Reply turned post, participatory medical education style

I have had the benefit of communicating to physicians who like to teach on the internet, not just in the real world. DoctorJen was really helpful with my KALI questionnaire. I have communicated with Dr. Fogelson of Academic Ob/Gyn, whose blog has inspired a reply turned post of its own.

Dr. Onyeije, a Maternal Fetal Medicine specialist, is also communicating with me about ethics, risk presentation and paternalistic (or not) obstetrics.

Here was his comment on reply turned post, Academic thought on VBAC style.

Just wanted to chime in and echo your comments regarding how risk is communicated and how it is received. What I’ve found is that there are multiple different ways to communicate risk and (perhaps just as many ways) to receive such information. It’s a two way street and problems can occur when the recipient and communicator are not on the same wavelength.

I certainly see this when counseling patients regarding all types of screening tests.

I’ll be interested to read your thoughts on risk perception.

I answered:

I have thoughts! I wrote a little bit about it here, but that is just the tip of the iceberg. Prenatal screening can be really problematic. High false positives in some screening tests can be emotionally devastating to a patient, especially if the physician and staff communicate risk poorly.

I know of a couple who called off their baby shower and told everyone they were getting a 20 wk termination over a “positive” quad screen – a high AFP level. And this was AFTER I personally warned them about the poor specificity of the test. Then, this couple who had told me they weren’t going to get amnio (prior to the quad screen) got an amnio, and of course, the amnio results were within normal range.

I have heard of a woman passing out at work and hitting her head on the desk because someone from her OB office called and told her her fetus has tested positive for Down’s syndrome. Not only was this incorrect, it was, again, just a quad screen result, not a diagnostic result, but they hadn’t even told the patient what the test was screening for until they called with the results. Every subsequent pregnancy she got the same low AFP, and then a “normal” amnio. Every pregnancy she got the amnio anyway.

Same thing with gestational diabetes screening. UpToDate is currently full of information about how unreproducible the results are for the initial challenge test screening and the GTT, and how there aren’t universally adopted thresholds. But, how many women have been bumped up to “high risk” by a GTT test, and then possibly even sectioned due to possible fetal macrosomia? I don’t even want a baby getting unnecessary heel sticks after every feeding, which is protocol in some places if the mother had GD. Especially if it subtly tells a new mother that her child will be hurt every time she attempts breastfeeding. It’s not worth it if it’s due to an imprecise diagnosis. I have another set of friends, the mother is a medical student, and the father has a PhD in psychology. She got a positive challenge test screen, and had a “freak out” (their words, not mine).

These are anecdotal studies, but I have read research about the anxiety these screening tests cause women.

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5 responses to “Reply turned post, participatory medical education style

  1. MomTFH –

    I’m not sure what your point is here. Gestational diabetes is real, and it does lead to fetal macrosomia and small increased rates of intrauterine fetal death. The ACOG recommended method of screening for GD is a glucola followed by a 3 hr GTT if positive. This method is both sensitive and specific. Some midwives believe that a fingerstick blood sugar is an adequate screening test, which I disagree with, as this is not nearly as sensitive as a challenge test. GD is a condition primarily of glucose intolerance, and does not present itself as much in the fasting state and standard type II diabetes.

    I recently had a midwife transfer that refused to believe that she had GDM when she had fingersticks in labor of 170-180. She thought it was because of some peanut butter she ate. She had not been screened with a GTT in pregnancy, only a fingerstick. She labored several hours after transfer and eventually delivered an 11 pound infant by cesarean, clearly affected by GDM in size and body habitus. She believed she had GDM then.

    Are our test 100% sensitive and 100% specific? Of course not. But your argument seems to be to doubt the validity and usefulness of these tests without offering a better alternative. Would you rather not screen for GDM at all?

    Section for GDM and macrosomia is a problem. It is very hard to estimate EFW at term, and many OBs do section for babies that are large but not technically macrosomic. This is an unfortunate practice, as the number of sections required to prevent a single shoulder dystocia in these infants is huge, and unjustified in my opinion.

    The fact that a patient had an abnormal quad screen in subsequent pregnancies and normal amnios in both is certainly a possible outcome mathematically, and says nothing about the underlying validity of those tests. I encourage patients to have these tests if they will find the data useful, particularly if they would choose to abort a T21 fetus. If not, the information from these tests is less useful, and changes little.

    • MomTFH

      I was answering a comment on another post about presenting risk. I don’t really have an answer. I wrote this comment in a hurry, and didn’t do a proper job of wrapping it up with conclusions.

      I do believe in blood sugar screening during pregnancy. I also think treating even “borderline” or “mildly” GDM women is a good idea, along with these recomemndations.

      This particular person who “freaked out” was only positive for the challenge test, not the GTT. She is still testing her sugar daily (necessary? Maybe not for all patients with her screening / diagnostic history) and following a low glycemic diet, which I think is a good idea. I think almost anyone can benefit from a low glycemic diet. I am just questioning how she was interpreting being screened positive (indicating further workup) but not diagnosed to be such a risky situation that she was crying and frantically worried about the outcome of her pregnancy.

