Podcast Transcript: Advanced Ultrasound for Endometriosis

[Dr. Mathew Leonardi]
There are definitely a few models that you can consider, but for me, one of the greatest benefits to being a sonologist is I can do a visit all-in-one with a patient. The traditional model of gynecologic care is you have a consult, talk with the doc and then they will write a requisition for you to go for an ultrasound. The patient leaves and at a later date, who knows how long thereafter they go for that ultrasound, and then there's a follow-up visit to discuss those findings. That could be a week or maybe it could be three months depending on your wait times. For me, all of that happens in one visit. My visits are long, they're probably about an hour because we talk to the patient, and then we do a scan and an exam, and then we talk to the patient. We have essentially three patient appointments in one patient appointment.

[Dr. Mark Hoffman]
Do you bring the ultrasound machine into the exam room with you or is there one room with the machine where they go into?

[Dr. Mathew Leonardi]
In my particular clinic, I have two machines dedicated to me and I have two what I call talk rooms. To try and improve the efficiency of the machine, we have a bit of a flow where people might start in a talk room, have a bit of a chat, empty their bladder, go in for their scan. Then once the scan is done, they're given privacy to address and get presentable again.

Sometimes these scans can be emotional for people or they can be even to degree uncomfortable, so we give them some time and then we bring them into another talk room. There's a bit of a flow. Keep in mind in my clinic I have fellows and I have residents and medical students, so some of the initial intake information is collected by them and then reviewed with me. The fellows are learning the advanced ultrasound as well. Sometimes they're performing the bulk of the ultrasound and then I come in over top, review their images in real-time in front of the patient and sometimes take a few more pictures if needed. Of course, over the duration of a fellow's training, which is two years, at the beginning there's a lot of extra pictures I'm taking. Then by the end, sometimes there's no pictures I'm taking because they're actually very competent and they've collected all the information they need. The structure of my clinic is very unique, everything happens in one timeframe for that patient. I think that's great for the patient overall because it's convenient. They're not visiting the hospital at multiple occasions, paying for parking, taking time off work. I realize that may not be the easiest model to have one-hour appointments. That's difficult.

[Dr. Mark Hoffman]
Amy and I have talked about this in the past too. In Kentucky, we have a big population of patients who are from rural areas coming to see us. We joke about it, like coming to Lexington, Kentucky is like going to Manhattan for a lot of folks. They're like one-way streets and parking garages, it's extremely overwhelming and it's very cost-prohibitive for them to come see us. Part of the fiber program I built, having the IR doc come to my clinic, having ultrasounds, MRIs, be able to be read the day of and seeing them all same day. That's the model that we used to build that. That was my thinking also for why I wanted a machine across the hall in my clinic, in my space so I could have them come to see me if we needed to do a scan and have slots open and we could be scanning the routine stuff too. Also have two to three slots per half day for all of my patients that come through so they can get a scan right then. They don't have to come back. Like you said, it can be weeks for the scan. I'm usually able to see them the day they get their scan so when they come back they just come right upstairs and see me that day to review the pictures in the scan. I've gotten it down to two visits now from three, but to have that machine and that availability in real-time has been a big push and I love hearing that that's how set it up. That's great. From a patient perspective, I'm sure they're just blown away that you're saving them weeks to months.

[Dr. Amy Park]
Yes, patient access and fit patient experience is huge here, what you're describing, both of you.

[Dr. Mathew Leonardi]
If there's an incentive from hospital administrators to focus on that patient experience and this is actually a really lovely model of care that can be considered. Now in Canada, we are in a fee-for-service model. The hospitals don't really make any extra money for the patients coming, so the hospitals are not so involved. In some ways a bit of a burden on us. I don't get to bill more though. There are some time-based things, but at the end of the day for me it's not about money.

Yes, of course, we all need to make money for our career. I feel like I'm really interested in pushing that agenda forward, doing the right thing, trying to encourage others to do that right thing for the patients, and not focus so much on the day-to-day billings. In time the money will come and I'll be fine, but I need to make sure that we're changing the game for these endo patients because the game is not working for them right now.

[Dr. Mark Hoffman]
I think Amy and I are on the same page, when we talk about money it's not because we're trying to figure out how to maximize our profit here. The thing though, especially in the US, the language we need to speak as physicians needs to include the financial side of it. If I expect my hospital to buy these machines, which are extremely expensive, and to purchase the time of sonographers and clinic space and all those things, we have to be able to justify that spend. We have to be able to justify the cost.

