Europe

Abstract

IntroductionIn Europe, the clinical use of diagnostic ultrasound started about 25 years ago, with a variable impact in different speciality fields (ob/gyn, gastroenterology, neurology etc.). The Congress of the newborn European Federation for Ultrasound in Medicine and Biology, in Munich 1975, was a milestone for the dissemination of the procedure among a large number of clinicians and radiologists. After that date, medical ultrasound exponentially increased its impact in all fields of clinical medicine, including specialities that at the beginning were considered very far from the possibilities of ultrasound (dermatology, orthopedics etc.). Whereas, in the early 1970s, only few pioneers were involved in exploring the capabilities of the procedure, and its use was essentially experimental; now more physicians of any speciality are using ultrasound, and there is an increasing request for learning basic principles and practice of diagnostic ultrasound. There is no other procedure based on a sophisticated technology whose utilisation has become so widespread and which has not been restricted to a single specialist. As a whole, it represents the third most used diagnostic procedure following laboratory investigations and X-ray examinations, and it is probably the second in outpatients. In Italy, which can be taken as a reference for western Europe, it has been calculated that more than 10 million ultrasound examinations have been performed in 1994 and that more than 15,000 ultrasound instruments were working with more than 20,000 physicians involved at different levels. In Germany, in the same period, more than 18 million ultrasound examinations were performed in private practice. These figures have probably increased by about 50% in recent years.Such a great and sudden change in clinical practice has occurred in Europe within different health systems and very variable socio-economic backgrounds. This led to inhomogeneous experiences and modalities of ultrasound services organisation. The continuous changing of equipment capabilities, leading every new year to exciting technological advances and giving the clinicians the impression that the performance of ultrasound equipment is far from reaching a “steady state”, has further complicated the achievement of a standardised clinical practice and a uniform organisation model. For instance, in the U.K., abdominal ultrasound is almost exclusively a component of training in radiology, and technicians are currently utilised for performing ultrasound scanning, whereas in Germany and in Italy, as well as in the majority of countries, only physicians are allowed to perform ultrasound, and subspecialised internists and surgeons are actively involved in ultrasound diagnostics and echo-guided interventional procedures. Furthermore, the sudden change in the political situation has created an even more rapid change in the former eastern countries, with a great demand for education and training and widespread distribution of new instrumentation.Therefore, the complex evolution of ultrasound practice in Europe has now posed problems to be considered and possibly solved. This is also stimulated by the changes in health care practice and medical regulations that are currently being implemented in many European countries, with the creation of formal accreditation programmes for physicians and other health professionals (sonographers), as well as for diagnostic ultrasound services, similar to what has been done in the U.S. for many years. The European Federation for Ultrasound in Medicine and Biology (EFSUMB), apart from a great effort in the advancement of knowledge and research in this field, is addressing more and more thoroughly all issues related to training and education and to quality standards of professionals and equipment. A key reference point for this work has been the report of the WHO study group on “Training in diagnostic ultrasound: essentials, principles and standards”, which worked in Philadelphia in March 1996 (WHO 1998WHO. Training in diagnostic ultrasound: Essentials, principles and standards. Technical report series. Geneva: World Health Organisation, 1998.Google Scholar). A workshop was held at the Euroson Congress in Tours (France) in 1998 on “Education and professionals standards,” with an interactive discussion with the audience. A questionnaire was subsequently mailed to all individual members (more than 13,000), including several questions related to professional status, needs for training and continuing education, and requisites for the equipment. Following these initiatives, EFSUMB is now constructing its action to improve and homogenise levels of clinical use of ultrasound in Europe.Training and educationIn spite of remarkable differences existing in the ultrasound practice in various European countries, it is agreed that three different settings exist regarding the level of training required and the level of equipment utilised. This is in keeping with the report of (WHO 1998WHO. Training in diagnostic ultrasound: Essentials, principles and standards. Technical report series. Geneva: World Health Organisation, 1998.Google Scholar).For level I setting, a general-purpose imaging unit without Doppler can be used by general practitioners or emergency physicians. Most clinical problems can be easily solved in this setting, giving a prompt answer to a large number of patients. This setting, however, could probably be soon modified by the advent of portable cheap machines equipped with colour and power Doppler facilities that are now commercially available.In level II and III settings, ultrasound