Ultrasound curricula in obstetrics and gynecology training programs

Around the world, ultrasound is performed and interpreted by a wide range of healthcare providers in the specialty of obstetrics and gynecology (Ob/Gyn), such as obstetricians/gynecologists, radiologists, sonographers, midwives and nurses. Practice differs depending on training and tradition, not only between but even within countries. For example, at the University of Toronto, Canada's largest academic center, obstetric ultrasound is performed and interpreted by radiologists and obstetricians/gynecologists who work closely with sonographers, nurses and trainees, whereas gynecological ultrasound is almost exclusively the domain of radiologists. Conversely, at the University of Ottawa, the maternal–fetal medicine specialists perform and interpret not only obstetric ultrasound but also a significant portion of gynecological ultrasound. It is therefore obvious that two cities, which are both under the jurisdiction of the College of Physicians and Surgeons of Ontario and the Royal College of Physicians and Surgeons of Canada (RCPSC), have a different approach to ultrasonography, particularly gynecological ultrasound. This is a perfectly adequate approach to care, in which qualified healthcare professionals provide quality care regardless of their specialty. However, it could result in various specialist training programs producing graduates with varying degrees of proficiency in Ob/Gyn ultrasound. If we are to provide quality care to women, it is imperative that those performing and interpreting Ob/Gyn ultrasound have undergone the appropriate training and are qualified to practice safely and competently. Recently, we completed a survey of Ob/Gyn trainees in Canada1 to determine whether Ob/Gyn ultrasound training across Canada is aligned with the recommendations of the RCPSC and the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG)2 . The study highlighted the variation in ultrasound training across Canadian Ob/Gyn training programs with respect to the format, quantity and focus of training. The time devoted to obstetric ultrasound training exceeded significantly that devoted to gynecological ultrasound, with an average of 85% of formal rotation time being dedicated to obstetric ultrasound compared with 15% for gynecological ultrasound. Five of the 16 Canadian residency programs did not include gynecological ultrasound training over the 5-year training period. Consequently, we identified low levels of self-reported competency in gynecological ultrasound tasks, which could limit future clinical practice. In this editorial, we compare and contrast Ob/Gyn training curricula published by regulatory bodies in four high-income English-speaking countries with the standards set by ISUOG, and make a case for the standardization of Ob/Gyn training, with due regard to available resources. In the contemporary field of Ob/Gyn, in which point-of-care ultrasonography is rapidly becoming an expectation and a requirement3, 4, there is a view that obstetrician/gynecologist training should go beyond understanding indications for ultrasound and how to manage the subsequent findings5. It follows that all Ob/Gyn trainees should receive, at minimum, a basic level of theoretical and skill-based education in both obstetric and gynecological ultrasound5. This is particularly relevant as ultrasound technology becomes more accessible and integral to the management of women's health3, 6. Pelvic floor dysfunction, endometriosis and cervical cancer are only some of the conditions for which there is substantial evidence that ultrasound has the potential to optimize patient care7-9. The real-time, dynamic nature of ultrasound lends itself well to being performed and interpreted by obstetricians/gynecologists to facilitate timely and appropriate treatment decisions. Central to the utility of ultrasound in Ob/Gyn is education. Both baseline standards of care and research and development in the field of ultrasound rely heavily on adequate and conscientious specialized training and education. As the leading organization for the use of ultrasound in Ob/Gyn, ISUOG's published recommendations for Ob/Gyn ultrasound training act as a benchmark (Table 1)2. These recommendations can be compared with training recommendations by various international regulatory bodies (Table 2). For example, the American College of Obstetricians and Gynecologists (ACOG) has aligned its comprehensive set of ultrasound professional competencies to these recommendations10. However, discrepancies between ISUOG and ACOG recommendations still exist: ACOG does not require its trainees to be able to perform an ultrasound assessment for pelvic masses and considers that their being able to interpret the ultrasound findings is satisfactory. ACOG collaborates with the American Institute of Ultrasound in Medicine (AIUM), which has its own set of necessary parameters in both obstetric and gynecological ultrasound11, 12. Although these are not specific to Ob/Gyn training, obstetricians/gynecologists who perform ultrasound are expected to adhere to these standards. To aid healthcare providers in understanding how to obtain sufficient training to perform safely ultrasound examinations, AIUM has also published physician training guidelines13, 14. Whereas both AIUM and ISUOG offer comprehensive and valuable guidance on basic