Transcript Established Technology Tends to Persist in the Face of New

Transvaginal Gyn Ultrasound Replaces the
Bimanual Pelvic Exam –Curriculum Review
and Preliminary Outcomes
Wm. MacMillan Rodney MD, FAAFP, FACEP
– Chair Academic Affairs, Medicos para la Familia
– Senior Member, American Institute for
Ultrasound in Medicine[AIUM]
– American Board of Family Medicine Obstetrics
Society of Teachers of Family Medicine
– Annual Meeting April 24-29, 2010
– Vancouver, BC; Canada
Transfer of Technology Megatrends 1971-2011
Procedural Skills and Office Technology
Bibliography/reprints.www.psot.com
After the development of basic OB ultrasound skill,
Gyn ultrasound is a natural addition. It provides the
woman the opportunity to have her exam at the
hands of a continuity physician who can explain the
findings at the bedside. This minimizes the
fragmentation of care and improves quality.
Over 15 years, a curriculum in ultrasound has led to
improved outcomes for patients and better
education for physicians.
The bimanual pelvic exam has poor sensitivity, low
specificity, and cannot be standardized for teaching.
Bibliography
1. Morgan WC, Rodney WM, Hahn RG, Garr DA, O'Brien J. Echografie bij Verloskunden en
gynaecologie in de praktijruiute: Een ondersteuning voor Luisartsenverloskunde (Office-based
ultrasound as a support for family centered obstetrics), Huissarts Nu (HANU) 1987; 16:277-280.
2. Morgan WC, Rodney WM, Garr DA, Hahn RG. Ultrasound for the primary care physician:
Applications in family-centered obstetrics. Postgrad Med 1988; 83(2):103-107
3. Hahn R, Ornstein S, Davies TC, Rodney WM, et al. Obstetric ultrasound training for family
physicians: results from a multi-site study. J Fam Pract 1988; 26:553-558.
4. Hahn RG, Davies TC, Rodney WM. Diagnostic ultrasound in general practice. Fam Pract--An
International Journal 1988; 5(2):129-135.
5. Rodney WM, Prislin MD, Hahn RG. Family practice obstetrical ultrasound in an urban
community health center: Birth outcomes and examination accuracy of the initial 227 cases. J
Fam Pract 1990; 30:163-168.
6. Rodney WM, Hahn RG, Hartman KJ, Deutchman ME. Obstetric ultrasound by family
physicians. J Fam Pract 1992; 34:186-200.
7. Deutchman ME, Hahn RG, Rodney WM. Maternal gallbladder assessment during obstetric
ultrasound: results and technique. J Fam Pract 1994; 39:33-37.
8. Euans DW, Hahn RG, Rodney WM. A comparison of manual and ultrasound measurements of
fundal height. J Fam Pract 1995; 40:233-236.
9. Rodney WM. Historical observations from the RRC 1994-2000: Maternity care[OB] training in
FP. J Am Board Fam Pract 2002;15:255-56.
10. Dresang LT. Rodney WM, Dees J. Teaching OB ultrasound to family practice residents. Fam
Med 2004; 36: 98-107.
11.Dresang LT, Rodney WM, Leeman L, Dees J, Koch, P, Palencio M. ALSO in Ecuador:
Teaching the Teachers. J Am Board Fam Practice. 2004;17(4): 276-282.
http://www.jabfp.org/cgi/content/full/17/4/276
12. Dresang LT, Rodney WM, Rodney KMM. Prenatal Ultrasound: A tale of two cities. J Nat Med
Association Feb 2006; 98: 167-171.
Transfer of Technology 19712011: OB-Gyn Ultrasound
Position paper with bibliography at website
for Procedural Skills and Office Technnology
www.psot.com
Summary—The bimanual pelvic exam has
poor sensitivity, low specificity, and cannot be
standardized for teaching. Deletion of the
bimanual exam, and open access ultrasound
will improve outcomes for patients. This is an
opportunity for family medicine.
