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ORIGINAL RESEARCH |
From the Division of Fetal Imaging, Department of Obstetrics and Gynecology, William Beaumont Hospital, Royal Oak, Michigan; Department of Obstetrics and Gynecology, Hutzel Hospital, Wayne State University, Detroit, Michigan; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan; and the American College of Obstetricians and Gynecologists, Washington, DC.
Address reprint requests to: Wesley Lee, MD, Division of Fetal Imaging, Department of Obstetrics and Gynecology, William Beaumont Hospital, 3601 West Thirteen Mile Road, Royal Oak, MI 48073–6769; e-mail: wlee{at}beaumont.edu.
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ABSTRACT |
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METHODS: One hundred thirty-six ultrasound program directors from 254 accredited obstetrics and gynecology residency programs completed a web-based survey regarding obstetric ultrasound training for residents. Questions were presented in yes-or-no, ranking, short-answer, and open-comment formats that examined general teaching environment and curriculum content. These results were compared with a mandatory fetal ultrasound training survey that was independently administered to 4,666 obstetrics and gynecology residents during the 2003 Council on Resident Education in Obstetrics and Gynecology (CREOG) In-Training Examination. Friedman one-way analysis of variance was used to compare ranked nonparametric data with the Dunn posttest. Statistical significance was taken at the P < .05 level.
RESULTS: Fifty-four percent of accredited obstetrics and gynecology residencies responded to the survey of ultrasound directors from November 2000 to April 2003. Nearly all responding directors were obstetrician-gynecologists, many of whom had subspecialty training in maternal-fetal medicine. Full-time faculty and sonographers were the most important individuals contributing to ultrasound training for obstetrics and gynecology residents. Hands-on scanning and observation were the most significant educational activities for ultrasound training. Ultrasound program directors generally rated the overall preparedness of residents as ranging from adequate to excellent. The most important learning obstacles were limited curriculum and faculty time. Most programs evaluated competency by direct observation of scanning skills. According to the CREOG survey, only 16.3% of residents indicated that the performance and interpretation of fetal ultrasound examinations were mandatory program requirements. Nearly two thirds of residents believed that their training would be adequate by the time of graduation. Only 18.4% of residents, however, were planning to perform or interpret fetal ultrasound scans in clinical practice.
CONCLUSION: Fetal ultrasound training for obstetrics and gynecology residents is perceived by most ultrasound program directors and residents to be adequate. Future development of standardized guidelines and competency assessment tools should consider that approximately one fifth of obstetrics and gynecology residents are currently planning to use this diagnostic modality in clinical practice.
LEVEL OF EVIDENCE: II-2
Prenatal ultrasonography is often considered one of the most significant technologic advances that have impacted modern obstetric care.5 This technology has allowed physicians to identify birth defects, monitor growth, guide invasive fetal procedures, and evaluate fetal well-being. Toward this end, the National Institutes of Health–sponsored Routine Antenatal Diagnostic Imaging With Ultrasound (RADIUS) trial represents the largest randomized controlled study of routine obstetric sonography for low-risk pregnancies.6 The study demonstrated only a 35% sensitivity for the detection of congenital anomalies before birth. This relatively low detection rate may have been partially related to inadequate fetal ultrasound training because physicians conducted the diagnostic interpretation of these studies. Therefore, a national survey was conducted regarding the current state of fetal ultrasound training for obstetrics and gynecology residents in the United States.
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MATERIALS AND METHODS |
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Ultrasound training directors also responded to the following ranking questions:
A national survey was also given to obstetrics and gynecology residents by the Council for Resident Education in Obstetrics and Gynecology (CREOG). This questionnaire included 6 questions about obstetric ultrasound training as part of a mandatory annual in-service examination for residents (January, 2003). Questions covered obstetrics and gynecology residency program requirements for fetal ultrasound training, total amount of curriculum time, teaching methods, estimation of training quality, and intentions for practicing obstetric sonography in future practice.
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RESULTS |
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). Most fetal ultrasound training programs (117 of 136 programs, 86.0%) were solely administered by obstetrics and gynecology departments; only 1 program was solely administered by a radiology department. Thirteen programs (of 136 programs, 9.6%) reported that the obstetrics-gynecology and radiology departments shared in this responsibility.