ultrasound standards and education, differences are revealed when evaluating critically their recommendations. For instance, ISUOG recommends the use of the International Ovarian Tumor Analysis Group terminology for the assessment of pelvic masses, whereas AIUM does not. ACOG and other regulatory bodies alike face challenges in determining which organization to follow when setting their guidelines. Recognize features of intrauterine pregnancy (gestational sac, yolk sac and embryo) Recognize fetal viability and non-viability Adequately measure MSD, CRL and BPD (if applicable) Ascertain if multiple gestation and, if so, determine chorionicity Understand how to calculate or correct gestational age estimation from CRL Recognize features of extrauterine (ectopic) pregnancy Understand concept of PUL and how to interpret serum biochemistry to assign risk Obtain standardized planes for anatomical and biometric evaluation (e.g. BPD, HC, AC, FL, cervical length) Understand interpretation of measurement deviations (e.g. for calculating gestational age, recognizing growth restriction) Recognize, subjectively or objectively, normal and abnormal amniotic fluid volume Recognize placental location in relationship to lower uterine segment and cervix (recognizing and reporting placenta previa) Recognize umbilical cord and its insertions on placenta and fetal abdominal wall Recognize fetal anatomical landmarks and identify possible abnormal findings Assessment of uterus in both its longitudinal and transverse planes Measurement of endometrial thickness and description of endometrial morphology. Recognizing and describing focal intracavitary pathology (polyps and submucous fibroids) Examination of myometrium for evidence of fibroids and adenomyosis Examination of ovaries, and how to describe their morphology and size. Pathology should be reported in terms of its appearance and dimensions using a standardized approach. This should include knowledge of IOTA terminology Examination of pelvis for presence of fluid Confirm diagnosis of multiple gestation by performing endovaginal or abdominal ultrasound examination Perform and/or interpret results of ultrasound used in diagnosis and management of early-pregnancy loss Perform and interpret results of endovaginal ultrasound to confirm diagnosis and location of ectopic pregnancy Crown–rump length and gestational age Confirmation of intrauterine pregnancy Recognition and documentation of fetal heart rate Identify intrauterine pregnancy in first trimester > 6 weeks Recognize number of fetuses Measure gestational sac to obtain mean sac diameter Measure crown–rump length Recognize presence/absence of fetal heart motion using M-mode Identify features of normal gestational sac and confirm its intrauterine location Measure gestational sac size and crown–rump length Identify early cardiac activity using B-mode Identify fetal number Perform accurate ultrasound examination to assess fetal growth Confirm diagnosis of fetal death by ultrasound examination Abdominal or endovaginal ultrasound to localize placenta and evaluate for possible placental separation Fetal position and number Placental location Amniotic fluid volume assessment Fetal biometry: biparietal diameter, head circumference, abdominal circumference, femur length Cervical-length measurement Biophysical profile test Recognize presence/absence of fetal heart motion using M-mode Determine presentation of pregnancy Measure deepest vertical pool Locate placenta Perform and interpret standard fetal measurements (head circumference, biparietal diameter, abdominal circumference, femur length) Perform and interpret assessment of amniotic fluid volume (maximum vertical pool depth and amniotic fluid index) using ultrasound Perform and interpret ultrasound assessment of placental site transabdominally Perform, and interpret results of, pelvic ultrasound and/or saline infusion ultrasound to determine cause of abnormal uterine bleeding Perform and/or interpret tests, such as endovaginal or abdominal ultrasound, to confirm diagnosis of pelvic mass Intermediate level – optional curriculum Consistently identify and examine uterus, ovaries, adnexa and pouch of Douglas Assess cyclical endometrial changes and endometrial responses to combined pill and other hormonal preparations Assess uterine size and measure accurately endometrial thickness Assess ovarian volume and functional changes in ovaries and adnexa during menstrual cycle: follicular appearances, variation in morphology of corpora lutea, functional cysts, fluid in pouch of Douglas In Canada, training objectives set out by the RCPSC for obstetricians/gynecologists were expanded in 2016 to include additional skills, such as identifying an intrauterine pregnancy and measuring crown–rump length to determine gestational age15, 16. Despite this revision, the list of standards for obstetric ultrasound skills is still not as comprehensive as that of ISUOG. Canadian graduates are not expected to diagnose multiple gestation in the first trimester, determine chorionicity or identify extrauterine pregnancies, as recommended by ISUOG. Furthermore, the RCPSC still focuses entirely on obstetric ultrasound and does not require Canadian trainees to receive any skill-based education in gynecological ultrasound. Interestingly, a joint statement addressing ultrasound examination of the female pelvis by the Society of