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:
Family physicians who practice ultrasonography must at the same time guard against a number of potential negative effects:
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:
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.
Indications for ultrasonography in women's health care can be categorized under seven headings:
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:
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
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.
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:
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:
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.
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)
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Diagnostic Ultrasonography in Women's Health Care (Position Paper)