Allen Worrall, MD

Articles

SAG Uterus (Transvaginal) Endometrial Polyp

:  "I'm Allen Worrall from Fairbanks, Alaska and  we're here at the 45th Annual meeting of the AIUM in Walt Disney World.   We're actually at the Dolphin Hotel and with me is Dr. Mark Deutchman,  he's in the Department of Family Practice at the University of Colorado  Health Sciences Center in Denver.  We're going to talk today about the  role of the primary practice doctor in ultrasound and also the teaching  resources that are available, particularly to the primary care physician  in ultrasound.  So, Mark, go ahead and tell us why you're here at this  meeting."
       
       

:  "I've been a AIUM member since around  1980.  I was in private practice in a rural area in Washington state and  discovered that I needed to send patients sixty miles away for  ultrasound so I better learn how to do it.  Obstetrics was a big part of  my practice as it still is, and I found that I couldn't practice modern  maternity care without ultrasound so I got one of the first real-time  scanners and learned real-time ultrasound.  It's been a very useful part  of my practice ever since."
       
       

:  "You do all types of ultrasound and not just obstetrics?"
       
       

:  "I do obstetric, gynecologic, and  general abdominal ultrasound and I've used it in the office, in the  hospital, and in the emergency department for many years."
       
       

:  "And you teach family practice residents?"
       
       

:  "Right, I left private practice ten  years ago and I've been teaching since then.  I teach residents and I  also teach a fellowship designed to train family physicians in the  skills they need to practice in a rural practice.  We teach them  surgical skills, endoscopy, and ultrasound is one of the skills that we  also teach."
       
       

:  "Now one of the problems or one of the  areas of contention in sonography is the untrained, unskilled, or  uncredentialed person doing ultrasound.  How are your family practice  residents going to convince the rest of the sonography world that  they're qualified?  I might say that the same thing is true of obstetric  residents, emergency room residents, or any others."
       
       

:  "I think that's a good question, it's  one that we're very concerned about.  There are quite a range of  sonographic skills and I think that a person needs to pick the  application that they're going to do, look at how frequently they're  going to use that application, and look at what training they need.  We  find that we can train essentially all of our residents to do a basic  core of skills that I call labor and delivery skills - fetal life, fetal  number, fetal presentation, and doing amniotic fluid indexes.  Frankly,  I think any physician that delivers babies should be able to use an  ultrasound scanner to do those kind of skills."
       
       

:  "Even the labor room nurses do that too."
       
       

:  "We find that there's really not much  trouble training all of our residents to do those skills.  However, if a  resident or a fellow or a faculty member wants to go ahead and learn  how to do fetal biometry and fetal anatomic surveys, that's a completely  different skill set and takes much more training and much more  supervised education and practice.  It's really a life long skill  because you keep adding as you go.  We also practice under the model  where the physician does his or her own scanning rather then hiring a  sonographer and then signing her over for validating the reports.  We  find that the clinical knowledge that the physician has of the patient  and of the biologic process enables that physician to do a better job,  and I encourage physicians to do their own scanning rather then hiring  someone else to do it."
       
       

:  "That's the way I practice sonography,  and I just can't imagine doing it any other way.  I don't want to imply  that sonographers can't reach huge and very high levels of skill, they  certainly can, but I find that as a gynecologist and obstetrician doing  my own scans is just the perfect way to do it.  Fortunately, I enjoy it  and it's a lot of fun.  We need to talk about the resources that are  available, and I know that you have an interest in producing educational  materials.  Do you want to talk about that?"
       
       

:  "About seven years ago I got  interested in the multimedia platform as a way to help people learn  ultrasound skills in an interactive fashion because the CD-ROM platform  enables you to do things like fetal measurements and identify structures  in an interactive way rather than sitting in a lecture or at a  videotape.  I've now written either myself or with co-authors four  multimedia CD-ROM's.  The first one is on obstetric ultrasonography, the  second one was general abdominal, basically upper abdominal.  The third  one is on fetal anomaly recognition and that, by the way, won a prize  in the scientific exhibits at the AIUM two years ago.  This year I have a  scientific exhibit on a CD-ROM on emergency and trauma ultrasound  co-authored with a friend in Denver.  The fetal anomalies one was  co-authored with a colleague in Belgium.  I found that these tools  really help people learn some of the cognitive-type skills as well as  some of the procedural skills of manipulating images and operating  electronic calipers.  It accelerates their learning curve so when they  actually learn on patients after that they're farther along then if they  just started from scratch."
       