Obstetricians and Gynecologists of Canada and the Canadian Association of Radiologists merely suggested that ‘subspecialty training in ultrasound’ is sufficient for obstetricians/gynecologists to be involved in the performance, supervision and interpretation of ultrasonography, without explicitly stating what constitutes ‘subspecialty training’17. In Australia and New Zealand, ultrasound training requirements are specified by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)18. The RANZCOG training objectives, although thorough with regard to obstetric ultrasound, still exhibit gaps in their standards. For example, ISUOG recommends that the diagnosis of an extrauterine pregnancy is a basic skill, whereas RANZCOG does not. Unlike RCPSC, RANZCOG requirements include gynecological ultrasound training to identify the uterus, ovaries and cervix. This does not, however, match ISUOG's list of basic gynecological tasks. Fortunately, Australia and New Zealand are unique in offering a formally recognized fellowship in ultrasound, entitled Certification in Obstetrical and Gynaecological Ultrasound, for obstetricians/gynecologists who hope to maximize their training and integrate ultrasound into their day-to-day practice19. The Royal College of Obstetricians and Gynaecologists (RCOG) in the UK has no baseline requirement for Ob/Gyn graduates to possess skills in gynecological ultrasound. However, similarly to RANZCOG, RCOG offers an optional intermediate-level curriculum in gynecological ultrasound for those keen to pursue advanced imaging education in this field. Nonetheless, all trainees are expected to achieve competency, as determined by clinical supervisors, in basic obstetric ultrasound20. The minimum standards of RANZCOG are aligned with the obstetric recommendations proposed by ISUOG, with the exception of not requiring trainees to be able to diagnose ectopic pregnancy or to determine chorionicity in multiple gestations. National training requirements and the path to competency in ultrasound differ between European countries5. Among countries in which obstetricians/gynecologists are known to perform the majority of ultrasound scans (France, Germany, Switzerland), completing a regulated supplementary program (outside of the regular Ob/Gyn specialist training) is required. Though this is reassuring in terms of ensuring competency of the graduates of these subspecialty programs, not all Ob/Gyn trainees undergo this high-level training. Therefore, are graduates of general Ob/Gyn programs able to fulfill basic recommended ultrasound skills? In some European countries, formal ultrasound curricula exist, and in some cases there are guidelines on the minimum number of scans required to achieve competency. Again, even though clear national standards are important for trainees, the variation in requirements (for example, 80 logged obstetric scans in Denmark vs 400 in Switzerland) begs the question of how competency is defined in each country5. The European Board and College of Obstetrics and Gynecology (EBCOG) is attempting to address this shortcoming by offering a set of standards for when an Ob/Gyn ultrasound is performed21, without outlining detailed skill-based requirements22. Nonetheless, it recommends that obstetricians/gynecologists should understand the relevant ultrasound aspects of the obstetric and gynecological disease processes23 and log at least 200 obstetric and 100 gynecological ultrasound scans prior to performing ultrasound examinations independently22, 23. The number of logged scans recommended by AIUM and ISUOG differ (300 vs 100 each for both obstetrics and gynecology, respectively)2, 13, 14. Ultimately, the specific number of scans required to obtain competency will depend on the trainee and the complexity of the cases. In the era of competency-based training programs, we must question whether a minimum threshold number of scans should even exist at all24. However, at this time, it seems that an estimate of the number of logged scans needed to establish competency is still necessary for regulatory bodies and educational centers to plan training programs. It may be useful to turn to learning-curve studies in order to understand the average process of learning a new technique to reach a level of competency25. To conclude, regulatory bodies within each country can learn from organizations such as ISUOG, AIUM and EBCOG with respect to developing more comprehensive training requirements. Beyond that, there should be an emphasis on whether current approaches to ultrasound training in Ob/Gyn are optimal for patient safety and whether they meet the standards for quality assurance. It is fortunate that the abovementioned organizations strive to combine evidence-based medicine with expert opinion to make recommendations on educational methodologies. It is now up to the regulatory bodies in individual countries to assess critically their current models of ultrasound education in Ob/Gyn and attempt to draft comprehensive standards with guidance from relevant international ultrasound societies. These standards should take into account specific considerations such as the available resources, clinical needs and historical practice patterns. Accordingly, Ob/Gyn trainees, and by extension the patients they will care for in future practice, will be much better served.

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