We have conducted the largest national survey of current use, training needs, and barriers to musculoskeletal ultrasound use among rheumatology groups in the USA. Most rheumatologists recognize the value of musculoskeletal ultrasound, but only half of VA rheumatology groups are currently using common diagnostic and procedural musculoskeletal applications. Several barriers have been identified that must be overcome to facilitate integration into clinical practice, and our findings can guide future POCUS implementation efforts in rheumatology.

POCUS has unique advantages in the care of patients with rheumatic diseases. Since the 1990s, early initiation of more aggressive therapies has been emphasized for inflammatory arthropathies to control disease activity, minimize joint damage and disability, and improve quality of life [5]. However, prolonged delays of several months continue to be an ongoing challenge, and clinical assessment supplemented by an ultrasound examination may facilitate early diagnosis [11, 12]. Ultrasound can help differentiate inflammatory from non-inflammatory conditions, and although further study on use of ultrasound in treat-to-target strategies is needed, initial evidence suggests that ultrasound can facilitate earlier diagnosis and assist in achieving disease remission [13]. Additionally, ultrasound can guide invasive bedside procedures and permit real-time, dynamic evaluation of the musculoskeletal system, a unique characteristic that is not possible with static imaging modalities [6, 14, 15]. Multiple organizations, including EFSUMB, ACR, and EULAR, have published guidelines on the use of ultrasound in rheumatic diseases [1,2,3,4].

Lack of training, including lack of funding and opportunities for training, was the most frequently reported barrier to ultrasound use by rheumatology groups. Training as a top barrier to POCUS use has been reported by multiple specialties, including primary care, emergency medicine, hospital medicine, and critical care [7,8,9,10]. Most rheumatology chiefs support POCUS training, but only 20% of chiefs had a process of obtaining POCUS training for their rheumatologists. Without a deliberate investment in training, POCUS use by rheumatologists in practice is unlikely to increase simply over time as seen in our data from 2015 to 2020. To help address the training gap for rheumatologists in practice, the Ultrasound School of North American Rheumatologists (USSONAR) developed a CME course in 2008 to provide mentor-based training over an intensive 8-month period. The formalized musculoskeletal ultrasound curriculum includes reading materials, online assignments, and hands-on training followed by a competency evaluation. While USSONAR and other EULAR and ACR courses have been instrumental in training more rheumatologists, relatively few rheumatologists in practice are able to participate because of the costs, time requirements, and limited availability [16,17,18]. Though attending POCUS CME courses has been the most common method of receiving training and several courses are available nationwide, training is a complex barrier for rheumatologists in practice that warrants further investigation.

POCUS training has been increasingly incorporated into rheumatology fellowship curricula. In 2008, 41% of rheumatology fellowship programs reported offering ultrasound training which increased to 94% by 2016 with 41% having formal POCUS training curricula [19]. Although competency in POCUS is not mandated by ACGME, the 2023 requirements state clinical sites must have access to ultrasound, and “fellows must demonstrate knowledge of the indications for and interpretation of ultrasonography” [20]. Additionally, the 2022 ACGME Supplemental Guide for Rheumatology includes ultrasound as a competency milestone under procedures for patient care [21]. Some European countries, including Germany and Italy, mandate musculoskeletal ultrasound training during rheumatology fellowship, and we anticipate similar trends in the USA. Since approximately 74% of medical schools and 61% of internal medicine residency programs had POCUS training curricula in 2019–2020, many new fellows seek rheumatology fellowship programs to continue building their musculoskeletal ultrasound skillset, and programs that offer ultrasound training will likely maintain a competitive advantage in recruitment [22, 23]. Recent consensus-based recommendations for Canadian rheumatology residency programs, as well as ACR resources, can guide development of ultrasound training curricula by rheumatology fellowship programs in the USA [24].

Lack of POCUS infrastructure, including image archiving, support staff, and standardized documentation, and limited access to ultrasound equipment were additional barriers identified. Image archiving and documentation are needed for disease monitoring and comparison of images longitudinally as recommended by ACR [3], as well as to fulfill billing requirements. A third of rheumatology groups reported lack of ultrasound equipment as a barrier. In comparison, utilization of POCUS among European rheumatologists appears to be much higher with 90% of providers reporting access to an ultrasound machine [25].

Our study has limitations. Self-reported data were collected from chiefs of staff and rheumatology chiefs, and despite the high response rates, the reported data may not accurately reflect actual clinical practice. Further, data were collected from rheumatology chiefs practicing at VA medical centers which may limit generalizability to other healthcare systems.