of the scientific literature. |

|Use internet and online and print resources to answer clinical questions. |

|Demonstrate understanding of the principles of research project design and implementation. |

|Demonstrate the ability to use all relevant information resources to acquire evidence-based data. |

| |

|Behavior and Attitude Objectives: |

| |

|Incorporate formative feedback into daily practice. |

|Follow-up interesting or difficult cases without prompting and share this information with appropriate faculty and fellow residents. |

|Participate in journal club, clinical conferences, and independent reading. |

|Participation in body imaging journal club. |

|Preparation of cases for multi-disciplinary conferences. |

| |

|Systems Based Practice |

| |

|Goal: |

| |

|Residents must demonstrate an awareness of, and responsiveness to, the larger context and system of health care, as well as the ability to call |

|effectively on other resources in the system to provide optimal health care. Residents are expected to: |

| |

|Knowledge Objectives: |

| |

|Understand how their image interpretation affects patient care. |

|Demonstrate knowledge of funding sources for research and clinical care. |

|Demonstrate knowledge of reimbursement methods. |

|Demonstrate knowledge and sensitivity to workflow and resource utilization issues. |

|Demonstrate knowledge of the regulatory environment. |

|Demonstrate knowledge of basic management principles such as budgeting, record keeping, medical records, and the recruitment, hiring, supervision |

|and management of staff. |

|Learn about the AIUM accreditation standards for ultrasound laboratories. |

| |

|Skill Objectives: |

| |

|Provide accurate and timely interpretations to decrease length of hospital and emergency department stay. |

|Appropriately notify the referring clinician if there are urgent or unexpected findings and document such without being prompted. |

|Practice using cost effective use of time and support personnel. |

|Demonstrate ability to design cost-effective care plans. |

|Review of literature, including ACR Appropriateness Criteria. |

| |

|Behavior and Attitude Objectives: |

| |

|Advocate for quality patient care in a professional manner, particularly concerning imaging utilization issues. |

|Attendance and participation in multi-disciplinary conference. |

|Interaction with department administrators. |

|Membership and participation in local and national radiological societies. |

| |

|Professionalism |

| |

|Goal: |

| |

|Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are |

|expected to demonstrate: |

| |

|Knowledge Objectives: |

| |

|Understanding of the need for respect for patient privacy and autonomy. |

|Understanding of their responsibility for the patient and the service, including arriving in the reading room promptly each day, promptly returning|

|to the reading room after conferences, completing the work in a timely fashion, and not leaving at the end of the day until all work is complete. |

|If the resident will be away from a service (for time off, meeting, board review, etc.), this must be arranged in advance with the appropriate |

|faculty and/or fellow. |

|Demonstrate knowledge of issues of impairment. |

| |

|Skill Objectives: |

| |

|Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, |

|disabilities, and sexual orientation. |

|Professionalism and compassion while obtaining informed consent in all patients undergoing US-guided procedure. |

| |

|Behavior and Attitude Objectives: |

| |

|Respect, compassion, integrity, and responsiveness to patient care needs that supersede self-interest. |

|Demonstrate excellence: perform responsibilities at the highest level and continue active learning throughout one's career. |

|Demonstrate honesty with patients and staff. |

|Demonstrate honor and integrity: avoid conflict of interests when accepting gifts from patients and vendors. |

|Demonstrate positive work habits, including punctuality and professional appearance. |

| |

|Interpersonal and Communication Skills |

| |

|Goal: |

| |

|Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, |

|their families, and professional associates. Residents are expected to: |

| |

|Knowledge Objectives: |

| |

|Know the importance of accurate, timely, and professional communication. |

| |

|Skill Objectives: |

| |

|Produce concise and accurate reports on most examinations, provide a clear report based on standard radiologic terminology. |

|Communicate effectively with physicians, other health professionals. |

|Obtain informed consent with the utmost professionalism. |

|Obtain pertinent clinical information and clear understanding of diagnostic question to be answered by communicating directly with clinicians if |

