Transvaginal Gyn Ultrasound Replaces the Bimanual Pelvic Exam –Curriculum Review and Preliminary Outcomes

1. TransvaginalGyn 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

2. Transfer of Technology Megatrends 1971-2011Procedural Skills and Office TechnologyBibliography/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.

3. 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.

4. Transfer of Technology 1971-2011: OB-Gyn Ultrasound • Position paper with bibliography at website for Procedural Skills and Office Technnologywww.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.

5. 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

6. 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.

7. GinecoObstetriciaMedicina 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

8. 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.

9. Ultrasound Curriculum 2000-2010: 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.

10. Office Gyn Ultrasound--Ovaries • Method of Wm. MacMillan Rodney MD • GinecoObstetriciaMedicinaFamiliar+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

11. Teach Normal anatomy with patients as they occur. Normal ovarian size , shape , and visual “fingerprint” Normal follicular cysts are less than 11mm

12. 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?

13. 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

14. 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

15. 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.

16. FM US Curriculum 2000-2010Phase 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]

17. 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?

18. 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.

19. 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? • TransvaginalSonography 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]: 31-36. • It is learnable core skill. Nothnagle M, et al. Required Procedural Training in Family medicine Residency: Fam Med 2008; 40: 248-252

20. 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

21. 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.

22. 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

23. 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

24. 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.

25. 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

26. 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.

27. 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

28. 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