services are delivered by radiology departments or other clinical specialised centres using more sophisticated equipment with special features (pulsed, colour and power Doppler), intracavitary transducers and interventional techniques. EFSUMB has established that level I training for physicians should be provided on a national basis, preferably following the general features of the curriculum suggested by (WHO 1998WHO. Training in diagnostic ultrasound: Essentials, principles and standards. Technical report series. Geneva: World Health Organisation, 1998.Google Scholar). For level II and III, to contribute to the national educational programmes, EFSUMB has founded in 1992 the Euroson School, with the purpose to offer uniform and advanced training in highly specialised fields (vascular Doppler, interventional, small parts, etc.) to expert sonologists from different European countries.It is remarkable that, in most European countries, ultrasonography is now part of the curriculum for medical students who must learn basic principles of ultrasound imaging, anatomy of main ultrasound scanning planes, major clinical applications of ultrasound and interpretation of most frequent pictures (solid/liquid differentiation, stones, space-occupying lesions).Textbooks, journals and on-site teaching courses are still considered by EFSUMB members to be the most useful tools for education. One to two weeks per year are thought to be appropriate for continuing education.A great discrepancy of opinions exists regarding licensing and certification. This has been definitely established only in a few European countries (Austria, UK, Germany, Norway), but with substantial differences regarding duration, time intervals for re-certification, and institution responsible for certification delivery. Most members believe that professional organisations should be responsible for certification (as it occurs in Germany, where a health insurance system is working), whereas others would like to give this responsibility to the university or academic centres, or to national scientific societies. In the U.K., where a national health system is working, radiologists are trained in centres accredited by the Royal College of Radiologists. Joint programmes are also organised with other Royal Colleges such as the Royal College of Obstetricians and Gynaecologists. Training in echocardiography is provided by the scientific society. The same occurs in Italy, where the national scientific society (SIUMB) has provided, for some time, the basic and advanced teaching for thousands of physicians. The requisites for teaching centres recognised by the society have been strictly defined and are verified annually.The concept of teaching the teachers is also strongly supported by most of the EFSUMB members. It is also felt that new technologies, such as electronic media, Internet and telecommunication systems, will soon make possible new approaches to training (and also to the interpretation of ultrasound examinations).AccreditationThe accreditation system was born in the U.S. where, at the beginning of the 1950s, the major professional organisations created the Commission for Accreditation of Hospitals. Following a great delay, mainly because of the different health systems but also because of the different mindset in the practice of clinical medicine, the process started also in Europe, beginning with the U.K. There, at the end of the 1980s, the King’s Fund established the organisational audit to promote quality standards within the hospitals. However, until recently, only a few countries (among which are the U.K., Germany and Switzerland) have implemented the accreditation (and certification) system for ultrasound services.Accreditation for ultrasound services should be based on many definite parameters such as: (1) number and characteristics of equipment; (2) number of physicians/sonographers involved in the service and their level of education; (3) adequacy of location; (4) continuous updating of technologies and of professionals; (5) access to the service; (6) waiting list and waiting times for inpatients and outpatients; (7) timing of the procedures in the routine and emergency settings; (8) recording systems of data; (9) format and content of the reports, etc. The process of accreditation is now considered mandatory and urgent by the majority of countries in Europe and will produce a great advance in the quality assurance of delivery of ultrasound services.Organisation of ultrasound services deliveryThis reflects the inhomogeneous experience in different European countries and the various modalities of training and education. In the hospitals and clinics, ultrasound equipment is generally disseminated in many clinical departments and in the radiological department, which generally guarantees emergency ultrasound examinations. In northern Europe, including the U.K. and Holland, ultrasound services are mainly concentrated in the radiological department as well as in cardiology and in ob/gyn.The advent of new portable high quality instrumentation has opened the possibility to bring the ultrasound examination to the bed of the patient. The impact of this new approach has not yet been thoroughly evaluated, but could greatly modify the organisation of ultrasound services, increasing the quality of assistance and saving time and resources. Bedside ultrasound is currently performed in emergency and intensive care units.Outside the hospitals, many clinical specialists as well as radiologists are performing ultrasound in their offices.General practitioners are allowed to perform ultrasound in all European countries, provided that they are trained, but only a few of them are currently involved in this practice, depending also on the health system working in the country. The interest in ultrasound is, however, growing among general practitioners, and advantages and disadvantages of ultrasound services delivery by them is now the subject of debate in Europe. Certainly, if the clinicians who have the direct responsibility of the patients could provide diagnostic services with the same quality as centralised services and without consuming more resources, this would imply a significant advantage in health care (Friedenberg 2010Friedenberg R.M. In 2010 who will practice radiology?.Radiology. 