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Words are Golden
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Copyright 2006 Terry J DuBose
Original article first published by: advance for Imaging & Radiation Therapy professional 2006 June 26;
Vol. 19 *Issue 14 * page 12

Confusion about whether to use "ultrasound" or "sonography," "sonographer" or "ultrasound tech," has done the profession a disservice.The following is the unedited version of the manuscript submitted, including references. The version referenced above was edited.

Sonography what is it? Words are golden.
Diagnostic sonography exploded into public consciousness in the early 1970s with the amazing ability to look into the world of prenatal development. Even with an ever growing work force of diagnostic sonographers, however, as an occupation the profession continues to lack cohesion.

Sonography has continued to move into every area of the hospital and clinic. Sonography was quickly adapted by many specialties: cardiology, vascular medicine, ophthalmology, obstetrics and gynecology, as well as radiology. Even psychiatry has used sonography to distinguish neurological perfusion problems from other brain maladies.

Historically, ultrasound was the word used to identify the modality. Originally the word ultrasound was used as a noun to identify acoustic energy with a frequency above the average human’s hearing. Later the use of ultrasound as a noun was expanded to include the images and procedures, as in “I am going to perform your ultrasound.” Ultrasound also became a verb, as in “please ultrasound Ms. Jones’s gallbladder”.

In early weeks in 1976 when we received the first sonographic machine in the hospital, there was some confusion over the term ultrasound . The Radiology Department was getting patients who were supposed to go to physical Therapy for therapeutic ultrasound; and the physical Therapy Department was getting obstetrical patients who were supposed to be coming to Radiology for diagnostic examinations. In 1969 a small group of sonographers-to-be gathered at an american Institute of Ultrasound in Medicine (AIUM) meeting and decided to form the american Society of Ultrasound Technical Specialists (ASUTS)… pronounced by some as “ASS-UTS”. In 1976 the name was changed to the Society of Diagnostic Medical Sonography (SDMS), and the term sonography was coined, resulting in the birth of sonographer, sonologist, sonographic, and sonogram. Joan p.Baker, the “Mother of american Sonography”, states that she had suggested the term sonography out of the term SONaR and a term used in Great Britain, radiographer.

“Because the occupation was so new, Baker, Nuss, and Staiano were determined to establish higher standards than those of most other allied health professions. as they discussed the mutual difficulty they were experiencing in establishing the term ‘technical specialist’, they agreed that the lack of success stemmed from the inability to prevent the use of the terms technician and technologist. Because the Registry was still in an embryonic stage, they seized the opportunity to adopt a new title. as a result of this, the Registry became the american Registry of Diagnostic Medical Sonographers (ARDMS). This action sent another message to the AMA – that we were indeed what we claimed and that we were serious about setting and maintaining high educational standards.”1

The noun, sonogram, is more grammatically correct, in my opinion, than ultrasound for describing an image made using ultrasonic energy. To call such an image an ultrasound is analogous to calling a photograph a light because it is made using reflected light. It also follows that “Sonographer” is better than “ultrasonographer”, or, heaven forbid, “ultrasound tech”.

Sonography is the most operator dependant diagnostic modality in modern medicine, and that difference has not received the attention that it deserves. Sonographers are really sonographic anatomists. The sonographer must be able to recognize normal anatomy, or they will never recognize abnormal; thus providing relevant, focused images used for diagnosis. The american Labor Relations Board defines a professional as one who has advanced education, has had specialized internship, and uses their judgment to perform tasks that cannot be performed in a specified time frame.

“NLRB Rules and Regulations [page 251-290] NATIONAL LABOR RELATIONS ACT also cited NLRA or the act; 29 U.S.C. Sec. Sec. 151-169 [Title 29, Chapter 7, Subchapter II, United States Code] findings and policies Section 1.
[Sec. 151.] http://www.nlrb.gov/nlrb/legal/manuals/rules/act.asp

