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1
Department of Radiology, The Dartmouth Hitchcock Medical Center, 1 Medical
Center Dr., Lebanon, NH 03756.
2
Department of Obstetrics and Gynecology, The Milton S. Hershey Medical Center,
The Pennsylvania State College of Medicine, 500 University Dr., Hershey, PA
17033.
3
Department of Health Evaluation Sciences, The Milton S. Hershey Medical
Center, The Pennsylvania State College of Medicine, Hershey, PA 17033.
Received October 12, 2000;
accepted after revision April 10, 2001.
Address correspondence to C. J. Kasales.
Abstract
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SUBJECTS AND METHODS. Written surveys were sent to the directors of 206 accredited radiology residency programs and 85 fellowship programs in the United States. The surveys encompassed obstetric sonographic experience during routine working hours and after hours, the level of supervision, the types of scanning performed, and the extent of formal lectures available during training. Additional questions concerned the relative knowledge of laboratory accreditation processes and training of faculty covering obstetric sonography.
RESULTS. Sixty (29%) of 206 accredited radiology residency programs and 24 (28%) of 85 fellowship programs returned surveys. The experience among residency programs was similar, providing fewer than 4 weeks per year of obstetric sonography, usually within their own department of radiology. Residents were more likely to be sent to outside departments for second or third trimester sonography experience. A decrease in scanning assistance was reported for examinations performed after hours, more so for second or third trimester studies. Lecture topics revealed similar deficiencies for residency and fellowship programs.
CONCLUSION. Greater emphasis on the performance of prenatal sonographic examinations may be warranted during formal sonography rotations. Current levels of experience in obstetric sonography may not be providing sufficient experience to allow residents to appropriately manage call cases or for practicing radiologists to provide such services after their training is completed.
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To quantify the obstetric sonography experience of radiology residents and fellows and to determine the effects of practice differences on this experience, we surveyed residency training and fellowship programs regarding aspects of daily sonography practice, differences in daytime and nighttime coverage, formal education in sonography, and hands-on experience by trainees.
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Additional survey questions included whether obstetric sonography was offered as a dedicated block; the role of the resident or fellow during the obstetric sonographic examination; exposure to first, second, and third trimester obstetric sonographic examinations and the locations of those experiences; the assistance of sonographers or nurses during day-time and after-hours examinations; assessment of supervision of residents and fellows during the day and after hours; and an assessment of formal lectures in obstetric sonography during training. Additional questions pertaining to the sonography laboratory's accreditation, the background and certification of sonographers, and the training of supervising (attending) physicians practicing sonography were also posed. Only fully completed surveys were included in the statistical assessment. Statistical analysis included descriptive statistics in the form of means, standard deviations, and frequency tables. The results are presented in the form of frequency tables.
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Obstetric sonography was offered in 100% of responding residency training programs: in 69% of programs as a formal block and in 31% of programs incorporated into the general sonography rotation. For fellowship programs (which are usually 1-year programs), obstetric sonography was offered in 87.5%, of which 82% incorporated it into general sonography rotations and 18% offered it as a dedicated block. Tables 1,2,3 display the location of residents' and fellows' experience and its duration. Information regarding the scanning experience of residents and fellows during obstetric sonographic examinations is detailed in Tables 4 (first trimester scanning experience) and 5 (second or third trimester scanning experience).
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Exposure to formal obstetric sonography lectures was fairly consistent among residents. Ninety-seven percent of residency training programs offered formal lectures, mostly as unknown-diagnosis case conferences (46%) or formal didactics (50%). Only 4% of lectures were provided in the form of videotapes. Such lectures were less common in fellowship programs, with only 79% of responding training programs offering formal obstetric sonography lectures (40% as unknown-diagnosis case conferences, 52% as formal didactics, and 8% as videotapes). Lecture topics are detailed in Table 6.
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Forty-eight percent of residency programs and 30% of fellowship programs surveyed stated their sonography laboratory was accredited by the ACR. Twenty-three percent of residency programs and 30% of fellowship programs were not aware of their laboratory's accreditation status. The survey results regarding the certification, training, and relative experience of sonographers and sonologists are presented in Table 7.
