International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) - the propagation of knowledge in ultrasound for the improvement of OB/GYN care worldwide: experience of basic ultrasound training in Oman

Background The aim of this study is to evaluate effectiveness of a new ISUOG (International Society of Ultrasound in Obstetrics and Gynecology) Outreach Teaching and Training Program delivered in Muscat, Oman. Methods Quantitative assessments to evaluate knowledge and practical skills were administered before and after an ultrasound course for sonologists attending the ISUOG Outreach Course, which took place in November, 2017, in Oman. Trainees were selected from each region of the country following a national vetting process conducted by the Oman Ministry of Health. Twenty-eight of the participants were included in the analysis. Pre- and post-training practical and theoretical scores were evaluated and compared. Results Participants achieved statistically significant improvements, on average by 47% (p < 0.001), in both theoretical knowledge and practical skills. Specifically, the mean score in the theoretical knowledge test significantly increased from 55.6% (± 14.0%) to 81.6% (± 8.2%), while in the practical test, the mean score increased from 44.6% (± 19.5%) to 65.7% (± 23.0%) (p < 0.001). Performance was improved post-course among 27/28 participants (96.4%) in the theoretical test (range: 14 to 200%) and among 24/28 (85.7%) trainees in the practical skills test (range: 5 to 217%). Conclusion Application of the ISUOG Basic Training Curriculum and Outreach Teaching and Training Course improved the theoretical knowledge and practical skills of local health personnel. Long-term re-evaluation is, however, considered imperative to ascertain and ensure knowledge retention.


Background
Ultrasound relies heavily on the technical skills of providers and effective training is essential to ensure consistently high-quality care. However, there is still a lack of standardized training for ultrasound in obstetrics and gynecology [1]. Recent surveys of trainees across the USA and Europe report widespread variability in availability, quality, and methods of training and assessment, both within and across countries [2]. As ultrasound equipment has become more affordable, its use (particularly in low and middle income countries) has also increased. This has raised additional challenges around implementation and personnel capacity and the demand for education and training is greater than ever [3].
The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) has been recognized, since its establishment in 1991, as a provider of high-quality medical education; it supports individuals and health services in obstetric and gynecological ultrasound. Among other initiatives, ISUOG is developing and providing systematic theoretical and practical training based on its basic training recommendations [4]. In particular, it is expanding educational activities globally through on-site, standardized, basic training courses. Since 2008, ISUOG has run nine such training courses and outreach programs in Haiti, Somaliland, Sudan, Oman, Ghana, Mongolia, Myanmar, Papua New Guinea, and Lebanon, with the aim of providing on-site education to local health personnel [5]. These training programs are contributing to ISUOG's long-term vision that every woman in the world has access to ultrasound, that every scan provider is competent and that the diagnosis of obstetric and gynecologic conditions is effective so that women's health outcomes improve [6,7]. ISUOG is, moreover, carrying out research to validate its educational activities and demonstrate the effectiveness of the range of training programs offered [8]. ISUOG's curriculum development and courses around the world are now sufficiently well established to allow scientific validation of these educational initiatives and determine their effectiveness. The aim of the study was to evaluate the learning outcomes of ISUOG's Outreach Course.

