Obstetric and Gynecologic Resident Ultrasound Education Project

ORIGINAL RESEARCH Obstetric and Gynecologic Resident Ultrasound Education Project Is the Current Level of Gynecologic Ultrasound Training in Canada Meeting the Needs of Residents and Faculty? Jessica Green, MD, Meldon Kahan, MD, CCFP, FRCPC, FCFP, MHSc, Suzanne Wong, MD, FRCS(C), DABOG Received October 24, 2014, from the Departments of Obstetrics and Gynecology (J.G., S.W.) and Family and Community Medicine (M.K.), Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; and St Joseph s Health Care Center, Toronto, Ontario, Canada (M.K., S.W.). Manuscript accepted for publication November 29, 2014. We thank Reem S. Abu-Rustum, MD, for sharing her survey tools and her insights into ultrasound education. Address correspondence to Suzanne Wong, MD, FRCS(C), DABOG, St Joseph s Health Care Center, 30 The Queensway, 5E-114, Toronto, ON M6R 1B5, Canada. E-mail: wongsu@stjoe.on.ca Abbreviations AIUM, American Institute of Ultrasound in Medicine; Gyn, gynecology; Ob, obstetrics; SOGC, Society of Obstetricians and Gynaecologists of Canada doi:10.7863/ultra.15.14.10067 Objectives Ultrasound is a critical diagnostic imaging tool in obstetrics and gynecology (Ob/Gyn). Obstetric ultrasound is taught during residency, but we suspected a gap in Gyn ultrasound education. Proficiency in Gyn ultrasound allows real-time interpretation and management of pelvic disease and facilitates technical skill development for trainees learning blinded procedures. This study sought to evaluate ultrasound education in Canada s Ob/Gyn residency programs and assess whether residents and physicians perceived a need for a formalized Gyn ultrasound curriculum. Methods We distributed a needs assessment survey to residents enrolled in Canadian Ob/Gyn residency programs and to all obstetrician/gynecologists registered as members of the Society of Obstetricians and Gynaecologists of Canada. Residents were asked to specify their current training in ultrasound and to rate the adequacy of their curriculum. All respondents rated the importance of proficiency in pelvic ultrasound for practicing obstetrician/gynecologists as well as the perceived need for formalized ultrasound training in Ob/Gyn residency programs. Results Eighty-two residents and 233 physicians completed the survey. Extents and types of ultrasound training varied across residency programs. Most residents reported inadequate exposure to Gyn ultrasound, and most residents and physicians agreed that it is important for obstetrician/gynecologists to be proficient in Gyn ultrasound and that the development of a standardized Gyn ultrasound curriculum for residency programs is important. Conclusions Current ultrasound education in Ob/Gyn varies across Canadian residency programs. Training in Gyn ultrasound is lacking, and both trainees and physicians confirmed the need for a standardized Gyn ultrasound curriculum for residency programs in Canada. Key Words curriculum development; gynecology; medical education; obstetrics; ultrasound; ultrasound education Diagnostic ultrasound imaging is the most commonly used imaging modality in obstetrics and gynecology (Ob/Gyn). Originally, its clinical debut was in Ob, in which sonography allowed for real-time imaging of the fetus without exposure of the mother or fetus to radiation. Today, it is vital to routine antenatal care, both as a diagnostic tool and as a method of providing visual guidance for interventional procedures in the growing field of fetal therapy. 2015 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2015; 34:1583 1589 0278-4297 www.aium.org

Ultrasound is equally valuable in Gyn, where it is used to evaluate pelvic disease and provides information integral to managing the most common problems referred to a gynecologist in both the ambulatory and emergency room settings. 1 3 Obstetrician/gynecologists perform numerous blind procedures, whose quality and safety are improved by using pelvic ultrasound for visual guidance. 3,4 In addition, congenital uterine anomalies can be accurately diagnosed by using 3-dimensional ultrasound imaging 5 instead of magnetic resonance imaging, the latter being difficult to provide in a timely manner. To our knowledge, the extent and degree of variation of ultrasound education in current Ob/Gyn residency programs across Canada s 16 university programs have not been studied. In 2003, Lee et al 6 surveyed both ultrasound program directors and residents in the United States regarding training in fetal ultrasound. Most responding program directors thought that residents were adequately prepared to perform fetal scans; however, they also reported a lack of standardized training and formal evaluation of resident competency. 6 In the same study, most residents reported that their programs lacked an Ob ultrasound rotation and that performing and interpreting ultrasound examinations were not competencies required by their programs. 6 From a Canadian perspective, a recent publication described a significant disparity in the quality and quantity of ultrasound training across emergency medicine programs, based on a survey of postgraduate program directors. 7 In Ob/Gyn postgraduate curricula, training in Ob ultrasound is often the focus of ultrasound rotations; the amount of trainee exposure to Gyn ultrasound examinations for investigating common pelvic conditions is unknown. The Royal College of Physicians and Surgeons of Canada provides a general but nonspecific statement describing the expectations for knowledge and competency in pelvic ultrasound. 8 Although there is no specific mention of Gyn ultrasound training, residents are required to have an understanding of the assessment, investigations, and management of various Gyn conditions, which involve diagnostic imaging. 8 This reflective, rather than prescriptive, attitude toward ultrasound education lacks clarity regarding which educational objectives should be met and which required competencies should be attained for Ob/Gyn residents on the completion of postgraduate training in Canada. In the United States and Europe, ultrasound is becoming an established part of the curriculum in Ob/Gyn residency programs. 9 The Council on Resident Education in Obstetrics and Gynecology and the American Institute of Ultrasound in Medicine (AIUM) have identified a need for Ob/Gyn residents to be proficient in their understanding, performance, and interpretation of diagnostic ultrasound examinations and sonohysterography. 10 In addition, there is mounting interest in integrated ultrasound education programs at both the undergraduate and postgraduate medical training levels. 11,12 A unique knowledge base and skill set separate from Ob ultrasound assessments is required to perform and interpret Gyn ultrasound examinations. It is unclear whether current residency programs are providing this necessary training, and we suspect a gap in Gyn-focused ultrasound education. The objectives of this study were to evaluate the current state of ultrasound education in postgraduate Ob/Gyn training programs in Canada, to assess whether the current level of training is meeting the perceived needs of residents and to determine if there is a perceived need for a formalized Gyn ultrasound curriculum, and to determine whether practicing Ob/Gyn physicians perceive a need for formalized Gyn ultrasound education in residency. Materials and Methods We developed cross-sectional needs assessment surveys that we conducted from June 2012 to October 2012 with both residents and practicing physicians. The University of Toronto Research Ethics Board gave approval for both the resident and physician surveys. Residents in all years of training from all postgraduate Ob/Gyn programs in Canada were eligible to participate. A letter of request was mailed to all program directors of the 16 Ob/Gyn residency programs in Canada for participation. An introductory letter stated the rationale and objective of the study, followed by a request for informed consent. If the program director agreed to participate, the surveys were then distributed to the residents by e-mail, through the program director. The survey was available in both English and French, the latter translated through a consultant associated with the Society of Obstetricians and Gynaecologists of Canada (SOGC). To access a large number of obstetrician/gynecologists, we attended the Annual Clinical Meeting in June 2012 in Ottawa, Ontario, Canada. We used a booth to distribute an English-only paper copy of the questionnaire to residents and practicing physicians. A link to the online version of the survey was supplied by the SOGC to its members and to the program directors of the residency programs. This version was created and completed through www.surveymonkey.com. Informed consent was assumed if, after reviewing the introductory letter, the respondent chose to complete the survey. 1584 J Ultrasound Med 2015; 34:1583 1589

