ob/gyn ultrasound symposium 2018 · 2018-09-20 · ob/gyn ultrasound symposium 2018 september...

Course Director

JACQUES ABRAMOWICZ, MD

OB/GYN Ultrasound Symposium 2018

September 28-30, 2018

Education in Ultrasound Alfred A. Abuhamad, MD

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Multi-SocietyTaskForceonUltrasoundTrainingCurriculumandCompetency

AssessmentinResidencyPrograms

AlfredAbuhamad,MD.EasternVirginiaMedicalSchool

WhatistheCurrentUltrasoundUtilizationinObstetricsintheUnitedStates?

Semin.Perinatol.2013Oct;37(5):292-4

• High-riskindicatorsinhistoryordelivery•  DeliveriesbyMFMphysicians• Medicare&Medicaid•  Stillbirths/abortions•  Deliveriesat<270days

Low-RiskPregnancies(n=61,717)DefinedbyExcluding:

Semin.Perinatol.2013Oct;37(5):292-4

Low-RiskPregnancies(n=61,717):

• Ina200,000livesplan,ultrasoundutilizationwasaround5-6/pregnancy

UltrasoundUtilizationinObstetrics

• High•  Exceedsrecommendationsofexistingnationalguidelines

• Mostlow-riskwomenget4-5ultrasoundsperpregnancy

NeedtoEnsureHighQualityofOb/GynUltrasounds

WhatistheCurrentQualityofOb/GynUltrasoundinClinicalPractice?

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ObstetricUltrasound&Quality ObstetricUltrasound

•  Obstetricultrasoundisinherentlydifficult•  Obstetricultrasoundiscommonlyperformedlookingfornormality

•  Incidenceofcongenitalabnormalitiesisrare•  Obstetricultrasoundisperformedindifferentvenues

PerformingQAisDifficult

ObstetricUltrasound

  Incidenceofcongenitalanomalies(3-5%)

Youcanbecorrect~95%ofthetime,withoutturningthemachineon!!

PerformingQAisDifficult

2AspectstoQualityinUltrasound

• Compliancewithexistingguidelines• UltrasoundDiagnosticperformance:“Arewemakingtherightdiagnosis?”– FalseNegatives– FalsePositives

Around40%ofpracticesinitiallyseekingaccreditationin2001–2004wereoperatingbelowtheminimumAIUMstandardsandguidelinesfortheperformanceofultrasoundexaminations.

JUltrasoundMed2004;23:1023–1029

QualityinOb/GynUltrasound


•  Clarkcounty,Nevadafrom2003to2006•  161majorCHDoutof77,000births(2/1000)

161

58(36%) 103(64%)

PrenatalDiagnosis PostnatalDiagnosis

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Ifprenatalultrasoundisnotperformingoptimallyfordetectionoffetalmalformations,…Howaboutfetalgrowthabnormalities?

•  Singletonbirths,allFrenchmaternityunitsin2010,over1weekperiod

•  RoutineUSbetween30and35weeks•  OfSGAinfants,only22%weresuspectedofFGRprenatally•  50%ofinfantssuspectedofFGRprenatallywerenotSGAafterbirth

BJOG–October2014

UltrasoundQuality•  Orderalotofultrasoundsinpregnancy•  Availabledatashowsthatqualityofultrasoundfordetectionofcongenitalmalformationsissuboptimal

• Wearealsounderperformingwithregardstofetalgrowthabnormalities

Don’tGetDepressed!!

CanWeImproveontheCurrentQualityofOb/GynUltrasoundinClinicalPractice?


ImpactofUltrasoundAccreditation

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ImpactofUltrasoundAccreditation

AmJPerinatol2015;32:599–604

•  BaselineQAreviewofobstetricUSexaminationsonsonographers(n=13)

• Mandatedelectronicchecklist•  PostQAreviewofUSexaminationsonaquarterlybasis

AmJPerinatol2015;32:599–604 AmJPerinatol2015;32:599–604

BJOG2016;123:400–407

In2007:Uniformnationwidescreeningprogramfordetectionoffetalanomalies

•  Theoreticalandpracticalexamination•  Maintaincaseloadof>150US/year•  QAassessmentQ2yearsbyasurveillancecommittee

Sonographers

BJOG2016;123:400–407

Comparing2002to2007versus2007to2012

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ObstetGynecol2014;123:149–54)

QualityofUltrasound

• Ultrasoundqualitycanbeimproved:– Standardizationofexamination– Compliancewithexistingguidelines– Ongoingoversight&qualityreview

Qualitystartswithtrainingandcompetency

WhatistheCurrentStatusofUltrasoundTraininginResidencyPrograms?