1995; 195: 45-47Google Scholar)SonographersUltrasound examinations are generally performed and interpreted by physicians, but in some countries (the U.K., The Netherlands and Scandinavian countries), allied health professionals, including sonographers and midwives, are responsible for some or all ultrasound scanning, leaving to physicians the responsibility for interpretation of ultrasound images and the diagnostic decision. In the U.K., a rigorous training and accreditation programme exists for sonographers, and their skill is mainly utilised for obstetric ultrasound and partially for nonobstetric abdominal ultrasound. In other countries (i.e., the U.K. and The Netherlands) they are also working in vascular ultrasound. The main advantage is that they can offer a full-time dedicated work to ultrasound performance, whereas most of the clinicians and radiologists perform ultrasound only as a part of their general medical work. However, in the majority of European countries, sonographers do not exist and their use is discouraged. Decisions in this setting are strongly influenced by the number of physicians working in a particular country and by the problem of unemployment in clinical medicine rather than by the analysis of cost/effectiveness. IntroductionIn Europe, the clinical use of diagnostic ultrasound started about 25 years ago, with a variable impact in different speciality fields (ob/gyn, gastroenterology, neurology etc.). The Congress of the newborn European Federation for Ultrasound in Medicine and Biology, in Munich 1975, was a milestone for the dissemination of the procedure among a large number of clinicians and radiologists. After that date, medical ultrasound exponentially increased its impact in all fields of clinical medicine, including specialities that at the beginning were considered very far from the possibilities of ultrasound (dermatology, orthopedics etc.). Whereas, in the early 1970s, only few pioneers were involved in exploring the capabilities of the procedure, and its use was essentially experimental; now more physicians of any speciality are using ultrasound, and there is an increasing request for learning basic principles and practice of diagnostic ultrasound. There is no other procedure based on a sophisticated technology whose utilisation has become so widespread and which has not been restricted to a single specialist. As a whole, it represents the third most used diagnostic procedure following laboratory investigations and X-ray examinations, and it is probably the second in outpatients. In Italy, which can be taken as a reference for western Europe, it has been calculated that more than 10 million ultrasound examinations have been performed in 1994 and that more than 15,000 ultrasound instruments were working with more than 20,000 physicians involved at different levels. In Germany, in the same period, more than 18 million ultrasound examinations were performed in private practice. These figures have probably increased by about 50% in recent years.Such a great and sudden change in clinical practice has occurred in Europe within different health systems and very variable socio-economic backgrounds. This led to inhomogeneous experiences and modalities of ultrasound services organisation. The continuous changing of equipment capabilities, leading every new year to exciting technological advances and giving the clinicians the impression that the performance of ultrasound equipment is far from reaching a “steady state”, has further complicated the achievement of a standardised clinical practice and a uniform organisation model. For instance, in the U.K., abdominal ultrasound is almost exclusively a component of training in radiology, and technicians are currently utilised for performing ultrasound scanning, whereas in Germany and in Italy, as well as in the majority of countries, only physicians are allowed to perform ultrasound, and subspecialised internists and surgeons are actively involved in ultrasound diagnostics and echo-guided interventional procedures. Furthermore, the sudden change in the political situation has created an even more rapid change in the former eastern countries, with a great demand for education and training and widespread distribution of new instrumentation.Therefore, the complex evolution of ultrasound practice in Europe has now posed problems to be considered and possibly solved. This is also stimulated by the changes in health care practice and medical regulations that are currently being implemented in many European countries, with the creation of formal accreditation programmes for physicians and other health professionals (sonographers), as well as for diagnostic ultrasound services, similar to what has been done in the U.S. for many years. The European Federation for Ultrasound in Medicine and Biology (EFSUMB), apart from a great effort in the advancement of knowledge and research in this field, is addressing more and more thoroughly all issues related