BOSTON - Advanced ultrasound and MRI procedures are making it easier for radiologists to identify fetal abnormalities. But telling a pregnant woman the news, often early in a pregnancy, is increasingly becoming the responsibility of pediatric radiologists, who are assuming roles as front-line physicians.
Unfortunately, few radiologists are trained in professional communication skills. However, with the advancements in fetal imaging, these skills are needed to help an expectant mother and her spouse or partner understand what they should know to manage a pregnancy when a fetus is abnormal.
The process isn't intuitive, according to Dr. Stephen Brown, a pediatric imaging and intervention specialist at Children's Hospital Boston, who discussed the topic with attendees at the Society for Pediatric Radiology (SPR) annual meeting being held April 13-17.
Brown recommended structured role-playing with a multidisciplinary team including professional family and patient representatives or professional counselors. The role-playing sessions should incorporate formal critiques and evaluations. Using an instructional video, he demonstrated how a well-meaning physician's clinical terminology-filled explanation of spina bifida confused and angered a young woman in her first trimester of pregnancy. Nothing was incorrect about the physician's explanation, but nothing was right about it either.
"The experience of presenting new, complex, and often difficult information is familiar to all of you in this room," he said. "As pediatric radiologists, you probably are experienced in talking with parents about an unexpected life-threatening diagnosis of their child. But the treatment options and the outcomes may be known and clearly defined. This is not the situation with many fetal abnormalities."
"A substantial gap exists between what we can image and what we can reliably know or extrapolate about the future child's capabilities," he explained. "This gap and other distinctive clinical features of prenatal care in the setting of a fetal abnormality make discussing difficult and unexpected information particularly challenging."
Brown told attendees that the prospect of talking about fetal abnormalities causes stress, which can linger after the meeting with the pregnant patient, no matter how many times the radiologist has experienced it. When discussing a fetal abnormality, radiologists worry that they will say the wrong thing, their remarks will cause pain, they may put themselves in medicolegal jeopardy, they don't have enough time, or the setting where the discussion takes place is inappropriate or distracting.
Radiologists need to prepare themselves in advance to know what information they wish to convey based upon what the patient needs to know, wants to know, and does not want to know, Brown counseled. He pointed out that some patients do not want to know a lot of details, and radiologists should respect this.
Brown recommended that radiologists acknowledge the stressfulness of the situation and acknowledge their emotions at the outset of a meeting. Being respectful, compassionate, humble, empathetic, and sensitive may help reduce or allay a patient's fears and anxieties, he said.
He offered a tip that he'd received from a pediatrician, who said a mentor told him at the beginning of his career to conspicuously take off his watch in front of the family members when going into a conference with them. "Now he takes off his watch and his pager, and turns off his cell phone and PDA," Brown said. "But the message is: 'Stop. Be quiet. Listen. Let's talk.' "
A two-way conversation is needed, and patients should be encouraged to express their feelings openly. The radiologist should assist the patient in articulating and prioritizing concerns and fears. Brown suggested identifying prior to the meeting the steps for all available options, as well as the medical professionals and support resources the patient may wish to consult.
Dealing with a fetal abnormality may entail terminating a pregnancy. Brown warned that physicians' own moral or religious convictions may affect what they say, and this bias may inappropriately affect patients. Training in formal communications and role-play may make radiologists aware of remarks that others consider biased.
Brown asked rhetorically: Should a radiologist share with the patient his or her own personal beliefs? Maybe. Maybe not. He had no answer. "There is an absence of standards on what information should be imparted," he said. "We are left to our own judgment, experience, and biases when we engage in these complex conversations with pregnant patients and their partners."
But it is important to learn optimal strategies for communicating with patients, he emphasized. It will make the patient feel better, it will reduce stress levels for everyone involved, and, based on other medical specialties' experiences, it may reduce the future risk of medicolegal issues.
By Cynthia E. Keen
AuntMinnie.com staff writer
April 16, 2010
Related Reading
Fetal MSK abnormalities need ortho surgeon involvement, April 2, 2010
More detailed US exams catch more fetal abnormalities, August 4, 2009
Fetal MRI distressing for many women, February 1, 2008
MR may be sounder than sonography for catching fetal abnormalities, November 29, 2004
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