Abstract
Objectives: To evaluate whether gynecologic surgical trainees (fellows) can become competent in the real-time classification of the pouch of Douglas (POD) obliteration state and direct visualization of bowel deep endometriosis (DE) during a program with a prespecified number of transvaginal ultrasound (TVUS) examinations. Methods: We performed a prospective study between December 2017 and December 2018. Three fellows (F1–F3) performed 50 scans each, which were all supervised by an expert sonologist, who performed the reference standard TVUS examination. The fellows performed a focused TVUS examination to assess the bowel and POD state, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's official classifications. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used. Results: A total of 150 examinations were performed on 145 patients. Twenty-six (17.9%) patients had a diagnosis of bowel DE, and 34 (23.4%) were classified as having a negative sliding sign by the reference standard. The overall accuracy of the presence/absence of bowel DE was 90% (range, 82%–94%). The overall accuracy of POD state classification was 93% (range, 90%–96%). The cumulative summation test for the learning curve for bowel DE showed that F1 did not reach competency by 50 scans, whereas F2 and F3 required 21 and 25 scans, respectively. For POD obliteration, F2 did not reach competency, whereas F1 and F3 required 40 and 22 scans. Conclusions: Not all trainees can reach competency for TVUS evaluations of POD obliteration and bowel DE in a predefined number of scans.
| Original language | English |
|---|---|
| Pages (from-to) | 2295-2303 |
| Number of pages | 9 |
| Journal | Journal of Ultrasound in Medicine |
| Volume | 39 |
| Issue number | 12 |
| DOIs | |
| Publication status | Published - Dec 2020 |
| Externally published | Yes |
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In: Journal of Ultrasound in Medicine, Vol. 39, No. 12, 12.2020, p. 2295-2303.
Research output: Contribution to journal › Review article › peer-review
TY - JOUR
T1 - One-Size-Fits-All Approach Does Not Work for Gynecology Trainees Learning Endometriosis Ultrasound Skills
AU - Leonardi, Mathew
AU - Ong, Jozarino
AU - Espada, Mercedes
AU - Stamatopoulos, Nicole
AU - Georgousopoulou, Ekavi
AU - Hudelist, Gernot
AU - Condous, George
N1 - Funding Information: All patients underwent an expert-guided TVUS examination of the pelvis with a Voluson E8 system (GE Healthcare, Milwaukee, WI) equipped with volumetric intravaginal transducers (GE RIC 5?9 MHz) by the ES (G.C.) as a reference standard scan. No bowel preparation, intravaginal saline solution, or bowel contrast was used in this study. The ES is considered a European Federation of Societies for Ultrasound in Medicine and Biology level 3 practitioner24 with expertise in endometriosis US.3,11 The expert-guided TVUS examination was performed per the recommendations of the IDEA group,11 including characterization of bowel DE lesions by location, measurement, and type. Pouch of Douglas obliteration was considered a dichotomized outcome (obliterated versus not obliterated), with partial-obliteration states categorized as obliterated for the purpose of the study. The ES was aware of the patient's clinical and surgical history, including any previous imaging results. The reference standard expert-guided TVUS examination was performed before the examinations by the fellows and always on the same day as the examinations by the fellows. We performed a prospective learning curve study at a tertiary endometriosis clinic in Sydney, Australia, over a 12-month period between December 2017 and December 2018. The learning curves of 3 fellows were evaluated for the diagnosis of bowel DE using direct visualization and POD obliteration using the sliding sign. This study received ethical approval from the Nepean Blue Mountains Local Health District Human Research Ethics Committee (HREC/16/NEPEAN/30), and written informed consent was obtained from all study patients. Consecutive patients with symptoms suggestive of endometriosis were recruited for the study. Patients were referred either for management of possible endometriosis or a US evaluation of possible endometriosis. Inclusion criteria included the following: postmenarchal and premenopausal status and clinical suspicion or confirmed current endometriosis (either based on signs/symptoms, including dysmenorrhea, dyspareunia, dyschezia, noncyclic chronic pelvic pain, and infertility, or confirmed by imaging or surgery). Exclusion criteria included premenarchal or postmenopausal status, surgical history of hysterectomy or bilateral oophorectomy, pregnancy, known M?llerian anomalies, and inability to undergo a TVUS examination (eg, virginal status). Participants included 3 fellows (F1?F3) of varying prestudy US experience, including core obstetrics and gynecology training. All were currently undergoing the same subspecialty training program in gynecologic sonology and minimally invasive