The questionnaire asked basic demographic data, including university and postgraduate year level. Questions focused on previous ultrasound education, as well as current curricula in the respondent s training program. Questions asked participants to specify the type of ultrasound training and method of evaluation in both Ob and Gyn ultrasound. Using a Likert scale, residents were asked to rate the adequacy of their current training program and to rate the importance of performing and interpreting ultrasound examinations in clinical practice. Finally, residents were questioned on their perceived need for a formalized curriculum in both Ob and Gyn ultrasound. Concurrently, there was a similar online survey distributed to practicing obstetrician/gynecologists registered as members of the SOGC to assess their perspective on resident ultrasound training. Similarly, filling out the survey after reading the cover letter implied consent. The questionnaire obtained basic demographic data, including practice location and number of years in practice. Physicians were asked to rate their perceived competence in performing and interpreting pelvic ultrasound examinations by using a Likert scale, the rating system being the same as for residents. Physicians also rated the perceived importance of pelvic ultrasound training in current Ob/Gyn residency programs and whether they perceived a need for a formal curriculum in Gyn ultrasound for residents. The surveys were anonymous, and respondents completing the online survey could choose their preferred language. Descriptive analyses were performed for all survey data. Results Resident Survey A total of 82 surveys were completed: 48 surveys were completed at the SOGC Annual Clinical Meeting, and 34 surveys were completed online. All surveys were completed in English. Based on the total number of trainees enrolled in Canada s 16 Ob/Gyn postgraduate programs (553 residents) during the 2012 2013 academic year, the survey response rate was 14.8%. Demographic Characteristics The demographic characteristics of the 82 respondents are listed in Table 1. Of all resident respondents, 90.2% were female (74 of 82). At least 1 resident from each of Canada s 16 postgraduate Ob/Gyn programs responded, with the largest number of respondents (17 of 82 [20.7%]) from the University of Toronto. Residents from all postgraduate year levels completed the survey. Resident Experience in Ultrasound Training Exposure to ultrasound education during medical school was reported by 52.4% of responding residents (43 of 82). Results describing residents current training in Ob and Gyn ultrasound are displayed in Figure 1. Most residents (59 of 82 [72.0%]) reported that their program provides a formal curriculum for learning Ob ultrasound. Of these 59 respondents, 96.6% (57 of 59) reported having a hands-on learning component; 54.2% (32 of 59) reported having a didactic learning component; 13.6% (8 of 59) reported a requirement to maintain a logbook of completed ultrasound examinations; and 52.5% (31 of 59) reported having formal evaluation of ultrasound skills. A formal curriculum for learning Gyn ultrasound was reported by 34.1% of residents (28 of 82). Of these 28 respondents, 82.1% (23 of 28) reported having a hands-on learning component; 42.9% (12 of 28) reported having a Table 1. Resident Demographic Characteristics Characteristic n (%) Age, y (n = 82) 20 25 11 (13.4) 26 30 47 (57.3) 31 35 17 (20.7) >35 7 (8.5) Sex (n = 82) Female 74 (90.2) Male 8 (9.8) University (n = 82) Memorial 3 (3.7) Dalhousie 3 (3.7) Laval 3 (3.7) Sherbrooke 3 (3.7) Montreal 5 (6.1) McGill 5 (6.1) Ottawa 8 (9.8) Queen s 3 (3.7) Toronto 17 (20.7) McMaster 4 (4.9) Western Ontario 3 (3.7) Manitoba 3 (3.7) Saskatchewan 3 (3.7) Calgary 4 (4.9) Alberta 3 (3.7) British Columbia 1 (1.2) Not specified 8 (9.8) International medical graduate a 3 (3.7) Postgraduate level, y (n = 82) 1 14 (17.1) 2 21 (25.6) 3 17 (20.7) 4 12 (14.6) 5 18 (22.0) a Currently in postgraduate training outside Canada. J Ultrasound Med 2015; 34:1583 1589 1585

didactic learning component; 14.3% (4 of 28) reported a requirement to maintain a logbook of completed ultrasound examinations; and 35.7% (10 of 28) reported having formal evaluation of ultrasound skills. Perceived Importance of Performing and Interpreting Gyn Ultrasound Examinations in Practice Most residents agreed that it is important for Ob/Gyn physicians to know how to perform and interpret Gyn ultrasound examinations (78.0% and 87.8%, respectively), and it is the responsibility of Ob/Gyn physicians to know how to perform and interpret Gyn ultrasound examinations (87.8% and 93.9%). Perceived Adequacy of Current Ultrasound Curriculum With respect to Ob ultrasound, most residents agreed that residency training will prepare them to perform and interpret Ob ultrasound examinations (68.3% and 64.6%, respectively), and 77.8% of residents reported wanting more formal training in Ob ultrasound. With