Episode 8.5 Ultrasounds of Twins, Tongue Ties, and Pap-sploitation
In this episode, we discuss the frequency of Pap smears for twin pregnancies as well as the need for using twin-based growth data for the diagnosis of fetal growth restriction in twins. We will poke the fire of controversy of the use of the terms “fetal growth restriction” and “small for gestational age” and discover how the terms might harm pregnancies.
Next, we discuss the new AAP guidelines for diagnosis of tongue ties. Finally, we answer a listener question about pushy doctors, paying for unnecessary tests, and the disconnect many gynecologists have with guideline and evidence based care.
00:00:02 Ultrasound Use in Twin Pregnancies
00:14:06 Twin Growth and Fetal Growth Restriction
00:20:00 Fetal Growth Assessment in Twin Pregnancies
00:29:10 Overdiagnosis of Tongue Tie in Infants
00:38:05Breastfeeding and Tongue Tie Recommendations
00:45:43 Controversy Surrounding Pelvic Exams
00:58:21 Unnecessary Physical Exams and IUD Preferences
Links Discussed
Should twin-specific growth charts be used to assess fetal growth in twin pregnancies?
An Alternative to the Pap Smear Is Here, No Speculum Required
Transcript
Announcer: 0:02
This is Thinking About OB-GYN with your hosts Antonia Roberts and Howard Herrell.
Howard: 0:17
Antonia.
Antonia: 0:18
Howard.
Howard: 0:19
What are we thinking about on today’s episode?
Antonia: 0:21
We’ll talk about some trends, basically some new guidance that has come out relating to pediatric management of breastfeeding problems, and we’ll address a few really good listener questions we got. But first, what’s the thing we do without evidence?
Howard: 0:37
How about ultrasounding twin pregnancies at basically every prenatal visit?
Antonia: 0:41
This is a really good one. I’m glad you’re bringing it up. I hung on to this for a really long time, just until really recently actually. So firstly, we do know that twins are at higher risk for several different complications, including growth restriction, low birth weight, preterm delivery and stillbirth. So even the most uncomplicated preterm delivery and stillbirth, so even the most uncomplicated healthy twin pregnancies will need some extra ultrasounds compared to if they were singleton pregnancies. But do they need it at every single visit? I thought yes for the longest time because in my mind you cannot possibly know for sure that you’re hearing two different heartbeats when you’re only listening with a Doppler, one after the other, and not visualizing two separate babies with an ultrasound, or not seeing two different tracings if you put on external monitors. So at least even in that case, if you’re not visualizing, you actually see the two different heartbeats, but with a handheld Doppler you don’t see them at the same time. It’s one after the other.
Antonia: 1:49
But for the first probably eight years of my career, starting from in residency, I always worked in OB clinics where somehow it was standard for at least every other exam room to just have a portable ultrasound sitting there. A lot of times we had just the cheaper versions. They were like little laptops on a rolling stand with an ultrasound probe. So on any given day the majority of my OB patients would just be getting an ultrasound, just for things like confirming they have a normal heartbeat, normal growth sometimes, or fetal position later on. And obviously then if they were twins, I would always just routinely look at both of them and make sure we got heartbeats on both of them. And for some of those OB patients I knew that, okay, the ultrasound wasn’t strictly necessary. I could have just Dopplered, for example, or maybe done a manual estimation of the fetal weight. But for the twins I always thought, yeah, I really needed this ultrasound. I couldn’t have Dopplered this to confirm that they’re both viable?
Howard: 2:55
You were basically doing a bunch of free ultrasounds, which I think I do too. It’s interesting, some of these issues about ultrasound and antenatal testing. We have this principle, the ALARA principle, which says that we should expose pregnancies to as low as reasonably achievable amounts of ultrasound, but people will just use B-mode or M-mode in the first trimester to minimize the energy exposure. However, the same people will ultrasound certain pregnancies I’m talking about maternal fetal medicine specialists will ultrasound certain pregnancies I’m talking about maternal fetal medicine specialists Will ultrasound certain pregnancies every two weeks for 40 weeks, but they’ll use B mode in the first trimester, given the ALARA principle.
Howard: 3:33
There’s the cost and resources availability issue of overusing ultrasound, especially if you’re charging patients for it.