|necessary. |

|Communicate relevant clinical history to ultrasound technologists. |

|Provide direct communication to referring physicians, and documenting communication in report for all significant positive findings. |

|Demonstrate skills in obtaining informed consent, including effective communication to patients of the procedure, alternatives, and possible |

|complications. |

|Demonstrate the verbal and non-verbal skills necessary for face to face listening and speaking to physicians, families, and support personnel. |

|Demonstrate findings to clinicians when they come to ultrasound department to review study. |

| |

|Behavior and Attitude Objectives: |

| |

|Work effectively as a member of the patient care team. |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

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| |

| |

| |

| |

| |

| |

|ROTATION 3-Stanford Hospital |

| |

|This rotation involves performance and interpretation of advanced sonography of the abdomen, pelvis, thyroid, scrotum, and obstetrical cases. Also,|

|an advanced level of color and spectral Doppler studies of carotid arteries, upper and lower extremity and abdominal vasculature. Some |

|ultrasound-guided aspirations and biopsies will be performed on the ultrasound rotation and others on the interventional rotation. |

| |

|Patient Care |

| |

|Goal: |

| |

|Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the |

|promotion of health. Residents are expected to: |

| |

|Knowledge Objectives: |

| |

|Describe more common and uncommon sonographic artifacts. |

|List indications, contraindications, and patient preparation for sonographically-guided procedures. |

|Continued mastery of material from rotation 2. |

|Normal OB exam and possible abnormalities. |

| |

|Skill Objectives: |

| |

|Become increasingly facile with scanning and utilize available information technology to manage patient information. |

|Perform US-guided aspirations and biopsies with occasional help from faculty or fellow. |

|Coordinate activities in the reading room, including providing direction for the technologists, consultation for other clinicians, and answering |

|the phone. |

|Observe ultrasound-guided biopsy of the thyroid gland. |

|Perform ultrasound localization for ultrasound-guided biopsy of the kidney by the nephrology service. |

| |

|Behavior and Attitude Objectives: |

| |

|Work with the health care team in a professional manner to provide patient-centered care. |

|Notify referring clinician for urgent, emergent, or unexpected findings, and document in dictation. |

| |

| |

| |

| |

| |

|Medical Knowledge |

| |

|Goal: |

| |

|Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as |

|the application of this knowledge to patient care. Residents are expected to: |

| |

|Knowledge Objectives: |

| |

|Understand clinical application of ultrasound. |

|Identify relevant anatomic structures on US images. |

|Diagnose all pathologic conditions in the abdomen and pelvis and understand their pathophysiology. |

|Understand principles of Doppler studies of abdominal vasculature, especially transplant studies |

| |

|Skill Objectives: |

| |

|Accurately interpret all US examinations, with only the necessary amount of faculty assistance. |

|Begin to perform more complex sonographic examinations such as US of the carotid and visceral arteries, upper extremity arteries and veins, |

|scrotum, and gravid uterus. |

|Demonstrate understanding of the pathophysiology and diagnostic criteria for all of the diagnoses listed in appendix B. |

|Endovaginal and transabdominal scans of the pelvis: Second and third year residents should learn the techniques for performing these examinations, |

|and should learn how to set up the endovaginal probe. They should also learn the proper technique for disinfecting the probe between studies. |

|Abdominal ultrasound: Second and third year residents should learn to perform emergency scans of the abdomen for indications such as suspected |

|cholecystitis. |

|Learn to perform imaging of the acute scrotum for suspected torsion and epididymitis. |

| |

|Behavior and Attitude Objectives: |

| |

|Recognize limitations of personal competency and ask for guidance when appropriate. |

| |

| |

|Practice-Based Learning and Improvement |

| |

|Goal: |

| |

|Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to |

|continuously improve patient care based on constant self-evaluation and lifelong learning. Residents are expected to develop skills and habits to |