(12) The term ``professional employee'' means-- (a) any employee engaged in work (i) predominantly intellectual and varied in character as opposed to routine mental, manual, mechanical, or physical work; (ii) involving the consistent exercise of discretion and judgment in its performance; (iii) of such a character that the output produced or the result accomplished cannot be standardized in relation to a given period of time; (iv) requiring knowledge of an advanced type in a field of science or learning customarily acquired by a prolonged course of specialized intellectual instruction and study in an institution of higher learning or a hospital, as distinguished from a general academic education or from an apprenticeship or from training in the performance of routine mental, manual, or physical processes; or (b) any employee, who (i) has completed the courses of specialized intellectual instruction and study described in clause (iv) of paragraph (a), and (ii) is performing related work under the supervision of a professional”2

The confusion for the public about whether it is ultrasound or sonography, sonographer or ultrasound tech has done the profession a disservice. The lay-person, and even many medical professionals, do not understand the sophisticated process that is sonography. It is different from simple “eye-hand coordination”. When a couple has an obstetrical sonographic study, they see the sonographer simply slide the “plastic thing on a cable” over the abdomen and these recognizable images appear on the monitor. There are even nurses and physicians who watch this process in the hands of a skilled sonographer and think, “I know anatomy, I can do this”, but they do not realize the complex cognitive and psychomotor skills that the sonographer must have to make it look simple. This problem is compounded by the fetal studios springing up in malls, often operated by the uneducated and unwashed that do not know anatomy and do not care because they are “nonmedical”.

Many often do not understand that there is a cybernetic process in which the sonographic instrument enters into the sonographer’s eye-hand neural loop, extending the sonographer’s vision and hearing beyond the skin surface. as the operator observes the image on the monitor, the brain directs the hand’s motions, the direction, angle, rotation, and how subtle to make the movements of the transducer. a complex graphic workstation is actually between the eye and the hand, and requires an accomplished knowledge of the three-dimensional anatomy and the physics of how sound interacts with human tissue to be successful as a sonographer. as students learn the anatomy, and their psychomotor skills are developed they quit looking at their hand and focus their total attention on the monitor in order to analyze the anatomy and mentally direct their scanning hand. Sonographers are highly skilled anatomists. This fact has been recognized since the earliest days of sonography as pointed out in 1982 by the late Dr. Kenneth Taylor of Yale University.

“".... There is a very important difference between sonographers and other imaging technologists. Other technologists may reject an image because of sub-optimal technical quality, but the sonographer usually rejects over 95% of the scans because they do not provide the diagnosis. The sonographer must make the diagnosis and be able to interpret the scan to document the presence of any abnormalities. This is the unique responsibility of the sonographer." Ken Taylor, Yale University, in the Nov/Dec., 1982, issue of the SDMS Newsletter.”3

The sonographer’s role and the requirement that they exercise independent judgment and have a responsibility in diagnosis have continued to be acknowledged by many medical luminaries. For the following and additional quotations from medical experts about the sonographic profession see: http://www.uams.edu/chrp/sonography/DMS-Quotations.asp.

"Many ultrasound examinations are performed by technologist [sic] when a physician is not present, and a report is issued by a physician at a later time. The legal responsibilities are extraordinary because a necessary part of care may involve rendering an interpretation at the time the study is performed, especially if real-time instrumentation is used. This differs from the relative roles of technologists and physicians in other imaging disciplines. “4

And this,

“Diane, I have studied all of the major imaging technologies over the last 25 years -- CAT scanning, magnetic resonance imaging, angiography, and nuclear medicine. all of these technologies are very complicated in their own right. But among those, there is no question in my mind that ultrasound is the most difficult to learn.” Roy Filly on ABC Primetime Live; January 14, 1998.5

The required focus on the image and anatomy while scanning becomes a problem in large institutions with many different models of sonographic machines. The fact that an intimate knowledge of the machine is required in order to adjust the many controls and optimize the image, WHILE SCANNING, means that fumbling with the controls makes the machine a barrier between the operator and patient. For this reason the best sonographers are intimate with the sonographic equipment they operate. When an individual tries to scan on the various models with which they are not familiar, the machine is a barrier even if she/he is skilled with a different model. If a physician skilled with the sonographic machine in their office tries to scan in a large hospital, with many different pieces of sonographic equipment, they often end up fumbling with the controls and losing their focus. The fact that physicians generally do not like to appear as though they do not know what they are doing means the process can affect their judgment. This means that the most skilled sonologist will ask a sonographer to operate unfamiliar machines while watching and discussing the case as the sonographer scans.