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Despite the growing accreditation processes, regulations governing the experience of residents and fellows in sonography, including obstetric sonography, remain ill defined. The Radiology Residency Review Committee currently requires that residents have rotations in sonography (dedicated or integrated with primary rotations in diagnostic radiology) and that they acquire experience in obstetric sonography. There are no minimal requirements for length of that experience, for the total number of examinations performed, or for the quality of that experience.
Most responding residency programs reported an experience of fewer than 4 weeks of obstetric sonography per year. Although most programs were able to offer first trimester sonography experience in their own radiology department, primary experience in second and third trimester examinations could be accomplished in-house in fewer than 70% of programs. This fact undoubtedly reflects the increasing volume of pregnant patients scanned by obstetricians as a part of their routine prenatal care. Alternatively, however, this fact may signal declines in the number of radiologists who feel they can provide such services and in the number of training programs with sufficient obstetric case load. We attempted to quantify this experience at outside departments by asking pointed questions regarding the role of the resident in scanning pregnant patients and in formulating reports. However, the number of responding programs was not sufficient to allow us to provide any statistically significant information.
A surprising number of programs reported that, despite performing obstetric sonography during the day, many did not offer such services after hours. This practice was more common for second or third trimester examinations than for first trimester studies. Coincidentally, however, we also noted a dramatic decline in assistance to radiology residents from sonographers, fellows, or supervising physicians in the performance of examinations at night when compared with those performed during routine working hours. (This trend is likely not unique to obstetric sonographic examinations but rather reflects a reduced level of sonographer, fellow, and supervising physician support for all sonographic studies.) If residents are performing sonography early in their training, they may have had fewer than 4 weeks' total experience in obstetric scanning, which may not provide them with sufficient expertise to operate independently.
A study by Wojak et al. [3] addressed a similar question regarding the diagnostic accuracy of radiology residents with 1-2 months of formal sonographic training compared with staff physicians in the detection of abnormalities associated with ectopic pregnancy. The authors noted that certain abnormalities (the presence of an adnexal mass with or without a gestational sac, free fluid, and corpus luteum cyst) were detected less frequently by residents scanning at night than by more experienced staff physicians scanning during the day. The differences noted by the authors were statistically significant. Wojak et al. concluded that, because of the improvements in diagnostic accuracy facilitated through experience in sonographic scanning, faculty review of findings was paramount to providing improved patient care and limiting morbidity and mortality in patients with possible ectopic pregnancy.
Recently, Hertzberg et al. [4] reported similar concerns regarding the ability of residents to perform diagnostic sonographic examinations. Ten first-year radiology residents under-went competency tests in sonography by repeatedly performing several predetermined sonographic studies that were then reviewed by dedicated faculty. Even after acquiring substantial scanning experience (200 cases), residents could successfully depict anatomic landmarks in only 56.5% of cases.
The combination of declining primary obstetric sonography experience in radiology departments and the relative lack of scanning assistance at night raises the larger concern that many radiology residents are currently acquiring insufficient hands-on experience in assessing the pregnant patient during their sonography rotations. It is doubtful that training programs can change the obstetric case load they offer trainees, so many programs would need to "farm out" trainees to outside institutions or departments to provide that experience. Such experiences, in general, often allow residents only the opportunity to observe the scanning of patients or perform examinations on a select number. Also, they may provide little experience in the formulation of patient reports. Although this may seem sufficient for training documentation purposes, the studies by Wojak et al. [3] and Hertzberg et al. [4] clearly attest to the need for prolonged hands-on experience to provide minimal competence in understanding the basics of anatomy as seen on sonography, let alone the ability to perceive and diagnose abnormalities.