|be able to: |

| |

|Knowledge Objectives: |

| |

|Assess US images for quality and suggest methods of improvement. |

| |

|Skill Objectives: |

| |

|Demonstrate independent self-study using various resources including texts, journals, teaching files, and other resources on the internet. |

|Facilitate the learning of students and other health care professionals. |

| |

|Behavior and Attitude Objectives: |

| |

|Incorporate formative feedback into daily practice. |

|Follow-up interesting or difficult cases without prompting and share this information with appropriate faculty and fellow residents. |

| |

|Systems Based Practice |

| |

|Goal: |

| |

|Residents must demonstrate an awareness of, and responsiveness to, the larger context and system of health care, as well as the ability to call |

|effectively on other resources in the system to provide optimal health care. Residents are expected to: |

| |

|Knowledge Objectives: |

| |

|Understand how their image interpretation affects patient care. |

| |

|Skill Objectives: |

| |

|Provide accurate and timely interpretations to decrease length of hospital and emergency department stay, |

|Appropriately notify the referring clinician if there are urgent or unexpected findings and document such without being prompted; and |

|Practice using cost effective use of time and support personnel. |

| |

|Behavior and Attitude Objectives: |

| |

|Advocate for quality patient care in a professional manner, particularly concerning imaging utilization issues. |

| |

| |

|Professionalism |

| |

|Goal: |

| |

|Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are |

|expected to demonstrate: |

| |

|Knowledge Objectives: |

| |

|Understanding of the need for respect for patient privacy and autonomy. |

|Understanding of their responsibility for the patient and the service, including arriving in the reading room promptly each day, promptly returning|

|to the reading room after conferences, completing the work in a timely fashion, and not leaving at the end of the day until all work is complete. |

|If the resident will be away from a service (for time off, meeting, board review, etc.), this must be arranged in advance with the appropriate |

|faculty and/or fellow. |

| |

|Skill Objectives: |

| |

|Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, |

|disabilities, and sexual orientation. |

|Professionalism and compassion while obtaining informed consent in all patients undergoing US-guided procedure. |

| |

|Behavior and Attitude Objectives: |

| |

|Respect, compassion, integrity, and responsiveness to patient care needs that supersede self-interest. |

| |

| |

|Interpersonal and Communication Skills |

| |

|Goal: |

| |

|Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, |

|their families, and professional associates. Residents are expected to: |

| |

|Knowledge Objectives: |

| |

|Know the importance of accurate, timely, and professional communication. |

| |

|Skill Objectives: |

| |

|Produce concise and accurate reports on most examinations. |

|Communicate effectively with physicians, other health professionals. |

|Obtain informed consent with the utmost professionalism. |

| |

|Behavior and Attitude Objectives: |

| |

|Work effectively as a member of the patient care team. |

|ROTATION 4: OB ULTRASOUND ELECTIVE (optional) |

|Can be taken at UCSF—note: this is the ONLY away rotation authorized by our GME office |

|Workflow: |

|The workday begins at approximately 8:30, immediately following morning conference |

|Readouts occur throughout the morning and afternoon. |

|Whenever possible, the resident should preview ultrasound cases with the body imaging fellow before readout. |

|The resident should dictate cases that he/she performed or checked once they have been reviewed with the attending. |

|The resident should field requests for emergency add-on studies and should elicit enough clinical history to insure that the correct study is |

|performed for the condition suspected. He/she should also find out whom to contact with the results, and where any outpatient should be sent when |

|the study is completed. |

|After cases are dictated, a brief summary of the findings should be recorded in the Diagnosis section of the Worksheet for that study on the |

|Ultrasound KinetDx workstation (Ultrasound mini-PACS). |

|First-year residents should also spend time observing the technologists perform diagnostic scans. During the first rotation, they should begin to |

|perform studies of the legs for suspected deep venous thrombosis. |

|Ultrasound conference is held with the attending staff and technologists on Thursdays at 12:30. |

