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02 October 2005

Verisimilitude Provocation



In Utero Tonight!

This story about unregulated ultrasound clinics raises more questions than it answers.

Australian ultrasound doctors say they are concerned about pregnant women using non-medical ultrasound studios to get images of their unborn children.

Sounds terrible, right? Why are we letting these amateurs with a machine near our babies? Will someone please think of the children!?

But nowhere in the story is it said that the non-medical ultrasounds are being used as a replacement for the medically-supervised ones. And the difference is crucial. I can understand the concern if parents are using unaccredited ultrasound "studios" instead of legitimate diagnosis. On the other hand, if the non-medical ultrasound — otherwise known as "entertainment ultrasound" — is merely in addition to the prescribed ultrasound sessions, what's the harm? The distinction it is not clearly stated, so what's going on here?

This isn't the sort of topic I normally discuss on, but the ambiguity annoyed me so I went digging.

Thanks to the magic of the Internets we can go to the website of the Australasian Society for Ultrasound in Medicine and check out their Statement on the Appropriate Use of Diagnostic Ultrasound Equipment for Non-Medical Entertainment Ultrasound. ASUM list four (really three) separate reasons to oppose entertainment ultrasound.

Miss Diagnosis, to see you, Doctor

First, there is the potential for misdiagnosis:

The potential clearly exists for not detecting significant diagnoses. Pregnant women may believe that this form of examination is an adequate substitute for a properly conducted examination involving appropriately trained sonographers and medical practitioners.

Note first of all that this is not an argument against the use of ultrasound for entertainment purposes, just that the ultrasound equipment should be used by an appropriately qualified individual.

But the key point here seems to be that some mothers may view entertainment ultrasound as a replacement for diagnostic ultrasound. A legitimate concern, but it does not follow that all ultrasound should therefore be conducted by accredited operators. An equally valid solution, it seems to me, would be for the entertainment ultrasound operators to take explicit steps to differentiate themselves from legitimate medical practitioners.

I'm not just talking about putting up a keep-the-lawyers-happy sign saying something like "ultrasounds conducted here are for entertainment purposes only, and have no medical value" (although it wouldn't hurt). There are any number of other possibilities, such as the entertainment ultrasounds requiring permission from the mother's obstetrician.

Assuming that these precautions are in place, and they are working to prevent mothers from using entertainment ultrasound as a replacement for diagnostic ultrasound, the problem of misdiagnosis goes way.

It is a given that non-medical operators are more likely to produce misdiagnosis than medically accredited ones (and I have no argument with this position). However, this is an irrelevant comparision, again assuming that the mother is attending all the right medically-advised ultrasounds. The danger of misdiagnosis by an unaccredited operator should not be compared with that of an accredited one, it should be compared with the danger of having no diagnosis at all.

Consider two mothers, A and B, each of whom are attending their prescribed medical ultrasounds. Mother A goes off to the entertainment ultrasound studio, and mother B sits on her butt. What additional danger has mother A placed her baby under?

Of course there is additional danger, but I would be surprised if any of the risks were comparable to the risk of, say, a car crash whilst driving to the ultrasound studio. The isolated risk of misdiagnosis is almost certainly less than the risk of no diagnosis in the first place.

That's baby's leg ... or is it his penis?

But what about the effect of misdiagnosis on the mother's mental state?

A potential problem is also created where the abnormalities are incorrectly diagnosed or doubt regarding normality is created, thereby producing significant patient anxiety.

This is not to ignore the impact of the mother's mental condition on the health of either her, or the unborn child. There are two possibilities here:

  • One scenario is for a mother to be lulled into a false sense of security by the intimate pictures of Little Unborn Johnny. The operator misses some potentially serious condition and the mother walks away blissfully unaware of this. It's hard to see how that that belief, in and of itself, should pose any health problems.

  • Perhaps more serious is the opposite scenario. The mother is induced into instant panic because the work experience kid driving the ultrasound machine that day couldn't tell the difference between a leg and a third arm, for instance. They alert the mother to a non-existent condition and cause the stress levels of the mother to go into overdrive. In this case the first thing the mother is likely to do is rush off to a real doctor and get a correct diagnosis, so it's not likely to be a very long-lived fit of panic.

Either way, the mothers mental state doesn't seem to be a very significant risk factor.

The Ultrasound Machine is Not a Toy, Mister!

