Delivering Bad Things

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Printer-Friendly Version Vol. 18 •Issue 6 • Page 38 Delivering Bad Tidings How can sonographers cope when they are forced to answer difficult questions from their patients?

By Wendy J. Meyeroff Being a sonographer in an OB/GYN unit is (for the most part) a joyful experience. But every once in a while, sonographers face times when they wish they were anywhere else.

Deborah Brown, RDMS, has been a sonographer since 1985, including the last 2 years at the new OB/GYN unit at Long Island College Hospital (LICH) in Brooklyn, N.Y. She said sonographers faced with the harder scenarios simply have "to put [their] feelings aside," and this is the advice she View these jobs and thousands more on gives her students. Press her, however, and she admits it's not ADVANCE for Healthcare Careers! always easy.

"I had this woman who was all hyped up. She'd been trying a long time, been through a lot of losses," Brown said. "This is her sixth pregnancy and she's in her fifth or sixth month and you can see she's thinking she's finally won out."

But when Brown checked the ultrasound, she could tell this baby wasn't going to survive in utero. And then the beaming mother asked the dreaded question: "What are you looking at?"

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Isn't this the doctor's job?

Search Jobs Salary calculator Both the number of ultrasounds being performed and number of sonographers employed have at least doubled at LICH's OB/GYN unit in the last 3 years. The good news about the upgrades in personnel and technology is that they've dramatically increased the number of patients the facility can service.

"This department saw 2,300 patients in 2001, the year before I arrived. It rose to 7,000 in 2002 and 10,000 in 2003," said Natan Haratz-Rubinstein, MD, director of the OB/GYN ultrasound unit.

Dr. Haratz-Rubinstein said that at least 80 percent of the patients they see are there about a pregnancy. The bad news is that with more and more pregnancies being checked via diagnostic imaging, it is more often falling to the sonographer to face the patients' first questions. Technically, LICH's sonographers are not supposed to answer questions. Dr. Haratz-Rubinstein said that's partly because of liability issues, but there is another reason.

"Our sonographers are so good, they can often distinguish one pathology better than the other, but they may not be as good at treatment options."

Brown prefers leaving the initial discussion to the doctor. "I don't want them hit twice," she said, pointing out that the patient would hear it from her and then again from the doctor.

Jessica Daniel, who was trained at LICH, has only been a sonographer for a year, but she agrees it can be difficult answering questions.

"I have to constantly remind them that I'm not a doctor," she said.

She does that with statements like, "It's not that I don't want to answer you, it's that I might give you the http://imaging-radiology-oncology-technologist.a...iewer.aspx?AN=XT_05mar7_xtp38.html&AD=03-07-2005 (1 of 3) [3/11/2005 9:00:11 PM]

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wrong answer." She urges sonographers to "know your boundaries."

Setting those boundaries That's not always easy to do, Dr. Haratz-Rubinstein admitted.

"The sonographer might have a better relationship with the patient than I do," he said. That's because they may spend more time in a certain visit than the doctor does. Also, he noted that "it's not unusual for them to see the same patient through different pregnancies."

So how can sonographers set those boundaries? What techniques help them cope when they can clearly see there's bad news for the patient?

When Brown's patients ask what she is viewing, she tries to hold off questions with statements like, "Just let me finish this scan." Generally, she finds that satisfies them.

Daniel believes that patients ask questions not because they are desperate for news, but because they have trouble coping with the silences that can develop in a 30 minute exam.

Daniel's technique is to start out by saying, "I'll try to explain things as I go along, but don't mind me if I'm not speaking or it's quiet."

Giving the patient some detail, but not too much, is another trick Daniel uses. If she's been explaining all along which is the heart and the kidneys etc., and then she says, "And that's the baby head," she said that she doesn't add, "And I see a lot of fluid there."

Instead, she just skips that detail, leaving it for the doctor. That way, the patient is generally no wiser during the scan that there's something wrong.

The downside of technology One of the improvements at LICH's state-of-the-art OB/GYN unit is a system that allows patients to see on their own monitor what the sonographer is viewing.

That has its advantages, except when things aren't going well. Brown remembers a scenario in which the mother could tell there was no heartbeat and that's what she kept saying: "'There's no heartbeat. Why is there no heartbeat?'"

"She was clearly upset, and just wanted to leave," Brown said. "I urged her to stay and wait for the doctor, but she didn't want to discuss anything, so I gave her her report. She thanked me and left. I had to tell the doctor she didn't want to wait."

In such a scenario, Brown said she will still try to make the patient wait for the doctor, saying, "Yes, there is no heartbeat as you can see. But let me bring in the doctor and he can discuss it with you."

How and when to empathize The amount of time that sonographers might spend with patients can make it even harder for them to stay objective. Brown admits that the high patient rate at LICH means that once bad news is delivered, she rarely has time to spend consoling the patient.

"We really don't have the luxury of sitting with the patient and helping them through their initial moment of grief," she said.

She admits that even if she could, there's really no place to do so and that, Brown said, isn't unusual.

"Where do you put a patient bawling? In an ideal world, every facility would have some place but they usually don't."

Even when you have the time to empathize, what's the "right" way to do it? Brown sometimes tells patients about when she miscarried a child many years ago.

"That makes them feel better because they see it happened to me," she said. She also went on to have children.

Still, she never says, "I know how you feel," because she's convinced, "No one can truly ever feel what someone else does."

Brown also advises sonographers to draw on other life experiences to help them. Losing a loved one like a parent can help them sympathize. Brown worked as a teen aide in a cancer center and she said that experience helped her learn how to be strong, and how not to bring her work home.

http://imaging-radiology-oncology-technologist.a...iewer.aspx?AN=XT_05mar7_xtp38.html&AD=03-07-2005 (2 of 3) [3/11/2005 9:00:11 PM]

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It's not always easy, but sometimes she just forces herself to take a step back and say, "OK, it's time to move on." She also provides that kind of counseling to the younger sonographers.

"We have to remember that it's our job to look not so much for the normal babies but the ones with problems," she said.

It is important to look at that as helping both the parent and the child. Sometimes she finds students who simply can't seem to develop a coping mechanism, so she suggests that perhaps they should consider an area besides OB/GYN. There's always hope As Dr. Haratz-Rubinstein said, "OB/GYN is generally a positive specialty, but some things can go wrong."

When that occurs, both the doctors and the sonographers "have to be compassionate and be able to give the patients hope," he said. "There's always a future."

That doesn't mean that you should try and force the patient to feel good, Brown said.

"Don't inflict yourself on that patient," she said. "They're entitled to be angry, upset, or whatever."

Still Daniel believes you should try and give the patient as optimistic an outlook as possible. "If I hear the doctor giving them stats about a 50/50 outcome, I tell them to try not to worry until we actually have more information," she said. "If there's a 60 percent chance that things are bad, I say, 'But you might be the other 40 percent.'"

It's not that she wears rose-colored glasses. Rather, Daniel believes that emphasizing the positive can only help the patient.

"You don't want to stress them too much. Stress plays an enormous role in what happens. I believe 70 percent of positive outcomes are thanks to medicine and the other 30 percent is through prayer or mindset or whatever you'd like to call it."

Both women think all the health information on TV doesn't help. Even when the patient is doing well, they say, they often know just enough to get scared or worried.

Ultimately, Brown said, "I tell them, 'Try and relax and enjoy your pregnancy.'"

Wendy Meyeroff is a freelance medical writer based in Maryland.

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