Transvaginal Gyn Ultrasound Replaces the Bimanual Pelvic Exam

1
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 MedicineAIUM
• 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
  16277-280.
• 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 26553-558.
• 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 30163-168.
• 6. Rodney WM, Hahn RG, Hartman KJ, Deutchman ME.
  Obstetric ultrasound by family physicians. J Fam
  Pract 1992 34186-200.
• 7. Deutchman ME, Hahn RG, Rodney WM. Maternal
  gallbladder assessment during obstetric
  ultrasound results and technique. J Fam Pract
  1994 3933-37.
• 8. Euans DW, Hahn RG, Rodney WM. A comparison of
  manual and ultrasound measurements of fundal
  height. J Fam Pract 1995 40233-236.
• 9. Rodney WM. Historical observations from the
  RRC 1994-2000 Maternity careOB training in FP.
  J Am Board Fam Pract 200215255-56.
• 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.
  200417(4) 276-282. http//www.jabfp.org/cgi/cont
  ent/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 Technnology
  www.psot.com
• SummaryThe 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.

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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 ObstetricsComplete 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.

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Gineco Obstetricia Medicina Familiar ER 2000-2010

• Develop a bilingual high touch high tech open
  access family medicine based healthcare centers
• Control practices NashvilleOne grew, one didnt
  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

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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.

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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 frequency2
• Become uncommonly good at common probs
• Develop and teach from clinical simulations.

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Office Gyn Ultrasound--Ovaries

• Method of Wm. MacMillan Rodney MD
• Gineco Obstetricia Medicina FamiliarER
• 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

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Teach Normal anatomy with patients as they occur.

• Normal ovarian size , shape , and visual
  fingerprint

• Normal follicular cysts are less than 11mm

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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?

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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

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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

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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.

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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 ERabdom, soft tissue

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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 qualitythe standard of care?
• Will it lose money, break even, or make money?

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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 IDundocumented. 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.

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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 982
  161-171
• Rodney Wm, et al. Los desaparecidos. Am J Clin
  Medicine Spring 2009 62 31-36.
• It is learnable core skill. Nothnagle M, et al.
  Required Procedural Training in Family medicine
  Residency Fam Med 2008 40 248-252

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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

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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.

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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 examinationcontrolled for time lt3
  minutes
• Physicians were asked to describe findings
• Visual findings--Cervix, sidewalls, perineum
• PalpableDid 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

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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 UTIs, 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

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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 clinicalLMPhistory , 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 FPs 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.

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PREDICTIONS FOR THE FUTURE

• The family physicians 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

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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.

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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

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AssignmentsUsing 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. Spurlocks 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