f04b.jpg (9303 bytes)It is hard to believe that one of this country’s leading researchers in ultrasound basically fell into the specialty. Beryl Benacerraf received her M.D. from Harvard Medical School (Cambridge, Mass.) in 1976 and was ready to set off on a career in interventional procedures. But, when she wanted to have children, the potential side effects of using fluoroscopy everyday led Benacerraf to change specialties temporarily to ultrasound.

“I said I would do ultrasound for a year in order to avoid fluoro exposure,” Benacerraf recalls. “I really had no interest in ultrasound, though.” As she went through two pregnancies as an ultrasound specialist, her interest grew and before long Benacerraf was hooked — and the field of obstetric ultrasound hasn’t been the same since. During her 20-plus years as an ultrasound researcher and clinician, Benacerraf has developed ultrasound techniques for detecting Down’s syndrome and chromosomal abnormalities in fetuses.

“I was at the right place at the right time and made innumerable observations, which we were able to publish,” she says modestly. “The field was ready to be hatched and now it is a huge field in clinical practice we use day in and day out.”

Today, Benacerraf is a clinical professor of obstetrics, gynecology, and radiology at Harvard Medical School and director of obstetrical ultrasound at Massachusetts General Hospital (Boston). She is an elected fellow of the American College of Radiology (ACR), the American Institute of Ultrasound in Medicine (AIUM) and the Society of Radiologists in Ultrasound. Earlier this year, she was awarded the AIUM’s William J. Fry Memorial Lecture Award for her contributions to the progress of ultrasound.

Recently, Medical Imaging spoke with Benacerraf to get her insights on the current state and future direction of ultrasound technology.

What do you see as the most significant technological breakthrough in ultrasound in recent memory?
I think the equipment has seen a great increase in resolution over the past few years. For example, harmonic imaging has made a tremendous difference in terms of the resolution of ultrasound images. We now are seeing things we haven’t seen before.

Another area that is interesting and perhaps promising for the future is 3D ultrasound and the reconstruction of volume data sets. With that, you can send it somewhere, re-evaluate it, rescan it in different orientations, and that is helpful for seeing things in orientations you haven’t seen before. It makes ultrasound more like CT or MRI where you can do reconstructions in planes that you don’t usually scan in.

In what stage of development do you see harmonic imaging and 3D ultrasound technologies?
They are in their infancy. Harmonics is taking hold much more easily than 3D. [Harmonics] is just an upgrade that people can install. You push a button and it improves your resolution right then and there. I think engineers are working on refining it more to include more of the sound waves in the harmonic.

3D requires additional expertise. It requires more time on the part of the physician or the sonographer, and there is a big learning curve there. There are different machines you need to purchase, so it is much more involved.

What applications will harmonics and 3D advance?
The better the resolution, the more things we’ll see — so they will open doors that we don’t even know about right now. We can look at fetal malformations in 3D and make it easier for pediatric surgeons to see what we’re looking at. Ultrasound people are used to thinking in three dimensions, even though they only have two dimensions available to them, whereas a lot of people we talk to — including patients, referring physicians and surgeons that need to deal with the newborn — can’t tell what we’re looking at. Looking at a 3D reconstructed image is helpful for those folks not trained in ultrasound.

Can you provide any examples of what abnormalities 3D can help detect?
A facial cleft is one example that helps the plastic surgeon plan what he or she has to do; also, in gynecology with post-menopausal bleeding and uterine cancers. That is an area that has developed recently with the advent of the transvaginal probe and high-frequency transducers. We can see the lining of the uterus much more closely than before. In fact, I diagnosed my mother’s uterine cancer in Stage I that way.

You keep close to home. Do you have an ultrasound system in your living room?
No, (laughs) but I do scan my parents once a year, looking at all their organs, and I found a cancer in my mother.

Do these new capabilities make ultrasound a more formidable competitor to MRI and CT? How does this change the role of ultrasound, keeping in mind the cost issues in imaging today?
The problem with the cost issues is that ultrasound is very under-reimbursed and the ultrasound machines that are needed to run these new technologies are going up in price. It is amazing that the directions are so opposite.

Because CT and MRI are reimbursed at such a higher level, they are more commensurate with what the costs are. There are a lot of departments that would rather do a CT than an ultrasound, because they will receive more [reimbursement] for it. I don’t know that ultrasound is going to take over the applications of CT and MRI — I don’t think it is. Ultrasound is much more operator dependent, it requires more of the doctor’s time and all these things are costly, while the reimbursements are going down, not up. These things have to be reversed before we see the full advantage of ultrasound.

You mentioned operator dependence and, across the board in radiology, there seems to be a shortage of qualified sonographers. Are you seeing this in ultrasound and, if so, what are the causes?
Yes, there is a huge shortage of technologists, sonographers and radiologists. People are not choosing radiology, and there are a lot of open jobs that can’t be filled in radiology today.