gynecologic surgery. All fellows enrolled in the fellowship program participated in the study, and no additional trainees were available for recruitment. At the initiation of the study, F1, F2, and F3 had performed approximately 500, 1000, and 100 basic TVUS examinations, respectively. No fellow had formal training or experience in advanced TVUS for endometriosis. The prestudy scans performed by F1 were done exclusively in the center where the study took place but focused on early pregnancy complications and general gynecologic conditions. All prestudy TVUS scans done by F1 were supervised by a gynecologic sonologist. Fellow 2 had moderate experience with formal diagnostic gynecologic US. These scans primarily took place in a general gynecology outpatient clinic and were performed and reported independently. The prestudy TVUS scans performed by F3 were done in a typical general radiology practice (run by sonographers and a radiologist). All 3 trainees performed their prestudy scans in large metropolitan cities. At the onset of the study, by the European Federation of Societies for Ultrasound in Medicine and Biology minimum training requirements,24 F2 would have been considered European Federation of Societies for Ultrasound in Medicine and Biology level 1, whereas F1 and F3 would not yet have been considered level 1 competent. All 3 trainees had prestudy gynecologic surgery exposure, including exposure to complex endometriosis laparoscopic surgery. A standardized educational program preceded study initiation. This involved self-directed theoretical learning through reading of key publications (including viewing figures and supplementary figures and videos).3,11 Videos of positive and negative sliding signs in anteverted and retroverted uteruses were included. In addition, fellows were present during 5 routine expert-guided TVUS examinations by an expert sonologist (ES), during which all fellows had the opportunity to witness bowel DE and POD obliteration in real time. Although not part of the official educational program, all fellows attended the same lectures and academic presentations on endometriosis at the 27th World Congress on Ultrasound in Obstetrics and Gynecology 3 months before patient recruitment. All patients underwent an expert-guided TVUS examination of the pelvis with a Voluson E8 system (GE Healthcare, Milwaukee, WI) equipped with volumetric intravaginal transducers (GE RIC 5?9 MHz) by the ES (G.C.) as a reference standard scan. No bowel preparation, intravaginal saline solution, or bowel contrast was used in this study. The ES is considered a European Federation of Societies for Ultrasound in Medicine and Biology level 3 practitioner24 with expertise in endometriosis US.3,11 The expert-guided TVUS examination was performed per the recommendations of the IDEA group,11 including characterization of bowel DE lesions by location, measurement, and type. Pouch of Douglas obliteration was considered a dichotomized outcome (obliterated versus not obliterated), with partial-obliteration states categorized as obliterated for the purpose of the study. The ES was aware of the patient's clinical and surgical history, including any previous imaging results. The reference standard expert-guided TVUS examination was performed before the examinations by the fellows and always on the same day as the examinations by the fellows. Each fellow performed 50 predetermined study expert-guided TVUS examinations (focusing on bowel and POD assessment) consecutively. This number was decided on the basis of previous studies.18?20 Throughout the study period, fellows continued to perform routine basic TVUS examinations on patients for non?endometriosis-related indications. Fellows were blinded to the clinical and surgical histories of all patients as well as the reference standard findings of the ES. They were aware that all patients were being evaluated for endometriosis. The ES was present during the fellow scans in an observation-only capacity. The ES was aware of the reference standard results at this point. After completion of the fellow's examination, the fellow vocalized the classification with respect to bowel DE and the POD obliteration state. This was recorded by the ES, after which feedback was provided to the fellow. In all cases, although especially those with incongruent findings, the ES provided verbal and hands-on guidance to optimize the diagnostic skills of fellows. Fellows were not required to describe the bowel DE location, measurement, or type in the same manner as the ES. Continuous variables are expressed as means ? standard deviations. Categorical variables are presented as frequencies and percentages. The accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios were calculated for the presence or absence of bowel DE and the POD obliteration state with 95% confidence intervals. The cumulative summation test for the learning curve (LC-CUSUM) was adopted for this study. As per Biau et al,25 it is a method to objectively define