Methods
The study took place during an outreach training program for obstetric and gynecologic ultrasound in Muscat, Oman, from 5th to 9th November, 2017. The Omani government had previously selected 30 trainees to become trainers in their own regions and approved the study. We collected information and assessed learning competency, short-term retention, and adaptation to change of practice. Quantitative assessment to evaluate obstetric knowledge and practical skills was administered to sonologists before and after the training program. Twenty-eight of the trainees attended the course and were included in the analysis. All participants provided written informed consent and were assigned identification numbers to ensure confidentiality.
We administered multiple choice questions, created for this purpose by senior clinicians for ISUOG, to assess the theoretical background of participants. In order to evaluate the efficacy of the course, the performance of the 28 trainees, who answered 19 theoretical questions to determine their original level of knowledge, was analyzed. The content of these questions involved basic theoretical knowledge in obstetrical ultrasound pertinent to fetal anatomy, biometry, and pathology, as well as the techniques for performing fetal ultrasound. These 19 questions represented important learning points from all lectures delivered during the 5-day course. After the completion of the theoretical training, physicians were required to answer a double number of questions (40 multiple choice questions, including the 19 questions that were administered to them at the outset of the training program). These extra questions were from the same lectures as the pre-course questions and explored further the theoretical knowledge acquired through the course.
The practical skills component of the program was similarly evaluated using pre-and post-training sets, in accordance with current consensus criteria on how to evaluate ultrasound competence [9]. Assessment of practical skills was performed in a clinical setting with patients. At the beginning of the practical training session, each trainee was asked to display their current level of ultrasound skills by demonstrating how they would capture and evaluate fetal images and biometric measurements as well as transvaginal gynecological scan images.
Trainees were asked to obtain the following images: head and abdominal circumference, femur length, placental localization including distance of placenta from internal cervical os, four-chamber fetal heart view and longitudinal section of uterus, and ovarian morphology in the obstetrical and the transvaginal ultrasound. Each training day comprised a 4-h theoretical session made up of lectures, which was followed by an equal time practical training in patients, during which participants were required to practice, among other skills, sliding, rotation, dipping, and angling transducer motions, as well as basic machine "knobology". The training course involved a series of hands-on sessions relevant to the three trimesters of pregnancy and included the assessment of fetal lie and presentation, viability, number of fetuses, placenta location, amniotic fluid volume, and fetal biometry. The trainees practiced on volunteer women who provided consent. Each trainee was asked to produce a second copy of the images on the last day of practical training; one copy was kept with the patient notes and the other was used for practical assessment of the trainees by the trainer.
Pre-and post-training practical scores were evaluated according to the Objective Structured Assessment of Ultrasound Skills (OSAUS) on a scale of 1 to 5: this involves four elements concerning the images obtained, including applied knowledge of ultrasound equipment, image optimization, systematic examination, and interpretation of images (Additional file 1: Table S1 and Additional file 2: Table S2) [4].
The collected data were analyzed using MedCalc Statistical Software version 12.7.7 (2013 MedCalc Software bvba, Ostend, Belgium). Quantitative variables were expressed as mean ± standard deviation (SD). The paired t-test was applied to detect differences between pre-and post-course variables after normality verification using the Kolmogorov-Smirnov test. Qualitative variables were expressed as numbers and percentages, and analysis was performed with the chi-square or Fisher's exact tests, as appropriate. P < 0.05 was considered statistically significant.

Results
All trainees taking part in the Oman course were female, as male doctors rarely if ever work in this field in Oman [10], the Oman Medical Specialty Board having recorded no male residents graduating in this specialty between 2006 and 2015. Table 1 depicts the background characteristics of the trainees. The average age was 38 years, with a range of 31-47 years. Nine trainees (30%) had been practicing ultrasound for between 5 and 10 years before the course, 11% for 3-5 years, and 18% for 0-3 years. The remaining trainees did not specify. On average, the trainees completed 38 obstetric scans per week (numbers ranging from 1 to 120). Very few trainees had performed gynecological ultrasound scans on a regular basis, if at all. Approximately half of the trainees who responded to the survey had received their ultrasound certificate before the course and five had formal training in the form of the official National Curriculum in Fetal Ultrasound. A small number of trainees reported having practiced ultrasound for over 5 years despite no formal training and no supervised clinical practice; others had no formal training, though some supervision.
From this study population of 30 trainees, 28 trainees were included in the analysis as two trainees did not attend the course. This analysis was composed of theoretical knowledge and practical skills assessment. Concerning the theoretical part, 19 questions were answered pre-and post-course. The score (number of correct answers per trainee) ranged from 26 to 74% in the pre-course test and from 63 to 95% in the post-course evaluation. There was a significant increase in the mean score, which increased from 56% (± 14%) to 82% (± 8%) (an increase of 47% (95%CI: 38 to 56%), p < 0.001). Twenty-seven out of the 28 trainees (96%) showed improvement, while in one case the performance worsened ( Figs. 1 and 2).
In the practical ultrasound skills test, scores ranged from 20 to 95% in the pre-course test and from 25 to 100% in the post-course evaluation. There was a significant increase in the score which increased from 45 to 66% (a mean increase of 47% p < 0.001). Eighty-six percent of the trainees improved their performance postcourse by a range of 5-217%. Half of the trainees (14/ 28) improved by at least 50%, while four trainees improved by 100% or more. Only two trainees showed a worsening by 20 and 14%, while for two trainees, the score remained unchanged after the practical course. In the pre-course test, the majority of the trainees (71%) had a score of < 50%, whereas 69% of the trainees scored ≥50% post-course (OR = 5.3, 95%CI: 1.7 to 16.5, p = 0.004). Furthermore, in the post-course test, 64% of the trainees scored ≥60%, whereas this figure was 14% precourse (OR = 10.8, 95%CI: 2.9 to 40.1, p < 0.001) (Fig. 3).