Another reason why entertainment ultrasound is bad according to ASUM:

Trivialising diagnostic medical technology and the role of trained technical and medical professional will inevitably erode the significant relationship between health care providers and patients that currently exists. This will ultimately be to the significant detriment of the maintenance of the high standard of practice upon which optimum medical outcomes are based.

Cue the sound of three-year-olds being forcibly separated from their toy stethoscopes.

Put it simply, I don't buy this argument, at least not as stated. The idea that the doctor has the trust of their patient because of the fact that they can drive the machine-that-goes-ping seems to be stretching the truth somewhat. I understand that the relationship between medicos and their patients is an important one. I just question how much of it is to do with the equipment possessed by the former. A surgeon is much more than a guy-who-can-wield-a-scalpel, as I think anyone will attest.

Perhaps the argument they are really trying to make here is that the widespread availability of ultrasound machines reduces the status of the profession of ultrasound operator. I can see that this might be the case, but the impact on patient health is a lot less clear to me. Or to put it more bluntly, the status of their profession is their problem.

Radiation, All Around, Sometimes Up, Sometimes Down

I have no problem with this stated reason for opposing entertainment ultrasound (by anyone, even accredited operators):

In terms of exposure to diagnostic ultrasound, all learned bodies emphasize the ALARA (as low as reasonably achievable) principle. This principle emphasizes that diagnostic medical ultrasound equipment be used by trained individuals to seek relevant diagnostic information with the minimum of exposure, thereby minimising the potential for bioeffects and tissue damage.

They also list as a separate "General Note":

There needs to be community discussion regarding the entitlement of a fetus to particular rights, including the right not to be exposed to a source of potential harm where no health benefit exists.

As far as I can see, these two are basically saying the same thing, namely that there is some non-zero risk involved in every ultrasound, and no medically-valid outcome of an entertainment ultrasound, so why risk it when you don't have to?

There are parallels in both the problem and in the response to mobile phone radiation. There is no such thing as scientifically-provable safety in either case, so there's no point asking for it.

But as with all such questions, the correct analysis looks at both the potential for benefit as well as the potential for harm. Producing pictures of unborn children merely for the gratification of their parents does seem, on the face of it, to have no medical value. But I don't think it's that easy. It is conceivable to me that the earlier the mother can see the child, the earlier they can start forming an emotional bond with that child. This benefit may be only very slight, but then again it only has to be, in order to counter a fairly low risk. Something to ponder anyway.

It's All About the Melbas

In summary, what seems to be going on here is a bit of nest-feathering by a professional body. The medically-accredited ultrasound operators want the business of entertainment ultrasound and as a value proposition they use an overstated potential for adverse impact on patient health. Understandable, I guess. But we all need to recognise this for what it is: marketing. And, from a policy perspective, respond accordingly.

Reducing the supply of ultrasound operators (by raising the bar of expertise required) necessarily increases the cost of ultrasound services. All ultrasound services, both medical and non-medical. Now I don't care about the cost of entertainment services, on the assumption that they are funded directly by the consumers of those services. But I do care about increasing health care costs, because we all pay for them.

Let the medical profession decide whether a procedure has any medical benefit or not. And if they determine that it doesn't, let them please get out of the way.


Posted by
2005-10-02 10:26:33 -0500

It occurs to me that turning this medical device into an entertainment device could have another benefit: significantly lower costs for ultrasound equipment, thanks to the expanded market for them. Adding a colour 3D (? or was it just proportional for once? The grabs shown on the news never make this clear enough) visualization of the ultrasound image is also a great leap forward over what I'd seen before ("And this blue patch over here, that's your baby. Oh wait, that's it over here.").

Melbas? As in the dessert? The singer?

P.S. The essay is good, but Less Is More, or rather shorter is bettereasier to sit through :)

Posted by
2005-10-02 10:26:33 -0500

Funny thing about blogging. Sometimes you surprise yourself as to how much you have to say about a topic that you've never even thought about before... But point taken about less is more. I'm sorry this essay wasn't shorter, I didn't have time, etc. Thanks for wading through it anyway.

Melbas as in the picture on the $100 note. (Perhaps it should have been Nellies instead. Or Dames. But that is possibly even more obscure.) So does that mean that you got my obscure Young Ones reference?

Posted by
2005-10-02 10:26:33 -0500

I'm not sure that the panic caused by a false positive should be so lightly put aside. We had a (medical ultrasound induced) false positive while Sureka was pregnant with Jeyanth, and, even though we were quite happy to pay to jump the queue and get a private followup it was a few days before it could be resolved. If we had had to wait for a followup in the public system, I guess it would have taken longer. It may not have been the most stressful time of my life, but if it wasn't, it was close.

