Ultrasound in primary care – Learning from the Nordic experience in Aalborg

University of Leeds Research Fellow Dr Erica di Martino talks about her recent CanTest Travelling Fellowship funded trip to Aalborg, Denmark, where she learnt more about the use of ultrasound in primary care.

Ultrasound has been described as the stethoscope of the future. Portable units are becoming more affordable and basic training is now included in the undergraduate medical curriculum. This raises the question of whether GPs could use ultrasound during consultations to help them rule in or rule out some types of cancer. Denmark and Norway are leading the way in researching ultrasound in primary care. Therefore, sponsored by a CanTest Travelling Fellowship, I travelled to Aalborg, Denmark, to join the 21st Nordic Congress of General Practice (17th-20th June 2019) and learn more.

The congress was fully packed with workshops on the use and regulation of point-of care ultrasound (POCUS) in general practice. Morten Glaso, Canh Le Nygaard and Hans-Christian Myklestul from Norway explained that POCUS is widespread in their country, with at least 60% of GPs using it occasionally. GPs are reimbursed for some procedures (i.e. residual urine, foetal presentation, first trimester bleeding, DVTs, gall bladder, aorta, and skin processes) but they may also use ultrasound to inform their diagnostic thinking for other conditions, such as muscle-skeletal or heart problems. Camilla Aakjaer Andersen and Troels Mengel-Jorgensen from Denmark discussed how in their country only a minority of GPs use POCUS, although most have received some training. Barriers include lack of a reimbursement scheme, time constraints and lack of available equipment, whilst concerns are lack of adequate skills, risk of misdiagnosis and incidental findings. Patient perspective on being scanned in their GP office, however, is extremely positive. They have more confidence in their doctors, and feel more listened to and reassured. GPs confidence in their own diagnostic decisions is also increased.

Surprisingly, both Denmark and Norway have very relaxed regulations and GPs do not require specific certification or training before using POCUS. Emphasis is put on the professional conduct of the clinician who is responsible to decide whether they feel sufficiently skilled to perform and interpret the scan. However, Thomas Lokkegaard and Soren Andersen illustrated how GP-tailored ultrasound courses are currently being developed in the Nordic countries, covering the types of examinations that are more relevant to primary care, based on their frequency and the additional diagnostic value of the scan.

The take-home message of the conference was that GPs can effectively use ultrasound to support their diagnostic thinking and inform their clinical decisions but that its use should be restricted to very specific and focussed yes/no questions, with the aim to rule-in rather than rule-out a diagnosis. Whether GPs could use POCUS for some types of cancers is still an open question requiring further research.

After the congress I had the opportunity to visit the Centre for General Practice in Aalborg and discuss possible joint research studies with the Aalborg team, which is led by Prof Martin Bach Jensen, and has recently published a systematic review on POCUS in primary care. Overall the CanTest Travelling Fellowship has given me a great opportunity to not only learn more about how POCUS is currently used in the Nordic countries but also to forge new collaborations.

The CanTest Travelling Fellowships are designed to support visits by Junior Faculty to partner CanTest institutions, or to attend conferences and courses. The aim is to enhance research skills and expertise in early detection research, as well as fostering links and collaborations across international boundaries.

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