Diagnostic Ultrasonography in Women's Health Care (Position Paper)

Introduction

Maternal/child care is integral to family medicine. The American Academy of Family Physicians (AAFP) strongly advocates that every family medicine residency training program train physicians in maternal/child care,1 and many family physicians want to have comprehensive women's health care skills. The cost of equipment and development of office skills can be easily justified in family practices that deliver more than 100 patients per year, and, even those family physicians who do not deliver babies are faced with clinical questions for which diagnostic ultrasonography is indicated. For a number of reasons, modern family medicine requires access to diagnostic ultrasonography in the management women's health care issues:

  • The need for clinical information at the time of patient contact in a remote setting
  • The need for immediate assessment of urgent clinical problems
  • The higher specificity of obstetric ultrasonographic information obtained by clinicians who know the patient
  • Significant reductions in time and cost
  • Improved continuity of care
  • Improved patient access
  • The likelihood that primary care allows more time than referral care for educational interaction between patient and provider

Family physicians who practice ultrasonography must at the same time guard against a number of potential negative effects:

  • The potential for misuse of this technology, particularly in the area of recreational viewing and information acquisition for non-medical uses2,3
  • The risk of over-utilization resulting from easy availability
  • The potential for unrealistic societal expectations (These may relate to the power of the tool, the skill of the provider or patients' outcome expectations.)
  • Ongoing inter-specialty conflicts regarding the utilization of this technology
  • The possiblity that the growing complexity of the technology will require providers to expand their knowledge more than their available time permits
  • The possiblity that increasing volume will lead physicians to ultrasonography to ultrasound technologists, thus distancing physicians and patients
  • The possibility that other clinical duties may not allow time for ultrasonographic examinations in the physician's schedule

Section I: Scope of Practice for Family Physicians

Diagnostic ultrasonographic examination appropriately enhances the diagnostic and therapeutic capabilities of family physicians. The applications of ultrasonography in family medicine can be divided into the following general areas:

  • First trimester diagnostic pregnancy care
  • Second or third trimester diagnostic pregnancy care
  • Gynecologic care
  • Emergency care of acutely ill patients in labor and delivery, in the emergency department and in the office
  • Ultrasound guided procedures (for instance, amniocentesis, external cephalic version, paracentesis, thoracentesis, organ biopsy, mass biopsy, dilation and curettage, intrauterine contraceptive device retrieval and insertion)
  • Evaluation of specific small parts and surface anatomy

A number of continuing medical education courses presented by family physicians extensively review the clinical applications, indications, and clinical settings in which diagnostic ultrasonography is useful in the hands of family physicians. Obstetric ultrasound courses organized and presented by family physicians and sponsored by the AAFP have been offered since 1989.

Section II:  Clinical Indications4

Indications for ultrasonography in women's health care can be categorized under seven headings:


Maternal factors:

  • Evaluation of pelvic mass
  • Evaluation of hydatidiform mole
  • Evaluation for ectopic pregnancy
  • Evaluation for uterine anomal

Prenatal diagnosis:

  • In evaluating the of risk of fetal anomaly
  • In procedures such as genetic amniocentesis, ceroscopy, fetal transfusion, and chorionic villi sampling
  • In evaluation of abnormal alpha-fetoprotein levels

In estimation of fetal age (accurate to within 1 week as assessed from between weeks 7 to 13, to within 2 weeks if measured in the early stages of the second trimester, and plus or minus 4 weeks during the third trimester)4 in various circumstances:

  • Before repeat cesarean section
  • In preterm labor
  • In irregular menses
  • In postterm pregnancy
  • In premature rupture of membranes
  • Before induction if presentation is uncertain
  • In amniocentesis for fetal maturity
  • When the date of the last menstrual period is uncertain

Growth abnormalities:

  • Evaluation of growth when at risk, for instance in pregnancy-induced hypertension, diabetes mellitus, macrosomia, multiple gestation, or chronic maternal disease
  • Evaluation of size/dates discrepancy
  • Evaluation of poor weight gain

Fetal assessment:

  • Determination of biophysical profile
  • Evaluation of decreased fetal movement
  • Confirmation of fetal death

Antenatal hemorrhage:

  • Confirmation of intrauterine pregnancy
  • Exclusion of placenta previa
  • Evaluation of suspected abruption