Several radiology departments have undertaken joint efforts with obstetric departments to allow well-trained obstetricians and perinatologists to scan patients and to continue to allow radiology or obstetric and gynecology departments to provide sonographic examinations of pregnant patients. Although this solution at first may seem threatening to an individual department, it offers many longterm benefits. First, this solution can provide access to more departmental funds, allowing sections to upgrade or better maintain sonographic equipment. Second, this system may allow access to a larger pool of sonographers with more in-depth obstetric sonographic experience. Third, such a system can allow both radiology and obstetrics and gynecology residents the opportunity to learn from well-trained clinicians no matter what their original training. Finally, teaching efforts can be more widely (and often more appropriately) distributed and the opportunity to perform quality research increased.
Many institutions may not find the "joint efforts" solution viable for their practices. In such cases, it is prudent that trainees be granted the opportunity to acquire their experience at an institution at which high-quality obstetric sonography is performed, whether in a department of radiology or a department of obstetrics and gynecology. In addition, teaching hospitals need to ensure that such examinations are performed by the most qualified individuals (diagnostic imager or obstetrician) and that the training experience provides sufficient opportunity to work primarily with such clinicians, to scan patients, to diagnose and assess abnormalities, and to formulate accurate and useful reports.
The Radiology Residency Review Committee requirements for didactic teaching in general and obstetric sonography in particular are vague. The Graduate Medical Education Directory [1] states only that teaching staff must be "organized" and that the effectiveness of the educational program must be evaluated in a "systematic manner." Although conferences are required, topics are not explicitly outlined, and the quality of educational programs is judged only by the performance of residents on the oral board examination. The need for greater direction in this area has recently been addressed by the Association of Program Directors in Radiology (APDR) who, with the assistance of the Society of Radiologists in Ultrasound, recently developed a core curriculum for diagnostic sonographic training. This curriculum has been posted on the Web site for the APDR (http://www.apdr.org/programdirector/ultrasound.html) and offers guidelines to assist program directors in organizing residents' experience during diagnostic sonographic and other radiology rotations. The APDR recommendations include many of the obstetric sonographic topics mentioned in our survey, as well as several others.
For both residency and fellowship training programs, those topics covered least frequently included fetal growth and well-being, the fetal heart and great vessels, and fetal dysrhythmias. Although one could argue that these three topics in particular would be applicable only to the most complex pregnancies, a firm understanding of each topic is paramount if one is to recognize complications of pregnancy that may benefit from timely intervention. Admittedly, many radiologists may not feel qualified to offer lectures in these particular areas. In such cases, either guest lecturers or videotaped lectures may offer viable alternatives, assuring a more complete didactic core for trainees.
We were surprised at the relatively low numbers of radiology residents and fellows who were aware of the accreditation status of their sonography section. This finding raises the concern that training programs are not teaching their residents about the process of seeking the approval of either the ACR or the AIUM, which may result in difficulties when pursuing accreditation as they complete training and join practices. Educational topics recommended by the Society of Radiologists in Ultrasound and APDR do not include certification requirements by the AIUM and ACR.
Although the response rate for our survey seems quite low (30%), random surveys conducted by mail are generally designed with expected response rates of approximately 33%. Funding limitations and time constraints did not allow us to conduct follow-up telephone calls or a second mailing of surveys. Despite this, the total number of completed surveys we received is adequate to allow reasonable estimations of the relative frequencies reported here. However, whether the survey respondents are truly representative of the target population or whether they represent a biased sample is impossible to determine.
In conclusion, most responding radiology residency and fellowship training programs estimate an experience of fewer than 4 weeks per year in obstetric sonography, with a reduced level of assistance from sonographers and staff at night. In view of such practices, greater emphasis on performance of the prenatal sonographic examination during formal training rotations may be warranted. Current levels of experience in obstetric sonography may not be sufficient for training and may not provide the quality of experience that would allow residents and fellows to readily perform and interpret obstetric sonography when they become practicing radiologists. The didactic teaching experience described at various training programs is similar and covers most topics recently recommended by the APDR and the Society of Radiologists in Ultrasound. Lack of knowledge regarding AIUM and ACR certification criteria and certification status of laboratories suggests that lectures on these topics may also be warranted.
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