respect to Gyn ultrasound, most residents did not agree that residency training will prepare them to perform and interpret Gyn ultrasound examinations (76.8% and 69.5%; Figure 2), and 88.9% of residents reported wanting more formal training in Gyn ultrasound. Most of the responding residents agreed that Ob/Gyn residency programs should be offering core training in how to perform and interpret Gyn ultrasound examinations (87.8% and 93.9%). Physician Survey A total of 233 surveys were completed by practicing obstetrician/gynecologists: 76 surveys were completed at the SOGC Annual Clinical Meeting; 123 surveys were completed online in English; and 34 surveys were completed online in French. Based on the total number of Ob/Gyn specialists registered as members of SOGC (259 physicians) during the 2012 2013 academic year, the survey response rate was 18.5%. Demographic Characteristics The demographic characteristics of the 233 respondents are listed in Table 2. Three physicians did not respond to questions about practice location. Surveys were completed by physicians currently practicing in 10 (of 13) Canadian provinces and territories, with the largest proportion of respondents from Ontario (99 of 230 [43.0%]). Respondents number of years in practice varied, with the largest proportion having practiced for more than 20 years (89 of 233 [38.2%]). Figure 1. Current training in Ob/Gyn ultrasound. Table 2. Physician Demographic Characteristics Characteristic n (%) Figure 2. Adequacy of current ultrasound training. Sex (n = 233) Female 141 (60.5) Male 92 (39.5) Practice location (n = 230) Ontario 99 (43.0) Alberta 18 (17.8) Manitoba 11 (4.8) Saskatchewan 8 (3.5) New Brunswick 9 (3.9) Quebec 55 (23.9) Nova Scotia 7 (3.0) Northwest Territories 0 (0.0) Newfoundland/Labrador 6 (2.6) British Columbia 14 (6.1) Prince Edward Island 3 (1.3) Nunavut 0 (0.0) Yukon 0 (0.0) Practice duration, y (n = 233) 0 5 46 (19.7) 6 10 27 (11.6) 11 15 42 (18.0) 16 20 29 (12.4) >20 89 (38.2) 1586 J Ultrasound Med 2015; 34:1583 1589

Physician-Perceived Confidence in Pelvic Ultrasound Of 230 responding obstetrician/gynecologists, 47.4% (109 of 230) and 56.5% (130 of 230) respectively reported feeling comfortable performing and interpreting pelvic ultrasound examinations in clinical practice (Figure 3). Physician-Perceived Importance of Pelvic Ultrasound for Ob/Gyn in Clinical Practice and Residency Training Most responding obstetrician/gynecologists (n = 230) agreed that the ability to perform and interpret pelvic ultrasound examinations is important for their profession (75.6% and 85.6%, respectively). Of responding physicians, 54.8% and 64.8% reported that performing and interpreting pelvic ultrasound examinations is the responsibility of their profession (Figure 4). Most physicians agreed that core training in Gyn ultrasound should be offered in postgraduate training (87.0%) and that it is important to have a formalized curriculum in Gyn ultrasound in Ob/Gyn residency programs in Canada (83.0%). Figure 3. Perceived confidence in ultrasound skills by responding obstetrician/gynecologists. Figure 4. Perceived importance of ultrasound skills by responding obstetrician/gynecologists. Discussion To our knowledge, a study assessing the needs of Ob/Gyn residents for ultrasound education in Canada s postgraduate training programs has not been reported previously. We focused on the unanswered question of whether Ob/Gyn residents perceive a gap in Gyn-specific ultrasound training. Most residents reported that proficiency in performing and interpreting pelvic ultrasound examinations is not only important for practicing obstetrician/ gynecologists but also a responsibility of the specialty. Although two-thirds of residents thought that their current training in Ob ultrasound will adequately prepare them for practice, less than one-third believed that they will be sufficiently trained in Gyn ultrasound. Residents report a need for more formal ultrasound education in both Ob and Gyn and agree that current postgraduate residency programs should be responsible for providing this training. Furthermore, most of the practicing physicians in Ob/Gyn surveyed agreed that competency in pelvic ultrasound is important for clinical practice and agreed that residency programs in Canada should offer a formalized curriculum in Gyn ultrasound. This survey was not the first to highlight deficiencies in ultrasound education within postgraduate training programs. There have been several published studies conducted in Europe and the United States that identified a lack of standardized training in ultrasound reported by staff obstetrician/gynecologists, 6 residents, 6 and maternal-fetal medicine fellows. 