Transvaginal Gyn Ultrasound Transvaginal Gyn Ultrasound Replaces the Bimanual Pelvic Replaces the Bimanual Pelvic Exam –Curriculum Review and Exam –Curriculum Review and

Preliminary OutcomesPreliminary Outcomes

Wm. MacMillan Rodney MD, Wm. MacMillan Rodney MD, FAAFP, FAAFP, FACEPFACEP– Chair Academic Affairs, Medicos para la FamiliaChair Academic Affairs, Medicos para la Familia– Senior Member, American Institute for Senior Member, American Institute for

Ultrasound in Medicine[AIUM]Ultrasound in Medicine[AIUM]– American Board of Family Medicine ObstetricsAmerican Board of Family Medicine Obstetrics

Society of Teachers of Family MedicineSociety of Teachers of Family Medicine– Annual Meeting April 24-29, 2010Annual Meeting April 24-29, 2010– Vancouver, BC; CanadaVancouver, BC; Canada

Transfer of Technology Megatrends 1971-Transfer of Technology Megatrends 1971-20112011

Procedural Skills and Office TechnologyProcedural Skills and Office TechnologyBibliography/reprints.www.psot.comBibliography/reprints.www.psot.com

After the development of basic OB ultrasound After the development of basic OB ultrasound skill, Gyn ultrasound is a natural addition. It skill, Gyn ultrasound is a natural addition. It provides the woman the opportunity to have provides the woman the opportunity to have her exam at the hands of a continuity physician her exam at the hands of a continuity physician who can explain the findings at the bedside. who can explain the findings at the bedside. This minimizes the fragmentation of care and This minimizes the fragmentation of care and improves quality. improves quality.

Over 15 years, a curriculum in ultrasound has Over 15 years, a curriculum in ultrasound has led to improved outcomes for patients and led to improved outcomes for patients and better education for physicians.better education for physicians.

The bimanual pelvic exam has poor sensitivity, The bimanual pelvic exam has poor sensitivity, low specificity, and cannot be standardized for low specificity, and cannot be standardized for teaching.teaching.

BibliographyBibliography1. Morgan WC, Rodney WM, Hahn RG, Garr DA, O'Brien J. Echografie bij Verloskunden en 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 gynaecologie in de praktijruiute: Een ondersteuning voor Luisartsenverloskunde (Office-based ultrasound as a support for family centered obstetrics), Huissarts Nu (HANU) 1987; 16:277-280.ultrasound as a support for family centered obstetrics), Huissarts Nu (HANU) 1987; 16:277-280.2. Morgan WC, Rodney WM, Garr DA, Hahn RG. Ultrasound for the primary care physician: 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):103-107Applications in family-centered obstetrics. Postgrad Med 1988; 83(2):103-1073. Hahn R, Ornstein S, Davies TC, Rodney WM, et al. Obstetric ultrasound training for family 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; 26:553-558.physicians: results from a multi-site study. J Fam Pract 1988; 26:553-558.4. Hahn RG, Davies TC, Rodney WM. Diagnostic ultrasound in general practice. Fam Pract--An 4. Hahn RG, Davies TC, Rodney WM. Diagnostic ultrasound in general practice. Fam Pract--An International Journal 1988; 5(2):129-135.International Journal 1988; 5(2):129-135.5. Rodney WM, Prislin MD, Hahn RG. Family practice obstetrical ultrasound in an urban 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 community health center: Birth outcomes and examination accuracy of the initial 227 cases. J Fam Pract 1990; 30:163-168.Fam Pract 1990; 30:163-168.6. Rodney WM, Hahn RG, Hartman KJ, Deutchman ME. Obstetric ultrasound by family 6. Rodney WM, Hahn RG, Hartman KJ, Deutchman ME. Obstetric ultrasound by family physicians. J Fam Pract 1992; 34:186-200.physicians. J Fam Pract 1992; 34:186-200.7. Deutchman ME, Hahn RG, Rodney WM. Maternal gallbladder assessment during obstetric 7. Deutchman ME, Hahn RG, Rodney WM. Maternal gallbladder assessment during obstetric ultrasound: results and technique. J Fam Pract 1994; 39:33-37.ultrasound: results and technique. J Fam Pract 1994; 39:33-37.8. Euans DW, Hahn RG, Rodney WM. A comparison of manual and ultrasound measurements of 8. Euans DW, Hahn RG, Rodney WM. A comparison of manual and ultrasound measurements of fundal height. J Fam Pract 1995; 40:233-236.fundal height. J Fam Pract 1995; 40:233-236.9. Rodney WM. Historical observations from the RRC 1994-2000: Maternity care[OB] training in 9. Rodney WM. Historical observations from the RRC 1994-2000: Maternity care[OB] training in FP. J Am Board Fam Pract 2002;15:255-56.FP. J Am Board Fam Pract 2002;15:255-56.10. Dresang LT. Rodney WM, Dees J. Teaching OB ultrasound to family practice residents. Fam 10. Dresang LT. Rodney WM, Dees J. Teaching OB ultrasound to family practice residents. Fam Med 2004; 36: 98-107. Med 2004; 36: 98-107. 11.Dresang LT, Rodney WM, Leeman L, Dees J, Koch, P, Palencio M. ALSO in Ecuador: 11.Dresang LT, Rodney WM, Leeman L, Dees J, Koch, P, Palencio M. ALSO in Ecuador: Teaching the Teachers. J Am Board Fam Practice. 2004;17(4): 276-282. Teaching the Teachers. J Am Board Fam Practice. 2004;17(4): 276-282. http://www.jabfp.org/cgi/content/full/17/4/27612. Dresang LT, Rodney WM, Rodney KMM. Prenatal Ultrasound: A tale of two cities. J Nat Med 12. Dresang LT, Rodney WM, Rodney KMM. Prenatal Ultrasound: A tale of two cities. J Nat Med Association Feb 2006; 98: 167-171.Association Feb 2006; 98: 167-171.

