“Are you comfortable? Am I pressing too hard?” I ask my patient these questions to assuage my own concerns and delay the inevitable as I study the ultrasound image of her 20-week-old fetus. Although she says she’s fine, my patient appears expectant and anxious as she, too, searches the black and white image of her unborn child. I wonder, of course, if she sees what I see—a cleft lip and palate.
If you’ve conducted ultrasounds for routine evaluation of your obstetric patients, you know that patients and their partners typically experience a mix of emotions, namely joy and worry, as they await results. You know, too, that delivering positive results is a pleasure as you share in your patient’s happiness and relief. In all likelihood, you also are relieved at escaping the discomfort of delivering bad news to your patient.
Delivering Abnormal Ultrasound Results
Telling your patient about any pregnancy or fetal abnormality, however common or rare, can be devastating for her, her husband/partner, and her family. After all, every patient wants to know her pregnancy is progressing as expected and her fetus is developing normally. It also can be difficult for you to tell your patient there is a problem. But as a practitioner, you must be prepared to deliver all results, good and bad, to your patients.
A key to delivering abnormal results to your patient includes knowing and using phrases that clearly and honestly apprise your patient of the results without stirring alarm.
Sound easy? It’s not! Even the most seasoned practitioners suggest they never become comfortable giving patients abnormal results.
When results aren’t cause for alarm, patients, especially those in a first pregnancy, still can be highly sensitive to even the slightest aberration. Furthermore, the situation can become complex given varied models for delivering care. For example, when a primary obstetrician sends a patient for scanning at an antenatal testing unit that a maternal-fetal medicine (MFM) specialist oversees, the question is whether the MFM or primary obstetrician should deliver the results. In some cases, patients have scans in emergency departments. What then? Does the radiologist, emergency physician, or primary obstetrician deliver the results?
As an MFM specialist in an antenatal testing unit, I follow my center’s policy to immediately inform patients about their ultrasound results, whatever the outcome. With empirical knowledge to support them, practitioners in my unit know that the longer patients await results, the more likely they are to ruminate, worry, and, in some cases, develop unfounded concerns about their ultrasound results.
With focus on the shared humanity between physician and patient, we treat each patient with careful consideration for her dignity and the compassion we would want for ourselves and our family members.
Once you have told your patient her results, get in touch with her primary obstetrician. In addition to giving the primary obstetrician an opportunity to prepare for a discussion with her/his patient, this approach is integral to delivering high-quality, comprehensive, and continued care.
Follow these tips for delivering abnormal results to your patient:
- Write down phrases you are comfortable using and practice them with a simulated patient (a family member or friend)
- Consider how you would feel if you were in the same situation
- When face to face with your patient, take a moment to gather your thoughts before speaking if necessary
- Use a calm voice
- Speak slowly and clearly
- Look at your patient when talking to her; if her husband/partner is in the exam room, also look at him/her
- Be straightforward and honest without creating alarm
- Be sensitive to emotional ques from your patient to pace discussion appropriately. A sobbing patient is unlikely to hear what you’re saying, so wait patiently until she’s ready to listen
- Ask your patient if she has questions; ask her husband/partner if he/she has questions
- Answer as many questions as you can; if the patient asks a question you cannot answer on the spot, tell her you will get an answer within the next day
- Reassure your patient of potential solutions for the situation without making promises
- Recommend educational material that can help your patient better understand the problem
- If the problem is genetic in origin, explain the value of genetic counseling before any future pregnancies
- Take extra time to address your patient’s concerns if necessary
- Ask your patient if she would like a referral for a counselor so that she can work through feelings about the results
- Follow up with your patient the next day with a phone call
Telling Your Patient About Ultrasound Results: Practice and Prepare!
All fetal abnormalities on ultrasound, even the most insignificant, are understandably upsetting for parents to be. But being prepared before you break the news can help you and your patients feel more comfortable discussing the situation, including potential outcomes and solutions.
One of the privileges of practicing obstetrics in the 2000s is that many of us deliver good news more often than bad news. But this also means that being adept at delivering abnormal ultrasound results requires practice outside as well as inside the office.
How do you deliver bad news to a patient? When do you provide counseling? Comment below or let us know on Twitter: @AIUM_Ultrasound.
Vivek Gupta, MD, is a clinical instructor and fellow in maternal-fetal medicine at the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin.