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 girtby.net, 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.