CouncilonResidencyEducationinObstetrics&Gynecology

• RequiredUSrotationin41%ofprograms• DidacticUStrainingin64%ofprograms• Requiredtoperform&interpretUSin16%ofprograms

SurveyonObstetricSonography–Jan20034,666residents(96%)

•  Surveyof136Ob-GynResidencyPrograms•  Performance&interpretationofUSismandatoryin16.3%

•  MedianexclusiveUScurriculumtime3.8+/-2.1weeks

•  90%ofprogramsdidnotrequireaminimalnumberforendovaginalUS(median40scans)

•  Competencyassessmentissubjectiveinmostprograms

ObstetGynecol2004;103:333–8. AJR:177,October2001

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82Residents


82Residents


233PracticingOb/Gyn


•  Surveyof67PGY4Ob-Gynand92MFMFellows•  37–46%reportednolimitationstoUSinobstetrics•  22–39%reportednolimitationstoDoppleruseinfirsttrimester

•  Knowhowtofind/useoutputdisplaystandards–  13.4%PGY4residents–  20.9%MFMFellows

IsThereaTargetNumberofUltrasoundExaminationsthatEstablishesCompetency?

AJR:174,May2000

•  Radiologyresidents(n=10PGY1)•  Competencyinvolved10ultrasoundstudies

– Residentacquiredimagesindependently– Residentinterpretedfindings– Facultyreviewedstudies– Standardizedchecklistusedforcompetencyassessment

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AJR:174,May2000 AJR:174,May2000

AJR:174,May2000 AJR:174,May2000

HowManyUltrasoundExaminationsarePerformedbyResidentsDuringtheirTraining?

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Conclusion•  Ultrasoundrotationsareingeneral<1monthindurationina4-yearresidencyprogram

•  Independentperformance&interpretationofultrasoundoccurin<20%ofresidencyprograms

•  Mosttraineesfeelthattheirtrainingingynecologicultrasoundisinadequate

Conclusion•  Bygraduation,mosttraineesdonotmeettheminimumrequiredultrasound-numbersforphysicianqualificationforAIUMaccreditation

•  Ultrasoundcompetencyassessmentisnonexistentorsubjectiveinmostresidencyprograms

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ThereisanUrgentNeedforaStandardizedCurriculumandCompetencyAssessmentToolsforUltrasoundTraininginResidency

Programs

Program Requirements for Graduate Medical Education in Obstetrics and Gynecology

January 1, 2008 / Revised 2015

Obstetrics

Gynecology

CouncilonResidencyEducationinObstetrics&Gynecology

ObstetricSonographyCouncilonResidencyEducationinObstetrics&Gynecology

GynecologicSonography

Guidelines

CME

Accreditation

SimulationClinical

Competency

Curriculum

PathwaytoQualityInImaging

Obstetrics2013

Guidelines

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Gynecologic2014

Guidelines Guidelines

2011 2013

CME Accreditation

1122Obpractices

AccreditationGuidelines

CME

Accreditation Competency

Curriculum

SimulationClinical


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Guidelines

CME


Curriculum

SimulationClinical

TaskForcePathwaytoQuality

InImagingUltrasoundTrainingCurriculum&Competency

Assessment

•  Todevelopaconsensus-baseddetailedcurriculumandcompetencyassessmenttoolsforultrasoundtraininginobstetrics&gynecology.

Mission

CognitiveCurriculum

CompetencyCurriculum

UltrasoundTrainingCurriculum&CompetencyAssessment

• Ob/Gynresidents•  Radiologyresidents•  Sonographystudents• Other:– Familymedicineresidents– Emergencymedicineresidents– Practioners

TargetAudience


•  ReflectsthebasicOb/Gynultrasoundexaminations,definedbyguidelines

•  RepresentsminimumrequirementsforthebasicOb/Gynultrasound

•  Arrangedbyyear/leveloftraining•  Requirestraineestoindividuallyobtaintherespectiveimagesforcompetencyassessment

Foundation


•  Forspecialties&practiceswhereprimarymodeofultrasoundimagingisbasedonimageinterpretation,competenciescanbeadaptedtoreflectthat.

•  Programsmayreorganizethelevelsoftrainingasitfitsintoclinicalpracticerequirements

Flexibility

TaskForceMembers•  AlfredAbuhamad,MD.–Chair•  BerylBenacerraf,MD.•  CarolBenson,MD.•  TrishChudleigh,PhD.DMU•  LoriCrites,BS.RDMS.•  PeterDoubilet,PhD.MD.•  RitaDriggers,MD.•  WesleyLee,MD.•  KarenMann,PhD.•  JamesPerez,DO.•  NancyRose,MD.•  LynnSimpson,MD.•  AnnTabor,MD.

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TaskForceMeetings

•  August10,2015•  October28,2015•  November2,2015•  February8,2016•  February9,2016• March18,2016(face-to-face)•  January3,2018(publication)

Publication

AJOG JUMUOG

CognitiveCurriculumTaskForceMembers

•  AlfredAbuhamad,MD.–Chair•  TrishChudleigh,PhD.DMU•  PeterDoubilet,PhD.MD.•  RitaDriggers,MD.• WesleyLee,MD.•  LynnSimpson,MD.

CognitiveCurriculum

•  AlfredAbuhamad,MD.–Chair•  BerylBenacerraf,MD.•  CarolBenson,MD.•  LoriCrites,BS.RDMS.•  KarenMann,PhD.•  JamesPerez,DO.•  NancyRose,MD.•  AnnTabor,MD.