Howard: 3:40
And then there is the ALARA principle about minimizing potential exposure to ultrasound waves. So I think if you have the ability to do a bedside ultrasound and you’re not charging the patient and you’re just quickly visualizing heart tones or maybe checking positions or whatever it is that you want to do in that routine visit, I think that’s okay. But unfortunately people are charging for these unindicated ultrasounds based on the premise at least that the ultrasound is necessary due to the inability to accurately detect the two different fetal heartbeats, when maybe they haven’t even bothered, trying to Doppler the twins first, and depending on all kinds of variables and payment plans and things like that, it may end up being a big copay that the patient gets a bill for after these visits, for several months later maybe, that they can’t afford. It goes to collections. And even if their insurance pays the whole thing, it was a medically unnecessary service, if nothing else, and it took away clinic time from other patients who might have needed that care.
Antonia: 4:33
This might be another side note, things we do for no reason. But the M mode is silent and I think a lot of us have that, at least have the impression that the patient wants to hear. A lot of us have that, at least have the impression that the patient wants to hear. They want to hear the boom, boom, boom, and so we’ll just put it on the loudest mode, which we don’t think about how that actually does expose the baby to more energy.
Antonia: 4:55
Anyway, now in my current setting I do not have ultrasounds sitting in any of my exam rooms. It’s always an actual order that I have to order a sonographer to do, and that’s been one of the bigger adjustments for me. Part of it is just the different setup and the different type of health system that I both was a provider and also a recipient of that care, and I remember in my first pregnancy I was still in that previous system. I got a lot of ultrasounds. This might be relevant to what we’re going to talk about later a little bit. But they were saying, like this baby is kind of borderline small. He’s just barely over the 10th percentile. We should just check on him a few more times.
Antonia: 5:36
I never paid a cent for any of it and in my mind it just was like, okay, sure, however many you think I need, we’ll just they were all free. And then when I came over here in my second pregnancy I got the one anatomy scan and I was paying almost a thousand per month for my commercial health insurance and then when that was applied, then I still had to pay 500 for that one ultrasound, which was just. It was just shocking to me to realize that’s actually the going rate for each ultrasound, at least for an anatomy ultrasound. I don’t know if those more limited ones then would be cheaper to some extent, but they all cost money. They’re all diagnostic tests that cost money.
Howard: 6:20
So Well, the machines are expensive, the maintenance contracts are expensive and, frankly, well, the machines are expensive, the maintenance contracts are expensive and, frankly, they’re a huge revenue generator, which I do think creates a conflict of interest about how they’re used and how recommendations for antenatal testing come about. So we have to think about that At least’s needed and not overburden our healthcare system with these costs, if we can help it.
Antonia: 7:12
Yeah, and I know that it’s not something that right, that’s not something that our clinic is going to get.
Antonia: 7:18
We’re not just going to get a bunch of extra ultrasound sitting around for us to use on a whim because it would be an excess and it would be very costly. So the first time that I saw twin patients in my new job for a prenatal visit and I saw that they weren’t scheduled for an ultrasound for that particular visit, at first I thought it was a mistake and I thought, wait, am I just supposed to Doppler these? And then I did, because I didn’t really have a choice. And then I actually was able to hear two different heartbeats. I moved it from side to side and I could hear an abrupt shift in the rate, and it wasn’t even a huge shift, but I could tell even the patient could tell yeah, that wasn’t just one baby’s heart rate, a variation of it dipping down a bit that that was clearly two different ones. So that was eye-opening and I didn’t think it was possible before. But I guess that’s actually how it should be done.
Howard: 8:11
Yeah, and we could get into a side conversation in here about is there even utility in listening to the heartbeat on any prenatal visit, especially when the mother’s feeling movements and all that? But yeah, it’s actually not that difficult to distinguish between the two different heartbeats with the Doppler. So if you’ve tried, it should be a rare thing to fail at distinguishing these heartbeats and then needing to add on an unscheduled ultrasound because you can’t tell the difference or don’t hear both. So the bigger question then just becomes is there another reason to go ahead and do routine ultrasound besides the need to just listen to two different heartbeats? But sure, if someone is routinely scheduling an ultrasound essentially at every visit because they think that it’s impossible to get two different heartbeats, and then charging the patient for basically a code that implies that they tried and were unable to hear the heartbeat, then that’s definitely a thing we do without evidence.
Antonia: 9:02
I do get this, even with single tents, every once in a while. Usually it’s someone that’s maybe 14 weeks or less, and in those cases I’ve ordered a stat ultrasound and then we say the baby is just like a little ricochet or like not sitting still at all. And then we say, oh, they just were running away from that at all. And when we say, oh, they just were running away from that. So I think that in my mind the fear that I had was that, let’s say that I put the Dopplers on and it’s a patient with twins and I definitely hear one heartbeat, and then maybe I think I hear a separate one, but it was actually the same one, and then that baby actually was deceased and we didn’t know. Yeah, that was my biggest fear, like what would happen then.