to training and education and to quality standards of professionals and equipment. A key reference point for this work has been the report of the WHO study group on “Training in diagnostic ultrasound: essentials, principles and standards”, which worked in Philadelphia in March 1996 (WHO 1998WHO. Training in diagnostic ultrasound: Essentials, principles and standards. Technical report series. Geneva: World Health Organisation, 1998.Google Scholar). A workshop was held at the Euroson Congress in Tours (France) in 1998 on “Education and professionals standards,” with an interactive discussion with the audience. A questionnaire was subsequently mailed to all individual members (more than 13,000), including several questions related to professional status, needs for training and continuing education, and requisites for the equipment. Following these initiatives, EFSUMB is now constructing its action to improve and homogenise levels of clinical use of ultrasound in Europe. In Europe, the clinical use of diagnostic ultrasound started about 25 years ago, with a variable impact in different speciality fields (ob/gyn, gastroenterology, neurology etc.). The Congress of the newborn European Federation for Ultrasound in Medicine and Biology, in Munich 1975, was a milestone for the dissemination of the procedure among a large number of clinicians and radiologists. After that date, medical ultrasound exponentially increased its impact in all fields of clinical medicine, including specialities that at the beginning were considered very far from the possibilities of ultrasound (dermatology, orthopedics etc.). Whereas, in the early 1970s, only few pioneers were involved in exploring the capabilities of the procedure, and its use was essentially experimental; now more physicians of any speciality are using ultrasound, and there is an increasing request for learning basic principles and practice of diagnostic ultrasound. There is no other procedure based on a sophisticated technology whose utilisation has become so widespread and which has not been restricted to a single specialist. As a whole, it represents the third most used diagnostic procedure following laboratory investigations and X-ray examinations, and it is probably the second in outpatients. In Italy, which can be taken as a reference for western Europe, it has been calculated that more than 10 million ultrasound examinations have been performed in 1994 and that more than 15,000 ultrasound instruments were working with more than 20,000 physicians involved at different levels. In Germany, in the same period, more than 18 million ultrasound examinations were performed in private practice. These figures have probably increased by about 50% in recent years. Such a great and sudden change in clinical practice has occurred in Europe within different health systems and very variable socio-economic backgrounds. This led to inhomogeneous experiences and modalities of ultrasound services organisation. The continuous changing of equipment capabilities, leading every new year to exciting technological advances and giving the clinicians the impression that the performance of ultrasound equipment is far from reaching a “steady state”, has further complicated the achievement of a standardised clinical practice and a uniform organisation model. For instance, in the U.K., abdominal ultrasound is almost exclusively a component of training in radiology, and technicians are currently utilised for performing ultrasound scanning, whereas in Germany and in Italy, as well as in the majority of countries, only physicians are allowed to perform ultrasound, and subspecialised internists and surgeons are actively involved in ultrasound diagnostics and echo-guided interventional procedures. Furthermore, the sudden change in the political situation has created an even more rapid change in the former eastern countries, with a great demand for education and training and widespread distribution of new instrumentation. Therefore, the complex evolution of ultrasound practice in Europe has now posed problems to be considered and possibly solved. This is also stimulated by the changes in health care practice and medical regulations that are currently being implemented in many European countries, with the creation of formal accreditation programmes for physicians and other health professionals (sonographers), as well as for diagnostic ultrasound services, similar to what has been done in the U.S. for many years. The European Federation for Ultrasound in Medicine and Biology (EFSUMB), apart from a great effort in the advancement of knowledge and research in this field, is addressing more and more thoroughly all issues related to training and education and to quality standards of professionals and equipment. A key reference point for this work has been the report of the WHO study group on “Training in diagnostic ultrasound: essentials, principles and standards”, which worked in Philadelphia in March 1996 (WHO 1998WHO. Training in diagnostic ultrasound: Essentials, principles and standards. Technical report series. Geneva: World Health Organisation, 1998.Google Scholar). A workshop was held at the Euroson Congress in Tours (France) in 1998 on “Education and professionals standards,” with an interactive discussion with the audience. A questionnaire was subsequently mailed to all individual members (more than 13,000), including several questions related to professional status, needs for training and continuing education, and requisites for the equipment. Following these initiatives, EFSUMB is now constructing its action to improve and homogenise levels of clinical