I don’t know why people aren’t coming into this area. I think people are burned out and medicine is not as fun as it used to be. There are so many more lawsuits, and I think medicine in general is going through some hard times. The specialties are getting the brunt of it. [The labor shortage] is definitely higher in the specialties. One place where it is really high is maternal fetal medicine, which is part of obstetrics. The highly sub-specialized people often are not reimbursed for the type of expertise they have and patients can’t get to them because of the gatekeepers. So, students in medical school are more likely to choose some of the more general medicines than the sub-specialties.

Do you see sonographers bouncing around in the market with all these opportunities available to them?
Sonographers have a different problem, because they get orthopedic problems from repetitive use, which leads to joint and wrist problems. Eventually. they burn out and that makes people not want to do it long-term. I think there are fewer sonographers going into the field, because I know from our side, it is extremely hard to find qualified songoraphers right now. There are plenty of positions open and not enough people to fill them. I think because the economy is good, people with technical training are more likely to go into a dot-com environment today.

Is there anything you use on a daily basis that you never dreamed of using when you first started in this field?
I developed much of the field on how to detect Down’s syndrome and fetal chromosomal abnormalities, so when I started there was nothing there. There were just a few measurements.

Where do you see the use of contrast agents headed?
This is a very exciting area that is just taking off. Ultrasound has always been good at looking at tumors in the liver, but CT has always been better. The ability to use contrast has rendered ultrasound much closer to CT in its capabilities. That is a very exciting area of intense investigation, but it is not FDA-approved yet.

How far off do you see contrast agents from being used in daily practice?
I would say in the next three to four years we’ll see it in use. I don’t know what they’re doing in Europe with it, as I’m focused on ob/gyn. I don’t see it being used often. There are a number of labs in the U.S. using it, so I don’t think it will be long.

What about the pace of technology development in recent years. Do you see development increasing and, if so, do you see it at the academic or corporate level?
It has always been a joint venture between academic and corporate entities. Manufacturers will keep developing new things. Basically, an ultrasound machine is a big fancy computer. And, they’re changing constantly and I think there is a lot we haven’t seen that computers will be able to do. All that technology will be put onto ultrasound machines to produce bigger and better things. So, I think we’re almost at the infancy of what computers can do and all the ultrasound companies are working in these areas. I see it as a parallel industry to these others.

Unfortunately, on the hospital front, because reimbursements have been so tight, people’s academic time has been taken away and there is much less academic work being done for clinical research. It is much harder to find time to do it, and people are burning out. They’re spending all their time doing clinical work, and not having any time to do research.

So, it is a case where hospitals are saying if it doesn’t produce a profit, it needs to be put on the back burner?
Yes, exactly. As a result, we’re seeing far fewer papers being written. Most of the editors of the journals I deal with are saying they see a decline in the number of papers being written, because people just don’t have the time.

How recent is this?
It has just been in the past three or four years, but it is getting worse.

Are there any efforts to improve this or create “think tanks” for ultrasound?
There is always some type of effort, but there is no one to pay for it. The ultrasound companies don’t have the money to pay for it. The drug companies have money, but there are no drugs in ultrasound.

Do you see the consolidation in the commercial ultrasound market affecting this? With fewer actual companies, will there be less research done on the corporate level?
No, I don’t worry about that. In fact, it may get better, because the larger companies may have more money to deal with.

What other new technologies do you see affecting the future of ultrasound?
We’re seeing the introduction of hand-held ultrasound systems, which are starting to become very important in cardiology. There is one company that has a transducer that just plugs into your laptop and you can just buy the software and put that on your computer. That is extraordinary. I think there is no limit right now to what computers can do and I think ultrasound will benefit from that.

Are you seeing any target applications for these hand-held systems?
We’re seeing them in the trauma room, the cardiology office and all sorts of places.

The issue then becomes whether these technologies will be in the hands of people who may not be trained in ultrasound?
That is the problem. The AIUM and ACR have been working very hard on the accreditation of ultrasound practices. But, you’re right — the quality of ultrasound varies from very good to very bad and there is really nothing policing ultrasound — no boards or no credentialing of ultrasound. There was no accreditation of ultrasound until these two bodies started working on it and now there are minimum compliance standards. The insurance companies were starting to credential people and that was going to be a nightmare.

I’m on the AIUM council of accreditation and I’m excited about doing that because this could run away with itself, which could be detrimental to the patient and the technologist.

It brings to mind the defibrillator market with the advent of automated external defibrillators. Does this type of path increase the chance of lawsuits?
The lawsuit situation has gotten out of hand with a lot of frivolous lawsuits. Especially in obstetrical ultrasound. It is bad right now. I think doctors are held to impossible standards. Nothing less than perfection. I’m not saying mistakes shouldn’t be rectified, because they should. But I don’t think doctors — particularly in obstetrics — can be held responsible for every bad outcome. A bad outcome is unfortunate, but it doesn’t have to be somebody’s fault. A lot of patients now are trying to point the finger.

It seems ironic that as the technology becomes more effective, even more is expected of the clinician?
Exactly. The patients’ expectations are incredibly high. They think you can do an obstetrical ultrasound exam and rule out all abnormalities and that is not true. Ultrasound picks up just more than half of the abnormalities a fetus can have. That is not 100 percent, and you can’t be held to a standard that doesn’t exist.end.gif (810 bytes)