Ultrasound Obstet Gynecol 2010; 36: 525–529 Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.8851

Editorial Basic European ultrasound training in obstetrics and gynecology: where are we and where do we go from here? ˚ SALVESEN*, C. LEES† and K. A. B. TUTSCHEK‡ *National Center for Fetal Medicine, St. Olav University Hospital of Trondheim and Department of Laboratory Medicine, Women’s and Child Health, Norwegian University of Science and Technology, Trondheim, Norway (e-mail: [email protected]), †Rosie Maternity-Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK (e-mail: [email protected]) and ‡Inselspital, Bern University Hospital, Bern, Switzerland (e-mail: [email protected])

More than with any other imaging modality, the medical use of ultrasound is highly operator-dependent. The potential for diagnostic error is magnified by the ongoing development of increasingly sophisticated equipment with extended applications. A gap is appearing between the sophistication of the most advanced machines and techniques and the skills of those expected to use them and interpret the images produced, due to a lack of training. Whilst many obstetricians and gynecologists in training attend courses addressing the finer points of, for example, cardiac Doppler, central nervous system posterior fossa imaging or three-dimensional endometrial visualization, relatively few are willing to attend courses on basic theoretical and practical ultrasound techniques. There are a few exceptions, for example in Scandinavia, where basic courses are mandatory. Are there steps missing in the training of doctors in the specialty? The impression we have is that there exists a relatively small number of talented and skilled ultrasound practitioners seeking to hone their skills ever more precisely, whilst many perfectly competent clinicians are perhaps less enthusiastic and more fearful of ultrasound as they have simply not been taught the basics. The failure of basic training to keep up with diagnostic and technical developments opens the door to misinterpretation, mistakes and poor reproducibility in using the equipment. At the same time, throughout the specialty ever greater reliance is placed on ultrasound diagnoses in management for both obstetrics and gynecology. Diagnostic error can only be overcome by

proper training – understanding both the limitations and the potential of ultrasound equipment.

Should all obstetricians and gynecologists be able to scan at a basic level? The answer should be yes. Modern obstetrics and gynecology practice is virtually impossible without the use of ultrasound. That does not mean that all obstetricians and gynecologists need to be experts in ultrasound. Certain aspects of the specialty require specific skills that are more important than ultrasound – for instance, gynecological oncology and urogynecology require surgical expertise, whilst maternal medicine requires specific medical knowledge. Nevertheless, it is clearly desirable for all obstetricians and gynecologists to have been trained robustly in basic sonographic skills so that their scanning in antenatal and gynecological clinics and on the labor ward is both safe and reproducible. Moreover, in order to gain maximum clinical benefit and to achieve optimal use of resources, there is a need for all ultrasound operators to have appropriate skills to perform and interpret ultrasound examinations.

What constitutes a ‘basic’ level of expertise? The European Board and College of Obstetrics and Gynaecology (EBCOG) has developed guidelines for basic education in obstetrics and gynecology (approved in June 2005). For ultrasound, the basic competence levels are

Authors’ involvement in professional organizations: K.A.S was formerly Chair of the Educational Committee of the Nordic Federation of Societies of Obstetrics and Gynecology (NFOG) and a Board Member of the European Board and College of Obstetrics and Gynaecology (EBCOG); C.L. is the UK National Ultrasound Officer of the Royal College of Obstetricians and Gynaecologists (RCOG); B.T. is a Board Member of the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) and Chair of its Web Editorial Board.

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd.

