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Re: to tell or notFrom: DRoss38040@aol.comSat Jan 23 20:45:27 1999
In a message dated 1/19/99 8:43:40 PM Eastern Standard Time, RobertsK@HWL.CO.NZ writes: << Diana, You wrote:"But my question is, how does this information change the management of the pregnancy? This knowledge does not change the outcome at all." This discussion brings out two point: 1) What findings alter the management of the pregnancy? 2) How much do you tell the patient? 1) A number of ultrasound findings are routinely noted, but do not influence the management of pregnancy at all. This particularly pertains to borderline findings and "soft signs". Does the patient have the right to know these findings are there and what they mean? I think so, even if the finding is borderline and will need follow-up. This pertains to a variety of things such as: CPC's, small subchorionic hemorrhages, marginal placentas, two vessel cords, isolated club-foot, borderline ventriculomegaly, and many others. In fact, only a miniscule fraction of pregnancies will have altered management following an ultrasound whether normal or not. 2) How much you tell the patient is a topic of a continuous and hot debate. It largely depends on your workplace, your comfort level in disclosing information, local regulations, and many other factors. In our workplace, we feel it quite appropriate to give patient some indication of what their ultrasound shows before they leave the department. Of course, we do not provide "counseling" per se; we leave that to the perinatal specialists. But I think it is important to establish a positive rapport with the patient, answer their questions, and give them some information about the ultrasound findings. It is precisely this patient interaction that distinguishes a sonographer from radiographers, etc. as has been discussed on this forum many times before. Of course, I do not expect agreement on this from everybody. There are those sonographers who religiously stick to the policy of saing nothing and referring the patient to a radiologist if they want to ask any questions. There are those who work in small community hospitals in the middle of nowwhere and routinely report their findings in the chart before discussing it with a radiologist next week. Most of us are somewhere in the middle of this spectrum. I doubt that one can find "right" and "wrong" here. To me, it's a difference of individual circumstances, and your personal opinion. Many Regards,
Martin Necas.
>> Dear Martin: You are right that circumstances make a big difference in what we tell our patients. Leaving out the trouble I can get into when I reveal the results of an exam, I will deal only with the question of what the patient needs to know from either doctor or sonographer. I agree that the patient is entitled to some information from the sonographer. Generally I try to limit my remarks to things I feel confident in explaining in depth and things which I feel comfortable discussing with the particular patient I am faced with. Naturally, I have better rapport with some patients than with others. I think the "soft signs" you describe do not actually fall into the same category. I know you live in New Zealand and perhaps did not see a show here in the US about some doctor who is still waiting for his (I believe 8 year old) son to show signs of mental retardation because the ventricles were measured prenatally to be 11mm. He was actually ready to abort the fetus based on this finding until a second opinion talked him out of it...but he is still waiting for "the other shoe to drop". We have lots of very nervous people here who are ready to fly off the handle at the very mention of any abnormality. Marginal placentas and extrachorionic hemorrhages are in a different category, IMHO, because there is some possible course of action available to the mother, who may decide to decrease her activity levels for a while to decrease the possibility of a miscarriage or bleeding. Isolated clubfoot and other signs may lead the parents to elect amnioscentesis, where they otherwise would not have done so. The patient has the right to know any information which can be gleaned from the report, but the patient also has the right to be spared any undue anxiety from misleading or (as yet) poorly supported data from suspicious signs like borderline ventriculomegaly and choroid plexus cysts. In the age of elective termination of pregnancy, a huge burden can be placed on the parents when "soft" signs are discovered. And I do feel that these things need to be discussed carefully and are probably best broached with one's own physician. There may be genetic factors which the patient would rather not discuss with the sonographer. As I write this, I am also realizing that most sonographers have higly developed people-skills and usually know who they can and who they cannot have this type of conversation with. And I am sure, Martin, that you are one of these. So there is no personal attack meant in this message, just a word of caution to all of us who discuss the exam with our patients. I also discuss the results of the exam with my patients. However, I am careful not to discuss too much, and I also take the mental status of my patient into consideration. Sometimes their anxiety level is so high that they cannot really understand what I am saying that well and their fear can distort what I have said. Diana Ross, RT, RDMS Editor, <A HREF="http://members.aol.com/dross38040/page/index.htm">The WAVE~~~ An Online Newsletter for Sonographers</A>
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