      Glucose challenge tests and GTTs are no fun. I don’t necessarily think retesting with another GTT is what anyone wants. I think women who screen with blood sugar above whatever threshold you are using should be counseled on diet and exercise, and should be given real tools to reform their diet. Most lay people have no idea what a high vs. low glycemic food is. I also think they should be told that it is not a necessarily reproducible “diagnosis”, is not a cesarean sentence, and should be told that they can affect the size of their baby, regardless of GDM diagnosis or not, by their blood sugar levels. Also, I think babies should be tested for hypoglycemia if they show symptoms or are severely macrosomic or have other indications, but maybe not after every feeding or if they are merely over 8 1/2 pounds (I was at a hospital that dd this. 8 1/2 pounds. Not 4500g. Not 5000g. Not only when then mom was diagnosed with GDM. Every feeding. Seemed excessive to me, but I am no pediatrician.)

      I also think hemoglobin A1C and home blood sugar monitoring may have a role to play. I also think Leopold maneuvers and ultrasound have a role to play, to look for polyhydramnios and predicted macrosomia (estimation of fetal weight), along with the higher risk of birth defects in obese and/or GDM mothers-to-be. But, I think these should be judiciously applied. I am not qualified to judiciously apply those. The link above indicated that cesarean section was reduced in the diet – adjusted group, and I can only assume this was done with the judicious application of estimates of fetal weight in the hands of experienced practitioners.

  2. Should doctors protect their patient’s from their own health information so as to keep them from “freaking out”? Sensitivity is necessary, but a patient’s reaction is their own.

    As a medical student and resident I often searched for the best way to tell a family that their loved one had died. I now know that there is no best way. The reaction is usually about the information, not the way it was delivered.

    • MomTFH

      Exactly. I personally counseled the one couple above about the high false positive rate of the quad screen, but when they were faced with the slight possibility of a child with an open neural tube defect, they pretty much thought their fetus was, in fact, severely deformed, even though they had no indication of such, even on recent ultrasound.

      I can only assume either the person who presented them with their results did not do a good job of weighing the risks for them, and that canceled out my previous explanations, or they were so worried about their precious pregnancy (which is can be expected in such a situation) that they did a good job of exaggerating the risk in their own head, despite everyone’s attempts to warn them that they were not diagnosed, just screened into a slightly – higher – risk group that needed follow up testing.

  3. doctorjen

    I always think discussion of prenatal testing is fascinating. I don’t know that the tests themselves are as problematic as the counseling surrounding them sometimes is.
    I screen universally for GDM with a 1 hour glucose tolerance, followed by a 3 hour if the positive screen. The borderline folks are the hardest to figure out what to do with, as we don’t have great data on the “diet-controlled gestational diabetic” as to exactly which interventions help, even though they do have increased risk for some poor outcomes (especially macrosomia and birth trauma) II completely agree with Dr. Fogelson on quad screen, or invasive testing for T21 – I suggest people get tested if the information is going to be useful to them. If it’s not going to be helpful to them, we skip it. I have seen in private practice in the community setting, many docs simply hand over an order for the quad screen and just say “get this test done before your next visit.” This leads to a lot of anxiety when there is a positive screen and the client didn’t know she was having a screening test. I’ve had the experience of the having a personal friend call in hysterics because a nurse told her on the phone that her blood test showed the baby could have Down syndrome – thankfully it was a false positive screen, but she was exceptionally anxious until she had the testing and results adequately explained.
    I’ve also had the personal experience of a CNM in the group practice I was seeing for care with my own second pregnancy telling me I was irresponsible for not having a MSAFP, and she couldn’t seem to understand my reasoning that for my own self, I’d prefer not to have a prenatal diagnosis and anyway, I was delivering at a tertiary care center where adequate care would be available for the baby after.
    I try to explain screening tests to clients in that they intentionally have some amount of false positive rate – basically with a screening test you want to catch as many folks as you can who might be at higher risk, and offer then a more diagnostic test after. For something like quad screen, you can make the false positive rate lower by setting the cut-off differently, but then you will miss more true positives as well. So, I make sure they know ahead of time that a positive quad screen isn’t a diagnosis of anything, just means they may be at increased risk and then have to decide what additional testing they want.
    If folks feel very strongly that they will make a decision on continuing a pregnancy based on chromosomal abnormalities, I encourage them to have genetic amnio or 1st trimester CVS rather than quad screen, because it doesn’t make sense to use a screening test that will add a week to your time to diagnosis in a situation where the results matter greatly.
    Interestingly, most folks I know who have had a false positive in one pregnancy DO choose to be tested in subsequent pregnancies – I think there is feeling perhaps that they dodged the bullet once, but need to stay extra vigilant for the future.
    I don’t think we need to protect patients from their own health information – more make sure they have all the information so they best know what their results mean.

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