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defined only in broad terms. With respect to obstetric ultrasound, the trainee should have ‘detailed theoretical knowledge of the normal and abnormal anatomy of the fetus, placenta and amniotic fluid compartment, estimation of gestational age, fetal biometry, fetal growth and behaviour, [and] of the evaluation of fetal and uteroplacental blood flow’1 . In gynecological ultrasound the trainee should have ‘detailed theoretical knowledge of ultrasonic aspects of normal pelvic anatomy; gynaecological disease; infertility and ultrasound guided invasive procedures’1 . In addition, each trainee should have a log book listing 200 antenatal obstetric scans and 100 gynecological scans2 . The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) is more detailed in its minimum training recommendations for the practice of medical ultrasound3 . For Level 1 (basic competence level) in gynecological ultrasound, EFSUMB recommends that trainees should perform a minimum of 300 examinations under supervision and keep an illustrated log book of 20 documented cases. They should receive a minimum of 20 hours of theoretical tuition, preferably at the beginning of the training period. For Level 1 in obstetric ultrasound the recommendations are that the trainee performs a minimum of 500 examinations under supervision, producing a log book listing the types of examinations, and receives 30 hours of theoretical tuition3 . In 1996, ISUOG (the International Society of Ultrasound in Obstetrics and Gynecology) Education Committee produced the most ambitious proposal in their ‘Update on proposed minimum standards for ultrasound training for residents in Ob/Gyn’4 . This document describes the contents of a basic theory course and required practical skills. It recommends that for certification a trainee should have 100 hours of supervised scanning including 100 gynecological and 200 obstetric scans. A log book with 30 cases with ultrasound images (including 15 fetal anomalies) should be included. Theoretical (multiple choice or written exam of three or four cases) and practical (transvaginal and fetal anomaly scan – 30 min for both) examinations were recommended. ISUOG may decide to update this proposal, but in the meantime its Clinical Standards Committee has provided practical advice in the form of guidelines for individual types of exam.

How is basic training organized at present in Europe? The difficulty in creating consistency in training standards throughout Europe has led to the separate and independent development of ultrasound training approaches in individual countries. We have, through contact with colleagues in other countries, performed an informal survey comparing ultrasound training in obstetrics and gynecology in some European countries. The results are presented in Table 1, which demonstrates that European countries differ in their formal definitions and requirements for basic obstetric and gynecological ultrasound training. Theoretical knowledge is taught in basic and intermediate ultrasound courses. Some countries test the theoretical

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd.

knowledge in course exams, whilst in the UK, membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) requires an ‘overall’ exam including all subject areas, of which only a small fraction will include ultrasound. Some do not assess theoretical knowledge among trainees at all. Whilst most systems require formalized theoretical teaching, ‘hands-on’ practical supervision is rarely formalized. Yet, this is the most critical aspect of basic training. Most hands-on supervision for trainees is probably ad hoc in an opportunistic, unstructured way in clinics and wards, rather than being arranged in advance with clear educational goals. Log books and check lists are frequently used to document a certain number of scans, and the quality of images can be checked by a supervisor. However, achieving a particular number of scans does not equate to a certain level of competence.

Where do we go from here? We suggest that four aspects should be discussed and decided upon: (1) Define the basic competence level This has been proposed previously by EBCOG, EFSUMB and ISUOG. However, a problem is that definitions vary and do not seem to be implemented uniformly in European countries (Table 1). In the UK, basic ultrasound training for obstetric ultrasound (though not gynecological ultrasound) has recently become mandatory and comprises two modules. The goal of training is that each trainee should be able to carry out a dating scan at 8–12 weeks and to undertake some aspects of late pregnancy scanning, for example amniotic fluid index assessment, fetal presentation, placental site and aspects of basic fetal biometry. While these may appear to be modest goals for basic training, they are a marked improvement: now all UK trainees will be expected to achieve at least basic competence. (2) Find a simple and reproducible assessment process Training must be offered and standards maintained, for which a robust assessment process is critical. However, the assessment process in European countries is variable (Table 1) and only a few countries have nationally applied assessment guidelines or tools. There are specific national considerations. In the UK, for example, objective and reproducible assessments are evidenced by RCOG (Royal College of Obstetricians and Gynaecologists) workplace-based assessments, which may be completed by medical or non-medical training supervisors. These include Objective Structured Clinical Examinations (OSCEs), Case Based Discussions (CBDs) and mini-CEXs (Clinical Examinations). Web-based resources to support trainers are available on the RCOG website5 , along with the RCOG curriculum, assessment tools and information6 . Both sonographers and obstetricians/gynecologists may, where appropriately

Ultrasound Obstet Gynecol 2010; 36: 525–529.

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd.

