It’s All in the Counseling …

Physicians have a lot of power over patient choices. In theory, physicians present patients with choices and then patients make informed decisions. In practice, this almost never happens. A physician can manipulate a patient into doing almost anything by counseling patients in a biased and skewed way; a doctor may even tell the truth, but if the information is presented in a certain way, the patient almost always will make a certain choice – and this choice may not be the best choice for the patient.

Let’s consider the example of external cephalic version (ECV) for non-cephalic pregnancies. This practice is woefully under-utilized. ECV is not offered to everyone who is a candidate, but even when it is offered, women often don’t choose it. Why don’t they choose it? It’s all in the counseling. If the obstetrics provider doesn’t want to do it or has a negative opinion of the practice, it will be obvious in the counseling, which will focus on potential negatives and potential risk factors for failures, rather than potential positives and risk factors for success. We manifest what we focus on, and what we focus on is not necessarily based on scientific evidence. Performing ECV on all eligible patients is the right and evidence-based thing to do, but most providers don’t. Performing vaginal hysterectomy on all eligible patients is the right and evidence-based thing to do, but most providers don’t. Performing vaginal birth after Cesarean is the right and evidence-based thing to do, yet most providers don’t. I could go for hours. In all these cases, those average providers would say something like, “Well I offered it to her, but she chose the other option.” Yet, therein lies the rub: it’s all in the counseling. This biased counseling, designed to persuade but not to inform, is paternalistic medicine at its worst.

Imagine this conversation between an obstetric provider and her patient, who is a 37-weeks G1 with a breech baby:

Version is an option, but I’m hesitant because you have an anterior placenta. I don’t like to be too aggressive with anterior placentas. The small chance that it works and that you would go on to have a vaginal delivery isn’t worth the risk of an emergency Cesarean.

This type of counseling is just daring the patient to say no to ECV. It’s full of scary words like “aggressive” and “emergency” and uses qualitative and vague words like “small chance” rather than concrete and quantitative words. This is persuasion, not informed consent.

Consider some actual data points regarding ECV:

  • While some studies have suggested that there is a higher failure rate for ECV with nulliparity and an anterior placenta, these are not contraindications to the procedure (and not all studies show a reduced success rate). There is no evidence that performing an ECV on patients with an anterior placenta is any riskier than performing it on patients with any other placental location.
  • Success rates for ECV are around 60% for all-comers, not just those who are good candidates. Those who are good candidates (lots of fluid, multiparous) have much higher success rates.
  • Abruption, cord prolapse, ruptured membranes, and even fetal death have been reported as consequences of ECV, but these are very rare outcomes (less than 1% added together) and the negative consequences are largely mitigated by performing the procedure in a labor and delivery unit where Cesarean delivery can be performed if needed (some providers perform the procedures in their offices).
  • More than 100 ECVs are performed before a single emergency Cesarean is required.
  • ECV reduces the risk of Cesarean delivery and therefore reduces the risk of maternal mortality and other negative outcomes, as well reduces healthcare costs.

Now let’s examine the counseling in light of facts:

  • “Version is an option.” No, version is recommended because it is a safe practice associated with a lower risk of Cesarean delivery. Cesarean delivery is associated with an increased risk of maternal death and worse fetal outcomes.
  • “I don’t like to be too aggressive with anterior placentas.” This implies that ECV is riskier in this patient population (it is not). Yes, it may be associated with a lower success rate (some studies say it isn’t), but that’s not what she said; she implied that it was more dangerous and so she shouldn’t be aggressive. This also implies that there is an aggressive and non-aggressive way to do ECV; this might be true, but she didn’t offer the the non-aggressive option.
  • “The small chance that it works.” Why not state the chance? Is 60% a “small chance”? There are many providers who have a near 50% rate of Cesarean delivery; do they tell their patients that they shouldn’t even try for a vaginal delivery because of the small chance that they will be successful? Unfortunately, I suspect that they do. If you were aware of a practice that would reduce the chance of Cesarean delivery by 60% or more in a given population of patients, would you not offer it to those patients?
  • “The risk of an emergency Cesarean.” Again, this implies that the risk is high and that an emergency Cesarean (which by definition is any Cesarean performed after labor has started) is dramatically greater than the risk of a planned Cesarean. But no actual numbers were given. If it were logical to perform 100 scheduled Cesareans to avoid 1 emergency Cesarean, then we should perform a schedule Cesarean delivery on all pregnant women at 39 weeks.