Transfer of Technology Transfer of Technology

1971-2011: OB-Gyn 1971-2011: OB-Gyn UltrasoundUltrasound

Position paper with bibliography at Position paper with bibliography at website for Procedural Skills and Office website for Procedural Skills and Office Technnology Technnology www.psot.com

Summary—The bimanual pelvic exam Summary—The bimanual pelvic exam has poor sensitivity, low specificity, and has poor sensitivity, low specificity, and cannot be standardized for teaching. cannot be standardized for teaching. Deletion of the bimanual exam, and open Deletion of the bimanual exam, and open access ultrasound will improve outcomes access ultrasound will improve outcomes for patients. This is an opportunity for for patients. This is an opportunity for family medicine.family medicine.

Family Medicine Ob-Gyn: Family Medicine Ob-Gyn: Curriculum Overview1989-Curriculum Overview1989-

19991999Family Medicine residency 36 months:Family Medicine residency 36 months:– continuity including pelvic exams weekly?continuity including pelvic exams weekly?– 2 months obstetrics+ 1-2 months Gyn2 months obstetrics+ 1-2 months Gyn

Advanced Life support in Obstetrics—Complete 2 Advanced Life support in Obstetrics—Complete 2 day course, pass tests, read ultrasound chapter. day course, pass tests, read ultrasound chapter. Try to attend course with ultrasound workshop.Try to attend course with ultrasound workshop.

Work in an office with a modern ultrasound Work in an office with a modern ultrasound machine with machine with open access open access to immediate to immediate performance of an US examination.performance of an US examination.

Structured sequence of supervised examinationsStructured sequence of supervised examinations– Ten “Quick Look” exams for fetal viability, number, Ten “Quick Look” exams for fetal viability, number,

presentation, placentapresentation, placenta– Forty OB examinations with the above plus biometry, Forty OB examinations with the above plus biometry,

anatomy review, and medical decision makinganatomy review, and medical decision making