Intrapartum:

  • Confirmation of presentation
  • Evaluation of cord position
  • Evaluation of abnormal fetal heart rate
  • Evaluation of abnormal patterns in labor
  • Assistance in delivery of multiple gestations, including fetal assessment, determination of presentation, and version

Section III: - Training Methodology

Training in ultrasonography may include programmed reading combined with didactic lessons, incremental introduction to equipment and patients, and scanning of patients followed by supervised practice. The efficacy of these methodologies has been established by direct examination of scanning capabilities, written tests, objective measurements of acquired basic data, compared patient outcomes, and matching family physicians' results to those of other practitioners.

In the ideal situation, physicians wanting to obtain skill in ultrasonography engage in a preliminary period of extensive reading, followed by a basic course that includes didactic and experiential activities. The  physician then engages in a supervised practice either through auditing of recorded scans or direct supervision.  This period of training is then followed by, with the learning curve dependent on the learner's enthusiasm.2

Section IV:  Testing, Demonstrated Proficiency, and Documentation

The standard content of examinations by organ systems and clinical conditions has been defined, with very little disagreement, by the American Institute of Ultrasound in Medicine (AIUM), the American Congress of Obstetricians and Gynecologists (ACOG), and the American College of Radiology (ACR). Existing training methodology addresses the standard exam content.

The AIUM has guidelines available for ultrasonography of the abdomen, retroperitoneum, breast, female pelvis, prostate and surrounding structures, scrotum, thyroid, and parathyroid, as well as for pediatric neurosographic, obstetric antepartum, and Doppler vascular ultrasound examinations (www.aium.org/resources/guidelines.aspx(www.aium.org). Accessed January 29, 2013.). The American Society of Echocardiography has guidelines and standards for the performance of cardiovascular examinations (www.asecho.org/i4a/pages/index.cfm?pageid=3317(www.asecho.org). Accessed January 29, 2013).

The documentation of experience and proficiency needs to demonstrate both an understanding of the technology and the ability to perform the procedure and interpret the information obtained in the context of the clinical question. Documentation of obtained skill falls into four categories: documentation of formally organized coursework, of the number of supervised patient studies performed, of the number of scans performed clinically in the presence of an examiner, and of successful completion of a cognitive examination.

For family medicine residents, longitudinal curricula in diagnostic ultrasonography will allow for acquisition of skill, but the individual physician's success depends on time committed, patient volumes, and enthusiasm. For practicing physicians who are currently performing this procedure, myriad continuing medical educational courses and clinical journals allow for expansion of skill.

Section V:  Credentialing and Privileging

Current Status and Systems

The issue of privileging is probably best viewed in two segments: office practice and hospital practice.

Office Practice. Office practice is currently unregulated in the sense that as long as an office-based physician has ultrasound equipment, the physician can use it as he or she sees fit. However, the AIUM has developed a system of accreditation for obstetric and gynecologic "ultrasound practices." (www.aium.org/accreditation/accreditation.aspx(www.aium.org). Accessed January 29, 2013.) This mechanism is similar to a system in use for vascular ultrasound laboratories. This accreditation system is open to any physician regardless of specialty and is based on meeting standard exam content, documentation, procedure volume, and maintenance standards. AIUM accreditation is now required by some payers before payment is issued.4,5

Hospital Credentialing/Privileging. The range of obstetric ultrasound services provided in hospitals varies from complete, standard examinations to emergency department applications and labor and delivery applications. For that reason, these three segments should be considered separately.

Complete or standard ultrasound examinations are usually performed in the department of radiology by technical personnel and interpreted and "validated" by radiologists (sonologists). Radiology departments generally guard their control of these studies. A variety of procedural, medical, legal, and financial arguments are raised against allowing nonradiologists access to the radiology department equipment. This, therefore, becomes an interspecialty issue involving OB/GYNs, family physicians, and radiologists.