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Many residencies followed scanning standards from the American College of Obstetricians and Gynecologists (n = 71) or the AIUM (n = 56). Several types of ultrasound equipment were used to train residents: Philips (n = 72), ACUSON (n = 69), General Electric (n = 59), Siemens (n = 19), Aloka (n = 12), Toshiba (n = 9), and Medison (n = 8). Approximately 3.8 ± 2.1 weeks of curriculum time was exclusively devoted to fetal ultrasound training. A few programs (14.4%) did not offer dedicated curriculum time for this subject matter. The most commonly used textbooks were authored by Callen (n = 83) and Romero (n = 63). Less frequently used textbooks included books authored by Sabbagha (n = 12), Chervenak (n = 4), and McGahan (n = 2). Didactic lectures were routinely offered as part of the formal curriculum in 116 (88.5%) of 131 responders.
All responding programs offered training in endovaginal sonography, biophysical profiles, and early pregnancy scans. A broad number of minimal studies, however, were established as part of their formal curriculum. Ninety of the 136 programs did not require a minimal number of endovaginal scans. Of those that did, the minimal number ranged from 5 to 300 (median 40 scans). Similarly, 91 programs did not require a minimal number of biophysical profiles. Responding programs reported a minimum number of required biophysical profiles as ranging from 4 to 500 (median 30 scans). Most programs (126 of 131 responders, 96.2%) taught residents to perform early pregnancy ultrasonography.
Programs mainly evaluated competency by direct observation of scanning skills (110 of 130 responders, 84.6%); this was followed by oral examination (19 of 130 responders, 14.6%), written examination (19 of 130 responders, 14.6%), and presentation of unknown fetal anomalies through videotape or multimedia (20 of 130 responders, 15.4%).
Full-time faculty and sonographers were perceived as the most important individuals contributing to ultrasound training for obstetrics and gynecology residents. On a scale of 1 to 4 (1 = most involved, 2 = moderately involved, 3 = marginally involved, 4 = not involved), program directors rated full-time faculty (median rating 1.0) and sonographers (median rating, 1.0) as being the most important persons involved with ultrasound training, followed by other residents (median rating 2.0), whose contribution to the teaching program was significantly greater than that of private attendings (median rating 4.0) (P < .001).
Hands-on scanning experience and observations of scans were perceived as being the most important educational activities. On a scale of 1 to 5 (1 = very important, 3 = neutral, 5 = not very important), program directors rated the most important educational activities as performing ultrasound scans (median rating, 1.0), followed by the observation of scans (median rating, 1.0) (P < .05). Didactic lectures (median 2.0) were the next important activity. Reading assignments (median rating 3.0) and review of multimedia materials (median rating 3.0) were perceived as having the least importance in the curriculum (P > .05, not significant).
Ultrasound program directors generally perceived the overall preparedness of residents as ranging from adequate to excellent for performing the basic obstetric examination, biophysical profiles, and endovaginal scans. On a scale of 1 to 5 (1 = poor, 2 = marginal, 3 = adequate, 4 = good, 5 = excellent), program directors rated the overall preparedness of their residents as being excellent for the performance of biophysical profiles (median = 5.0). Preparedness was considered to be good to adequate for the basic obstetric ultrasound examination (median rating = 4.0) and the first-trimester scan (median rating = 3.5), respectively.
The most important learning obstacles were related to limited curriculum and faculty time. On a scale of 1 to 6 (1 = most significant, 6 = least significant), program directors rated the most important obstacles to residents in learning about obstetric sonography as being associated with a lack of curriculum (median rating 2.0) and faculty time (median rating 3.0) (P < .001). Declining interest (median rating 5.0) and sleep deprivation (median rating 5.0) were the least important (P > .05, not significant). Low obstetric volume (median rating = 6.0) and lack of skilled faculty (median rating = 6.0) were not perceived as obstacles to resident training. During the study period, more than two thirds of the programs (86 of 128 responders, 67.2%) did not modify resident post-call activities during the ultrasound rotation.
The CREOG survey received responses from 4,467 of 4,666 examinees (95.7% response rate). The residency programs were described as being primarily university (63.0%) or community (35.0%) based. Approximately 73.6% of responding residents were women. More than one third (35.8%) of responding residents reported that maternal-fetal medicine fellowship training was offered by their programs. Anticipated postresidency practice settings included community private (47.2%), mixed-academic private (29.8%), fellowship (13.9%), and academic (7.4%).