Welcome to Medicos para la Welcome to Medicos para la FamiliaFamilia

Medicos was opened in 1999 as a health care Medicos was opened in 1999 as a health care experiment for uninsured Spanish speaking experiment for uninsured Spanish speaking patients in Memphis. Nashville Meharry and patients in Memphis. Nashville Meharry and Nashville Medicos were opened in 2002 and Nashville Medicos were opened in 2002 and 2004.2004.The Technology Transfer Project led to a blend of The Technology Transfer Project led to a blend of Family Medicine Obstetrics, public health, and ER Family Medicine Obstetrics, public health, and ER . Ultrasound has been a key curriculum . Ultrasound has been a key curriculum innovation.innovation.Medicos is open 7 days a week and patients do Medicos is open 7 days a week and patients do not need an appointment. In 2009 Medicos saw not need an appointment. In 2009 Medicos saw over 63,000 patients and delivered over 600 over 63,000 patients and delivered over 600 babies. babies. Medicos does not receive government funds, or Medicos does not receive government funds, or charity support. Medicos pays taxes. charity support. Medicos pays taxes. Through Grace, Medicos provides twice the Through Grace, Medicos provides twice the service at less than half the cost. service at less than half the cost.

Gineco Obstetricia Medicina Gineco Obstetricia Medicina Familiar +ER 2000-2010Familiar +ER 2000-2010

Develop a bilingual high touch high tech open Develop a bilingual high touch high tech open access family medicine based healthcare centersaccess family medicine based healthcare centers– Control practices Nashville—One grew, one didn’t why?Control practices Nashville—One grew, one didn’t why?– Memphis 2000: 6,000 visits, 72 deliveries; 300 ultrasounds/yr.Memphis 2000: 6,000 visits, 72 deliveries; 300 ultrasounds/yr.– Memphis 2009: 44,000 visits; 500+ deliveries; 3000 +Ultrasounds/yr.Memphis 2009: 44,000 visits; 500+ deliveries; 3000 +Ultrasounds/yr.

Ultrasound training became a core requirement of Ultrasound training became a core requirement of Family Medicine Obstetrics fellowship curriculum. Family Medicine Obstetrics fellowship curriculum. – Stopped rescheduling to “ultrasound clinic 1d/wk”.Stopped rescheduling to “ultrasound clinic 1d/wk”.– Daily ultrasound experiences woven into the daily Daily ultrasound experiences woven into the daily

routine of community health careroutine of community health care– Accept need for same day OB Gyn Ultrasound servicesAccept need for same day OB Gyn Ultrasound services

Develop Phase 3 CurriculumDevelop Phase 3 Curriculum

Family Medicine Based Family Medicine Based Ultrasound Curriculum Ultrasound Curriculum 2000-2010: Phase 32000-2010: Phase 3Track and report data; see bibliography; JPS Track and report data; see bibliography; JPS

presentation, “ Is office ultrasound feasible for presentation, “ Is office ultrasound feasible for family physicians who do not do OB”.family physicians who do not do OB”.

Develop ultrasound study hall of mandatory Develop ultrasound study hall of mandatory review of interactive experiences.review of interactive experiences.

Deutchman ME. Obstetrical ultrasound; principles and Deutchman ME. Obstetrical ultrasound; principles and techniques. (CD ROM) 1995 Silver Platter Education. techniques. (CD ROM) 1995 Silver Platter Education. Norwood, MA.Norwood, MA.

Deutchman ME. Ultrasound in Emergency Medicine and Deutchman ME. Ultrasound in Emergency Medicine and Trauma (CD ROM) 2001 Challenger Memphis, TN.Trauma (CD ROM) 2001 Challenger Memphis, TN.

Rodney -Sally and Sue transvag simulators: Ectopic versus Rodney -Sally and Sue transvag simulators: Ectopic versus IUPIUP

Required to review standard texts and Required to review standard texts and bibliography.bibliography.

Developed written and examination tools.Developed written and examination tools.

Ultrasound Curriculum Ultrasound Curriculum 2000-2010: Gyn at the 2000-2010: Gyn at the

bedsidebedsideSelect, read, and reread durable materials.Select, read, and reread durable materials.

Gyn Text Timor; Callen OB; Gabbe cognitive; ER textGyn Text Timor; Callen OB; Gabbe cognitive; ER text

Websites, Medicos email J Club weeklyWebsites, Medicos email J Club weekly

Constantly use online and telemedicine Constantly use online and telemedicine resources for immediate access to consultation resources for immediate access to consultation when needed. when needed.