Course exam Hands-on sessions within the course Log book, minimum no. Ob scans

Formal US teaching material Required basic US courses

US teaching during residency Formal curriculum for US teaching during specialist training

Specialist exam (to complete residency)

Ob/Gyn residency Minimum duration (years) Training all in one hospital Formalized subspecialty programs Type and length of subspecialty program

Reprod med, 2 years

No

—

No

—

— —

—

15 hours + integrated in other courses No No

80

No

Yes (text book)

Course, log book

Yes

No (must change every 6 months) Yes

No

No

5

France

6

Denmark

No log book, 500 scans required

Yes Some

No

No

No

State Authority

MFM, surg/onc, endo (2 years each)

Yes

Yes

5

Germany

No

Yes Yes

No

No

No

Yes

—

No

Yes

5

Italy

Table 1 Basic ultrasound training during obstetrics and gynecology specialist training in Europe

250

Yes Yes

5 days

No

Course, log book

No

—

No

Yes

5.5

Norway

No

No No

5 days

No

Not separate but incl in various clinical parts

Optional

—

No

Yes

5

Sweden

Yes

No

7

UK

No log book, 400 scans required

No No

Yes (national guidelines) One half-day

No

Competence-based; minimum three OSATs per core competence

Theory only for basic and intermediate No No

Theory course mandatory, practical competence to be signed off Yes

MFM, surg, endo + MFM, gyn onc, reprod med reprod med, urogyn (2 years each) FMH MRCOG Parts 1,2

No (must change at least once) Yes

5

Switzerland

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Yes: Diploma Inter-university: first of 2 years can be done during specialist training

100 h theory, 160 h practice; log book with literature reviews; nationally standardized exam incl practical (20-week scan)

No

—

10% > 95% of all routine obstetric scans

70%

—

Ob 3 weeks, Gyn 3 weeks

30 %

—

France

90

Denmark

0%

85%

Log book, exam (oral and practical); re-eval every 2 years

Yes: DEGUM level (I and) II; certain certificates required for billing

In larger hospitals: 3–6 months

See above

Germany

0%

Unknown

—

No

Yes

No log book

Italy

> 95% of all routine obstetric scans

Unknown

FMF accreditation optional

No

No

50

Norway

> 95% of all routine obstetric scans

Unknown

—

No

No

No

Sweden

Yes

Competence-based

UK

< 5%

80%

> 90%

< 5%

Yes: certificate of Yes: module competence for completion pregnancy US allows (requirements can progression to be fulfilled during intermediate and specialist subspecialty training) Log book, 300 Theory course + practical supervised scans competence to be (100 in each signed off by trimester), 5-day local ultrasound course; re-eval supervisor after 5 years

In larger hospitals: 3–6 months

See above

Switzerland

*Estimate. DEGUM, German Society for Ultrasound in Medicine; endo, endocrinology; FMF, The Fetal Medicine Foundation; FMH, Swiss national medical accreditation body; gyn onc, gynecological oncology; incl, including; MFM, maternal–fetal medicine; onc, oncology; OSAT, Objective Structured Assessment of Training; reprod med, reproductive medicine; RCOG, Royal College of Obstetricians and Gynaecologists; re-eval, re-evaluation; surg, surgery; urogyn, urogynecology; US, ultrasound.

General % Ob/Gyn US scans done by practitioners in independent practices* % Ob/Gyn scans done by sonographers/ midwives*

–Requirements

Log book, minimum no. Gyn scans Focused clinical supervision during specialist US training US training/ certificate

Table 1 (Continued)