CompetencyCurriculumTaskForceMembers


CognitiveCurriculum-Obstetrics

•  Basicprinciplesofmedicalultrasound•  Basiccharacteristicsoftheultrasoundequipment•  Aspectsoftheultrasoundexamination•  Ultrasoundinfirsttrimester•  Ultrasoundinsecond&thirdtrimester•  Ultrasoundevaluationoftwins•  Placentalabnormalities•  Amnioticfluidassessment

Level1/Year1


•  Ultrasoundevaluationoftwins

Level1/Year1

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•  Recognizeanddescribeindicationsforpelvicsonography

•  Recognizeanddescribesonographicfeaturesofthenormaluterus

Level1/Year1

CognitiveCurriculum-Gynecology

• Ultrasoundinthefirsttrimester• Ultrasoundevaluationoftwingestations• Placentalabnormalities• Amnioticfluidassessment

Level2/Year2


• Ultrasoundevaluationoftwingestations

Level2/Year2CognitiveCurriculum-Obstetrics

•  Recognizeanddescribeultrasoundevaluationofanatomiclocationsofleiomyomas

•  Recognizeanddescribeendometrialabnormalities(leiomyomas,polyps,..)

Level2/Year2


• Ultrasoundinthesecondandthirdtrimesters(fetalmorphology)

Level3/Year3


•  Recognizeanddescribesonographicfeaturesofadenomyosis.

•  Explainclassificationofcongenitaluterinemalformations(2D&3Dultrasound).

•  Recognizeanddescribeintrauterinecontraceptivedevices(2D&3Dultrasound).

Level3/Year3


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• Ultrasoundevaluationoftwingestations

Level4/Year4

CognitiveCurriculum

• Thereare41competenciesspreadover4levels/yearsasfollows:


CompetencyCurriculumLevel1/Year1

BasicBiometryBiophysicalProfile


CervicalLengthBasicGynecology


BasicFetalAnatomyWritingaReport


Level4/Year4 FetalFaceAmniocentesis

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AdditionalCompetencies CompetencyforFemurLength

Representativeultrasoundimage

Howisitdone?

CompetencyforFemurLength

7criteria

Representativeultrasoundimage

Howisitdone?FemurLength

Howisitdone? Passinggradeissetatoraround70%forall

FemurLengthHowisitdone? Missingasteriskcriterionwillfailimage

FemurLengthHowisitdone? Fivepassingimagesrequired

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Why5images?

• Consensusofpanelmembers• Notalotofdataonthissubject• Somesupportingdatafromsimulation

UltrasoundObstetGynecol2014;44:693

Initialscoresfromfirst2iterations

UltrasoundObstetGynecol2014;44:693

Novicesreachedtheexpertlevelwithamedianof5

iterations.

UltrasoundObstetGynecol2013;42:213–217


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IsthereEvidencethatStandardizationofTraining&EvaluationImproves

Outcome?


•  Prospectivebeforeandafterstudy• Ob/Gynresidents•  LargetertiaryhospitalinFrance• Gynecologicemergencysetting


•  1hourclassonOb/Gynultrasoundbyexpert

• Writtenstandardizedimagingprotocol

AllresidentsReceived:

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•  Submissionof5completeUSexaminations

•  Feedback&reviewprovidedfromUSexpertusingasonographyscore

AccreditationTrainingGroup:


ComparingPreandPostAccreditationPerformance

IsthereEvidencethatUltrasoundSimulationEnhancesTraining?

SimulationSimulation


•  Randomizedstudy,transvaginalultrasound•  33residentswithnopriorUSexperience•  Controls:clinicaltrainingalone(15)•  Cases:clinicaltraining+simulation-basedtraining(18)

•  Outcomeisclinicalperformanceonpatientsassessed2monthspoststudy


ObjectiveStructuredAssessment

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WhatareNextSteps?

NextStepsNextSteps

•  Seekendorsementfromrepresentativesocieties– Endorsedby:AIUM,SMFM,ACOG,ISUOG,ACOOG– Supportedby:SRUandACR

•  Publishtaskforcedocumentinpeer-reviewedjournals–done

•  Developandshareimplementationstrategies•  Facilitate&supportresearchonsubject•  Monitorprogressovertime

ALotofChallengestoOvercome

Challenges!!Challenges

• Crowdedcurricula• Busypractitioners&sonographers• Lackoffacultyultrasoundexpertise• Lackofequipmentavailability• Lackoffinancialresources

OvercomingChallengesStandardizedcurriculum&competencytools•  Endorsements&supportbysocieties(done)

•  Standardizedimplementationtools•  Structuredlectureseries•  Simulation

•  Cognitive•  Competency

•  Incorporatingultrasoundskillsinboardexaminations

OvercomingChallengesStandardizedcurriculum&competencytools

Optimalapproachwillincludecollaboration

SocietiesImplementationTools

Roadmap

ProgramsCommitment

LocalResources

IndustryUSEquipmentSimulation

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Guidelines

CME


Curriculum

SimulationClinical

ThankYou


ob/gyn ultrasound symposium 2018 · 2018-09-20 · ob/gyn ultrasound symposium 2018 september...

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