Family Medicine Ob-Gyn:
Curriculum Overview1989-1999
Family Medicine residency 36 months:
– continuity including pelvic exams weekly?
– 2 months obstetrics+ 1-2 months Gyn
Advanced Life support in Obstetrics—Complete 2 day course,
pass tests, read ultrasound chapter. Try to attend course with
ultrasound workshop.
Work in an office with a modern ultrasound machine with
open access to immediate performance of an US examination.
Structured sequence of supervised examinations
– Ten “Quick Look” exams for fetal viability, number, presentation,
placenta
– Forty OB examinations with the above plus biometry, anatomy
review, and medical decision making
Welcome to Medicos para la Familia
Medicos was opened in 1999 as a health care
experiment for uninsured Spanish speaking patients
in Memphis. Nashville Meharry and Nashville
Medicos were opened in 2002 and 2004.
The Technology Transfer Project led to a blend of
Family Medicine Obstetrics, public health, and ER .
Ultrasound has been a key curriculum innovation.
Medicos is open 7 days a week and patients do not
need an appointment. In 2009 Medicos saw over
63,000 patients and delivered over 600 babies.
Medicos does not receive government funds, or
charity support. Medicos pays taxes.
Through Grace, Medicos provides twice the service
at less than half the cost.
Gineco Obstetricia Medicina
Familiar +ER 2000-2010
Develop a bilingual high touch high tech open
access family medicine based healthcare centers
– Control practices Nashville—One grew, one didn’t why?
– Memphis 2000: 6,000 visits, 72 deliveries; 300 ultrasounds/yr.
– Memphis 2009: 44,000 visits; 500+ deliveries; 3000 +Ultrasounds/yr.
Ultrasound training became a core requirement of
Family Medicine Obstetrics fellowship curriculum.
– Stopped rescheduling to “ultrasound clinic 1d/wk”.
– Daily ultrasound experiences woven into the daily routine
of community health care
– Accept need for same day OB Gyn Ultrasound services
Develop Phase 3 Curriculum
Family Medicine Based Ultrasound
Curriculum 2000-2010: Phase 3
Track and report data; see bibliography; JPS
presentation, “ Is office ultrasound feasible for
family physicians who do not do OB”.
Develop ultrasound study hall of mandatory review
of interactive experiences.
Deutchman ME. Obstetrical ultrasound; principles and
techniques. (CD ROM) 1995 Silver Platter Education.
Norwood, MA.
Deutchman ME. Ultrasound in Emergency Medicine and
Trauma (CD ROM) 2001 Challenger Memphis, TN.
Rodney -Sally and Sue transvag simulators: Ectopic versus IUP
Required to review standard texts and bibliography.
Developed written and examination tools.
Ultrasound Curriculum 20002010: Gyn at the bedside
Select, read, and reread durable materials.
Gyn Text Timor; Callen OB; Gabbe cognitive; ER text
Websites, Medicos email J Club weekly
Constantly use online and telemedicine
resources for immediate access to
consultation when needed.
Acknowledge limits and use second opinions
when indicated. Consultation frequency=2%
Become uncommonly good at common probs
Develop and teach from clinical simulations.
Office Gyn Ultrasound--Ovaries
Method of Wm. MacMillan Rodney MD
– Gineco Obstetricia Medicina Familiar+ER
– Acknowledgments to Ricardo Hahn MD, Clark Smith MD, Mark
Deutchman MD, Eduardo Scholcoff MD, the STFM Working Group
on Hospital Medicine and Procedural Training, and others
Curriculum
–
–
–
–
–
Didactic Overview of Expectations
Recommended Video Materials
Recommended Reading
Hands on Instruction
QA-QI Reports and Case logs
Teach Normal anatomy with
patients as they occur.