Howard: 9:51
You wouldn’t do it to me, you wouldn’t do anything different though if you did know is the truth. So there’s one alive. It’s not like you’re going to induce for the fetal demise or anything like that. So there’s that sort of again utility question of why are we doing heartbeats at all? We can have that philosophical conversation later, and at 14 weeks the mother can’t feel so obviously that’s a separate situation where you are confirming viability at those visits.
Howard: 10:15
But I think you can take the approach that or, if you’re uncertain, go ahead and order the ultrasound, but at least try first, I think is the point, and, as you discovered, it can be surprisingly easy. So the truth is we’re doing this stuff for reassurance, not oftentimes because it makes a practical difference, I think sometimes people think we’re screening for bradycardia or tachycardia. We’re not. We would never design a screening test for those rare conditions that we checked constantly at multiple visits for. And as for antenatal testing, though for twins, we’ll recall that ACOG doesn’t recommend anything for uncomplicated dichorionic diamniotic twins until 36 weeks. So the idea that twins of all stripes are, quote, high risk and should get additional ultrasounds just because they’re twins is certainly not evidence-based.
Antonia: 10:59
Yeah, I guess at least with singletons, if we detect that the baby is deceased, then at least then we could get them set up for maybe an induction or something. But if it’s twins and there’s one surviving twin that you heard, then you want to keep letting that twin grow.
Howard: 11:17
You’re not going to do anything different.
Antonia: 11:19
Yeah, okay. So with twins, what about surveilling for growth and growth restriction? Because, yes, as you said, we don’t start any antenatal testing until 36 weeks. There is that increased risk of stillbirth that feasibly we’re looking for, even though we don’t know if the testing actually decreases that risk. But we know that they tend to be smaller than singletons, so should they be getting monthly ultrasounds?
Howard: 11:48
Yeah, so this is a different question than the one originally premised, and obviously twins complicated by monochorionicity or other obstetric or medical issues will require more testing and surveillance for that issue. But as far as growth restriction is concerned, in a dichorionic pregnancy, there’s a couple of issues that we need to think about. The first one is simply the question of whether or not uncomplicated dichorionic-diamniotic twins are actually at increased risk of fetal growth restriction. So we have to make a distinction, I think, between small for gestational age and fetal growth restriction. Now I want to clarify something before I use the term We’ve all been taught.
Howard: 12:26
I think that small for gestational age is a term we use after the pregnancy’s ended and the child is born it’s a pediatric term and that fetal growth restriction, or the previous IUGR, intrauterine growth restriction, is a term we use while they’re still pregnant, and that’s actually not true. That’s just something that we’ve fallen into a habit of and actually people get pedantic about it some. So previously the pediatricians would use low birth weight, very low birth weight, these sorts of terms, and they were based upon just is the baby more than 2,500 grams or not correlated to the gestational age, and we have decades, hundreds of years of data about these birth weights so we can make generalizations that 2,500 grams roughly corresponds to a term, pregnancy, things like that. But now it’s unusual to have a pregnancy, a newborn, where you don’t have an expected gestational age at delivery. So that’s still out there, but that’s not what pediatricians use anymore.
Howard: 13:24
They correlate and put it on a chart to understand was this a small for or large for gestational age delivery? Because they know the week’s gestation. You can read Gabby’s obstetrics for these terms. People who correct people about SGA or LGA as a postpartum term, not an intrapartum term, don’t really understand that these terms can be applied. Estimate is less than 10th percentile for that estimated gestational age, which we also usually define and this is a very controversial definition as fetal growth restriction. Now fetal growth restriction can be defined with some other ways and there’s a lot of controversy about fetal growth restrictions definition and we cast a wide net to discover those that are pathological and those that are just small for gestational age.
Howard: 14:30
But the spirit of it truly is that there’s some amount of pregnancies that are small for gestational age and that’s just arbitrarily the bottom 10 percentile. But most of those are actually just constitutionally small. They’re not pathologically small. And then there’s some real number of pregnancies that are fetal growth restriction. Most of those are less than 10th percentile, although you could be the 30th percentile and have pathologic growth restriction. And that’s where we think about other definitions like a bottom 10th percentile, abdominal circumference or things like that. But for all practical purposes we call all the less than 10th percentile fetuses fetal growth restriction. But appreciate that’s actually not true. Most of them don’t have growth restriction. Maybe 35 or 40 percent do. They’re just small for gestational age and that’s usually due to maybe an incorrect due date or just constitutionally small or other reasons.