As far as I'm aware, the jury is still out on whether stress during pregnancy carries a specific risk for the unborn; however, given that there is some evidence in this direction - and in any case, stress is a significant physiological event - it would appear that the ALARA principle applies.

Of course, you can imagine that for some people regular 'entertainment' ultrasounds would be greatly stress reducing, giving regular doses of reassurance...

Posted by
2005-10-02 10:26:33 -0500

Good points Chris, and I think people more likely to be seeking entertainment ultrasound in the first place are likely to be more stressed as a result of a false positive.

I guess I was imagining a situation whereby the entertainment ultrasound operators that suspect any abnormalities would simply request, in a "I'm sure it's nothing, but..." type of manner, that the mother report to her doctor for further examination. On reflection I suppose this would result in some anxiety, which in turn should not be dismissed perhaps as lightly as I did.

I can remember from various ultrasound sessions that it's quite apparent when the ultrasound operator is performing a medical examination and when they are simply trying to get a good picture for the parents to take home. I don't know enough about the procedure, but I would imagine that the rate of false positives during entertainment ultrasound would be quite low, simply because they are not actively looking for any problems.

I certainly don't think the first ultrasound should be an entertainment ultrasound...

Posted by
2005-10-02 10:26:33 -0500

it would depend at which point during the pregnancy you went for the entertainment ultrasound. the sex can be hard to determine prior to 18 weeks gestation. and most stuff after 35 weeks can be really hard to make out because its all so big. Our final at 41+3 weeks with willow was to estimate the amount of amniotic fluid and approximate size of baby, was nearly impossible for the woman to get a clear view of what was going on.

and i have also heard a case put forward that constant ultrasound-ing is not very healthy for the baby. so, as you say, why bother.

Then there are the DIY doppler devices I've heard can be purchased all over the USA, they generally cause more stress than relief for parents-to-be. i have heard that maternity wards are constantly fielding phonecalls from worried sick people cause their baby's heartrate can't be dected, or has changed slightly.

You don't need to be watching footage or listening in all the time. just pay attention to your body and the baby's movement.

And for what its worth, i think 3D ultrasounds are WEIRD.

Posted by
2005-10-02 10:26:33 -0500

I can't help noting the fact that Tom Cruise has bought an ultrasound machine for the purpose of looking at his unborn baby. This provoked a remonstration from the American medial establishment, using arguments very similar to those discussed above.

Posted by
2005-10-02 10:26:33 -0500

Has anyone considered the motivation of easy money? Most ultrasounds don't look like much to the average Joe so untrained or undertrained persons can get by with a lot!! Women are often desperate to get pregnant and pay huge dollars for that chance. They will pay good money for any validation of that state.

Yes, it's true that ultrasound delivers energy in the form of heat to the fetus (99% of the energy to create the ultrasound beam stays in the body as heat). Additionally the fetus is in water which does not absorb much of the energy so that more of the energy is delivered to the baby than the mother.

Yes, it's true that entertainment ltrasounds are not so concerned about the baby's development as they are in taking your money. Medical ultrasounds do not always see developmental problems either. The critical factor for the patient is to insist that their exams are performed by professionals that hold credentials in OB ultrasound. (Yes, there are several specilities in training, and your sonographer may not be credentialed in the exam that you are getting!)

Yes it is true that ultrasound machines are becoming more affordable so more offices are adding them to suppliment their ever decreasing revenues. Credentialed sonographers are expensive and therefore not often used by the office looking to make a quick profit.

Yes, the profession has worked very hard to be recognized and increase the standards for the profession. Entertainment ultrasounds offend as well as scare them.

Yes, it is true that the professional organizations that advise and support sonographers unaminously warn against participating in entertainment ultrasound exams.

Yes, it is true that once that beautiful baby is born, almost no one goes back to view their ultrasound images!!

What is underappreciated in the expertise of the properly trained sonographer. Sonographers are not allowed to diagnose (you need a medical liscense for that) but sonographers are responsible for finding the diagnosis and reporting the findings to an interpreting physician. Careful sonographers are worth their weight in gold and save lives because of their expert knowledge, critical thinking and developed scanning skills. There is much more to scannig than meets the eye. Sure it's pretty safe for all concerned, but so is playing Russian roulette if you miss the bullet!