There are two issues here. One is the knowledge and skills that are required for successful sonography, and the other issue is, "Does it matter what the process and those who perform it are called?" Some would propose that, “Sticks and stones may break my bones, but words will never hurt me.” Others will quote Shakespeare, “"What’s in a name? That which we call a rose by any other word would smell as sweet". There is some truth in both of these quotations. However, if you call a florist and order chrysthanthemums, I’ll wager that you will not get sweet smelling roses.

The issue of whether words can harm a sonographer is more complex because it requires some discussion of linguistics. Basically words are used as symbols by people to organize and communicate thoughts about concepts, things, and feelings. If we are not precise with the words that we use, then those listening to us will interpret our meaning with what they believe we told them. as one of my mentors used to say, “You may think you understand what I said, but what you don’t understand is that I did not say what I meant.”

We think with words, words have meaning, and what we think will eventually become our reality. “Linguistic Determinism refers to the idea that the language we use to some extent determines the way in which we view and think about the world around us.”6 When administrators, legislators, and the public think about sonography, they need a specific term and definition in order to understand the object of the thought. If they do not understand the operator dependency of sonography, they tend to think of it as simple technology. This will effect how they set pay scales, write laws, and communicate about the profession of sonography.

If sonographers do not use these terms correctly, then its likely that no one else will either. We need to insist that publications, employers, and the public use the proper terms when referring to our profession. Hospital and clinic signage should say “Sonography (Ultrasound)” as so many currently have signs that say “Radiology (X-Ray).” The accurate use of these words does make a difference in how people will think about our profession. It is this specific linguistic use of terms that makes doctors want to be called “Doctor”, and nurses want to be called “Nurse”, and the reason corporations trademark their product names. It is a matter of “branding” so that the public knows specifically what a name means.

The term ultrasound has a place in history and physics; but ultrasonographer is a mouthful, and ultrasound tech or just tech become the less difficult, yet inadequate terms for describing our complex profession. While sonographer is not as simple as tech, it is unique and specific to our profession and communicates clearly that sonographers are not “techs”. Sonography and sonographer are in all modern dictionaries, even though the terminology is often currently given second place to ultrasound, and ultrasonographer. It is the task of those in the sonographic profession to exploit every opportunity to communicate clearly and educate the public and medical community about who we really are… it will make a difference to our profession in the long run.

Author: Terry J. DuBose, M.S., RDMS, FSDMS, FAIUM
Terry is Director, Division Diagnostic Medical Sonography & DMS program and Associate Professor in the College of Health Related Professions, University of Arkansas for Medical Sciences. Terry's on-line CV can be accessed at http://www.uams.edu/chrp/sonography/faculty/DuBose.asp

References
  1. Joan Baker; Society of Diagnostic Medical Sonographers: Focus on the Future – A History of SDMS’ First 25 Years; SDMS/Lippincott-Raven 1995, p. 2-17.
  2. NLRB Rules and Regulations [page 251-290] NATIONAL LABOR RELATIONS ACT also cited NLRa or the act; 29 U.S.C. Sec. Sec. 151-169 [Title 29, Chapter 7, Subchapter II, United States Code] findings and policies Section 1. [Sec. 151.]. http://www.nlrb.gov/nlrb/legal/manuals/rules/act.asp, accessed June 2, 2006.
  3. Kenneth Taylor; Yale University, SDMS Newsletter, Nov/Dec., 1982.
  4. James A E, Bundy A L, Fleischer A C, et al; "Legal Aspects of Diagnostic Sonography" in SEMINARS in ULTRASOUND, CT and MR; Grune & Stratton, Inc., 6:209; June, 1985.
  5. PrimeTime Live, “Sound Advice” National Headliner Awards: Investigative Reporting First Place: ABC News - Prime Time Live; Diane Sawyer and Dr. Roy Filly of the University of California in San Francisco. http://www.uams.edu/chrp/sonography/DMSQuotations.asp accessed May 15, 2006.
  6. Linguistic Determinism: A Definition; http://venus.va.com.au/suggestion/sapir.html accessed May 14, 2006.