|In OB ultrasound, residents should observe the studies being performed, and sit in on readout sessions. |

|Duties: |

| |

|Required scanning skills: |

| |

|Venous Doppler studies of the extremities: First year residents should learn to perform studies for suspected deep venous thrombosis of the upper |

|and lower extremities. At least 20 cases should be performed. |

| |

|Endovaginal and transabdominal scans of the pelvis: Second and third year residents should learn the techniques for performing these examinations, |

|and should learn how to set up the endovaginal probe. They should also learn the proper technique for disinfecting the probe between studies. |

| |

|Abdominal ultrasound: Second and third year residents should learn to perform emergency scans of the abdomen for indications such as suspected |

|cholecystitis. |

| |

|Testicular ultrasound: Second and third year residents should learn to perform imaging of the acute scrotum for suspected torsion and epididymitis.|

| |

|Guidance for renal biopsies. Second, third and fourth year residents on the ultrasound service should learn to set up the transducer within a |

|sterile drape and with a biopsy guide in order to assist the nephrologists' renal biopsies. |

| |

|Preparing Cases: |

| |

|Studies are reviewed on the KinetDx workstation in the ultrasound reading room. Once a study is reviewed, it should be marked as "Read" on the |

|study list. Brief diagnoses are recorded directly into the KinetDx workstation after the studies are reviewed. |

|The resident should note whether there are prior comparison ultrasound studies. The technologists will often print out the reports of prior |

|studies. If there are prior ultrasound studies, the resident should check whether they are available online for viewing, or whether they need to be|

|re-loaded onto the server manually. If the latter, the resident should note which tape has the study in question and inform the technologists so |

|that they can re-load the study. |

|If there are relevant comparison images from other modalities, these should be brought up onto the PACS workstation in the ultrasound reading area.|

|The resident should note whether there are any outside cases to be reviewed. If so, these should be reviewed on the PACS in the ultrasound reading |

|room. |

|Time allowing, the resident may pre-dictate studies using the Nuance voice recognition software. The studies will then enter status 60, or |

|"dictated." |

| |

| |

|What to do during readout |

| |

|During readout, the resident should articulate the indication for the examination and be able to provide brief patient history. This may mean |

|looking up some history in EPIC before the readout has begun. |

|While the attending reviews the images, the resident should state what his/her impression was of the findings for any cases they have checked or |

|scanned. |

|During the readout, the resident should jot down a brief list of the findings to be included in the dictation on the tracking form for the |

|patient's study so that all findings will be included. The resident should be sure he/she understands what the "bottom line" is for the study |

|BEFORE the case is signed off, so that the report will convey the significance of the findings. Questions are welcome during readout. |

|Conference Schedule/Format |

|Title |Day |Time |Location |

|Abdominal imaging core conferences |Tuesday |Noon |Lucas |

|Ultrasound QA conference |Thursdays |12:30, monthly |Ballroom |

| | | | |

|Method of Assessment of Performance: |

|Written evaluation of resident by responsible faculty member monthly |

|Verbal feedback to resident by faculty |

|ACR In-Training Service Exam annually |

|Recommended Reading |

| |

|ROTATION ONE: |

|Clinical Sonography: A practical guide. Roger A. Sanders. Boston: Little Brown and Co., 1991.This handbook for technologists is a great place for |

|the beginner to start. The book reviews the controls on the ultrasound machine and describes techniques for performing scans. |

|Ultrasound: the requisites. Alfred B. Kurtz and William D. Middleton. St. Louis: Mosby-Year Book, Inc, 1996. An excellent overview of clinical |

|ultrasound. |

| |

|ROTATION 2/3: |

|Sonography of the abdomen. R. Brooke Jeffrey Jr. and Philip W. Ralls. New York: Raven Press, 1995. A rich source of information on abdominal |

