title: Decision-making in the referral process of sonographers in primary care screening centers.
abstract: OBJECTIVE
  To explore the decision-making process (whether or not to refer) of sonographers performing the 20 weeks standard anomaly scan (SAS) in the screening setting.
  
  
  METHODS
  A survey was sent to SAS-sonographers; it assessed experience, training, volume, type of practice, perceived difficulty per organ system, feelings after missing anomalies and reasons for uncertainty and doubt concerning referral.
  
  
  RESULTS
  The response rate was 50%. Sonographers tend to seek reasons for uncertainty in patient factors and not in their skills or difficulty of the scan. Most mentioned reasons to refer in case of doubt were repeated visualization of a possible abnormality (98%). We hypothesize that the need of repeated imaging of an abnormality might partly explain why some fetal anomalies are still being missed. Sonographers with limited experience and low volume SAS more often revised, referred and asked colleagues for help than experienced sonographers with high volume SAS. In cases of a missed diagnosis, sonographers frequently blamed internal factors (personal failure 71%).
  
  
  CONCLUSIONS
  Level of experience and volume of SAS influence revision and referral rates. Personal factors seem to play a role in the decision-making process of screening sonographers. Future research should focus on these personal factors, to optimize screening ultrasound programs. © 2016 John Wiley & Sons, Ltd.
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, The Netherlands.
authors.forename: Jolande J
authors.initials: JJ
authors.lastname: Oosterhuis
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, The Netherlands.
authors.forename: Ada
authors.initials: A
authors.lastname: Gillissen
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, The Netherlands.
authors.forename: Claudia A
authors.initials: CA
authors.lastname: Snijder
authors.affiliation: Department of Medical Decision Making, Leiden University Medical Center, The Netherlands.
authors.forename: Anne
authors.initials: A
authors.lastname: Stiggelbout
authors.affiliation: Department of Obstetrics, Leiden University Medical Center, The Netherlands.|Center for Prenatal Screening Leiden, The Netherlands.
authors.forename: Monique C
authors.initials: MC
authors.lastname: Haak
mesh_terms: D000328:Adult; D000066491:Clinical Decision-Making; D005260:Female; D006282:Health Personnel; D006801:Humans; D008297:Male; D008875:Middle Aged; D008880:Midwifery; D011247:Pregnancy; D011320:Primary Health Care; D012017:Referral and Consultation; D016216:Ultrasonography, Prenatal; D055815:Young Adult