13 In Canada, however, most published studies in ultrasound education are from specialties other than Ob/Gyn, although there is a similar need for standardized training as described. Kim et al 7 surveyed program directors of Canada s postgraduate training programs in emergency medicine regarding the current level of ultrasound education in residency curricula. Although all programs are now including ultrasound education as part of training, the extent of this training and the type of education (didactic versus practical) vary across programs. 7 This study demonstrates that trainees perceive current ultrasound training delivered by Canada s Ob/Gyn residency programs as inadequate and identifies the need for a standardized ultrasound curriculum. These findings collectively echo the needs identified by the Council on Resident Education in Obstetrics and Gynecology and AIUM, which have specified that performing and interpreting pelvic ultrasound examinations should be a required competency for trainees in Ob/Gyn. 10 There is now a published AIUM ultrasound curriculum for residents in Ob/Gyn postgraduate training pro- J Ultrasound Med 2015; 34:1583 1589 1587

grams in the United States. 14 This program provides a comprehensive introduction to ultrasound, as well as focused training in Ob and Gyn imaging. 14 The AIUM recommends that this ultrasound curriculum be incorporated into Ob/Gyn postgraduate residency programs, taught by faculty instructors to provide residents across the United States with standardized ultrasound education. 14 In contrast, in Canada, objectives and required competencies for ultrasound training are not specified by the Royal College of Physicians and Surgeons of Canada. This factor likely has limited the inclusion of ultrasound education in postgraduate Ob/Gyn training programs, and prescription may be necessary to change the requirements for Canadian residency programs. There is robust literature demonstrating the feasibility of incorporating ultrasound training programs during residency. Hall et al 9 designed and validated a comprehensive competency-based ultrasound curriculum for postgraduate trainees in Ob/Gyn at the University of New Mexico. This training program was reported to sufficiently prepare residents for accreditation by the AIUM. The use of virtual models has also been studied for acquiring ultrasound skills. Burden et al 15 demonstrated construct validity for a virtual reality ultrasound simulator to develop skills in routine Ob imaging. A combined curriculum involving virtual reality models alongside livepatient ultrasound examinations has been proposed as a more feasible and effective option for standardized training. 16 In Canada, research in postgraduate ultrasound training is led by emergency medicine. Lee et al 17 implemented and successfully validated a 2-week ultrasound training program for emergency medicine residents at the University of Ottawa. Interestingly, their program included a component on Gyn ultrasound examinations, which may be easily transferrable to an Ob/Gyn residency curriculum. Although developing a standardized curriculum can be challenging, this literature demonstrates that such a task is feasible. To our knowledge, this is the first published study to evaluate the current state of ultrasound education among Canada s 16 postgraduate training programs in Ob/Gyn. Our results confirm a suspected gap in resident exposure to Gyn-specific ultrasound training. This study, however, had several limitations. The response rates were only 14.8% for residents and 18.5% for physicians, and although all respondents had an equal opportunity to participate, it is possible that this sample is not representative of all Canadian Ob/Gyn residents and physicians. The survey respondents were self-selected, which could have introduced a bias into the results, as the respondents may be particularly passionate about ultrasound. In addition, most of the surveys were completed in English, which may indicate that the opinions of French-only speaking respondents were missed. Although both surveys had respondents from a wide geographic area within Canada, there were disproportionately more responding physicians from Ontario and more responding residents from Toronto. This factor may have skewed the results, as ultrasound practices and residency curricula may vary by region. It is also possible, however, that obtaining a larger sample of residents might further highlight the disparities in ultrasound training across programs, implying that this sample may have underestimated