|ultrasound, with particularly good images of gastrointestinal applications. |

|Emergency Imaging. R. Brooke Jeffrey, Philip Ralls, Ann Leung, Michael Brant-Zawadzki. Philadelphia: Lippincott Williams and Wilkins, 1999. A |

|concise overview of diagnostic imaging in the acute setting. Chapters 11 and 12 discuss cholecystitis and appendicitis, and are especially |

|pertinent. |

| |

|Reference Text: |

|Diagnostic Ultrasound, Third Edition. Carol M. Rumack, Stephanie R. Wilson, and J. William Charboneau. St. Louis: Elsevier-Mosby, 2005. |

|This outstanding two-volume text contains beautiful color illustrations and has excellent discussions on the most common ultrasound procedures. The|

|first volume covers material likely to be encountered during the Stanford hospital ultrasound rotation. The second volume is devoted to obstetrics |

|and pediatrics. |

| |

|OB ELECTIVE: |

|Ultrasonography in Obstetrics and Gynecology, Fourth Edition. Peter W. Callen. Philadelphia: W. B. Saunders Company, 2000. An in-depth, |

|comprehensive reference on obstetrical and gynecologic ultrasound. Great for boards. |

| |

|Stat DX |

| |

|RadPrimer |

| |

|As a suggestion, you should do selected readings nightly on topics which have come up on cases seen during the day. This is much more effective |

|than reading texts cover-to-cover and, in general, results in better retention of material because you will be able to associate what you’ve read |

|with a real case that you’ve recently seen. |

| |

Appendix A: knowledge objectives in rotation one in preparation for call.

|Pre-call |  |  |  |

|  |  |1 |Acute Calculous Cholecystitis |

|  |  |2 |Acute Pyelonephritis |

|  |  |3 |Biliary Ductal Dilatation |

|  |  |4 |Choledocholithiasis |

|  |  |5 |Cholelithiasis |

|  |  |6 |Deep Vein Thrombosis |

|  |  |7 |Epididymitis/Orchitis |

|  |  |8 |Hemorrhagic Cyst |

|  |  |9 |Hydrocele |

|  |  |10 |Hydronephrosis |

|  |  |11 |Hydrosalpinx |

|  |  |12 |Ovarian Teratoma |

|  |  |13 |Torsion |

|  |  |14 |Peripheral Arterial Pseudoaneurysm |

|  |  |15 |Peripheral Arteriovenous Fistula |

|  |  |16 |Pyogenic Hepatic Abscess |

|  |  |17 |Portal Vein Gas |

|  |  |18 |Scrotal Trauma |

|  |  |19 |Testicular Carcinoma |

|  |  |20 |Testicular Torsion/Infarction |

|  |  |21 |Tubo-ovarian Abscess |

|  |  |22 |Urolithiasis |

|  |  |23 |Varicocele |

Appendix B: knowledge objectives for the remainder of the rotations.