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Editorial qualified, perform assessments7 . This is important because in the UK, the majority of obstetric ultrasound examinations are carried out by sonographers. (3) Consider additional teaching methods Indication for ultrasound investigations, the sonographic appearance of normal anatomy in the standard planes, the correct settings of an ultrasound system as well as safety issues can easily be taught in conventional ways (lectures, books, videos), but the practical usage of an ultrasound system and, in particular, handling of the ultrasound probes (positioning, insonation angle) and adjustments for fetal movements and positional changes must be taught on a one-to-one basis. Once these basic abilities have been mastered, however, there are some other potentially useful educational tools: Online lectures. Several societies and dedicated individuals offer educational lectures on the Internet, ranging from basic to very advanced topics. ISUOG, for example, offers the contents of several ultrasound courses, covering both obstetric and gynecological topics, in full-media format (audio and video). While many of these lectures cover advanced topics, some also address concepts such as the fetal cardiac screening exam. These lectures are available for all members from ISUOG’s website (www.isuog.org). In several European countries, trainees are able to access the ISUOG website through a free membership program. Multimedia-based self-study, using offline material (CD ROM). CD ROMS have been produced by various authors, including ISUOG, who offer an educational series of CD ROMS, some produced jointly with The Fetal Medicine Foundation, London (downloadable from ISUOG’s website). Ultrasound simulators. Ultrasound simulators in basic obstetric and gynecological ultrasound training have been studied, but only sparsely, and their applicability for basic training has been disputed8,9 . However, once basic abilities (use of the ultrasound system, handling of the probes, acquisition of standard images) have been achieved by a trainee, there may be a possible role for digitally preserved pathological specimens both in basic and advanced training10,11 . (4) Involve societies and organizations responsible for harmonization in Europe EBCOG has representatives from all European countries and could agree on a structure for basic and intermediate ultrasound training, allowing harmonization between different European countries. The potential for putting together a joint course curriculum and for combining and sharing existing teaching material and expertise between the national societies is unarguable. ISUOG has come a long way in advanced women’s imaging education, arranging well-attended, high-quality conferences, producing a top-ranked journal and providing a large and growing body of media-rich lectures and

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other tools on its website. The focus so far has, however, been on developing the skills of already competent ultrasound practitioners. We therefore suggest that the time is right to team up in order to craft a basic training program for ultrasound in obstetrics and gynecology that is geared towards residents’ training. Without doctors being taught the basics, they are unlikely to become confident and competent advanced ultrasound practitioners. It is unrealistic to expect an overall and unified European ultrasound training scheme, though with increasing movement of doctors and patients within Europe this might be desirable. But there is no reason why a template for basic, intermediate and advanced training, both theoretical and practical, cannot be developed jointly between national bodies and supranational organizations. How this training is provided and assessed will differ from country to country, but a template may at least guide national societies to improve ultrasound education for all obstetricians/gynecologists. This will be rewarded by safer and more confident clinical management of patients in both obstetrics and gynecology.

ACKNOWLEDGMENT The Authors are very grateful to Kurt Biedermann, Gianluigi Pilu, Ann Tabor, Lil Valentin, Klaus Vetter and Yves Ville for provision of information used in the construction of Table 1 of this article.

REFERENCES 1. EBCOG. Recommendations for postgraduate training and assessment in Obstetrics and Gynaecology. Approved June 2005; http://www.ebcog.org [Accessed 28 September 2010]. 2. EBCOG. Postgraduate training and assessment in Obstetrics and Gynaecology. Log book. Approved June 2005; http://www.ebcog.org [Accessed 28 September 2010]. 3. EFSUMB. Minimum training recommendations for the practice of medical ultrasound. Ultraschall 2005; 26: 79–88. 4. ISUOG Education Committee. Update on proposed minimum standards for ultrasound training for residents in Ob/Gyn. Ultrasound Obstet Gynecol 1996; 8: 363–366. 5. RCOG. Workplace-based assessment. http://www.rcog.org. uk/education-and-exams/postgraduate-training/workplacebased-assessment [Accessed 15 July 2010]. 6. RCOG. Ultrasound. http://www.rcog.org.uk/education-andexams/curriculum/ultrasound [Accessed 15 July 2010]. 7. Lees C, Hinshaw K. RCOG ultrasound training recommendations for trainee obstetricians and gynaecologists. Ultrasound 2010; 18: 108–109. ¨ ¨ 8. Maul H, Scharf A, Baier P, Wustemann M, Gunter HH, Gebauer G, Sohn C. Ultrasound simulators: experience with the Sono Trainer and comparative review of other training systems. Ultrasound Obstet Gynecol 2004; 24: 581–585. 9. Merz E. Ultrasound simulator – an ideal supplemental tool for mastering the diagnostics of fetal malformations or an illusion? Ultraschall Med 2006; 27: 321–323. 10. Tutschek B. Simple virtual reality display of fetal volume ultrasound. Ultrasound Obstet Gynecol 2008; 32: 906–909. 11. Tutschek B, Pilu G. Virtual reality ultrasound imaging of the normal and abnormal fetal central nervous system. Ultrasound Obstet Gynecol 2009; 34: 259–267.

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