Musculoskeletal ultrasound has become a useful tool in recent years that has been incorporated into clinical practice to aid decision-making in the diagnosis, activity, and treatment of rheumatic diseases1. As a result, training in this major field of rheumatology has entered the routine of rheumatology training specialists, and most European countries have specific national training programmes in this technique. Since 1996, the Spanish Society of Rheumatology (SER), through their School of Ultrasound, have developed a systematic ultrasound training programme that has promoted the implementation of the technique throughout the country as standard training for rheumatologists interested in using musculoskeletal ultrasound in our specialty. This ultrasound training system has been pioneering in Europe2, and in line with European recommendations3 offers 4 levels of continuous training, and provides teaching material prior to the courses, tutorials in the courses and progressive competency assessment overseen by the School’s tutors. Our country has a long tradition in training in ultrasound as applied to rheumatology, and according to data from a survey to determine the degree of ultrasound implementation and training in Europe, Spain was among the 4 countries reporting that more than 50% of rheumatologists had received specific ultrasound training, together with Bulgaria, Finland and Slovakia; only surpassed by Germany, at more than 80%4. In addition, Spain is among the countries offering the highest number of courses per year, the highest percentage of practical training compared to theoretical training, and the fewest students per tutor.

However, despite the efforts of the SER and particularly the SER School of Ultrasound, training in this essential imaging technique for rheumatologists may not be uniform among the different rheumatology departments with teaching accreditation. Putting training into practice depends on factors such as the availability of ultrasound equipment, staff qualified in musculoskeletal ultrasound, access to national and/or international ultrasound courses and residents being given the opportunity to complete rotations in musculoskeletal ultrasound within or outside their department.

The primary objective of the present study is to assess the perceived quality of the musculoskeletal ultrasound training of residents in rheumatology departments in Spain. The secondary objectives include establishing whether there are differences in the quality of training in musculoskeletal ultrasound according to the year in which the training period started.

A cross-sectional study was undertaken that included rheumatologists who started their training period in rheumatology between 2009 and 2019, and who answered an online survey (Table 1) to gather information on their training in ultrasound throughout their period as residents, and how they perceived its level of quality.

The sources of information for data collection included: 1) list of residents completing their training period in the last 10 years provided by the National Commission of Rheumatology, 2) list of residents accessing the ultrasound school courses provided by the SER during their training period in the last 10 years, and 3) responses from an online survey given to the subjects of the study which was disseminated through the ECOSER email group, the SER newsletter, and social networks during November and December 2019. The first two signatories of the study designed all the questions of the survey. The aspects to be evaluated in the survey included: 1) access to SER and EULAR ultrasound courses, 2) completion of the SER or EULAR ultrasound course competency accreditation, 3) access to specific rotations in musculoskeletal ultrasound (within or outside their department/unit)4, access and degree of satisfaction with ultrasound training in its different aspects including non-musculoskeletal examinations, and 5) degree of overall satisfaction with ultrasound training during residency. Table 1 shows all the questions evaluated. The data collected were processed in accordance with Organic Law 15/1999, of 13 December, on the Protection of Personal Data. To evaluate how perceived quality has evolved over the last decade, the total number of respondents was divided into two groups according to the year in which they began their residency period (2009–2013 and 2014–2019) and the variables included in the survey were compared between the two groups.

In the last two decades, the use of ultrasound in rheumatology has become widespread in the management of many rheumatic diseases1. Ultrasound facilitates many musculoskeletal examinations but has recently reached a turning point as its use has extended from the musculoskeletal system to extra-articular disease, such as vascular ultrasound in the diagnosis of giant cell arteritis5, ultrasound of salivary glands in Sjögren’s disease6, or lung ultrasound for the diagnosis of diffuse interstitial lung disease7. This has led to this imaging technique being gradually incorporated into specific training programmes in rheumatology. To date, there are no studies that specifically evaluate the perceived quality of training in musculoskeletal ultrasound for residents in rheumatology departments in Spain, and therefore we believe that this study promoted by the SER ultrasound group (ECOSER) may help identify the strengths and weaknesses of this training for our residents.