|Liver |  |  |  |

|  |Diffuse Parenchymal Disease |

|  |  |24 |Acute Hepatitis |

|  |  |25 |Cirrhosis, Hepatic |

|  |  |26 |Diffuse Microabscesses, Hepatic |

|  |  |27 |Lymphoma, Hepatic |

|  |Cyst and Cyst-like Lesions |

|  |  |28 |Hepatic Cyst |

|  |  |29 |Caroli Disease |

|  |  |30 |Amebic Hepatic Abscess |

|  |  |31 |Hepatic Echinococcus Cyst |

|  |  |32 |Hepatic Trauma |

|  |Focal Solid Masses |

|  |  |33 |Hepatic Adenoma |

|  |  |34 |Focal Nodular Hyperplasia |

|  |  |35 |Hepatocellular Carcinoma |

|  |  |36 |Hepatic Cavernous Hemangioma |

|  |  |37 |Hepatic Metastases |

|  |Vascular Conditions |

|  |  |38 |Portal Hypertension |

|  |  |39 |Portal Vein Occlusion |

|  |  |40 |Budd-Chiari Syndrome |

|Biliary System |  |  |

|  |Gallstones and Mimics |

|  |  |41 |Echogenic Bile, Blood Clots, Parasites |

|  |  |42 |Gallbladder Cholesterol Polyp |

|  |Gallbladder Wall Pathology |

|  |  |43 |Acute Acalculous Cholecystitis |

|  |  |44 |Chronic Cholecystitis |

|  |  |45 |Porcelain Gallbladder |

|  |  |46 |Hyperplastic Cholecystosis |

|  |  |47 |Gallbladder Carcinoma |

|  |Ductal Pathology |

|  |  |48 |Choledochal Cyst |

|  |  |49 |Cholangiocarcinoma |

|  |  |50 |Ascending Cholangitis |

|  |  |51 |AIDS-Related Cholangiopathy |

|Pancreas |  |  |  |

|  |Pancreatitis |  |

|  |  |52 |Pancreatitis, Acute |

|  |  |53 |Pancreatic Pseudocyst |

|  |  |54 |Pancreatitis, Chronic |

|  |Simple Cysts and Cystic Neoplasms |

|  |  |55 |Mucinous Cystic Pancreatic Tumor |

|  |  |56 |Serous Cystadenoma of Pancreas |

|  |Solid-Appearing Pancreatic Neoplasms |

|  |  |57 |Pancreatic Ductal Carcinoma |

|  |  |58 |Pancreatic Islet Cell Tumors |

|  |  |59 |Solid and Papillary Neoplasm |

|Spleen |  |  |  |

|  |  |60 |Splenomegaly |

|  |  |61 |Splenic Tumors |

|  |  |62 |Splenic Trauma |

|Urinary Tract |  |  |

|  |Normal Variants and Pseudolesions |

|  |  |63 |Column of Bertin, Kidney |

|  |  |64 |Renal Ectopia |

|  |  |65 |Horseshoe Kidney |

|  |  |66 |Ureteral Duplication |

|  |  |67 |Ureteral Ectopia |

|  |  |68 |Ureteropelvic Junction Obstruction |

|  |Calculi and Calcinosis |

|  |  |69 |Nephrocalcinosis |

|  |Cysts and Cystic Disorders |

|  |  |70 |Simple Renal Cyst |

|  |  |71 |Complex Renal Cyst |

|  |  |72 |Cystic Disease of Dialysis |

|  |  |73 |Multilocular Cystic Nephroma |

|  |  |74 |Renal Trauma |

|  |  |75 |Perinephric Fluid Collections |

|  |Urinary Tract Infection |

|  |  |76 |Focal Bacterial Nephritis |

|  |  |77 |Emphysematous Pyelonephritis |

|  |  |78 |Pyonephrosis |

|  |  |79 |Renal Abscess |

|  |  |80 |Xanthogranulomatous Pyelonephritis |

|  |  |81 |Tuberculosis, Urinary Tract |

|  |Solid Renal Neoplasms |

|  |  |82 |Renal Cell Carcinoma |

|  |  |83 |Renal Angiomyolipoma |

|  |  |84 |Transitional Cell Carcinoma |

|  |  |85 |Renal Lymphoma |

|  |Vascular Conditions |

|  |  |86 |Renal Artery Stenosis |

|  |  |87 |Renal Vein Thrombosis |

|  |Prostate |  |  |

|  |  |88 |Prostatic Hypertrophy |

|  |  |89 |Prostatic Carcinoma |

|  |Bladder |  |  |