acquisition of skill competency, presumes that the trainee is not competent at the start of monitoring, and signals when the trainee has reached the acceptable predefined level of performance. The null hypothesis, H0, is defined as inadequate performance for the detection of POD obliteration or bowel DE and is progressively tested against the alternate hypothesis, H1, defined as adequate performance by way of successive outcomes. Each of a trainee's successive outcomes contributes to an LC-CUSUM score, in which correct interventions or performances yield progressively negative scores, and vice versa, each incorrect result leads to a more positive LC-CUSUM score. When the summation LC-CUSUM score reaches a predefined level (h), the H0 is rejected in favor of H1, signifying that adequate performance has been reached. Similar to Biau et al25 and Tammaa et al,18 we used the following parameters: for the learning curve: the hypothesis H0 was set with P0 = 0.175 (failure rate, 17.5%; process out of control), H1 with P1 = 0.1 (failure rate, 10%; process in control), and a control limit of h = 1.25 was chosen. Publisher Copyright: © 2020 by the American Institute of Ultrasound in Medicine
PY - 2020/12
Y1 - 2020/12
N2 - Objectives: To evaluate whether gynecologic surgical trainees (fellows) can become competent in the real-time classification of the pouch of Douglas (POD) obliteration state and direct visualization of bowel deep endometriosis (DE) during a program with a prespecified number of transvaginal ultrasound (TVUS) examinations. Methods: We performed a prospective study between December 2017 and December 2018. Three fellows (F1–F3) performed 50 scans each, which were all supervised by an expert sonologist, who performed the reference standard TVUS examination. The fellows performed a focused TVUS examination to assess the bowel and POD state, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's official classifications. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used. Results: A total of 150 examinations were performed on 145 patients. Twenty-six (17.9%) patients had a diagnosis of bowel DE, and 34 (23.4%) were classified as having a negative sliding sign by the reference standard. The overall accuracy of the presence/absence of bowel DE was 90% (range, 82%–94%). The overall accuracy of POD state classification was 93% (range, 90%–96%). The cumulative summation test for the learning curve for bowel DE showed that F1 did not reach competency by 50 scans, whereas F2 and F3 required 21 and 25 scans, respectively. For POD obliteration, F2 did not reach competency, whereas F1 and F3 required 40 and 22 scans. Conclusions: Not all trainees can reach competency for TVUS evaluations of POD obliteration and bowel DE in a predefined number of scans.
AB - Objectives: To evaluate whether gynecologic surgical trainees (fellows) can become competent in the real-time classification of the pouch of Douglas (POD) obliteration state and direct visualization of bowel deep endometriosis (DE) during a program with a prespecified number of transvaginal ultrasound (TVUS) examinations. Methods: We performed a prospective study between December 2017 and December 2018. Three fellows (F1–F3) performed 50 scans each, which were all supervised by an expert sonologist, who performed the reference standard TVUS examination. The fellows performed a focused TVUS examination to assess the bowel and POD state, having been blinded to the patient's clinical history and reference standard findings. Immediate feedback and hands-on teaching were provided after each of the fellow's official classifications. To evaluate the number of scans needed to gain competency, the cumulative summation test for the learning curve was used. Results: A total of 150 examinations were performed on 145 patients. Twenty-six (17.9%) patients had a diagnosis of bowel DE, and 34 (23.4%) were classified as having a negative sliding sign by the reference standard. The overall accuracy of the presence/absence of bowel DE was 90% (range, 82%–94%). The overall accuracy of POD state classification was 93% (range, 90%–96%). The cumulative summation test for the learning curve for bowel DE showed that F1 did not reach competency by 50 scans, whereas F2 and F3 required 21 and 25 scans, respectively. For POD obliteration, F2 did not reach competency, whereas F1 and F3 required 40 and 22 scans. Conclusions: Not all trainees can reach competency for TVUS evaluations of POD obliteration and bowel DE in a predefined number of scans.
KW - competency-based medical education
KW - deep endometriosis
KW - endometriosis
KW - learning curve
KW - transvaginal ultrasound
KW - uterine sliding sign
UR - http://www.scopus.com/inward/record.url?scp=85090951579&partnerID=8YFLogxK
U2 - 10.1002/jum.15337
DO - 10.1002/jum.15337
M3 - Review article
C2 - 32412170
AN - SCOPUS:85090951579
SN - 0278-4297
VL - 39
SP - 2295
EP - 2303
JO - Journal of Ultrasound in Medicine
JF - Journal of Ultrasound in Medicine
IS - 12
ER -