use of ultrasound in Europe. Training and educationIn spite of remarkable differences existing in the ultrasound practice in various European countries, it is agreed that three different settings exist regarding the level of training required and the level of equipment utilised. This is in keeping with the report of (WHO 1998WHO. Training in diagnostic ultrasound: Essentials, principles and standards. Technical report series. Geneva: World Health Organisation, 1998.Google Scholar).For level I setting, a general-purpose imaging unit without Doppler can be used by general practitioners or emergency physicians. Most clinical problems can be easily solved in this setting, giving a prompt answer to a large number of patients. This setting, however, could probably be soon modified by the advent of portable cheap machines equipped with colour and power Doppler facilities that are now commercially available.In level II and III settings, ultrasound services are delivered by radiology departments or other clinical specialised centres using more sophisticated equipment with special features (pulsed, colour and power Doppler), intracavitary transducers and interventional techniques. EFSUMB has established that level I training for physicians should be provided on a national basis, preferably following the general features of the curriculum suggested by (WHO 1998WHO. Training in diagnostic ultrasound: Essentials, principles and standards. Technical report series. Geneva: World Health Organisation, 1998.Google Scholar). For level II and III, to contribute to the national educational programmes, EFSUMB has founded in 1992 the Euroson School, with the purpose to offer uniform and advanced training in highly specialised fields (vascular Doppler, interventional, small parts, etc.) to expert sonologists from different European countries.It is remarkable that, in most European countries, ultrasonography is now part of the curriculum for medical students who must learn basic principles of ultrasound imaging, anatomy of main ultrasound scanning planes, major clinical applications of ultrasound and interpretation of most frequent pictures (solid/liquid differentiation, stones, space-occupying lesions).Textbooks, journals and on-site teaching courses are still considered by EFSUMB members to be the most useful tools for education. One to two weeks per year are thought to be appropriate for continuing education.A great discrepancy of opinions exists regarding licensing and certification. This has been definitely established only in a few European countries (Austria, UK, Germany, Norway), but with substantial differences regarding duration, time intervals for re-certification, and institution responsible for certification delivery. Most members believe that professional organisations should be responsible for certification (as it occurs in Germany, where a health insurance system is working), whereas others would like to give this responsibility to the university or academic centres, or to national scientific societies. In the U.K., where a national health system is working, radiologists are trained in centres accredited by the Royal College of Radiologists. Joint programmes are also organised with other Royal Colleges such as the Royal College of Obstetricians and Gynaecologists. Training in echocardiography is provided by the scientific society. The same occurs in Italy, where the national scientific society (SIUMB) has provided, for some time, the basic and advanced teaching for thousands of physicians. The requisites for teaching centres recognised by the society have been strictly defined and are verified annually.The concept of teaching the teachers is also strongly supported by most of the EFSUMB members. It is also felt that new technologies, such as electronic media, Internet and telecommunication systems, will soon make possible new approaches to training (and also to the interpretation of ultrasound examinations). In spite of remarkable differences existing in the ultrasound practice in various European countries, it is agreed that three different settings exist regarding the level of training required and the level of equipment utilised. This is in keeping with the report of (WHO 1998WHO. Training in diagnostic ultrasound: Essentials, principles and standards. Technical report series. Geneva: World Health Organisation, 1998.Google Scholar). For level I setting, a general-purpose imaging unit without Doppler can be used by general practitioners or emergency physicians. Most clinical problems can be easily solved in this setting, giving a prompt answer to a large number of patients. This setting, however, could probably be soon modified by the advent of portable cheap machines equipped with colour and power Doppler facilities that are now commercially available. In level II and III settings, ultrasound services are delivered by radiology departments or other clinical specialised centres using more sophisticated equipment with special features (pulsed, colour and power Doppler), intracavitary transducers and interventional techniques. EFSUMB has established that level I training for physicians should be provided on a national basis, preferably following the general features of the curriculum suggested by (WHO 1998WHO. Training in diagnostic ultrasound: Essentials, principles and standards. Technical report series. Geneva: World Health Organisation, 1998.Google Scholar). For level II and III, to contribute to the national educational programmes, EFSUMB has founded in 1992 the Euroson School, with the purpose to offer uniform and advanced training in highly specialised fields (vascular