       

:  "Did you do a lot of the actual  production?  In other words, did you have to learn the software that  allows you to produce these educational material?"
       
       

:  "I've done a lot of image editing and  processing, and the current CD that is being exhibited in the scientific  exhibits is done with HealthStream.  There are physicians that are  learning how to produce these things on their own so as the technology  evolves there are more options as time goes on.  Another advantage of  the CD-ROM format is it enables a person to encounter many more  abnormals than they ever possibly could scanning on their own.  So in a  few hours you can pack into your brain some recognition of abnormalities  that would take you years to see if you were scanning patients."
       
       

:  "That's a very important point.  I have  a very small practice and I'm simply overwhelmed when I hear someone  like Beryl Benacerraf say they do on average eighty prenatal scans a day  in her laboratory.  It takes me two or three months to do eighty  prenatal scans so there's just no question that if you have a low volume  prenatal practice you're going to be greatly disadvantaged by not  seeing anomalies because most babies are normal, thank goodness.  Thank  you very much."
       
       

:  "Again, this has been Dr. Mark  Deutchman from Denver, Colorado talking about the family practice and  primary care teaching of ultrasound."

OBGYN.net Conference CoverageFrom 45th Annual Conference of the AIUM - Orlando, FL 2001

The Role of the Primary Care Physician in Ultrasound and  Teaching Resources Available

: "I'm Dr. Allen Worrall from Fairbanks, Alaska and with me is..."

: "I'm Don Shuwarger and I'm from Forest, Virginia a suburb just outside of Lynchburg."

: "Now we got together because we both  changed our practice style several years ago. I mentioned on this  network a year or so ago that I had gotten older and given up surgery  and went into OB-GYN ultrasound. It's a fine profession for the aging  physician who doesn't want to quit or can't afford to quit, and you also  had a change."

: "Yes, about six years ago I moved to my  current location from Houston, Texas. There was a big infiltration of  managed care and it became a very fierce and competitive environment and  one that I did not feel comfortable in so my wife and I looked for a  new location and a new environment where we could practice medicine  without as much interference from the third party payers. That's how we  ended up in Lynchburg but since then a lot of things have changed for  both of us - increasing reliance on ultrasound as a part of your office  practice and then you've seen changes in ultrasound too. What sort of  things are you doing nowadays with ultrasound that you didn't do six or  ten years ago?"

: "At our clinic we started out in the 1970's  with an ultrasound machine which I think was made by ADR. It was a  suitcase-type, little bitty screen, and we now have a very fine ATL 5000  machine. The machines have gotten much much better of course, the  probes have gotten more versatile, and the things that we can do with  ultrasound, for example, sono-hysterograms are very simple and an easy  procedure that's safe. I've never heard of any complication from it and  it's very, very helpful. The question of whether a patient has an  endometrial polyp or a submucous myoma can be resolved with almost 100%  accuracy."

: "Allen, don't you find it interesting when  you do the sono-hysterograms that if the patient can see it at the same  time it makes counseling and education just a breeze?"

: "There's no question about that. We have a  monitor on the wall for the patient and I can show them the image and  show them the water going in and the polyp being outlined, and they can  clearly understand what the problem is. Yes, it's a wonderful thing and  the same thing is true in prenatal sonography when you find an anomaly  or a possible anomaly you can show that to them and they can understand  to some degree what the problem is."

: "How does your clinic store your ultrasound images?"

: "With our ATL HDI 5000 we have the Magneto  optical disk and the images can be stored digitally directly from the  machine to this disk. I personally record all my exams on super VHS tape  so I only use the Magneto optical disk if I see something interesting  or something that I might want to put on the Internet or ask a question  about as an attachment to an e-mail on the Internet."

: "Do you report to referring physicians by e-mail or through any other technological solution?"

: "I use BABE software for both OB and GYN  and BABE's prenatal version permits me to fax directly from my computer  to the provider, and then I always send them a hard copy also.  Otherwise, we just mail a report but the GYN software is just a beta  copy, it's been in beta for seven or eight years and it doesn't have the  fax."

: "Yes, it's very good. I enjoy it but they  never did go to market with the GYN version. Of course, I produce a  formal report on every scan that I do and that's very helpful I think."

: "Does your clinic do any resident education or continuing education?"