|  |  |90 |Bladder Carcinoma |

|  |  |91 |Ureterocele |

|  |  |92 |Bladder Diverticulum |

|  |  |93 |Bladder Calculi |

|Renal Transplants |  |  |

|  |  |94 |Allograft Hydronephrosis |

|  |  |95 |Perigraft Fluid Collections |

|  |  |96 |Allograft Rejection |

|Adrenal Gland |  |  |

|  |  |97 |Adrenal Hemorrhage |

|  |  |98 |Myelolipoma |

|  |  |99 |Adrenal Cysts |

|  |  |100 |Pheochromocytoma |

|  |  |101 |Adrenal Carcinoma |

|Abdominal Wall/Peritoneal Cavity |

|  |  |102 |Groin Hernias |

|  |  |103 |Peritoneal Carcinomatosis |

|  |  |104 |Appendicitis |

|  |  |105 |Intussusception |

|Female Pelvis |  |  |

|  |Cervical and Myometrial Pathology |

|  |  |106 |Adenomyosis, General Uterine |

|  |  |107 |Leiomyoma, General Uterine |

|  |Endometrial Disorders |

|  |  |108 |Hematometrocolpos |

|  |  |109 |Endometrial Polyp |

|  |  |110 |Endometrial Hyperplasia |

|  |  |111 |Endometrial Carcinoma |

|  |  |112 |Endometritis |

|  |Pregnancy-Related Disorders |

|  |  |113 |Ectopic Pregnancy |

|  |  |114 |Interstitial Ectopic Pregnancy |

|  |  |115 |Failed First Trimester Pregnancy |

|  |  |116 |Retained Products of Conception |

|  |  |117 |Gestational Trophoblastic Neoplasm |

|  |Ovarian Cysts and Cystic Neoplasms |

|  |  |118 |Functional Ovarian Cyst |

|  |  |119 |Ovarian Hyperstimulation |

|  |  |120 |Serous Ovarian Cystadenoma/Carcinoma |

|  |  |121 |Mucinous Ovarian Cystadenoma/Carcinoma |

|  |  |122 |Polycystic Ovarian Syndrome |

|  |Non-Ovarian Cystic Masses |

|  |  |123 |Parovarian Cysts |

|  |Vaginal and Vulvar Cysts |

|  |Miscellaneous Ovarian Masses |

|  |  |124 |Ovarian Fibrothecoma |

|  |  |125 |Endometriomas |

|Scrotum |  |  |  |

|  |  |126 |Undescended Testis |

|  |  |127 |Testicular and Epididymal Cysts |

|  |  |128 |Testicular Microlithiasis |

|  |  |129 |Tubular Ectasia |

|  |  |130 |Epididymal Masses |

|Head and Neck |  |  |

|  |Thyroid and Parathyroid |

|  |  |131 |Differentiated Thyroid Carcinoma |

|  |  |132 |Hashimoto Thyroiditis |

|  |  |133 |Multinodular Goiter |

|  |  |134 |Graves Disease |

|  |  |135 |Parathyroid Adenoma, Visceral Space |

|  |  |136 |Anaplastic Thyroid Carcinoma |

|  |Adenopathy |  |

|  |Salivary Glands |

|  |Parotid Space |  |

|  |Miscellaneous Lumps |

|  |Congenital |  |

|Breast |  |  |  |

|Musculoskeletal |  |  |

|  |Tendon Disorders |

|  |Subcutaneous and Muscle Injury |

|  |Arthropathies |  |

|  |Neurovascular Abnormalities |

|  |Infection |  |  |

|  |Articular and Para-Articular Masses |

|  |Soft Tissue Tumors |

|Vascular |  |  |  |

|  |Cerebrovascular |

|  |  |137 |Carotid Stenosis/Occlusion |

|  |  |138 |Vertebral Stenosis/Occlusion |

|  |Abdominal Vessels |

|  |  |139 |Takayasu Arteritis |

|  |  |140 |Aortic/Iliac Aneurysm |

|  |  |141 |Aorto-Iliac Occlusive Disease |

|  |  |142 |IVC Obstruction |

|  |Extremities |  |

|  |  |143 |Subclavian Steal |

|  |  |144 |Varicose Veins/Incompetent Perforator |

|Liver Transplants |  |  |

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