So here is a fairer statement to make to this patient:

If we do nothing, you are almost guaranteed to have a Cesarean delivery; this might be planned at 39 weeks or might be emergent if you present in labor before then. Either way, Cesarean delivery carries substantially higher risk for both the mother and baby, including a nearly 7-fold increased risk of maternal death. If you want more children in the future, each pregnancy will be riskier if you have a Cesarean compared to having a vaginal delivery in this pregnancy. Even though you have some factors which make an ECV harder to do, you still have about a 60% chance of success. There is a very small risk that something will happen at the time of the ECV that will require an emergency Cesarean delivery, but we will be in the hospital and ready for this. In fact, think of it this way: there is maybe a 1% chance that you will have to have an unplanned Cesarean at the time of ECV, but if do not attempt the ECV, there is almost a 100% chance you will have a Cesarean delivery, and because you may go into labor before 39 weeks, there is about a 10% chance that you will have to have an emergency Cesarean delivery if you don’t do the ECV.

Which provider sounds like she believes in evidence-based medicine and practices both competent and compassionate care? It’s all in the counseling.

We focus too much on worst case scenario thinking in medicine. Any potential scenario can be presented in three different ways: describing what might happen in the worst case scenario, what might happen in the best case scenario, and what typically happens in most scenarios.

What if the hypothetical bad doctor above were to counsel a mom about taking her two young children to the park to play? How would she counsel her if she were consistent in style?

You should know that going to the park involves driving a car; there have been situations where even perfect drivers were struck by other cars and killed. In fact, you and your children could be killed or suffer other injuries that would leave you or your children permanently disabled. Even if you do nothing wrong, your car might suffer mechanical failure that causes you to crash, potentially killing you or others. If you are fortunate enough to make it to the park, there are dozens of dangers awaiting, including kidnapping, broken bones, etc. I think if it were me, I would just stay home and watch TV. After all, better safe than sorry. I just want a healthy momma and healthy babies.

This is worst case scenario thinking, and doctors are plagued by it. Of course, the average scenario is that they go to the park and have a good time. The best case scenario is that they go to the park, stop for gas, by a lottery ticket, and become millionaires. It is just as legitimate to go through this best case scenario as it is the worst case scenario. What patients need to know is what typically happens and how to avoid unnecessary risks. Yes, you and the kids should buckle up while going to the park (do the ECV in the hospital) and you should keep an eye on the kids (monitor the baby before, during, and after the ECV), but overall, the benefits of going to the park outweigh the risks.

When I first wrote the hypothetical counseling paragraph about going to the park, it was much more gruesome; my editor told me it was too much, too graphic, and sickening to think of what could happen to small children. She felt it was gratuitous. So I softened it and took out some of the graphic descriptors. But that is the point: no mother can stand to think of something bad happening to her child, whether at birth or going to the park. I can tell the truth about possibilities and use the right filter and tone and manipulate any mother into doing anything. My editor couldn’t even finish reading it, thinking about the horrors being described about young children, and that wasn’t even a real scenario. In the same way, no reasonable mother would ever choose ECV (or VBAC, etc.) with this type of worst case scenario description. Physicians have no right to prey on the fear of mothers.

It is all in the counseling. If you want to scare someone into not doing something, give them the worst case scenario. If you want to talk someone into doing something, give them the best case scenario. If you want to counsel someone in an ethical and compassionate way, give them the average and expected scenario along with a quantified and balanced assessment of both risks and benefits. It’s their decision, not yours.