Normal ovarian size , shape ,
and visual “fingerprint”
Normal follicular cysts are less
than 11mm
62693 19 yo Pelvic Pain; 626.4;
HCG neg; Diagnosis made easier
Identify
– Endometrial stripe
– Posterior surface of the
uterus
– A hypoechoic area
– A lemon shaped area
posterior to the uterus
which has a texture
different than the uterus.
From this image, is an
intrauterine pregnancy
likely?
Using calipers and labels to demarcate
the significant finding of free fluid
Annotation features
can and should be
used for later review
of each image.
Is the architecture of
this ovary normal?
Is there any condition
more likely to create
free fluid and a
mushy ovary? HCG
neg
Ovarian size and consistency
How is ovarian
volume measured?
What is the upper
limit of normal
ovarian volume?
What conditions are
associated with an
enlarged ovary?
Neoplasm
Cysts
PCOS
Other
Color Doppler identifies vessels
and other structures with fluid
Measurement commands
are blocked until the image
is frozen
Color doppler commands
are blocked if the image is
frozen.
A visible fallopian tube is
unusual. But can be
mistaken for a blood vessel.
FM US Curriculum 2000-2010
Phase 3
Develop, present and publish studies.
See bibliography
Focused residency rotations. Assignments + 10
documented exams per day in the office. Goal
50 documented exams in one week.
Train visiting professors. Curriculum plus 300
reviewed exams.
Conduct small prototype studies
– Family Medicine Obstetrics Fellowship followups
Poster presentation Tuesday April 27
– Expand to include Gyn + ER[abdom, soft tissue]
Without OB, is Office Ultrasound
Feasible in Family Medicine?
A research question from--David McCray MD.
Does ultrasound belong in the Family Medicine
market basket of services? --Dr. Young
If the equipment costs $35,000, will reimbursement
cover equipment cost, overhead, and a reasonable
payment to the physician?
Can family physicians demonstrate and maintain
high quality[the standard of care]?
Will it lose money, break even, or make money?
Recorded Ultrasound Events: 2009
44,408 visits suggests the equivalency of 7
physicians seeing 6,300 visits a year each.
Computer log
with ID
No ID
OB exams
2513
583
Gyn exams
493
69
Abdominal exams
117
19
Computer log without ID[undocumented]. These no-ID
exams suggest psychosocial-uncharged use.
Do the arithmetic at $100/exam and less than 15
minutes per exam. These data imply there is an upside.
Transvaginal ultrasound is
feasible in the office
Radiologists do not perform the examinations , they review
images and bill. Many of the techs ask the women to insert
the transvaginal probe themselves. Is this high quality?
Transvaginal Sonography should be part of the physical
examination for women with abdominal or pelvic pain.
Goldstein SR. Routine use of office gyn ultrasound. J Ultrasound Med 2002; 21: 489-92.
Malpractice covers it. Rodney WM, KM
Rodney-Arnold,et al
Impact of Deliveries ….. J Nat Med Association October 2006; 98: 1685-1690.
It is reimbursable through medicaid—
Dresang L, et al. Prenatal ultrasound: A tale of two cities. J Nat Med Assoc Feb
2006; 98[2]: 161-171
Rodney Wm, et al. Los desaparecidos. Am J Clin Medicine Spring 2009; 6[2]: 3136.
It is learnable core skill. Nothnagle M, et al. Required Procedural Training in
Family medicine Residency: Fam Med 2008; 40: 248-252
Problems with the Bimanual Pelvic
Examination
Its sensitivity and specificity are poor for many
regularly ocurring conditions.
Physicians have never received predictably
accountable training in this skill.
Use of live training surrogates never simulated
actual abnormalities seen in the community.
Previously sacred traditions such as the rectovaginal
exam and prevention of ovarian cancer have been
discarded as scientifically unproven.
And others
A preliminary study
Ten senior residents and five family medicine faculty
confirmed that the routine bimanual pelvic
examination was a “core skill”
None could say yes to the following statement. “ I
believe that I am capable of detecting most
significant adnexal and uterine abnormalities using
the bimanual pelvic examination.”