According to data from a recent survey on access to imaging techniques in rheumatology in Europe8, ultrasound is included in national training programmes in 65% of European countries. Most national societies organise ultrasound training courses, and most include different levels of training. Spain is one of the European countries with the highest access for rheumatologists to the practice of ultrasound (more than 60%). In terms of the different European countries’ national training programmes, Spain offers the highest number of courses per year, followed by Germany. In Spain, the duration of these courses is also the second longest (between 5 and 10 days), only surpassed by France. It is also the country that offers more practical than theoretical training (80% practical and 20% theoretical), and is among the countries with the fewest students per tutor in practical sessions (4 students on average). According to data published in 2011, the demand for training in ultrasound of the locomotor system by SER members has increased progressively since the SER School of Ultrasound was created, but it has been much more marked since 20042. Most notably demand among rheumatology residents has soared since 2011, which reflects the rapid expansion of ultrasound in our specialty. Furthermore, the current training programme for rheumatology residents, drawn up in 2002 and published in the Official State Gazette in October 2009, ranks ultrasound as an important and highly recommended technique for rheumatologists in training9.

The availability of equipment and qualified teaching staff in centres with teaching accreditation is a requirement to ensure adequate ultrasound training. Almost all the respondents (97.1%) have access to ultrasound equipment in their departments and 59% have 2 or more. However, only 61.1% undertake specific ultrasound rotations, and 16% of the total number of residents, even though they have dedicated ultrasound consultations in their departments, have no access to ultrasound. It is essential therefore, to improve access for these rotations, and ultrasound must be considered in drawing up training plans for residents in every centre.

According to the data obtained, residents in our specialty have gained greater access in recent years to ultrasound training through courses at the SER School of Ultrasound (Fig. 2), especially at the introductory and basic levels. These data demonstrate, on the one hand, the efforts by the School to increase their offer and, on the other hand, residents’ growing interest in starting training in this imaging technique. Of the respondents, almost 9 out of 10 took one of the School’s courses during their residency, but only a minority took intermediate and advanced courses. This could be because the SER ultrasound training programme generally starts in the second year of residency and therefore, as one course is offered per year, the advanced course is usually taken after residency has come to an end. Greater effort is needed in the future to ensure that most residents complete all levels of training offered during their residency.

According to recent EULAR recommendations10, competency assessment during rheumatology training is essential to guide learning and ensure quality of care. They also state that competency assessment should be a structured and continuous process that takes place regularly throughout the residency period. According to the results of the present survey, although there is wide access to ultrasound courses promoted by the SER or EULAR, completion of these courses with competency accreditation is low (5% of the respondents). This means that most residents have not completed competency accreditation in performing ultrasound by the time they have started as associate specialists. Promoting competency accreditation for the courses taken should be a joint effort by course promoters, teachers, resident tutors, and the students themselves, as a fundamental way of evaluating, correcting, and progressing in learning.

Ultrasound in rheumatology has expanded in recent decades to cover a wide range of examinations, often beyond the musculoskeletal system. Assessment of inflammatory activity is the most frequent indication for ultrasound examination in rheumatology and receives the highest score in level of training, according to the residents. Although extra-articular examinations are less frequent, vascular ultrasound received the highest score in level of training. The quality of training perceived by the residents is generally positive (almost half the respondents rate it as good to excellent), although almost 20% rate it as poor. Nevertheless, most of the respondents perceive the training they received as useful for their future practice and skills as rheumatologists.

As a secondary objective, we analysed how different aspects have evolved in relation to quality of training over the last decade. Access to ultrasound equipment and the overall assessment of the quality and usefulness of the training received do not seem to differ significantly between the two periods studied (2009−2013 and 2014−2019). There has been greater access to ultrasound rotations in recent years, a sign of residents’ interest in specific training in this field, and ultrasound has been progressively included in each centre’s training plans.

The study has some significant limitations. Firstly, the scope of the survey was smaller than theoretically expected, which may limit the validity of the results obtained. Moreover, participation in the survey from autonomous communities with centres with teaching accreditation was not uniform, and some communities were not represented.

In summary, ultrasound training during residency training has increased over the last decade. Most residents have completed ultrasound rotations outside or within their training centre. Participation is high in SER ultrasound courses, and moderate in EULAR courses, whereas only a minority of residents completed competency accreditation for the courses taken. Although access to national training courses is high, competency accreditation is an area for future improvement. The residents generally perceive the quality of training as good and that it will improve their practice as rheumatologists in the future.

The authors have no conflict of interests to declare.