: "No, we're in Fairbanks, Alaska and they do  get residents up there for the emergency room at the hospital, and I  think from time to time there may have been a few other residents farmed  out from their program but we don't really have any medical school in  Alaska."

: "In our practice we're primarily  responsible for the education and training of first and second year  family practice residents on OB and GYN. I think it's been very  enlightening for them to come and watch, say, a sono-hysterogram so that  they can actually identify the imaging with the disease process and  then follow the patient to the operating room and learn the pathology.  It gives them a sense of continuity as well as it helps demystify some  of these conditions - submucous fibroid versus intramural fibroids and  subserosal fibroids that a lot of the time these are just terms to them,  when they can translate the terms into visual images and then transfer  the visual images to things that they see at the time of surgery or  treatment protocols and outcomes - it's a great teaching tool as well."

: "Let's talk a little bit about some of the  technology that's impacting our practices, for example, integrating  e-mail or a website into your practice. Have you done anything in that  direction?"

: "I think we've done a bit, everybody who  works in our practice has a desktop computer from the medical assistant  to the office manager and everywhere in between including our  sonographer. Everybody who has a computer has an e-mail address and we  use e-mail extensively within our reasonably small office. We only have  three physicians, a physician assistant, and a full-time sonographer so  there's not too many of us there and even within that small office  environment we use e-mail extensively for intra-office communications.  Often times we get unsolicited patient questions coming in by way of  e-mail because our e-mail address is on our business cards, it's on our  website, and it's on our patient literature so they know that we are  available to them by e-mail. We'll get unsolicited questions like - I  was in the other day and you asked me to do this, now just what was that  for again and so we'll fill in the blanks or we'll answer questions  regarding medication side effects or general questions. Of course, we  try not to practice by e-mail, that wouldn't work too well but often  times it saves a phone call, we can do it off line, you can answer it  from home or from the hospital so it has really freed us up in many  respects. I know a lot of people are concerned about confidentiality  issues but my response to that is if the patient herself generates the  e-mail question then she's taken on the responsibility of deciding  what's confidential and what's not confidential. I don't initiate an  e-mail conversation with the patient but I'll certainly respond to it,  and if I think it gets into a particularly sensitive area, I'll often  times just say that this topic may be too sensitive to talk about on  e-mail and maybe this is something we better discuss on the phone or  face-to-face and they're very accepting of that. They understand for the  most part that e-mail is more like a bulletin board than a telephone.  We also about a year ago started doing electronic patient records, and I  was concerned up front about what the patient's acceptance would be  about electronic patient records. Actually, patient acceptance wasn't  the issue - they love it. They love it because no matter which of our  physicians they see they know that that physician has a complete and  accurate chart updated as of the very last moment because our electronic  patient records are instantaneous and online. We don't have to wait for  transcription for the data to appear so somebody could walk out the  front door after a visit, get home, dial the nurse, and ask a question  related to the visit - what was that blood test you ordered or what did  he say that medicine was or any type of question. She has immediate and  instant access to that data and the phone call is already logged in the  electronic patient record system as well as the nurse's response to the  phone call so we have a very good communications recording tool and  instantaneous online regular patient records. The other thing was that  in terms of security, I think, electronic patient records are far more  secure than paper records. Every one of us employs some janitorial staff  or perhaps some part-time staff and making sure that these people are  not accessing records in an unauthorized way is a constant vigilance for  us. At night when we leave there's only one way to get into the  computer system and that's with a pass word and a user I.D., and I can  assure you the janitor doesn't have that."

: "Also, if we had a catastrophic loss like a  water main break in the ceiling or the ceiling caved in from snow or,  God forbid, a fire wiped out the office, we would lose all our records  all at once. With our electronic patient records that is almost an  impossibility because we backup our records every single day. The  backups go off site and they are contained on a small 4mm backup  cartridge, which goes in the pocketbook of one of our staff members.  That cartridge cannot be read on just your average home p.c., you'd have  to have the same operating system and the same software that we have to  read that cartridge so it's not useful to her. It's not useful to  anybody that would get their hands on her pocketbook so for us to lose  our patient data in a catastrophic way we would have to have that fire  that I talked about on the same night that my secretary lost her  pocketbook so I feel pretty comfortable with that."

: "Yes, that's good. Did you have any trouble with doctor acceptance of the record?"