Since most family physicians who perform obstetric ultrasound do so in their offices, this might not often be a significant issue. However, where the office practice and equipment are owned by a hospital, the radiology departments might try to assert their sovereignty over office imaging practice, including plain radiography and diagnostic ultrasound, and thus infringe on family physicians' office-based practices. This may include residency training situations in which residencies are denied ultrasound equipment based on a radiology department's objections and despite evidence of the quality of ultrasonography performed in family medicine residencies.6  Still, a 2009 AAFP survey indicated that 17.5% of family physicians perform obstetric ultrasonography and 14.8% perform nonobstetric ultrasonography in the office.7

Use of diagnostic ultrasonography in the emergency department is becoming recognized as clinically important and as within the scope of care of the physicians who practice there. Courses developed by family physicians in general ultrasonography have been attended by emergency department physicians. Family physicians conducting these courses have been asked to conduct similar courses specifically for emergency physicians. Training and credentialing in emergency department ultrasonography is currently an issue that faces some of the same challenges as are being addressed in this document.

Essentially every physician who delivers babies can make use of diagnostic ultrasonography for a limited number of applications that often arise suddenly and can have significant impact on patient care.2 These applications include the diagnosis of fetal life, fetal number, and fetal presentation as well as assessment of amniotic fluid and of placental location.

These applications are widely recognized as being readily learned by family physicians and are included as an option in the AAFP-sponsored Advanced Life Support in Obstetrics courses. Modern obstetric care benefits from the availability of ultrasound equipment in, or readily accessible to, the labor and delivery area for these purposes. Accessibility of this equipment to all physicians who practice and the acquisition of these basic skills by all physicians who deliver babies is highly desirable.

Numbers and Outcomes. Any family physician desiring to perform obstetric ultrasound would be best advised to keep a record of the following:

  • Courses taken, including the number of hours of formal learning involved
  • The number of directly supervised scans performed
  • The total number and types of scans performed, including standard examinations, labor and delivery scans, emergency department scans, and sonographically guided procedures performed

Documentation of outcomes is acknowledged as important in demonstrating proficiency and supporting credentialing. In the case of obstetric ultrasonography, the specific outcomes that are most likely to be scrutinized include these:

  • Accuracy of gestational age assessment by correlation of eventual delivery date and gestational age at birth
  • Accuracy of fetal anatomic survey by follow-up of infants suspected of having fetal anomalies or those in whom fetal anomalies were missed

Section VI: Miscellaneous Issues

Ensuring the quality of ultrasonography courses is important; quality can be fostered through the AAFP Prescribed credit mechanism using expert physicians within the AAFP or in other professional organizations.

The public health implication of expanding family physicians' use of diagnostic ultrasound is improved access to care for patients.

The financial implications of expansion of obstetric ultrasound skills for family physicians include the cost savings inherent in improved access. The implications for practicing physicians include the revenue generated by this procedural skill and the enhanced attractiveness to managed care organizations of practices that can provide more complete services.

The main educational research agenda items are clear definition of competency-based measures required for profiles in ultrasound, and analysis of outcomes.

References

1. American Academy of Family Physicians and American College of Obstetricians and Gynecologists. Maternity and gynecologic care: Recommended curriculum guidelines for family medicine residents. Leawood, KS: American Academy of Family Physicians, 1998. www.aafp.org/online/etc/medialib/aafp_org/documents/about/rap/curriculum/maternitycare.Par.0001.File.tmp/Reprint261.pdf. Accessed January 28, 2013.

2. Deutchman ME, Hahn R. Office procedures. Obstetric ultrasonography. Prim Care. 1997;24(2):407-31.

3. Salvesen K, Lees C, Abramowicz J, et al; Bioeffects and Safety Committee of the Board of the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG). ISUOG-WFUMB statement on the non-medical use of ultrasound, 2011. Ultrasound Obstet Gynecol. 2011;38(5):608.

4. Deutchman M, Myers T. Diagnostic Ultrasound in Pregnancy. Advanced Life Support in Obstetrics Provider Course Syllabus, Copyright 2009. American Academy of Family Physicians.

5. Hale RW. Working to resolve the ultrasound accreditation debate. ACOG Today. 2000;44(6):9.

6. American College of Obstetricians and Gynecologists. ACOG against mandatory ultrasound accreditation. ACOG Today. 2007;51(1):3.

7. Keith R, Frisch L. Fetal biometry: a comparison of family physicians and radiologists. Fam Med. 2001 Feb;33(2):111-4.

8. American Academy of Family Physicians. Practice Profile II. Leawood, KS: American Academy of Family Physicians; 2009.

(2002) (2013 COD)