Acknowledge limits and use second opinions Acknowledge limits and use second opinions when indicated. Consultation frequency=2%when indicated. Consultation frequency=2%

Become uncommonly good at common probsBecome uncommonly good at common probs

Develop and teach from clinical simulations. Develop and teach from clinical simulations.

Office Gyn Ultrasound--Office Gyn Ultrasound--OvariesOvaries

Method of Wm. MacMillan Rodney MDMethod of Wm. MacMillan Rodney MD– Gineco Obstetricia Medicina Familiar+ERGineco Obstetricia Medicina Familiar+ER– Acknowledgments to Ricardo Hahn MD, Clark Smith MD, Acknowledgments to Ricardo Hahn MD, Clark Smith MD,

Mark Deutchman MD, Eduardo Scholcoff MD, the STFM Mark Deutchman MD, Eduardo Scholcoff MD, the STFM Working Group on Hospital Medicine and Procedural Working Group on Hospital Medicine and Procedural Training, and othersTraining, and others

CurriculumCurriculum– Didactic Overview of ExpectationsDidactic Overview of Expectations– Recommended Video MaterialsRecommended Video Materials– Recommended ReadingRecommended Reading– Hands on InstructionHands on Instruction– QA-QI Reports and Case logsQA-QI Reports and Case logs

Teach Normal anatomy with Teach Normal anatomy with patients as they occur.patients as they occur.

Normal ovarian size , shape , Normal ovarian size , shape , and visual “fingerprint”and visual “fingerprint”

Normal follicular cysts Normal follicular cysts are less than 11mmare less than 11mm

62693 19 yo Pelvic Pain; 62693 19 yo Pelvic Pain; 626.4; HCG neg; Diagnosis 626.4; HCG neg; Diagnosis

made easier made easier IdentifyIdentify– Endometrial stripeEndometrial stripe– Posterior surface of Posterior surface of

the uterus the uterus – A hypoechoic areaA hypoechoic area– A lemon shaped area A lemon shaped area

posterior to the uterus posterior to the uterus which has a texture which has a texture different than the different than the uterus.uterus.

From this image, is From this image, is an intrauterine an intrauterine pregnancy likely?pregnancy likely?

Using calipers and labels to Using calipers and labels to demarcate the significant demarcate the significant

finding of free fluidfinding of free fluidAnnotation features Annotation features can and should be can and should be used for later review used for later review of each image.of each image.

Is the architecture of Is the architecture of this ovary normal?this ovary normal?

Is there any Is there any condition more likely condition more likely to create free fluid to create free fluid and a mushy ovary? and a mushy ovary? HCG negHCG neg

Ovarian size and Ovarian size and consistencyconsistency

How is ovarian How is ovarian volume measured?volume measured?

What is the upper What is the upper limit of normal limit of normal ovarian volume?ovarian volume?

What conditions are What conditions are associated with an associated with an enlarged ovary?enlarged ovary?

NeoplasmNeoplasm

CystsCysts

PCOSPCOS

OtherOther

Color Doppler identifies Color Doppler identifies vessels and other structures vessels and other structures

with fluidwith fluidMeasurement Measurement commands are commands are blocked until the blocked until the image is frozenimage is frozen

Color doppler Color doppler commands are commands are blocked if the image is blocked if the image is frozen.frozen.

A visible fallopian tube A visible fallopian tube is unusual. But can be is unusual. But can be mistaken for a blood mistaken for a blood vessel.vessel.

FM US Curriculum 2000-FM US Curriculum 2000-20102010

Phase 3Phase 3Develop, present and publish studies.Develop, present and publish studies.

See bibliographySee bibliography

Focused residency rotations. Focused residency rotations. Assignments + 10 documented exams Assignments + 10 documented exams per day in the office. Goal 50 per day in the office. Goal 50 documented exams in one week.documented exams in one week.

Train visiting professors. Curriculum plus Train visiting professors. Curriculum plus 300 reviewed exams.300 reviewed exams.

