Accepted Manuscript Electronic fetal heart rate monitoring (EFM) credentialing examination – Pros and cons Shashikant L. Sholapurkar , MD, DNB, MRCOG PII:
S0002-9378(14)00513-4
DOI:
10.1016/j.ajog.2014.05.045
Reference:
YMOB 9855
To appear in:
American Journal of Obstetrics and Gynecology
Received Date: 23 April 2014 Accepted Date: 19 May 2014
Please cite this article as: Sholapurkar SL, Electronic fetal heart rate monitoring (EFM) credentialing examination – Pros and cons, American Journal of Obstetrics and Gynecology (2014), doi: 10.1016/ j.ajog.2014.05.045. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Title Page Letter to the Editor Electronic fetal heart rate monitoring (EFM) credentialing examination – Pros and
Author:
RI PT
cons. Mr Shashikant L SHOLAPURKAR
Department of Obstetrics and Gynaecology,
SC
MD, DNB, MRCOG
Disclosure:
M AN U
Royal United Hospital Bath NHS Trust, Bath, United Kingdom The author wishes to disclose his competing interest (and publications) in
debating alternative possibly more physiological and scientific categorization of FHR decelerations in the context of absence of any proven systems. None
Corresponding Author:
TE D
Financial support:
Mr Shashikant L SHOLAPURKAR
Department of Obstetrics and Gynaecology, Princess Anne Wing, Royal United Hospital
EP
Bath NHS Trust, Combe Park, Bath, BA1 3LE, United Kingdom.
Tel:
[email protected]
AC C
e-mail:
Business 44 (0)1225 428331, Fax: 44 (0)1225 825464, Home: 44(0)1225 423829
Word Count:
400
ACCEPTED MANUSCRIPT 2
Letter to the Editor, Electronic fetal heart rate monitoring (EFM) credentialing examination – Pros and
RI PT
cons. Dear Editor,
The paper by Berkowitz et al1 is very thought-provoking and invites a debate on a complex subject. Experts have achieved significant consensus about the need for
SC
standardization of terminology of EFM. 2 Consequently, periodic skills retraining and even some local assessments of knowledge gained are already in place in some countries.
M AN U
Although a very painstaking, commendable and valuable endeavour1; the pros and cons of a progression to ‘pass/fail credentialing examinations’ could be debated by American nurses and Obstetricians.
The need for an extremely elaborate statistical processing of questions and answers1
TE D
itself highlights the significant gaps and difference of opinions in assessment of EFM traces. Even this complex statistical modelling may not guarantee exactitude of the script. Judgement questions (termed ‘script concordance’ test)1 to assess contextual reasoning and
EP
progressive decision making are particularly prone to subjectivity and different interpretations. Is it justifiable to ‘fail’ practicing Obstetricians and midwives using such
AC C
examinations (sometimes funded by insurance companies)? What support mechanisms or supervision will be in place? The RCOG (London) in its on-line training module ‘eFM’ provided 100 test cases of EFM for progressive decision making with answers by three experts. Most often one expert (at random) disagreed with the other two. The fallible nature of judgement questions may be apparent in the very example provided for illustration.1 When an additional information is provided, why shouldn’t there be good or strong impact (e.g.
ACCEPTED MANUSCRIPT 3
corroboration) on ‘thinking’ about the management (as questioned)1 even though this information may not change the management itself? Moreover, the interpretation of EFM traces is not absolute, given or clinically proven.
RI PT
The standardization of terminology, guidelines and knowledge-based testing do have merit, but these should withstand basic scientific scrutiny. The author of a recent American study (Editor’s choice)3 concluded that EFM interpretation remained unhelpful in practice
SC
particularly because of the peculiar nomenclature of FHR decelerations (not just academic considerations) leading to loss of meaning. Definitions of FHR decelerations were proposed
condition.
2
M AN U
as entirely theoretical constructs without any discernible correlation to aetiology or fetal Many questions about EFM remain unanswered by the experts.
4
Hence,
alternative models proposed may need some consideration rather than being summarily discarded as non-concrete or unproven. ‘Pass/fail’ examinations may risk discouraging alternative thinking, challenges and possibly innovation/improvements. The science of EFM
TE D
is still too imperfect (even compared with many other scientific controversies) and evolving; and may not be ripe for ‘credentialing’ examinations comprising judgement questions.
Disclosure:
EP
Mr Shashikant L SHOLAPURKAR, MD, DNB, MRCOG The author wishes to disclose his competing interest (and publications) in
AC C
debating alternative possibly more physiological and scientific categorization of FHR decelerations in the context of absence of any proven systems. References
1. Berkowitz RL, D'Alton ME, Goldberg JD et al. The case for an electronic fetal heart rate monitoring credentialing examination. Am J Obstet Gynecol 2014;210:204-7.
ACCEPTED MANUSCRIPT 4
2. National Institute of Child Health and Human Development (NICHD) Research Planning Workshop. Electronic fetal heart rate monitoring: research guidelines for interpretation. Am J Obstet Gynecol 1997;177:1385-90.
neonatal academia. Am J Obstet Gynecol 2012;207:206.e1-8.
RI PT
3. Cahill AG, Roehl KA, Odibo AO, Macones GA. Association and prediction of
4. Clark SL. Reply. Comment on. Algorithm for management of category II fetal heart
AC C
EP
TE D
M AN U
SC
rate tracings: a standardization of right sort? Am J Obstet Gynecol. 2014;210:175-6.