Doppler, interventional, small parts, etc.) to expert sonologists from different European countries. It is remarkable that, in most European countries, ultrasonography is now part of the curriculum for medical students who must learn basic principles of ultrasound imaging, anatomy of main ultrasound scanning planes, major clinical applications of ultrasound and interpretation of most frequent pictures (solid/liquid differentiation, stones, space-occupying lesions). Textbooks, journals and on-site teaching courses are still considered by EFSUMB members to be the most useful tools for education. One to two weeks per year are thought to be appropriate for continuing education. A great discrepancy of opinions exists regarding licensing and certification. This has been definitely established only in a few European countries (Austria, UK, Germany, Norway), but with substantial differences regarding duration, time intervals for re-certification, and institution responsible for certification delivery. Most members believe that professional organisations should be responsible for certification (as it occurs in Germany, where a health insurance system is working), whereas others would like to give this responsibility to the university or academic centres, or to national scientific societies. In the U.K., where a national health system is working, radiologists are trained in centres accredited by the Royal College of Radiologists. Joint programmes are also organised with other Royal Colleges such as the Royal College of Obstetricians and Gynaecologists. Training in echocardiography is provided by the scientific society. The same occurs in Italy, where the national scientific society (SIUMB) has provided, for some time, the basic and advanced teaching for thousands of physicians. The requisites for teaching centres recognised by the society have been strictly defined and are verified annually. The concept of teaching the teachers is also strongly supported by most of the EFSUMB members. It is also felt that new technologies, such as electronic media, Internet and telecommunication systems, will soon make possible new approaches to training (and also to the interpretation of ultrasound examinations). AccreditationThe accreditation system was born in the U.S. where, at the beginning of the 1950s, the major professional organisations created the Commission for Accreditation of Hospitals. Following a great delay, mainly because of the different health systems but also because of the different mindset in the practice of clinical medicine, the process started also in Europe, beginning with the U.K. There, at the end of the 1980s, the King’s Fund established the organisational audit to promote quality standards within the hospitals. However, until recently, only a few countries (among which are the U.K., Germany and Switzerland) have implemented the accreditation (and certification) system for ultrasound services.Accreditation for ultrasound services should be based on many definite parameters such as: (1) number and characteristics of equipment; (2) number of physicians/sonographers involved in the service and their level of education; (3) adequacy of location; (4) continuous updating of technologies and of professionals; (5) access to the service; (6) waiting list and waiting times for inpatients and outpatients; (7) timing of the procedures in the routine and emergency settings; (8) recording systems of data; (9) format and content of the reports, etc. The process of accreditation is now considered mandatory and urgent by the majority of countries in Europe and will produce a great advance in the quality assurance of delivery of ultrasound services. The accreditation system was born in the U.S. where, at the beginning of the 1950s, the major professional organisations created the Commission for Accreditation of Hospitals. Following a great delay, mainly because of the different health systems but also because of the different mindset in the practice of clinical medicine, the process started also in Europe, beginning with the U.K. There, at the end of the 1980s, the King’s Fund established the organisational audit to promote quality standards within the hospitals. However, until recently, only a few countries (among which are the U.K., Germany and Switzerland) have implemented the accreditation (and certification) system for ultrasound services. Accreditation for ultrasound services should be based on many definite parameters such as: (1) number and characteristics of equipment; (2) number of physicians/sonographers involved in the service and their level of education; (3) adequacy of location; (4) continuous updating of technologies and of professionals; (5) access to the service; (6) waiting list and waiting times for inpatients and outpatients; (7) timing of the procedures in the routine and emergency settings; (8) recording systems of data; (9) format and content of the reports, etc. The process of accreditation is now considered mandatory and urgent by the majority of countries in Europe and will produce a great advance in the quality assurance of delivery of ultrasound services. Organisation of ultrasound services deliveryThis reflects the inhomogeneous experience in different European countries and the various modalities of training and education. In the hospitals and clinics, ultrasound equipment is generally disseminated in many clinical departments and in the radiological department, which generally guarantees emergency ultrasound examinations. In northern Europe, including the U.K. and Holland, ultrasound services are mainly concentrated in the radiological department