Despite estimating their performance frequency as
“at least once a week”, none could describe or recall
any specifics regarding a case in which a bimanual
examination which led to a change in management.
Methods
A bimanual pelvic exam record was created and physicians were asked to
fill out all fields at the time of pelvic examination.
– Age, G,P, contraception, ethnic, comorbidities
– Reason for pelvic examination today
Patients were used a visual analog scale to rated perceived discomfort on
line measuring 10 cm.
– Insertion of speculum
– Bimanual examination[controlled for time <3 minutes]
Physicians were asked to describe findings
– Visual findings--Cervix, sidewalls, perineum
– Palpable—Did you feel any abnormalities of the uterus or adnexae?
Physicians were asked to describe their diagnosis following the pelvic
exam.
The pelvic exam was immediately followed with transvaginal
examination, and post ultrasound diagnosis was obtained.
Significant differences between Pre and post ultrasound diagnoses were
tabulated
Patient Selection
Premenopausal, reproductive age women
presenting without appointment because of an
undiagnosed complaint relating to genitourinary
tract of onset within the last two months.
Women with chronic conditions normally not
requiring a pelvic exam were excluded.
Women with routine UTI’s, known pregnancies, and
Paps smears were not included in the study.
Target complaints included pelvic pain, irregular
vaginal bleeding, 626.0, lower abdominal pain, lost
IUD, dyspareunia, infertility
Medicos Gyn ultrasound
Preliminary Report 2010
Among twenty patients, 12 had significant findings such
a painful ovarian cyst, free fluid, imbedded IUD, PID, or
unsuspected pregnancy. Residency trained physicians
were unable to make diagnoses with the bimanual pelvic
examination.
The clinical[LMP]history , the physical exam, the fundal
height, and lab are inferior compared to ultrasound in the
hands of Medicos faculty.
Fragmented care is common with non OB FP’s and ER
providing suboptimal care. Ultrasound improves quality.
Weakness--Medicos is seeing these patients in an open
access system similar to the ER. Ultrasound is used as
easily as one might use a stethoscope. Few residencies
have equipment or faculty to meet this need.
PREDICTIONS FOR THE FUTURE
The family physician’s office
will become a high quality
center for preventive care,
acute care, patient education,
diagnostic technology, and
therapeutic procedures. WMR 1987
FAMILY MEDICINE-er-ob
WMR 2002
A Fork in the Road 1972
The Physician isolated from a medical center
will not be able to provide high quality state
of the art medical care.
Technology will continue to assist physicians
in community-based offices such that high
quality state of the art care will be possible for
over 90% of patients who walk in through the
door.
A Fork in the Road1972-2010
The Physician isolated from a medical center will
not be able to provide high quality state of the art
medical care.
– Spending 17% of GNP on Health Care in 2006
– The Illusion of endless abundance is irrational
Technology continues to improve the skills of
community physicians such that high quality state of
the art care is possible for over 90% of patients who
walk in through the door.
– Disruptive technologies effectively focus on the ten percent of the
information that makes over 90% of the difference.
– Twice the service might be provided at less than half the cost.
– Counterintuitive , but more spending may make care worse.
– All are for progress, but change is resisted
Assignments—Using ultrasound images and
documented reports, assemble a database of
outcomes.
Improve on previously published reviews by creating a study with
images demonstrating the ability to make diagnoses with ultrasound
at the bedside.
Each fellow will complete a case report as part of the curriculum..
This material will generate questions for the American Board of
Family Medicine Obstetrics.
2009-2010. Spurlock’s images are dramatic and typical. Abruptio
Placenta has occurred four times,. Display of the normal placenta is
the usual situation; ie, abruptio is a clinical diagnosis. Uterine
rupture may be suspected in the case of the painful contracting
repeat CS who displays significant amount of free fluid.
Postpartum cardiomyopathy with ICU intubation x2, Chest
radiograph as the index image