A required obstetric ultrasound rotation was confirmed by 41.4% of residents. More than half of responding residents (64.4%) reported that their program currently offered specific didactic training. Only 16.3% of respondents reported that their program required them to perform or interpret obstetric diagnostic ultrasonography The amount of time dedicated to obstetric sonography training was perceived as being sufficient (62.6%), too little (34.1%), or too much (1.9%). The quality of their prenatal ultrasound training was rated as being comprehensive (23.1%), adequate (52.0%), barely adequate (16.8%), inadequate (5.8%), or nonexistent (0.8%); 1.5% of surveys had missing data. Interestingly, only 18.4% of residents were planning to perform or interpret obstetric ultrasound examinations. These residents indicated that they planned to perform first-trimester dating scans (85.5%), second-trimester anatomical surveys (46.2%), third-trimester fetal growth evaluation (60.1%), and scans involving congenital anomalies (9.9%).
The following list summarizes the ultrasound program directors’ comments.
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DISCUSSION |
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The most important study limitations were related to the number of nonresponding programs as well as the amount of time (2.4 years) that was required to personally contact faculty and collect data. Some programs may have not responded in cases in which the ultrasound training curriculum was not being emphasized. During this study period, CREOG educational objectives remained unchanged for both the knowledge and performance objectives related to fetal ultrasound training.7,8 Most states with accredited obstetrics and gynecology programs were represented with slightly more than half of ultrasound training directors responding through the Internet. By contrast, ascertainment of resident data was estimated to include 95.7% of potential respondents who took the 2003 CREOG In-Training Examination survey.
More than a decade ago, Ahram et al9 conducted a national survey of 292 obstetrics and gynecology residency programs in the United States to determine the extent to which ultrasound training complied with educational guidelines that had been established by the AIUM. Their survey response rate of 78.8% was higher than that achieved by our study of ultrasound directors. Although most respondents claimed to have "ultrasound training" in their program, more than 55% indicated no resident experience with either reading or writing ultrasound reports. Only 39% of program chiefs reported the experience of greater than 200 ultrasound scans per resident over 4 years. More recently, Kasales et al10 conducted a different survey of 206 accredited radiology residency programs regarding training in obstetric sonography. Their survey had a 29% response rate. Several deficiencies regarding the amount and quality of ultrasound training were cited. Collectively, both studies suggest that many programs are not meeting fetal ultrasound training guidelines.
Competency is a complex topic that depends on the scope of a specific medical practice or procedure that is being considered. General training standards for physicians who interpret diagnostic ultrasonography have been established by the AIUM.11 They have recommended a minimum of 300 scans for physicians who perform sonographic examinations in a single subspecialty application such as obstetrics. The basis for establishing these practice guidelines, however, has not been clearly justified for defining an appropriate standard of patient care.
In this study, competency refers to the qualification of health care professionals for the performance and interpretation of prenatal ultrasound examinations. Hertzberg et al12 attempted to determine the minimum number of cases that was required to document competency in reading sonographic examinations. Competency tests were administered to 10 first-year radiology residents in increments of 50 cases up to a total of 200 examinations. Each competency test consisted of a resident scanning and interpreting 10 scans in comparison to the examination performed by the sonographer and interpreted by an attending physician. Despite progressive improvement in resident performance, the overall performance of the group was poor even after involvement of 200 cases. Their results indicated that 200 or fewer scans were insufficient for radiology residents to achieve an acceptable level of competence in sonography. Only 10.8% of their scans involved pregnant subjects.
Ultrasound program directors perceive that the most significant learning obstacles for residents are related to limited curriculum and faculty time. Many faculty members experience increasing difficulty with their capacity to offer curriculum time that can be exclusively devoted to fetal ultrasound training. Obstetrics and gynecology residents report that relatively few programs require them to perform or interpret obstetric ultrasound examinations. Fewer than one half of these residents have the opportunity to rotate on a dedicated ultrasound service. This situation is worsened by the Residency Review Committee for Obstetrics and Gynecology requirement for structured training in primary care medicine and by the ACGME-placed restriction of resident work hours.
Many program directors cite a need for improved evaluation tools to assess competency for scanning and diagnostic interpretation skills. Most programs currently use direct observation of scanning as their primary evaluation method. Oral examination, written tests, and presentation of unknown anomalies are used less frequently. Further studies will be necessary to better understand how these evaluative approaches are being quantified. In this context, one faculty member commented, "I am concerned when residents are taught just enough to think they are competent, but not enough to actually be competent."