Conduct small prototype studiesConduct small prototype studies– Family Medicine Obstetrics Fellowship followupsFamily Medicine Obstetrics Fellowship followups

Poster presentation Tuesday April 27Poster presentation Tuesday April 27

– Expand to include Gyn + ER[abdom, soft tissue] Expand to include Gyn + ER[abdom, soft tissue]

Without OB, is Office Without OB, is Office Ultrasound Feasible in Ultrasound Feasible in

Family Medicine?Family Medicine?A research question from--David McCray MD. A research question from--David McCray MD. Does ultrasound belong in the Family Medicine Does ultrasound belong in the Family Medicine market basket of services? --Dr. Young market basket of services? --Dr. Young

If the equipment costs $35,000, will If the equipment costs $35,000, will reimbursement cover equipment cost, reimbursement cover equipment cost, overhead, and a reasonable payment to the overhead, and a reasonable payment to the physician?physician?

Can family physicians demonstrate and Can family physicians demonstrate and maintain high quality[the standard of care]?maintain high quality[the standard of care]?

Will it lose money, break even, or make money?Will it lose money, break even, or make money?

Recorded Ultrasound Events: Recorded Ultrasound Events: 20092009

44,408 visits suggests the equivalency 44,408 visits suggests the equivalency of 7 physicians seeing 6,300 visits a of 7 physicians seeing 6,300 visits a year each.year each.Computer log Computer log with ID No IDwith ID No ID

OB exams OB exams 25132513 583583

Gyn examsGyn exams 493 493 69 69

Abdominal examsAbdominal exams 117 117 19 19

Computer log without ID[undocumented]. These no-Computer log without ID[undocumented]. These no-ID exams suggest psychosocial-uncharged use.ID exams suggest psychosocial-uncharged use.

Do the arithmetic at $100/exam and less than 15 Do the arithmetic at $100/exam and less than 15 minutes per exam. These data imply there is an minutes per exam. These data imply there is an upside.upside.

Transvaginal ultrasound is Transvaginal ultrasound is feasible in the officefeasible in the office

Radiologists do not perform the examinations , they Radiologists do not perform the examinations , they review images and bill. Many of the techs ask the review images and bill. Many of the techs ask the women to insert the transvaginal probe themselves. women to insert the transvaginal probe themselves. Is this high quality?Is this high quality?Transvaginal Sonography should be part of the Transvaginal Sonography should be part of the physical examination for women with abdominal or physical examination for women with abdominal or pelvic pain. pelvic pain. Goldstein SR. Routine use of office gyn ultrasound. J Goldstein SR. Routine use of office gyn ultrasound. J Ultrasound Med 2002; 21: 489-92.Ultrasound Med 2002; 21: 489-92.

Malpractice covers it. Malpractice covers it. Rodney WM, KM Rodney-Arnold,et alRodney WM, KM Rodney-Arnold,et al

Impact of Deliveries ….. J Nat Med Association October 2006; 98: 1685-1690.Impact of Deliveries ….. J Nat Med Association October 2006; 98: 1685-1690.

It is reimbursable through medicaid—It is reimbursable through medicaid—Dresang L, et al. Prenatal ultrasound: A tale of two cities. J Nat Med Dresang L, et al. Prenatal ultrasound: A tale of two cities. J Nat Med Assoc Feb 2006; 98[2]: 161-171Assoc Feb 2006; 98[2]: 161-171

Rodney Wm, et al. Los desaparecidos. Am J Clin Medicine Spring 2009; Rodney Wm, et al. Los desaparecidos. Am J Clin Medicine Spring 2009; 6[2]: 31-36.6[2]: 31-36.

It is learnable core skill. It is learnable core skill. Nothnagle M, et al. Required Procedural Nothnagle M, et al. Required Procedural Training in Family medicine Residency: Fam Med 2008; 40: 248-252Training in Family medicine Residency: Fam Med 2008; 40: 248-252

Problems with the Bimanual Problems with the Bimanual Pelvic ExaminationPelvic Examination

Its sensitivity and specificity are poor for Its sensitivity and specificity are poor for many regularly ocurring conditions.many regularly ocurring conditions.

Physicians have never received predictably Physicians have never received predictably accountable training in this skill.accountable training in this skill.

