When does more care lead to worse care? That’s a question we in the medical field have really started asking ourselves in the past few years.
There’s no doubt that advanced tests and procedures save lives, but we also need to remember that there can be consequences to overtreatment or overtesting. During pregnancy, for example, it could lead to delivering a baby early because we’re worried the infant is in jeopardy when it’s actually not.
When extra tests make prenatal care a challenge
I was in this situation in April 2016 with a patient. An ultrasound suggested that her baby wasn’t growing as well as expected, so we performed a test on the umbilical cord blood flow. When done under this circumstance, the test can help us decide our next steps in care – and in this case it suggested the placenta might not be functioning as well as hoped. But then I re-calculated the baby’s measurements and weight and found that the baby actually was growing just fine.
Unfortunately, the extra test had already been done, and the results weren’t clear. I talked through the finding and possible implications with the patient and we decided that we wouldn’t do anything differently for right now. Though no harm was done to mom or baby, the extra test and vague results could have led to additional testing or even early delivery.
The tests you undergo are not for your doctor to make alone – you have the right and responsibility to ask questions. In fact, the “Choosing Wisely” campaign that began in 2012 is focused on empowering patients to ask their doctors questions and choose care that is supported by evidence and truly necessary.
What is the Choosing Wisely campaign?
Choosing Wisely is the brainchild of the American Board of Internal Medicine Foundation, which asked national medical organizations to identify common tests or procedures that patients and physicians should question and discuss.
The goal is to facilitate a patient/doctor conversation that – ideally – will lead to better one-on-one care. As of spring 2016, the campaign had 70 specialty societies participating. There are even patient resources developed by Consumer Reports with categories ranging from “Do I need this cancer test or treatment?” to “Scheduling early delivery of your baby.”
How did we get to the point where we need the Choosing Wisely campaign? It’s because we now realize the United States spends more on health care than anywhere else on the planet – and we don’t even get the outstanding outcomes you’d think would naturally follow. I see a real change in patients wanting to know how much care is going to cost and what benefit it may bring them. This is perhaps the only positive outcome from the abundance of high-deductible health insurance plans on the market. Patients are taking the initiative to ask, “Do I really need this test?” Even when there is no direct medical risk to a test or procedure, the financial cost and other possible downstream effects are worth considering.
I work with women who have high-risk pregnancies, and we use some very expensive tests, such as fetal MRI. These tests often can give us a better idea of how to proceed with care. However, sometimes they just give the patient a better sense of the prognosis, but don’t actually make a difference in how we care for mom or baby. I make sure the patient understands this – so they can understand the value the test brings to their care and then help decide if it is worth undergoing.
What questions should I ask my Ob/Gyn about tests or procedures?
What I really hope patients get from the Choosing Wisely campaign is that it’s OK to ask, “Why?”
If your doctor says, “I’m going to order this test,” you should ask:
- “Why is this test needed?”
- “How will this test impact the care that I get?”
- “What are the consequences of a positive or negative result?”
- “What will this test cost?”
Patients should be full partners in their health care. Don’t be intimidated, or worry your question is silly. And don’t let your physician off the hook. If you don’t understand the answer, keep asking questions until you do understand.
Some tests are mandated by law, such as screening for HIV and syphilis during pregnancy. We perform other tests based on recommendations from medical organizations such as the Society for Maternal-Fetal Medicine. But many tests are done based on the opinion of the individual physician. Remember, just because your physician recommends something doesn’t mean you shouldn’t ask, “Why?”
Choosing Wisely recommendations for pregnancy
In spring 2016, some organizations updated their recommendations for the Choosing Wisely campaign, including the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. Both expanded their “5 things physicians and patients should question” to include 10 recommendations.
While not every recommendation pertains to every pregnancy, these are some I frequently discuss with my patients:
- Don’t schedule elective or non-medically indicated inductions or Cesarean sections before 39 weeks: It’s often best for mom and baby to let the body decide when it’s ready to deliver.
- Don’t routinely recommend activity restriction or bed rest during pregnancy for any indication: This is a new recommendation, and it’s a strong position against a commonly used practice. We’ll take a closer look at this in a future blog article.
- Don’t use progesterone to try and prevent preterm birth in uncomplicated twin gestations: We know progesterone has been shown to prevent premature delivery in women with singleton pregnancies who have had previous preterm births. A 2013 study, however, found that progesterone use throughout pregnancy did not have the same effect on twin pregnancies.
- Similarly, don’t place a cerclage in women with a short cervix who are pregnant with twins: A cerclage is a stitch in the cervix that is meant to help prevent preterm birth in certain high-risk patients, but it doesn’t help in twin pregnancies.
- Don’t screen for fetal growth restriction with Doppler blood flow studies: This is the test I spoke of earlier that came back to haunt me. While it can help determine a path for care once we know a baby’s growth is behind schedule, using this test to diagnose abnormal growth has not proven reliable and helpful.
I suggest that you take a look at the recommendations made for both obstetric and gynecologic care. Don’t be intimidated by references that sound complicated or include medical terms you don’t understand. For example, you may not know what “thrombophilia evaluation” is unless you have a history of pregnancy loss, intrauterine growth restriction, or preeclampsia. You can always ask your doctor for help clarifying any of the statements you are unsure about.
Don’t be afraid to ask your doctor to explain tests, procedures, and results to you in a way you can understand. That’s what we’re here for – to arm you with the knowledge and care you need for the safest pregnancy and delivery possible.