Others investigators have described innovative approaches for obstetric ultrasound training. For example, Calhoun et al13 reported a successful integrated curriculum for teaching obstetric sonography by using structured reading materials, scanning opportunities, review of CD-ROM materials, and didactic lectures. Pretests and posttests were taken to measure learning performance and pass rates for certification boards. Monsky et al14 recently reported on the use of an ultrasound simulator for house-staff training. Another novel program was implemented by the Royal College of Obstetricians. A comprehensive teaching program for basic obstetric ultrasonography involves approximately 12–14 practical sessions, completion of a skills checklist, and passing of a final examination that is given twice yearly. Theoretic training includes basic physics, safety, pregnancy-dating methods, and screening for Down syndrome. Practical training includes patient-related skills, use of the ultrasound system, anatomical evaluation, and fetal biometry. Participants are required to take dedicated training time at accredited training centers and are evaluated after 100 hours of training.
Ultrasound training for obstetrics and gynecology residents is likely to benefit from a core curriculum that emphasizes minimum training standards with well defined outcome measures. Acquisition of scanning and diagnostic interpretation skills, however, will require the validation of appropriate evaluation tools to assess specific competencies. Curriculum development should also consider data suggesting that only one fifth of obstetrics and gynecology residents are currently planning to perform or interpret obstetric ultrasound studies after graduation. Successful implementation of this approach will critically depend on the availability of sufficient curriculum time. From a practical perspective, however, the manner by which it is specifically implemented will need to be tailored to the individual needs of each program.
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Footnotes |
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The authors acknowledge the Vesna Margulis Memorial Fund for partial research support.
doi: 10.1097/01.AOG.0000109522.51314.5c
Received July 10, 2003. Received in revised form October 9, 2003. Accepted October 24, 2003.
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2. Long DM. Competency-based residency training: the next advance in graduate medical education. Acad Med 2000; 75:1178–83.[Medline]
3. Accreditation Council for Graduate Medical Education. Information related to the ACGME’s effort to address resident duty hours and other relevant resource materials (2002). Available at: http://www.acgme.org. Retrieved June 26, 2003.
4. Rich EC, Liebow M, Srinivasan M, Parish D, Wolliscroft JO, Fein O, et al. Medicare financing of graduate medical education. J Gen Intern Med 2002;17:283–92.[Medline]
5. Wade RV. Images, imagination, and ideas: a perspective on the impact on the practice of obstetrics and gynecology. Presidential address. Am J Obstet Gynecol 1999;181: 235–9.[Medline]
6. Crane JP, LeFevre ML, Winborn RC, Evans JK, Ewigman BG, Bain RP, et al. A randomized trial of prenatal ultrasonographic screening: impact on the detection, management, and outcome of anomalous fetuses. The RADIUS Study Group. Am J Obstet Gynecol 1994;171:392–9.[Medline]
7. Education Committee of the Council on Resident Education in Obstetrics and Gynecology (CREOG). Educational objectives: core curriculum in obstetrics and gynecology. 6th ed. Washington, DC: The Council; 2000.
8. Education Committee of the Council on Resident Education in Obstetrics and Gynecology (CREOG). Educational objectives: core curriculum in obstetrics and gynecology. 7th ed. Washington, DC: The Council; 2002.
9. Ahram J, Feinstein SJ, DePhillips H. Survey of ultrasound training in obstetrics and gynecology residency training programs in the United States. Obstet Gynecol 1987;70: 405–7.[Medline]
10. Kalsales CJ, Coulson CC, Mauger D, Chertoff JD, Matthews A. Training in obstetric sonography for radiology residents and fellows in the United States. Am J Roentgenol 2001;177:763–7.
11. American Institute of Ultrasound in Medicine. Official statement: training guidelines for physicians who evaluate and interpret diagnostic ultrasound evaluation. Laurel, MD: The Institute; 1997.
12. Hertzberg BS, Kliewer MA, Bowie JD. Physician training requirements in sonography: how many cases are needed for competence? Am J Roentgenol 2000;174:1221–27.
13. Calhoun BC, Hume RF. Integrated obstetric curriculum for obstetrics and gynecology residency, radiology residency and maternal-fetal medicine fellowship program at an accredited American Institute of Ultrasound in Medicine diagnostic ultrasound center. Ultrasound Obstet Gynecol 2000;16:68–71.[Medline]
14. Monsky WL, Levine D, Mehta TS, Kane RA, Ziv A, Kennedy B, et al. Using a sonographic simulator to assess residents before overnight call. Am J Roentgenol 2002; 178:35–9.
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