Structured Training for Fetal Diagnostic Skills in a Maternal-Fetal Medicine Fellowship

Successful Implementation of the AIUM Standardized 4-Year Residency Ultrasound Curriculum in Obstetrics and Gynecology: Lessons Learned and Way Forward

BACKGROUND

Significant disparities in sonographic education exist in Obstetrics and Gynecology programs in the United States. To address the lack of standardization in ultrasound teaching, the American Institute of Ultrasound in Medicine (AIUM) assembled a multi-society task force in 2018 that resulted in the publication of a Consensus Report outlining a standardized ultrasound curriculum and competency assessment.

OBJECTIVES

The primary objective of the study was to implement the AUIM standardized curriculum within an Obstetrics and Gynecology residency program at a tertiary medical center, and report on the early implementation experience. The secondary objective was to assess current national practices in ultrasound training in Obstetrics and Gynecology residency programs.

STUDY DESIGN

Study design was an effectiveness-implementation hybrid study of a structured ultrasound educational program based on the 2018 AIUM Consensus Report. The theoretical portion of the curriculum consisted of 26 hours of didactic lectures distributed over 4 years. For the practical component, residents received instruction from faculty and sonographers and independently acquired the required images as part of their regular clinical work. Simulator app access was also provided for additional opportunities to practice and acquire images. Deidentified images for the required competencies were uploaded to a WhatsApp group for review. Theoretical knowledge was assessed with a series of multiple-choice exams. Practical skills were assessed through grading of images submitted through WhatsApp as well as direct observations of resident scans. At the completion of 4 years, the assessment of both theoretical knowledge and practical skills was carried out using the ISUOG Basic Training Examination. National patterns in the area of ultrasound education were assessed with a four-question electronic survey of Obstetrics and Gynecology program directors in the United States. Analysis of both portions of the study was primarily descriptive.

RESULTS

Four Obstetrics and Gynecology residents completed the curriculum spanning postgraduate years 1 through 4. The number of competencies completed ranged from 7 to 19 out of 41. All of the residents passed the theoretical and practical components of the ISUOG Basic Training Examination. For the residency program director survey portion of the study, response rate was 20% (59 of 290). Among the respondents, 55.9% reported having a structured curriculum and 34.4% reported implementing the AIUM curriculum. The two most commonly cited obstacles to implementation of structured ultrasound teaching were uncertainty with how to start the process (49.2%) and lack of faculty engagement (49.2%).

CONCLUSIONS

Implementation of the AIUM Curriculum within the framework of an Obstetrics and Gynecology residency program at a tertiary medical center is feasible. In our experimental group, completion of the curriculum resulted in passing of an internationally recognized validated assessment. Obstacles to implementation in our program included a wide range of engagement and participation among residents, and limited opportunities to obtain some of the required competencies. Identification of obstacles to implementation from the perspective of residency program directors is critical for developing targeted approaches to ensure widespread implementation. Successful standardized validated sonographic training of graduating Obstetrics and Gynecology residents is crucial for this operator-dependent modality that has tremendous implications on patient safety and clinical care.

Examining ultrasound diagnostic performance improvement with utilization of maternal-fetal medicine tele-interpretation

BACKGROUND

Telemedicine can extend essential health services to under-resourced settings and improve the quality of obstetrical care. Specifically, the evaluation and management of fetal anomalies require perinatal subspecialists, rendering prenatal diagnosis essential, and may benefit from telemedicine platforms to improve access to care.

OBJECTIVE

This study aimed to evaluate the impact of a maternal-fetal medicine telemedicine ultrasound program on the diagnostic accuracy of fetal anomalies when used within practices where ultrasounds are interpreted by general obstetricians or family medicine physicians.

STUDY DESIGN

This was a cross-sectional study of all patients receiving care at 11 private obstetrical practices and imaging centers who had obstetrical ultrasounds performed from January 1, 2020, to July 6, 2020. All ultrasounds were performed by sonographers remotely trained under a standardized protocol and interpreted by maternal-fetal medicine physicians via telemedicine. Ultrasound characteristics and interpretation were extracted from ultrasound reports. Before the introduction of maternal-fetal medicine telemedicine, all ultrasound interpretations were reviewed by general obstetricians and family medicine physicians with reliance predominantly on the sonographer's impression. The primary outcome was potential missed diagnosis of a fetal anomaly, defined as an ultrasound designated as normal by a sonographer but diagnosed with an anomaly by a maternal-fetal medicine physician via telemedicine. This outcome serves as a proxy measure for anomaly diagnoses that would likely be missed without the supervision of a maternal-fetal medicine physician. The characteristics of the potential missed diagnoses were compared by type of scan and fetal organ system in univariable analysis. Moreover, a survey was conducted for sonographers and obstetrical providers to assess their perceptions of ultrasound interpretation via telemedicine.

RESULTS

Overall, 6403 ultrasound examinations were evaluated, 310 of which had a diagnosis of fetal anomaly by a maternal-fetal medicine physician (4.8%). Of the fetal anomalies, 43 were diagnosed on an anatomic survey (13.9%), and 89 were diagnosed as cardiac anomalies (28.7%). The overall rate of the potential missed diagnoses was 34.5% and varied significantly by type of ultrasound (anatomy scans vs other first-, second-, and third-trimester ultrasounds) (P<.01). Moreover, there were significant differences in the rate of the potential missed diagnoses by organ system, with the highest rate for cardiac anomalies (P<.01).

CONCLUSION

Expertise in maternal-fetal medicine telemedicine improves the diagnostic performance of antenatal ultrasound throughout pregnancy. However, there are implications for improving the quality of antenatal care, such as ensuring appropriate referrals and site of delivery, particularly for cardiac anomalies.

Detailed Fetal Anatomic Ultrasound Examination Duration and Association With Body Mass Index

OBJECTIVE

To evaluate the association of the duration of the detailed fetal anatomic ultrasound examination with maternal body mass.

METHODS

This was a retrospective chart review of patients presenting to our clinic for detailed fetal anatomic examinations between January 1, 2010, and June 30, 2017. After excluding multifetal pregnancies and other examinations expected to have a longer duration, a total of 6,522 examinations were performed between 18 0/7 and 22 0/7 weeks of gestation. Results were analyzed using analysis of variance and Student's t-test.

RESULTS

Mean (SD) body mass index (BMI) was 29.3 (±7.7), and mean examination time was 51.5 (±10.4) minutes. We found that mean examination time was 48.8 (±9.6) minutes for patients with normal BMIs, 50.6 (±10.0) minutes for overweight patients, 52.2 (±10.4) minutes for patients with class I obesity, 54.6 (±10.3) minutes for patients with class II obesity, and 57.7 (±10.3) minutes for patients with class III obesity (P<.001). The duration of the detailed fetal anatomic ultrasound examination increased continuously with BMI (r=0.285, P<.001).

CONCLUSION

We found that the duration of detailed fetal anatomic examinations increased with BMI. Examinations for gravid patients with class III obesity lasted 8.9 minutes longer than those for gravid patients with normal BMIs; examinations for gravid patients with BMIs of 50 or higher lasted 13.5 minutes longer. This information may be useful for fetal ultrasound examination scheduling.