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Ultrasonography, Diagnostic in OB/GYN (Position Paper)
TRAINING AND CREDENTIALING OF FAMILY PHYSICIANS IN DIAGNOSTIC OB/GYN ULTRASONOGRAPHY
OVERVIEW AND JUSTIFICATION
There are a number of positive reasons for family physicians to perform diagnostic ultrasonography in women's health.
- The need for clinical information at the time of patient contact in a remote setting.
- Immediate assessment of urgent clinical problems.
- Higher specificity of obstetrical ultrasonographic information obtained by clinicians who know the patient.
- Significant reductions in time and cost.
- Comprehensive women's health care skills are desired by many family physicians.
- The cost of equipment and development of office skills can be easily justified in family practices that deliver more than 100 patients per year.
- Improved continuity of care.
- More time for an education interaction between patient and provider.
- Improved patient access.
- There is a potential for misuse of this technology, particularly in the area of recreational viewing and information acquisition for non-medical uses.2
- There is the risk of over-utilization because of ease of availability.
- Unrealistic societal expectations may develop. These may relate to the power of the tool, the skill of the provider and outcome expectations of the patient.
- There have been, and will continue to exist, significant inter-specialty conflicts regarding the utilization of this technology.
- As the complexity of the technology increases, providers will be required to expand their knowledge base beyond their time commitment capabilities.
- As volumes increase, physicians may delegate these interventions to ultrasound technologists resulting in distancing between physicians and patients.
- Examination of patients is most productive in real time. It requires practice time that frequently competes with other clinical duties.
SECTION I - SCOPE OF PRACTICE FOR FAMILY PHYSICIANS
- First trimester diagnostic pregnancy care ultrasound scans
- Second or third trimester diagnostic pregnancy care ultrasound scans
- Gynecologic scans
- Emergency scans performed for acutely ill patients in labor and delivery, the emergency department and the office
- Ultrasound guided procedures (e.g., amniocentesis, external cephalic version, paracentesis, thoracentesis, organ biopsy, mass biopsy, dilation and curettage, intrauterine contraceptive device retrieval and insertion)
- Specific small parts and surface anatomy ultrasonographic scans
SECTION II - CLINICAL INDICATIONS3
- Evaluation of pelvic mass
- Evaluation of hydatidiform mole
- Evaluation for ectopic pregnancy
- Evaluation for uterine anomaly
- Evaluation of patient risk for fetal anomaly
- Adjunct to such procedures as genetic amniocentesis, ceroscopy, fetal transfusion, and chorionic villi sampling
- Evaluation of abnormal alpha-fetoprotein levels
- Prior to repeat cesarean section
- Preterm labor
- Irregular menses
- Post dates
- Premature rupture of membranes
- Prior to induction (if presentation is uncertain)
- Adjunct to amniocentesis for fetal maturity
- Uncertain last menstrual period
- Evaluation of growth when at risk, such as pregnancy-induced hypertension, diabetes mellitus, macrosomia, twins, or chronic maternal disease
- Evaluation of size/dates discrepancy
- Evaluation of poor weight gain
- Biophysical profile
- Evaluation of decreased fetal movement
- Confirmation of fetal death
- Confirmation of intrauterine pregnancy
- Exclusion of placenta previa
- Evaluation of suspected abruption
- 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, presentation and version
SECTION III - TRAINING METHODOLOGY
In the ideal situation, physicians wanting to obtain this skill would engage in a preliminary period of extensive reading, followed by a basic course that includes didactic and experiential activities. The provider would then engage in a supervised practice either through auditing of recorded scans or direct supervision. Following this period, there is a continuous lifelong incremental learning curve strictly dependent on the learner's enthusiasm.2
SECTION IV - TESTING, DEMONSTRATED PROFICIENCY AND DOCUMENTATION
The AIUM has guidelines available for performance of abdominal and retroperitoneal, antepartum obstetrical, breast, female pelvis, pediatric neurosonology, prostate and surrounding structures, scrotal, thyroid and parathyroid, and vascular/Doppler ultrasound examinations. The American Society of Echocardiography has guidelines and standards for the performance of cardiovascular examinations.
The documentation of experience and proficiency needs to incorporate an understanding of the technology, ability to actually perform the procedure and interpret the information obtained in the context of the clinical question. Documentation of obtained skill falls into four categories: (1) formally organized coursework; (2) minimum number of supervised patient studies; (3) clinically performed scans in the presence of an examiner; and (4) cognitive examination.
For family medicine residents, longitudinal curricula in diagnostic ultrasonography will allow for acquisition of skill, but is dependent upon time, patient volumes and enthusiasm. For practicing physicians who are currently performing this procedure, there are a myriad of continuing medical educational courses and clinical journals that allow for expansion of skill.
SECTION V - CREDENTIALING AND PRIVILEGING
Current Status and Systems
A. Office Practice
Office practice is currently unregulated in the sense that if an office-based physician has ultrasound equipment, he or she can use it as he or she sees fit. However, the AIUM has developed a system of accreditation for obstetric and gynecologic "ultrasound practices." 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
B. 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 viewed separately.
Radiologic Department Privileges - 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 would be doing so in their offices, this might not often be a significant issue. However, in practice settings where the office practice and equipment are owned by a hospital, radiology departments might try to assert their sovereignty over office imaging practice including plain x-rays 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. However, in a 1998 AAFP survey, 10.2% of OB-capable family physicians reported having hospital privileges for diagnostic OB/GYN ultrasound.5
Emergency Department Privileges - Use of diagnostic ultrasonography in the emergency department is becoming recognized as clinically important 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.
Labor and Delivery Unit Privileges - 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
- fetal presentation
- assessment of amniotic fluid
- assessment of placental location
Numbers and Outcomes
- Specific courses and number of hours of formal learning
- Number of directly supervised scans
- Total number and types of scans performed, including standard examinations, labor and delivery scans, emergency department scans and sonographically guided procedures performed
- 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
- Quality assurance of courses is important and 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 enhanced attractiveness to managed care providers of practices that can provide more complete services.
- The main educational research agenda item is clear definition of competency-based measures required for profiles in ultrasound, and analysis of outcomes would be equally important.
- Kwolek DS, Witzke D, Sloan DA. Assessing the need for faculty development in women's health among internal medicine and family practice teaching faculty. J Wom Health & Gen-Bas Med 1999;8(9):1195-1201.
- Deutchman ME, Hahn R. Obstetric ultrasonography. Prim Care 1997;24(2):407-31.
- American Academy of Family Physicians. Management of Maternity Care (MOM Care). Leawood, KS: American Academy of Family Physicians; 1996.
- Hale RW. Working to resolve the ultrasound accreditation debate. ACOG Today 2000;44(6):9.
- American Academy of Family Physicians. Survey of procedural skills. Leawood, KS: American Academy of Family Physicians; 1999.