SAPD position statement on the integration of digestive ultrasound into digestive system units as a clinical, teaching, and organizational necessity

Introduction and competence

Gastrointestinal ultrasound (GIUS) is a well-established technique with high diagnostic and therapeutic value in our units due to its safety, accessibility, cost-effectiveness, and ease of immediate use for our patients. Its non-invasive nature, absence of ionizing radiation, and portability with the new equipment available today make it an essential tool for clinical care and decision-making[1].

Despite the great advances made in recent decades and the constant efforts to promote ultrasonography by the Andalusian Society of Digestive Pathology (from Spanish "Sociedad Andaluza de Patología Digestiva") through the Andalusian Journal of Digestive Pathology (RAPD) and its partners, a recent survey conducted in 22 hospitals in Andalusia shows that it has yet to be implemented in many gastroenterology services, with at least 20% of them not performing it, delegating this task to other units, dedicating an average of three days a week in the work schedule, and only 50% of residents are trained in their own department, largely due to the problems that gastroenterology specialists encounter in obtaining adequate training during their residency. In many gastroenterology services where GIUS is carried out, the necessary resources have not actually been allocated to develop true gastroenterology units, ultrasound equipment is obsolete in many cases and does not meet the care needs of the specialists, and, in some cases, the training organization chart delegates this responsibility to radiodiagnostic units, where rotation is rather passive, or interferes with the training of radiologists or other specialties where its learning is also becoming increasingly important. Despite its proven usefulness, in many cases, gastroenterology units rely entirely on the Radiology department to perform it, with the consequent delay in continuous care and clinical integration. In other specialties, such as Cardiology, Endocrinology, Obstetrics, Rheumatology, Pulmonology, or, for example, Internal medicine, through the SEMI-excellent program, which accredits Clinical Ultrasound Units at the teaching level for their specialists, unthinkable a few years ago, or Emergency medicine, where specialists, perfectly trained in ultrasound, provide fully integrated and widely extended care.

Added to this situation is the enormous heterogeneity in the teaching of this discipline in different hospitals across the country, where training is sometimes based on external rotations, which are of limited duration, shared with other rotators, or carried out in workplaces where, for logistical reasons, there are not enough rooms available on a daily basis, sufficient equipment, or days per week on which to perform the required number of procedures to implement a reasonable learning curve. The training program for the gastroenterology specialty includes a minimum of two months to perform at least 200 supervised ultrasounds. The reality is that this training time is insufficient to acquire the necessary skills and abilities in this discipline, which is increasingly demanding and growing in use in inflammatory bowel disease, percutaneous intervention, echoendoscopy, etc. Added to this is the advent of new equipment and features (use of Doppler modes, contrasts, elastography, etc.) that increase the level of complexity and, inevitably, the time required for quality training, requiring standardization in the performance of different techniques and the writing of reports, as is the case in other areas such as endoscopy, all of which results in a greater contribution to comprehensive care[2].

Conclusion

Based on the above, at SAPD, we believe that GIUS deserves a place in our specialty that, in many cases, it is not given, probably as a result of inadequate promotion and/or support for the technique, underestimating its usefulness and diverting resources away from its definitive implementation in gastroenterology services, despite being part of the training program in Spain under Ministerial Order SAS/2854/2009 of October 9[3]. To overcome these obstacles, it needs to be urgently considered as a tool based on scientific evidence and the experience of professionals, in order to achieve a result that is fully in line with the clinical care needs of today, with minimal risk to the patient. Our society advocates the need to promote GIUS as a key discipline in the diagnostic process of digestive diseases, considering the quality of its implementation to be the strategic element on which this transformation and improvement is based, and as conveyed by the SEPD-AEED, its implementation by gastroenterologists[3],[4]. And, in accordance with all of the above, we understand that gastroenterology services and units, with the support of the Health Administration and the backing of our scientific societies, should be the auditors and guarantors of the correct training in ultrasound of gastroenterology specialists.