: "In the office, as you might be able to  tell, I'm the technologically oriented physician, there are two other  physicians and there is differing levels of acceptance. Some people are  technologically challenged, shall we say, other people are sort of  neutral to it, and some people are very embracing of technology. I think  we cover the entire spectrum but, nevertheless, when the decision was  made that this is what we were going to do and the opportunity to write  on paper went away, then it's sink or swim. What you know is that  physicians by nature are swimmers and not sinkers, and even the  technologically challenged reached an excellent level of competence on  our electronic patient records."

: "Does an electronic system pay for itself or didn't you approach it that way?"

: "I think if I were to run the numbers that I  would probably never ever be able to justify going to an electronic  patient record because how can I convince myself that the improved  documentation's going to get me better reimbursement without doing it?  How can I prove to myself that the security of having backups of my  patient records is worth it? How can I prove to myself that I'm seeing  two or three more patients a day because my documentation is going  faster and yet it's more complete if I don't do it? To some extent it is  an issue of confidence or, if you will, a leap of faith. I don't think  the time is too distant when medical practices will ultimately find  themselves in the mode where they have to do this whether they want to  or they think it's cost effective, they just have to do it, and I feel  more comfortable that we have already taken the step. I feel comfortable  where we are and what we're doing now with our electronic patient  records is now we're saying - okay, we're on them, we're using them,  they're working, now how more useful can we make them over and above  their original purpose for us? What can we do to improve outcomes? What  can we do for documentation, and what can we do for research - things  that will help us help our patients that we never could have done with a  piece of paper. So we're trying to take it to the next level."

: "That's very interesting. I think we should probably end this interview now."

AIUM 46th Annual Meeting - Orlando, Florida - March, 2001

Changes in Private Practice

:  "I'm Dr. Allen Worrall from Fairbanks, Alaska and  I'm an OB-GYN doctor who does a good deal of prenatal and GYN  ultrasound.  My job today is to interview Dr. Art Fougner from Forest  Hills, New York, and I'm interested in that because I was born and  raised on Long Island and used to drive by Forest Hills on the Long  Island Railroad when I went into New York City.  It used to be a big  tennis center; I remember that when I was a kid.  Art is going to talk  about       the prenatal assessment of the risk of Down's syndrome, and my  interest in this was started by several things; I'm due to give a talk  on April 21st and I chose that as my topic.  I had a very recent case  that sparked my interest even more; I scanned a thirty-four year old  woman who would be thirty-five at the time of her delivery and her  biophysical triple screen risk was something like 1 in 7,000 - very low  risk.  I scanned her at about nineteen weeks and found what I  interpreted to be echogenic bowel.  I was not sure whether the echogenic  bowel overrode the very low triple screen risk or whether an  amniocentesis was indicated or not indicated.  I decided that I should  recommend to my obstetrical colleague that he do an amniocentesis and he  did.  He is also here in Orlando at Walt Disney World but on vacation  and not coming to this meeting.  By one chance in five million, I ran  into him yesterday and he told me that the amniocentesis revealed a  mosaic for 46-XY and 45-X.  I don't know what that's got to do with  echogenic bowel but, Art, tell us how do you integrate these two  findings - the age of the patient and the triple screen and, of course,  the triple screen includes the age of the patient and the ultrasound  risk?  We could talk about lowering the risk and raising the risk."
       
       

