Ultrasound in a Small Rural Ob/Gyn Private Practice

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Dr. Pamela Yoder: "We're at the 43rd annual meeting of the American Institute of Ultrasound in Medicine, and I've met some interesting people here, including these two folks who are from Lynchburg, Virginia. We have Kim Shaver, RDMS, who works as a sonographer at the Forest Women's Center, and we also have Don Shuwarger, who's an Ob/Gyn physician and has an infertility practice, also at Forest Women's Center. Don, can you talk first about what services they provide to the women in the Lynchburg area, and then talk a little about how they got there?"

Dr. Don Shuwarger: "We started our center about a year and a half ago, and we offer a full range of obstetrical and gynecological care. In addition, we also have a full-time sonographer - Kim Shaver, as you mentioned - and we also have a licensed clinical therapist who works in our practice, as well, who also received her endorsement in family and marital therapy."

Dr. Pamela Yoder: "That's interesting. So you provide full services for women?"

Dr. Don Shuwarger: "Across the age spectrum."

Dr. Pamela Yoder: "How many members of your staff are women?"

Dr. Don Shuwarger: "All of them except for me. There's another physician that works with me - her name is Dr. Uray - and then we have one ultrasonographer, one licensed clinical therapist, two licensed practical nurses, a medical assistant, and three people who work in the front office in the reception, billing, and collections area."

Dr. Pamela Yoder: "I've attended some of the sessions with you and took notes with regard to fetal imaging. Is that one of your areas of interest?"

Kim Shaver, RDMS: "Yes, we do fetal imaging up until Level II. We have to send those off, but we do first-trimester, second-term, biophysical profiles, and also gynecology imaging."

Dr. Pamela Yoder: "Do you do imaging at the hospital as well?"

Dr. Don Shuwarger: "Our local hospitals do imaging, and the imaging that's done there is done by the radiology staff. Usually that's related to just straight x-rays, specialized studies, or patients who are in the hospital who need ultrasound and get their studies done at that time."

Dr. Pamela Yoder: "I know you've had an interesting career path, from Houston to Lynchburg. Can you tell me a little bit about that?"

Dr. Don Shuwarger: "I went to medical school at Baylor after graduating from USC, stayed there to do my residency in obstetrics and gynecology, and then went into several private practices in Houston. I stayed there until 1994, when the HMOs came into our suburb and pretty much sewed up the business of about 60% of the local patients and brought in their own closed panel of physicians. So, many of us who were in private practice in the community found that within ninety days we had 60% fewer patients. Our choices were to join this closed-panel, staff model HMO that was extending offers, to scale back our practices, or to ask ourselves if this is the way it's going to be, and is this where we really chose to live?"

Dr. Pamela Yoder: "How did you find the Lynchburg community? Did they recruit you, or did you seek out positions there?"

Dr. Don Shuwarger: "I did not go the recruitment route. My wife and I discussed it, and we thought that if we were going to make a move at this point of our careers - I was thirty-seven at the time - then we would not let the tail wag the dog. We would find out where we wanted to live first, and then figure out if there was a way to have a viable practice in that community. Although practice viability was a strong component of our decision, we considered lots of other things such as crime, cost of living, the climate, whether or not there was a single industry or single employer, and the dependence of the community on governmental programs and financing - really different components."

Dr. Pamela Yoder: "A matrix approach to finding a new home..."

Dr. Don Shuwarger: "That's right."

Dr. Pamela Yoder: "How did it go?"

Dr. Don Shuwarger: "Unexpectedly well. We are very pleased."

Dr. Pamela Yoder: "What's the population there?"

Dr. Don Shuwarger: "I'm not certain. I think the population in Lynchburg itself is in the 30,000 to 40,000 range, but if you count the surrounding areas from which we draw many of our patients, I think we're up to about 100,000 to 120,000."

Dr. Pamela Yoder: "Now you're involved in OBGYN.net as one of the Advisory Board Members and Consultants online. How did you get involved in that?"

Dr. Don Shuwarger: "OBGYN.net's been one of the best things that has happened to me as a small practice practitioner in a community that doesn't have a medical school or obstetrics-gynecology residency training program. It has enabled me to keep in contact with those who are elsewhere in the world, and are more connected than I am, on a daily basis. I'm able to have discussions with faculty and with practitioners from not only across the U.S., but also the world, and I'm able to draw on the experience and information that they have to give me. This is something that I had readily available in Houston with the availability of the Texas Medical Center, and you lose that when you go to places that don't have such centers."

Dr. Pamela Yoder: "What would you recommend for physicians who are in similar situations in terms of getting involved in such an organization? How do they go about getting onto OBGYN.net? How do you find it, or what's the URL, for example?"