For me to have one patient visit that takes an hour but then opens up clinic space a week, two weeks, whenever they were supposed to come back, moving GYN and ultrasound out of the OB unit. Now I'm backfilling, so you have to look at total cost, and all those things. Why I think it's important is to be able to have that conversation in a meeting with your administrative side say, "Okay, this is what I want to do and here's why it's great for patients, it's great for turnover, and throughput and all those things."

It's also a smart business decision to condense all of that work into one visit. Then I can just go boom, to the OR we've just eliminated steps and obviously, the steps are bigger and tougher for our patients, but now I have to have two clinic appointments. I've to have an MRI room that patient twice and do intake twice and I have to have a frontdesk person do all of that work is doubled or tripled by having them come back. It is the kind of thing that a lot of us hear and we get pushback when we're asking about building new programs. I do think it's important to talk about those things as well because we have to be able to explain why it's important, not just for our patients, which is obviously is, but also how to get it done.

[Dr. Amy Park]
I agree. I think you have to make the argument from an administrative point of view. You have to spend money to make money and you need to examine, what Mark is describing is essentially decanting volume from the obstetric ultrasound unit to a gynecologic unit. I need $100,000 to pay for this machine or whatever you pay. Then if you can facilitate and fill your block time in an efficient manner here, I don't know about the Canadian system, but the more efficiently you can fill your ORs, that also is compelling. I know generally speaking, I'm assuming it's the same way in Canada, there's just not enough MIG surgeons to meet the demand. There's just too few of you, I would say PAG is the same way, Pediatric, Adolescent, and Gynecology. There's only 21 PAG graduates a year, and they're all spoken for MIG surgeons. You guys are like, I don't know how many fellowships there are 40 or 50 or something, but just not enough.

[Dr. Mathew Leonardi]
It really speaks to me to the prioritization of the obstetrics part of our specialty. Mark, it sounds like you have a very supportive Maternal Fetal Medicine Department head, I do as well. In general, our specialty is OBGYN and there's such a prioritization on pregnancy. You can't ignore pregnancy. It's visible and there is a volcanic eruption at the end. [laughter]

[Dr. Mark Hoffman]
It's coming no matter what we do, that train will arrive every day.

[Dr. Mathew Leonardi]
You can't ignore it. That is very different than the endometriosis patient who unfortunately is ignored a lot and is much easier to ignore because it's pain and it's women's pain. It's historical, it's societal, and so I think that's a big part of why there's a backlog of surgeries. There's not enough surgeons, there's not enough operative time. I certainly could use more operative time. I'm sure both of you could for your populations as well. These are bigger concepts that are not easy to fix. I know there's individuals across both of our countries that are advocates working for this. That's optimistic.

[Dr. Mark Hoffman]
Yes, and that's why I wanted to have you on. As we're doing all these things, as we're experiencing all of these challenges, is to have a roadmap from someone who's done it and say, "Okay, so I have access to a machine, I have clinic space, I have a stenographer. How do I learn how to do this?" I was lucky. I know my intern year, we did tons of hands-on scans, and then something happened where MedLegal was like, "Hey, you can't let an intern run around with an ultrasound machine in the ER. Who's looking at these scans?" There was no way to save the images. There was no way to prove that they had done it, so they stopped allowing us to use ultrasound point-of-care all the time. I had gotten 100 of scans my intern year. Then by the time I was a chief, they started bringing it back because they could allow those scans to be captured. I had one of my third years, "Hey, go scan this patient real quick, see if she's got an ectopic or what you think." She's like, "What do you mean go scan the patient?" I was like, "No, grab the probe, take a look and see if you think there's anything going on [unintelligible 00:41:15] She was an amazing resident, she's a GY oncologist now, looked at me and goes crazy.

Just having had those few hundred scans my intern year and using it as a point-of-care tool, I never forgot how valuable and powerful that was. I've continued to do that. I've continued to look at the scans I've had. I've called radiologists after the fact and say, "Hey, by the way, that was different than what you said," in a friendly way." They can learn too, but how do you learn to get better? How do you real-time learn to get better?

[Dr. Mathew Leonardi]
What I did when I first came back to my institution to McMaster was talk to the residency program director, and suggested that the ultrasound rotation should diversify from primarily obstetrics to gynecology as well. Even though in the guidelines for residency in Canada, there are very few line items that are gynecology focused that I think is going to change with time and I'm going to try to be behind that advocacy.