:  "In order to do that, we almost have to  go back to the beginning.  Amniocentesis was first used to diagnose Down  syndrome in the older woman.  It was first used prenatally in the  1970's and the situation used to be very easy, the counseling and risk  assessment simply consisted of asking a woman - how old are you and that  was it.  If you were over a certain age you were offered amniocentesis,  and if you were under a certain age you weren't.  That's the way it  stood until Merkatz in the eighties serendipitously discovered four  fetuses with Down syndrome whose maternal serum AFP's were much lower  than the medium.  Then this progressed rapidly into using other analytes  to nail down and make the test even more sensitive without sacrificing  specificity so now by serum screen we have Down syndrome detection rates  of conservatively around 60%-70%.  Subsequently several investigators,  most notably the group out of Massachusetts headed by Dr. Beryl       Benacerraf, reported on several ultrasound findings which might  also be used to rule in or rule out or I should say modify risks for  Down's such as nuchal folds and then later certain characteristics of  the fetal hand and the fetal heart.  It's almost gotten to the point now  that there are so many markers - I counted over twenty the last time I  looked - for Down's syndrome that one could almost justify an  amniocentesis on virtually every pregnant woman simply based on the  presence or absence of markers.  One of the problems with risk  assessment is you have to know what the individual relative risk is of  the individual finding.  You bring up echogenic bowel, for example,  what's not well appreciated is that the most common correlate with  echogenic bowel and probably the most common cause is bleeding into the  amniotic fluid and subsequent fetal swallowing that let's you get some  bio breakdown and that shows up as inspissated meconium and echogenic  material.  The second thing is that the equipment over the years is  getting better and so the transducer frequencies are getting higher and  higher and produce more and more false-positives.  Now we can detect  things that we never saw previously so the first thing we need to know  is relative risk of the individual findings.  The reason that's  important is if you want to modify risks you have to know by how much  does this finding contribute to a risk.  That's not well defined in  various populations, as a matter of fact, in any population and the  problem with jumping in using markers right now is that all these things  were first described in populations that were already considered to be  at high risk because the original use of ultrasound was not to rule in  an amniocentesis, it was to tell which patient was truly reluctant -  actually your risks are probably lower because your fetus really doesn't  have any of these findings.  Now it's gone completely the opposite  where we're taking       young women who are very happy with their pregnancy and all of a  sudden you see the jaws begin to drop and now they're rapidly becoming  scared to death.  Yesterday it was announced that there's going to be a  consensus panel over the summer to address many of these issues.  In  answer to your question, I'm not sure that really answers your question  because we're all kind of stuck so the best you can do is what you did -  you present the findings to your patient, you have to tell her that  these things have been associated with things, and ultimately the final  choice is up to her.  I think if this were a cancer-screening test, we  wouldn't be doing any of these things because the yield is so poor.  No  cancer detections test would pass muster if a positive finding consisted  of 1 in 300, it just wouldn't pass muster which leaves me to believe  that, perhaps, the only thing our society tolerates less than cancer is  Down syndrome.  Now whether that's a positive or negative can be debated  but that seems to be what the facts are right now."
       
       

:  "Is it true that you can reduce a woman's risk between the ages of 35 and 40 by a negative ultrasound?"
       
       

:  "Yes, I believe that you can.  You can  probably reduce it conservatively by a factor of 75%, 3 out of 4 and  some centers aggressively claim that their detection rates are around  90%.  I'm always leery of that because my own personal bias is that if  you want to see the chromosomes you have to do a specific test that's  for chromosomes.  As of yet, ultrasound hasn't gotten down to the high  frequency necessary to visualize chromosomes so, therefore, you almost  have to look but I do believe that you could at least modify the risks."
       
       

:  "Now how about the woman under 35,  let's say, a low risk woman who has a triple screen that indicates a  risk of 1 in 200 but a negative ultrasound.  How would you advise her?"
       
       

:  "Again, the trick is given the practice  environment in which we live, you can't advise anybody to do anything.   What you can do is you can say - these are your risks and ultimately  it's your pregnancy, you need to talk to people.  This is a decision  that I can't make for you, you need to make that decision that your  risks have to be reduced but they're not zero.  A common analogy I use  is that in our neighborhood we have Queen's Boulevard, it's easily one  of the widest thoroughfares in the world, and people get killed  periodically crossing the street so the risk of getting killed on  Queen's Boulevard given the number of people that cross the street is  very low but it's not zero.  I think this is an analogous situation."
       
       

:  "We do expect a paper, I believe, this  afternoon from Dr. Nyberg.  He has some interesting new information I  think about the independence of ultrasound and biochemistry.  This is a  field that is important and we know that we're overusing these minor  markers, and Doctors Filly and Benacerraf have written recent papers on  this subject that stimulated the AIUM to call a consensus panel so we  all will know how to use these things.  I think it takes a good deal of  courage to find a soft marker in an otherwise low risk patient and just  ignore it and not even mention it because       any baby can be born with Down syndrome, and if that one is born  with Down syndrome and the patient gets it to a lawyer, and the lawyer  finds that the baby had an echogenic focus that you didn't mention - why  you might be in trouble so that's the problem."

Allen Worrall, MD

Articles

SAG Uterus (Transvaginal) Endometrial Polyp

SAG Uterus (Transvaginal) Endometrial Polyp

The Role of the Primary Care Physician in Ultrasound and Teaching Resources Available

Changes in Private Practice

The Prenatal Ultrasound Assessment for the Risk of Down's Syndrome