See also:
Maternal/Child Care (Obstetrics)
Reproductive Decisions
Women's Health Specialty
Women's Health Care, Family Physicians Providing
Women's Health Care
Ultrasonography, Diagnostic in OB/GYN (Position Paper)
TRAINING AND CREDENTIALING OF FAMILY PHYSICIANS IN DIAGNOSTIC OB/GYN ULTRASONOGRAPHY
OVERVIEW AND JUSTIFICATION
Maternal/child care is integral to the discipline of family medicine, and the American Academy of Family Physicians strongly advocates that every family medicine residency training program train physicians in maternal/child care. Even those family physicians who do not deliver babies are faced with clinical questions for which diagnostic ultrasonography is indicated. Modern family medicine requires access to diagnostic ultrasonography to properly manage and treat women's health care issues.
There are a number of positive reasons for family physicians to perform diagnostic ultrasonography in women's health.
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 are a number of negative effects that can also be identified.
- 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
Diagnostic ultrasonographic examination by family physicians is an appropriate skill that enhances the diagnostic and therapeutic capabilities of family physicians. There are varied applications of this intervention in family medicine. These interventions can be divided into the following general areas:
- 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
A number of continuing medical education courses presented by family physicians extensively review the clinical applications, indications and clinical settings in which diagnostic ultrasonography in the hands of family physicians is useful. Obstetrical ultrasound courses organized and presented by family physicians and sponsored through the American Academy of Family Physicians have been presented since 1989.
SECTION II - CLINICAL INDICATIONS3
Maternal factors:
- Evaluation of pelvic mass
- Evaluation of hydatidiform mole
- Evaluation for ectopic pregnancy
- Evaluation for uterine anomaly
Prenatal diagnosis:
- 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
Estimation of fetal age (accurate to within 1 week under 20 weeks, + 2 weeks at 20 to 28 weeks, and + 4 weeks after 28 weeks):
- 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
Growth Abnormalities:
- 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
Fetal assessment:
- 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, presentation and version
SECTION III - TRAINING METHODOLOGY
There are various complementary training methodologies for this procedure. These may include: programmed reading combined with didactic lessons; incremental introduction to equipment and patients; and scanning of patients followed by supervised practice. The acquisition of skills by these methodologies have been tested by direct examination of scanning capabilities, written tests, objective measurements of acquired basic data, compared patient outcomes and matching family physicians to other practitioners.
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
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 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), ACOG, and the American College of Radiology (ACR). There exists tested training methodology to meet the standard exam content.
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.
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
The issues of privileging is probably best viewed in two segments: (A) office practice; and (B) hospital practice.
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 reimbursement 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:
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 reimbursement 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
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 supports 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:
- 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
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:
- 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.
REFERENCES
- 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.
(2002)