Howard: 15:18
So don’t be so pedantic about SGA. We can use it as an antenatal term to distinguish babies that are below the 10th percentile, but we don’t think have fetal growth restriction. It’s just not our tradition to do that now because essentially everybody gets treated the same, because we’re surveilling that group more intensely. So at first glance it can appear the same SGA as fetal growth restriction. Fetal growth restriction is always pathologic the way we use that term and small for gestational age may not be. Again, it can just be you have two small parents and they have a small child, constitutionally small or something like that.
Howard: 15:55
Now the thing about twins is that in the third trimester in particular, they have a slower growth velocity compared to singleton pregnancies.
Howard: 16:02
So if you measure a twin and use singleton data from a nomogram to assign a percentile, then it will make twin fetuses appear that they’re small for gestational age or growth-restricted, have fetal growth restriction arbitrarily.
Howard: 16:16
But there are charts for twins which reflect the fact that twins grow at a slower velocity and if you compare the difference, twins measured on a singleton chart have a rate of almost one in three being labeled as fetal growth restriction or small for gestational age, whereas twins measured using a twin chart have a small for gestational age rate of only four percent or so, although using the same statistical method, we would expect that to be also close to 10 percent if you had a large data set. But in any event, a third of twins are labeled out there in the world as small for gestational age if we’re using singleton charts to do these ultrasounds with, and the vast majority of those pregnancies are then going to get extra testing and antenatal testing and all these other follow-up things that are just not necessary because they actually don’t have fetal growth restriction and they’re actually not small for gestational age, whichever definition you want to use.
Antonia: 17:06
Well, right now ACOG does not make a recommendation about whether you should compare twins against other twins or just compare them against singletons. But internationally the recommendation, at least by FIGO for example, is to use twin-specific charts. The International Society for Ultrasound and Obstetrics and Gynecology also recommends twin charts for twins singleton charts for singletons.
Howard: 17:32
Yeah, and I’ll put a link to a very good article from the Gray Journal in July of 2022 that reviews this issue in detail and clearly makes the case that we should be using twin charts.
Howard: 17:41
If twins grew at the same rate as singletons do, for example, then a twin pregnancy at 38 weeks would have a combined weight of about 6,500 grams, and that would do nothing but increase the risk of fetal death because of the utero-placental insufficiency that would follow so much demand from the large combined weight of these fetuses, from the placentas and likely risks of maternal death from the increased uterine distention and the larger placental mass and all of the negatives that causes.
Howard: 18:10
So if we could wave some magic wand and make twins grow with the same trajectory as singletons if we’re acting like that’s the ideal and we’re upset that it’s not happening, we would actually be doing more harm than good. But it’s fairly clear from this review article and others from the last two or three years that we are over-diagnosing in twin pregnancies and then consequently doing a lot more surveillance and extra testing among a group of pregnancies that are often delivered by 37 or 38 weeks anyway, which would be the normal intervention for the vast majority of pregnancies that you’ve diagnosed even as having pathologic fetal growth restriction. So there’s just no evidence that we’re helping twin pregnancies by using singleton pregnancy comparators, and using a twin data set would diminish that rate of overdiagnosis. So fetal growth restriction and all the extra interventions that come along with that.
Antonia: 19:02
That is a really interesting theory and perspective that the twins’ relatively smaller size is a healthy survival adaptation, and I can only imagine all kinds of really complex signaling and, I don’t know, maybe growth hormone that goes into it rather than it being always a pathologic thing due to maybe a lack of placental blood supply between both of them or even somehow just being too physically crowded to grow the way a singleton normally would.
Antonia: 19:33
And I think people obviously still do worry about the increased complications of twins and they associate that with fetal growth restriction. So if these twins are growth restricted or small compared to singletons and we know they have that higher risk of stillbirth and maybe they might have more trouble with things after birth like blood sugar regulation or temperatures or respiratory support. But if we even were to go with the twin specific growth curves and say their risk against other twins at least is still only around 10% or less, we still would want to screen them with ultrasound in the twin pregnancies because even if we can detect with a Doppler two different heart rates, we really can’t estimate their growth in any other way. We know fundal heights don’t work anyway, not even with singletons, if we’re being honest, but palpation is not going to be anywhere near as accurate, even compared to singletons, when you’ve got two different babies in there. So it seems like our only possible way to assess growth even in the rough sense with twins would be with ultrasound.