Use of live training surrogates never Use of live training surrogates never simulated actual abnormalities seen in the simulated actual abnormalities seen in the community.community.

Previously sacred traditions such as the Previously sacred traditions such as the rectovaginal exam and prevention of ovarian rectovaginal exam and prevention of ovarian cancer have been discarded as scientifically cancer have been discarded as scientifically unproven.unproven.

And othersAnd others

A preliminary studyA preliminary studyTen senior residents and five family medicine Ten senior residents and five family medicine faculty confirmed that the routine bimanual faculty confirmed that the routine bimanual pelvic examination was a “core skill”pelvic examination was a “core skill”

None could say yes to the following statement. “ None could say yes to the following statement. “ I believe that I am capable of detecting most I believe that I am capable of detecting most significant adnexal and uterine abnormalities significant adnexal and uterine abnormalities using the bimanual pelvic examination.”using the bimanual pelvic examination.”

Despite estimating their performance frequency Despite estimating their performance frequency as “at least once a week”, none could describe as “at least once a week”, none could describe or recall any specifics regarding a case in which or recall any specifics regarding a case in which a bimanual examination which led to a change a bimanual examination which led to a change in management.in management.

MethodsMethodsA bimanual pelvic exam record was created and physicians A bimanual pelvic exam record was created and physicians were asked to fill out all fields at the time of pelvic were asked to fill out all fields at the time of pelvic examination.examination.– Age, G,P, contraception, ethnic, comorbiditiesAge, G,P, contraception, ethnic, comorbidities– Reason for pelvic examination todayReason for pelvic examination today

Patients were used a visual analog scale to rated perceived Patients were used a visual analog scale to rated perceived discomfort on line measuring 10 cm.discomfort on line measuring 10 cm.– Insertion of speculumInsertion of speculum– Bimanual examination[controlled for time <3 minutes]Bimanual examination[controlled for time <3 minutes]

Physicians were asked to describe findingsPhysicians were asked to describe findings– Visual findings--Cervix, sidewalls, perineumVisual findings--Cervix, sidewalls, perineum– Palpable—Did you feel any abnormalities of the uterus or adnexae?Palpable—Did you feel any abnormalities of the uterus or adnexae?

Physicians were asked to describe their diagnosis following Physicians were asked to describe their diagnosis following the pelvic exam.the pelvic exam.

The pelvic exam was immediately followed with transvaginal The pelvic exam was immediately followed with transvaginal examination, and post ultrasound diagnosis was obtained.examination, and post ultrasound diagnosis was obtained.

Significant differences between Pre and post ultrasound Significant differences between Pre and post ultrasound diagnoses were tabulateddiagnoses were tabulated

Patient SelectionPatient SelectionPremenopausal, reproductive age women Premenopausal, reproductive age women presenting without appointment because of an presenting without appointment because of an undiagnosed complaint relating to undiagnosed complaint relating to genitourinary tract of onset within the last two genitourinary tract of onset within the last two months.months.

Women with chronic conditions normally not Women with chronic conditions normally not requiring a pelvic exam were excluded.requiring a pelvic exam were excluded.

Women with routine UTI’s, known pregnancies, Women with routine UTI’s, known pregnancies, and Paps smears were not included in the study.and Paps smears were not included in the study.

Target complaints included pelvic pain, irregular Target complaints included pelvic pain, irregular vaginal bleeding, 626.0, lower abdominal pain, vaginal bleeding, 626.0, lower abdominal pain, lost IUD, dyspareunia, infertilitylost IUD, dyspareunia, infertility

Medicos Gyn ultrasound Medicos Gyn ultrasound Preliminary Report 2010Preliminary Report 2010

Among twenty patients, 12 had significant findings Among twenty patients, 12 had significant findings such a painful ovarian cyst, free fluid, imbedded IUD, such a painful ovarian cyst, free fluid, imbedded IUD, PID, or unsuspected pregnancy. Residency trained PID, or unsuspected pregnancy. Residency trained physicians were unable to make diagnoses with the physicians were unable to make diagnoses with the bimanual pelvic examination.bimanual pelvic examination.