S0002-9378(14)00513-4
DOI:
10.1016/j.ajog.2014.05.045
Reference:
YMOB 9855
To appear in:
American Journal of Obstetrics and Gynecology
Received Date: 23 April 2014 Accepted Date: 19 May 2014
Please cite this article as: Sholapurkar SL, Electronic fetal heart rate monitoring (EFM) credentialing examination – Pros and cons, American Journal of Obstetrics and Gynecology (2014), doi: 10.1016/ j.ajog.2014.05.045. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Title Page Letter to the Editor Electronic fetal heart rate monitoring (EFM) credentialing examination – Pros and
Author:
RI PT
cons. Mr Shashikant L SHOLAPURKAR
Department of Obstetrics and Gynaecology,
SC
MD, DNB, MRCOG
Disclosure:
M AN U
Royal United Hospital Bath NHS Trust, Bath, United Kingdom The author wishes to disclose his competing interest (and publications) in
debating alternative possibly more physiological and scientific categorization of FHR decelerations in the context of absence of any proven systems. None
Corresponding Author:
TE D
Financial support:
Mr Shashikant L SHOLAPURKAR
Department of Obstetrics and Gynaecology, Princess Anne Wing, Royal United Hospital
EP
Bath NHS Trust, Combe Park, Bath, BA1 3LE, United Kingdom.
Tel:
[email protected]
AC C
e-mail:
Business 44 (0)1225 428331, Fax: 44 (0)1225 825464, Home: 44(0)1225 423829
Word Count:
400
ACCEPTED MANUSCRIPT 2
Letter to the Editor, Electronic fetal heart rate monitoring (EFM) credentialing examination – Pros and
RI PT
cons. Dear Editor,
The paper by Berkowitz et al1 is very thought-provoking and invites a debate on a complex subject. Experts have achieved significant consensus about the need for
SC
standardization of terminology of EFM. 2 Consequently, periodic skills retraining and even some local assessments of knowledge gained are already in place in some countries.
M AN U
Although a very painstaking, commendable and valuable endeavour1; the pros and cons of a progression to ‘pass/fail credentialing examinations’ could be debated by American nurses and Obstetricians.
The need for an extremely elaborate statistical processing of questions and answers1
TE D
itself highlights the significant gaps and difference of opinions in assessment of EFM traces. Even this complex statistical modelling may not guarantee exactitude of the script. Judgement questions (termed ‘script concordance’ test)1 to assess contextual reasoning and
EP
progressive decision making are particularly prone to subjectivity and different interpretations. Is it justifiable to ‘fail’ practicing Obstetricians and midwives using such
AC C
examinations (sometimes funded by insurance companies)? What support mechanisms or supervision will be in place? The RCOG (London) in its on-line training module ‘eFM’ provided 100 test cases of EFM for progressive decision making with answers by three experts. Most often one expert (at random) disagreed with the other two. The fallible nature of judgement questions may be apparent in the very example provided for illustration.1 When an additional information is provided, why shouldn’t there be good or strong impact (e.g.
ACCEPTED MANUSCRIPT 3
corroboration) on ‘thinking’ about the management (as questioned)1 even though this information may not change the management itself? Moreover, the interpretation of EFM traces is not absolute, given or clinically proven.
RI PT
The standardization of terminology, guidelines and knowledge-based testing do have merit, but these should withstand basic scientific scrutiny. The author of a recent American study (Editor’s choice)3 concluded that EFM interpretation remained unhelpful in practice
SC
particularly because of the peculiar nomenclature of FHR decelerations (not just academic considerations) leading to loss of meaning. Definitions of FHR decelerations were proposed
condition.
2
M AN U
as entirely theoretical constructs without any discernible correlation to aetiology or fetal Many questions about EFM remain unanswered by the experts.
4
Hence,
alternative models proposed may need some consideration rather than being summarily discarded as non-concrete or unproven. ‘Pass/fail’ examinations may risk discouraging alternative thinking, challenges and possibly innovation/improvements. The science of EFM
TE D
is still too imperfect (even compared with many other scientific controversies) and evolving; and may not be ripe for ‘credentialing’ examinations comprising judgement questions.
Disclosure:
EP
Mr Shashikant L SHOLAPURKAR, MD, DNB, MRCOG The author wishes to disclose his competing interest (and publications) in
AC C
debating alternative possibly more physiological and scientific categorization of FHR decelerations in the context of absence of any proven systems. References
1. Berkowitz RL, D'Alton ME, Goldberg JD et al. The case for an electronic fetal heart rate monitoring credentialing examination. Am J Obstet Gynecol 2014;210:204-7.
ACCEPTED MANUSCRIPT 4
2. National Institute of Child Health and Human Development (NICHD) Research Planning Workshop. Electronic fetal heart rate monitoring: research guidelines for interpretation. Am J Obstet Gynecol 1997;177:1385-90.
neonatal academia. Am J Obstet Gynecol 2012;207:206.e1-8.
RI PT
3. Cahill AG, Roehl KA, Odibo AO, Macones GA. Association and prediction of
4. Clark SL. Reply. Comment on. Algorithm for management of category II fetal heart
AC C
EP
TE D
M AN U
SC
rate tracings: a standardization of right sort? Am J Obstet Gynecol. 2014;210:175-6.