Discussion
Several factors seem to create barriers to regular use of ultrasound in clinical practice. Among them, lack of appropriate training appears to be the most important issue. However, issues such as lack of equipment, equipment malfunction, and lack of maintenance of hardware seem to equally restrict dissemination of knowledge as well as retention of theoretical and practical skills that is required for optimal clinical practice [11]. In this study, we evaluated the performance of 28 trainee physicians in Oman with regard to the theoretical knowledge and practical skills acquired in obstetrical and gynecological ultrasound after a 5-day Outreach training course organized by ISUOG Outreach partners together with the Omani government; this was the first national ultrasound training conducted in this country. We showed that the course was associated with a remarkable improvement in post-course scores compared to pre-course, not only for theoretical but also practical components. This highlights the success of the course in fulfilling the training needs, as well as the goals of ISUOG. Our study highlighted that there was significant heterogeneity in experience and inconsistency in prior training at baseline; this further validates our approach, as ISUOG's Basic Training program ensures standardized training and ensures that all trainees have experience in both obstetric and gynecological ultrasound. As part of this, ISUOG also initiated the use of log books among trainees in order for each trainee to better record her experience obtained and practice performed throughout the year.
Before the course, the participants gave the appearance of forming a rather disparate group, showing a significant dispersion in the level of their theoretical knowledge. By the end of the training process, however, the participants, overall, gave evidence of having considerably improved their level of knowledge, while their differences in knowledge were remarkably decreased with respect to the theoretical subjects they had been taught. Identification of these differences leads to the conclusion that the interobserver discrepancy noted pre-and postcourse could also be partly attributed to provider skills. These differences have already been described in the setting of advanced gynecological ultrasound [12]; however, it remains unclear whether the trainers' ability to evaluate the skill of participants is enhanced following the completion of these courses.
The results of the practical course evaluation were equally impressive: before practical training, the trainees demonstrated their initial level of ultrasound skill by producing specific images in obstetric and gynecological ultrasound. After its completion, the trainees were asked to once again produce the specific images, and their preand post-course performance was evaluated based on the OSAUS scoring system (Additional file 2: Table S2). The average improvement of practical skills (47% (range 45-66%)) is also very encouraging and underlines the importance of this Outreach Program.
Despite the ubiquitous success of the project, two participants had lower scores following the completion of the practical component of the course. Obviously, the acquisition of practical skills may be slower in some trainees, but the aforementioned minimal decline that was shown in practical skills may be due to two incidental factors: the position of the baby during the final practical exam, which made it more technically demanding for the specific trainee, and the maternal habitus, since the exam took place in real pregnant women. These occurrences happen unexpectedly as the baby moves or stays still for prolonged periods and in unfavorable positions.
One limitation of our study is that we only assessed short-term retention of information. Data concerning trainees' retention of the theoretical background are scarce in the literature and seem to be conflicting [13,14]. While several methods have been suggested, including live lectures, podcasts, and e-learning activities, none of them has proved to be superior to the old teaching methods [14,15]. In 2016, Hempel et al. demonstrated that the incorporation of an e-learning activity following the completion of a hands-on training session significantly increases knowledge retention and trainees' satisfaction [16]. To this end, WhatsApp Messenger groups (https://en.wikipedia. org/wiki/WhatsApp) were established after the conclusion of this week of training between the designated trainer and the Omani trainees to ensure continuous communication for the next semester, which will enable ultrasound image and text exchange so that trainees' questions can be answered; further work to assess these longer-term effects on retention of knowledge and skills is underway.

Conclusion
The findings of our study show that the conduct of basic ultrasound training programs significantly improves both the theoretical and practical skills of trainees. The results of this analysis demonstrate that the basic training course in Oman, like many others previously organized in numerous other countries by ISUOG, successfully achieved the ISUOG goals and gives every appearance of serving its purpose for the propagation of physicians' and midwives' knowledge in ultrasound, with the ultimate goal of improving healthcare in the field of obstetrics and gynecology worldwide. Future research activities should evaluate the retention of skills over time and the successful implementation of ultrasound in prenatal care in order to ensure long-term sustainability of providing quality basic ultrasound examinations to women in low-resource settings.
Additional file 2: Table S2. OSAUS questionnaire for each investigated parameter.
Abbreviations ISUOG: International Society of Ultrasound in Obstetrics and Gynecology; OSAUS: Objective Structured Assessment of Ultrasound Skills; SD: standard deviation