as well as in cardiology and in ob/gyn.The advent of new portable high quality instrumentation has opened the possibility to bring the ultrasound examination to the bed of the patient. The impact of this new approach has not yet been thoroughly evaluated, but could greatly modify the organisation of ultrasound services, increasing the quality of assistance and saving time and resources. Bedside ultrasound is currently performed in emergency and intensive care units.Outside the hospitals, many clinical specialists as well as radiologists are performing ultrasound in their offices.General practitioners are allowed to perform ultrasound in all European countries, provided that they are trained, but only a few of them are currently involved in this practice, depending also on the health system working in the country. The interest in ultrasound is, however, growing among general practitioners, and advantages and disadvantages of ultrasound services delivery by them is now the subject of debate in Europe. Certainly, if the clinicians who have the direct responsibility of the patients could provide diagnostic services with the same quality as centralised services and without consuming more resources, this would imply a significant advantage in health care (Friedenberg 2010Friedenberg R.M. In 2010 who will practice radiology?.Radiology. 1995; 195: 45-47Google Scholar) This reflects the inhomogeneous experience in different European countries and the various modalities of training and education. In the hospitals and clinics, ultrasound equipment is generally disseminated in many clinical departments and in the radiological department, which generally guarantees emergency ultrasound examinations. In northern Europe, including the U.K. and Holland, ultrasound services are mainly concentrated in the radiological department as well as in cardiology and in ob/gyn. The advent of new portable high quality instrumentation has opened the possibility to bring the ultrasound examination to the bed of the patient. The impact of this new approach has not yet been thoroughly evaluated, but could greatly modify the organisation of ultrasound services, increasing the quality of assistance and saving time and resources. Bedside ultrasound is currently performed in emergency and intensive care units. Outside the hospitals, many clinical specialists as well as radiologists are performing ultrasound in their offices. General practitioners are allowed to perform ultrasound in all European countries, provided that they are trained, but only a few of them are currently involved in this practice, depending also on the health system working in the country. The interest in ultrasound is, however, growing among general practitioners, and advantages and disadvantages of ultrasound services delivery by them is now the subject of debate in Europe. Certainly, if the clinicians who have the direct responsibility of the patients could provide diagnostic services with the same quality as centralised services and without consuming more resources, this would imply a significant advantage in health care (Friedenberg 2010Friedenberg R.M. In 2010 who will practice radiology?.Radiology. 1995; 195: 45-47Google Scholar) SonographersUltrasound examinations are generally performed and interpreted by physicians, but in some countries (the U.K., The Netherlands and Scandinavian countries), allied health professionals, including sonographers and midwives, are responsible for some or all ultrasound scanning, leaving to physicians the responsibility for interpretation of ultrasound images and the diagnostic decision. In the U.K., a rigorous training and accreditation programme exists for sonographers, and their skill is mainly utilised for obstetric ultrasound and partially for nonobstetric abdominal ultrasound. In other countries (i.e., the U.K. and The Netherlands) they are also working in vascular ultrasound. The main advantage is that they can offer a full-time dedicated work to ultrasound performance, whereas most of the clinicians and radiologists perform ultrasound only as a part of their general medical work. However, in the majority of European countries, sonographers do not exist and their use is discouraged. Decisions in this setting are strongly influenced by the number of physicians working in a particular country and by the problem of unemployment in clinical medicine rather than by the analysis of cost/effectiveness. Ultrasound examinations are generally performed and interpreted by physicians, but in some countries (the U.K., The Netherlands and Scandinavian countries), allied health professionals, including sonographers and midwives, are responsible for some or all ultrasound scanning, leaving to physicians the responsibility for interpretation of ultrasound images and the diagnostic decision. In the U.K., a rigorous training and accreditation programme exists for sonographers, and their skill is mainly utilised for obstetric ultrasound and partially for nonobstetric abdominal ultrasound. In other countries (i.e., the U.K. and The Netherlands) they are also working in vascular ultrasound. The main advantage is that they can offer a full-time dedicated work to ultrasound performance, whereas most of the clinicians and radiologists perform ultrasound only as a part of their general medical work. However, in the majority of European countries, sonographers do not exist and their use is discouraged. Decisions in this setting are strongly influenced by the number of physicians working in a particular country and by the problem of unemployment in clinical medicine rather than by the analysis of cost/effectiveness.