Now, I have usually a resident, third-year, fourth-year resident coming to the clinic. They come every week for about a four-week rotation. Certainly, it's not enough time to learn advanced things, but they definitely, by the end, know how to identify the uterus and find the ovaries, and they are picking up hands-on skill. Are they ready to go off into the world? No, not yet, but it's a first step. There are usually ultrasound rotations at a lot of institutions in residency programs. That's a way to start that learning. If they don't exist, build it in, find a way to build in an ultrasound rotation, or create an ultrasound elective for those that are interested in it. I think that's one tangible way that we can start that learning.

For me, the exposure to ultrasound was that pivotal moment of fascination. Getting to have my hand on the probe even though it was very much obstetrical focused in my PGY-1 year. I just loved the tool. Getting people to get familiar with it, the knobology of the machine, interacting with the patient. It's not hard to see that passion develop because it is so fun. I think that's one thing that I've done and it's been successful so far at inspiring people to think about it a little bit differently than they have. Fellowship programs as well is another way to start to integrate that into their training. In my training program here, they do become competent by the end. In other programs around the country, they're not getting that hands-on learning. Because this reputation for gyne ultrasound is growing here, I've noticed some of the programs are offering their fellows a day with the radiologist. They're starting that dialogue, and I think that's a place to start.

If that's where ultrasound is done, get the fellow to go and spend time with the radiologist, even if it's to learn MRI, just get that familiarity with looking at imaging. This is going to be a career project for me, changing the culture of GYN surgery to make future surgeon sonologist. The dialogue starts now. The slow culture change starts now.

[Dr. Amy Park]
I was just going to say, I love what you're saying. I think that the other thing that I really hope you're inspiring words are just getting my wheels going is thinking about how do we break down barriers among the fields and radiology and other things. Because I know my MFM colleagues are using ultrasound to rule out hepatic rupture for severe preeclampsia and using fast criteria. The ED ultrasound fellowships, there was one in DC where I was previously, they had a very robust trauma surgery culture.
I watched this SGS video on ultrasound findings for endo and the sliding sign and the endometriosis kissing ovary sign and the endometrioma signs and also the advent of video like you were saying about YouTube and all that, it's so visual as well as tactile, having those resources available and Googleable is like a huge deal. I don't know if there's a lot of SurgeryU videos on it or in terms of AGL, what the popularity of the ultrasound videos have been, but I think you're right about the culture change.

[Dr. Mathew Leonardi]
When I was doing residency, I remember vividly some of the other surgical services. They would have the images open in the operating room, they'd be looking at the images right before operating on the patient. I can tell you in my residency of OB-GYN, there was a single surgeon, Lisa Allen, who is a PEG and an MIS surgeon, duo, amazing. She was the only person that I remember doing that with opening the ultrasound images in the operating room right before operating on the patient. It was not part of the culture. I think that's another strategy that's really easy to do now as well. As long as you have access to the pictures, open them before you're going to operate on them. If you're the resident that's going to be involved in the case, look at the pictures, start to correlate to the sonographic views with the surgical views, even if they're not the advanced ultrasounds that are looking for deep endometriosis yet, starting to understand what adenomyosis looks like, what fibroids look like, what different ovarian cysts look like.

It's right there in front of you. You have the ultrasound images, the report, the surgical view, and then finally, the surgical pathology. That learning curve is right there for you, but it's not part of the culture yet. I'd encourage residents who are really intrigued, that's one other strategy that you could use. People will find other strategies for sure, like attending conferences and courses. Though it is not exactly finalized, it's very exciting that we're probably going to be hosting a pre-congress course at the World Congress on endometriosis next May in Edinburgh. It's going to be hosted on the 3rd of May. I have the great honor of hosting this pre-congress course. It's hopefully going to be very visual, very practical learning. Maybe don't attend the surgical course that day if there's one, attend the ultrasound course to get those skills. There are ways.

[Dr. Mark Hoffman]
That's great. Will the course be available only in person or will there be a hybrid format to the meeting that'll allow those of us who maybe can't get to Edinburgh very easily?

[Dr. Mathew Leonardi]
I think it's primarily or exclusively in person at this point. I think a lot of congresses are trying to get back to that only in-person style. Whether that's right or wrong is not for me to decide, it's the Congress organizers, but I think it's going to be in-person only.