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Dr. Don Shuwarger: "The URL couldn't be simpler - in your basic web browser you just type www.obgyn.net and your web browser will take you directly to the home page of OBGYN.net. From there you'll be able to navigate through the various sections of interest to you. There are sections that allow practitioners to respond to patient questions, and there are sections where there are no patient questions at all, but strictly inter-practitioner discussions. There's an entire e-mail list of practitioners of various degrees and patients, so you can have interdisciplinary conversations, but OBGYN.net is a great place to start getting connected with your colleagues."

Dr. Pamela Yoder: "Is there privacy, so physicians can talk to their colleagues about being concerned about patients in their comments?"

Dr. Don Shuwarger: "At different levels, there's privacy, but I think one needs to remember that most electronic media need to be considered as bulletin boards or post-cards, rather than sealed letters."

Dr. Pamela Yoder: "Good analogy. What do you see in terms of the future of online bulletin boards such as this?"

Dr. Don Shuwarger: "There's no question that, in my life, having an electronic medium to keep in contact with colleagues and keep informed with regard to changes in the field has helped me feel like I'm more current, and more up-to-date. It has reduced my need to actually get on an airplane and travel to some remote site and pay thousands of dollars to go to continuing education courses. How can you afford to do that once a year, or even more than once a year? Whereas you can get online every single day, and when you have a patient in the hospital with a particularly curious issue, you can bring that up for discussion with your colleagues, and you can get pointers or ideas. Some people will even give you references that you can look up and examine through the Medline links."

Dr. Pamela Yoder: "Kim, are you finding online courses for sonographers?"

Kim Shaver, RDMS: "I haven't looked very much lately, but I've been to other ultrasonography sites online and found a lot of information there as well. I will use them in the future in cases that I have questions that they can't answer at the office."

Dr. Pamela Yoder: "Are you studying images over the Internet yet, or through e-mail files?"

Dr. Don Shuwarger: "There are a few online images of particularly interesting cases in the ultrasound section of OBGYN.net. The limitations to viewing those have to do with the speed of your Internet access. If you're with an institution or your hospital has a good connection speed then you can look at those and not be frustrated, but if you're have dial-up access at home, this may not be the time to do that yet."

Dr. Pamela Yoder: "Are you working toward getting the connections that you need to share your images?"

Dr. Don Shuwarger: "Right now, in our area Bell Atlantic does offer ISDN residential service which is very good for web browsing, but still somewhat limited for high-resolution graphics and video. There's the promise of DSL or ADSL in the near future, although I have to tell you that at the speed of which that is progressing, I think the near future is not so near. I am more hopeful for other forms of technology, especially as we read in USA Today, I believe, this week, there is an increasing amount of merger activity between traditional phone companies and traditional cable companies. So I think there'll be some opportunities for competition enhancement in that area."

Dr. Pamela Yoder: "For a physician who hasn't had as much experience as you've had in telematics, telemedicine, and so forth, what would you recommend in terms of getting started with OBGYN.net?"

Dr. Don Shuwarger: "If you have access to a computer that has dial-up access or faster, and you have a web browser on that computer, then just type in those letters that we talked about earlier - www.obgyn.net - hit 'enter,' and start from there. There's really no substitute for play, because play is fun and play is educational, in this case. The more you play, the more you'll be able to find things that will bridge the gap between play and education. Kim, can you describe the type of ultrasound equipment that we're currently using in our office?"

Kim Shaver, RDMS: "Yes. We're using General Electric Logic 200. It's a black and white system only. It doesn't have color, or a Doppler, but it still has very good imaging quality. I've been very pleased with both the paper printer and the thermal printer for our images."

Dr. Don Shuwarger: "You mentioned black and white only. I assume that we all know there are systems out there that have everything from color to three-dimensional rendering to real-time, three-dimensional views. Where do you think they come into play in a private practice setting?"

Kim Shaver, RDMS: "Those might help, but they're not necessary right now. I think they will be, once they get faster, and the color and the Doppler will be nice. But the black and white imaging is very good, especially when it's good quality - it shows you everything you need to know."

Dr. Don Shuwarger: "We're here at the AIUM Conference because we're looking into issues such as accreditation. It is currently voluntary to be accredited by AIUM, is that right?"

Kim Shaver, RDMS: "Yes."

Dr. Don Shuwarger: "As a sonographer, what are some of the steps that you've had to deal with in terms of meeting the qualifications and the criteria for AIUM accreditation?"

Kim Shaver, RDMS: "I've had to find out about the training of the physicians, continuing medical education, and also the policies and the procedures of the office. They want high-quality patient care, and we have to provide that for them - case studies and documentation."

Dr. Don Shuwarger: "How can small practices affordably provide that? What are some of the steps that you can do?"

Kim Shaver, RDMS: "They can get the application, and there are guidelines and standards on it that the AIUM wants to have. After that, they can get their practices up to standard just by providing that patient care."

Dr. Don Shuwarger: "Thank you."

Dr. Pamela Yoder: "This was very interesting. Thank you both very much."

Dr. Don Shuwarger: "Thank you."

Kim Shaver, RDMS: "Thank you."