the unmet needs of residents. Finally, although the research team reviewed the surveys for readability and ease of comprehension, they were not formally validated, and it is possible that questions were misread and inappropriately answered by respondents. This study evaluated the current level of ultrasound education in Canadian postgraduate training programs in Ob/Gyn. On the basis of this study s results, there appears to be a gap in Gyn ultrasound education in Canada s postgraduate training programs. Most residents and practicing obstetrician/gynecologists surveyed together agreed that competency in pelvic ultrasound is important for clinical practice and that a standardized curriculum for ultrasound education should be offered by Canada s postgraduate training programs. These findings are well aligned with those of the Council on Resident Education in Obstetrics and Gynecology and AIUM, whose collaboration has resulted in a formal Ob/Gyn ultrasound curriculum for residents in the United States. As residency programs in Ob/Gyn across both Europe and the United States are providing adequate training for their residents to graduate with competency in pelvic ultrasound, it is critical for Canada s programs to meet this new standard of ultrasound education and ensure that the future practitioners of our specialty are not deprived of this essential skill set. References 1. Timor-Tritsch IE. Transvaginal sonography in gynecologic office practice. Curr Opin Obstet Gynecol 1992; 4:914 920. 2. Goldstein SR. Routine use of office gynecologic ultrasound. J Ultrasound Med 2002; 21:489 492. 3. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med2011; 364:749 757. 4. Acharya G, Morgan H, Henson G. Use of ultrasound to improve the safety of postgraduate training in obstetrics and gynaecology. Eur J Ultrasound 2001; 13:53 59. 1588 J Ultrasound Med 2015; 34:1583 1589

5. Ghi T, Casadio P, Kuleva M, et al. Accuracy of three-dimensional ultrasound in diagnosis and classification of congenital uterine anomalies. Fertil Steril 2009; 92:808 813. 6. Lee W, Hodges AN, Williams S, Vettraino IM, McNie B. Fetal ultrasound training for obstetrics and gynecology residents. Obstet Gynecol 2004; 103:333 338. 7. Kim DJ, Theoret J, Liao MM, Hopkins E, Woolfrey K, Kendall JL. The current state of ultrasound training in Canadian emergency medicine programs: perspectives from program directors. Acad Emerg Med 2012; 19:E1073 E1078. 8. Royal College of Physicians and Surgeons of Canada. Objectives of training in obstetrics and gynecology. McGill Faculty of Medicine website; 2010. https://www.medicine.mcgill.ca/postgrad/accreditation_2013/ PSQs/1_Obstetrics_Gynecology/05_OTR_Obstetrics_Gynecology_2010.pdf. Accessed August 1, 2013. 9. Hall R, Ogburn T, Rogers RG. Teaching and evaluating ultrasound skill attainment: competency-based resident ultrasound training for AIUM accreditation. Obstet Gynecol Clin North Am 2006; 33:305 323. 10. Council on Resident Education in Obstetrics and Gynecology. Educational objectives: core curriculum in obstetrics and gynecology. 9th ed. Columbia University Medical Center website; 2009. http://www.cumc.columbia.edu/dept/obgyn/downloads/creog_ educational_9th.pdf. Accessed August 1, 2013. 11. Bahner DP, Adkins EJ, Hughes D, Barrie M, Boulger CT, Royall NA. Integrated medical school ultrasound: development of an ultrasound vertical curriculum. Crit Ultrasound J 2013; 5:6. 12. 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. 13. Blumenfeld YJ, Ness A, Platt LD. Maternal-fetal medicine fellowship obstetrical ultrasound experience: results from a fellowship survey. Prenat Diagn 2013; 33:158 161. 14. American Institute of Ultrasound in Medicine. Training guidelines for physicians who evaluate and interpret diagnostic abdominal, obstetric, and/or gynecologic ultrasound examinations. American Institute of Ultrasound in Medicine website; 2013. http://www.aium.org/ resources/ptguidelines.aspx. Accessed August 1, 2013. 15. Burden C, Preshaw J, White P, Draycott TJ, Grant S, Fox R. Validation of virtual reality simulation for obstetric ultrasonography: a prospective crosssectional study. Simul Healthc 2012; 7:269 273. 16. Tutschek B, Tercanli S, Chantraine F. Teaching and learning normal gynecological ultrasonography using simple virtual reality objects: a proposal for a standardized approach. Ultrasound Obstet Gynecol 2012; 39:595 596. 17. Lee D, Woo MY, Lee CA, Frank JR. A PILOT evaluation of the effectiveness of a novel emergency medicine ultrasound curriculum for residents at a Canadian academic centre [abstract]. CJEM2010; 12:260 261. J Ultrasound Med 2015; 34:1583 1589 1589