The clinical[LMP]history , the physical exam, the The clinical[LMP]history , the physical exam, the fundal height, and lab are inferior compared to fundal height, and lab are inferior compared to ultrasound in the hands of Medicos faculty. ultrasound in the hands of Medicos faculty.

Fragmented care is common with non OB FP’s and ER Fragmented care is common with non OB FP’s and ER providing suboptimal care. Ultrasound improves providing suboptimal care. Ultrasound improves quality.quality.

Weakness--Medicos is seeing these patients in an Weakness--Medicos is seeing these patients in an open access system similar to the ER. Ultrasound is open access system similar to the ER. Ultrasound is used as easily as one might use a stethoscope. Few used as easily as one might use a stethoscope. Few residencies have equipment or faculty to meet this residencies have equipment or faculty to meet this need.need.

PREDICTIONS FOR THE PREDICTIONS FOR THE FUTUREFUTURE

The family physician’s office The family physician’s office will become a high quality will become a high quality center for preventive care, center for preventive care, acute care, patient education, acute care, patient education, diagnostic technology, and diagnostic technology, and therapeutic procedures. therapeutic procedures. WMR WMR 19871987

FAMILY MEDICINE-er-ob FAMILY MEDICINE-er-ob WMR 2002WMR 2002

A Fork in the RoadA Fork in the Road 19721972

The Physician isolated from a medical The Physician isolated from a medical center will not be able to provide high center will not be able to provide high quality state of the art medical care.quality state of the art medical care.

Technology will continue to assist Technology will continue to assist physicians in community-based offices physicians in community-based offices such that high quality state of the art such that high quality state of the art care will be possible for over 90% of care will be possible for over 90% of patients who walk in through the door. patients who walk in through the door.

A Fork in the Road1972-A Fork in the Road1972-20102010The Physician isolated from a medical center The Physician isolated from a medical center

will not be able to provide high quality state of will not be able to provide high quality state of the art medical care.the art medical care.

– Spending 17% of GNP on Health Care in 2006Spending 17% of GNP on Health Care in 2006– The Illusion of endless abundance is irrationalThe Illusion of endless abundance is irrational

Technology continues to improve the skills of Technology continues to improve the skills of community physicians such that high quality community physicians such that high quality state of the art care is possible for over 90% of state of the art care is possible for over 90% of patients who walk in through the door. patients who walk in through the door.

– Disruptive technologies effectively focus on the ten percent of Disruptive technologies effectively focus on the ten percent of the information that makes over 90% of the difference.the information that makes over 90% of the difference.

– Twice the service might be provided at less than half the Twice the service might be provided at less than half the cost.cost.

– Counterintuitive , but more spending may make care worse.Counterintuitive , but more spending may make care worse.– All are for progress, but change is resistedAll are for progress, but change is resisted

Assignments—Using ultrasound Assignments—Using ultrasound images and documented reports, images and documented reports,

assemble a database of outcomes.assemble a database of outcomes.

Improve on previously published reviews by creating a Improve on previously published reviews by creating a study with images demonstrating the ability to make study with images demonstrating the ability to make diagnoses with ultrasound at the bedside.diagnoses with ultrasound at the bedside.

Each fellow will complete a case report as part of the Each fellow will complete a case report as part of the curriculum.. curriculum..

This material will generate questions for the American Board This material will generate questions for the American Board of Family Medicine Obstetrics. of Family Medicine Obstetrics.

2009-2010. Spurlock’s images are dramatic and typical. 2009-2010. Spurlock’s images are dramatic and typical. Abruptio Placenta has occurred four times,. Display of the Abruptio Placenta has occurred four times,. Display of the normal placenta is the usual situation; ie, abruptio is a normal placenta is the usual situation; ie, abruptio is a clinical diagnosis. Uterine rupture may be suspected in the clinical diagnosis. Uterine rupture may be suspected in the case of the painful contracting repeat CS who displays case of the painful contracting repeat CS who displays significant amount of free fluid. significant amount of free fluid.

Postpartum cardiomyopathy with ICU intubation x2, Chest Postpartum cardiomyopathy with ICU intubation x2, Chest radiograph as the index imageradiograph as the index image