Howard: 20:47
Yeah, I think that’s absolutely right. So then the question is how early and how often should twin pregnancies receive an ultrasound just for that pure screening purpose, to detect fetal growth restriction or small for gestational age? So it might be reasonable to do monthly fetal weight starting at 28 weeks. There is no universal prescriptive standard for when and how often to do any growth ultrasounds really for anything. This is yet another thing that departments essentially make up their own rules based on what resources and the population they have and somewhat depends on how soon you might act on an abnormal result or what interactions you could take.
Howard: 21:21
So if you find severe growth restriction of one or both fetuses at 24 weeks reverse Doppler’s and everything then maybe in the most extreme case it could lead to very early delivery to prevent death. But those tests of course have very high false positive rates and that’s one of the problems. So you have to think what would be the risk of a false finding that would lead to an iatrogenic 24-week delivery. It’s hard to know and you really have to consider when. Does the benefit of doing this ultrasound outweigh the risks of these iatrogenic interventions and significant patient distress from them and iatrogenic preterm delivery due to false positive findings. So I think doing monthly growth ultrasounds for uncomplicated dichorionic twin pregnancy, starting at 28 weeks, let alone 24 weeks, and then every two to three week growth scans that some places might do, is very hard to justify. The rate of growth restriction and even just SGA fetuses is not increased in twin pregnancies when you use twin charts compared to singleton. So you’re just screening the population and although the rate of fetal death of course is increased in twins versus singletons, there’s no evidence that the extra growth scans or antenatal testing makes any difference in those outcomes. So even the most extreme policy you could come up with maybe every two weeks, starting at 24 weeks would just add up to massive amounts of completely unindicated and useless ultrasounds.
Antonia: 22:43
Yeah. So if you’re routinely comparing twins against singletons, as if you’re expecting they should be as big as a singleton of that gestational age, which I think many in the US probably are then you’re probably going to think you’ve got all kinds of good catches. One in three patients with twins are going to be getting referred for what’s the appropriate thing. When you catch a baby under the 10th percentile, you put them in more monitoring. They get Doppler’s. They’ll probably get delivered early. They might get late preterm steroids, depending on the situation, but it could be that we’re actually just making up a problem that doesn’t exist. For most of them, they’re actually just healthy and they’re, in most cases, growing exactly as they should be. But by labeling them as pathologic, we end up potentially causing a lot more NICU admissions and all the potential severe morbidities.
Antonia: 23:40
From that, it sounds like the AJOG paper from 2022 suggests that, yes, we could actually be causing more harm by trying to overdiagnose fetal growth restriction in twins, and I’ll just review percentiles that. I’m sure you could review this too, but I think there may be some general confusion about this. So, just to recap, as we said, 10% of all fetuses are in the bottom 10th percentile for weight, just like in another example of a normal distribution, 10% of all adults are the shortest 10% of the population. Some of them are totally healthy. Maybe some of them had stunted growth from malnutrition, but it encompasses the whole population. That includes a lot of just healthy people.
Antonia: 24:28
So when it’s a fetus, we will tend to say that they’re under the 10th percentile, it’s pathologic fetal growth restriction until proven otherwise, and it feels like we have to say that initially, but then we put them in that category, we work them up, we do a little bit of extra surveillance and follow them and I think in many cases, if you’re actually thinking about the difference between the pathologic fetal growth restriction and being a healthy, constitutionally small baby, you can actually exclude pathology in a lot of cases and avoid early delivery if you can reasonably assume that this is likely a healthy small to a gestational age baby, especially if you can see that both parents are short. A gestational age baby, especially if you can see that both parents are short. They had a small prior kid that was healthy, those normal Dopplers et cetera. Those kinds of things.
Howard: 25:21
Yeah, that seems so obvious, but I do think people just don’t understand how percentiles work, including physicians.
Howard: 25:26
I went to a recent meeting of a group that’s concerned about public health advocacy in Tennessee and they provided a fact sheet based on public data about the county that I live in and this revealed that 8% of the babies born in my county were low birth weight.
Howard: 25:41
This was presented as a cause of concern and something we needed to work on to make babies bigger, and I think this helps raise money from potential donors who don’t understand that 10% of babies, by definition, should be considered low birth weight or small for gestational age. I suppose because it’s merely, by definition, the bottom 10 percentile of newborn weights. In fact, to make that number lower would mean shifting our bell-shaped curve to include more large babies, which would probably mean more obesity and diabetes in the community, which is, in fact, a bad thing. But if you only had 5% of your newborns being of low birth weight, it probably reflects an obesity epidemic because the weights have shifted too high compared to national standards and in fact, throughout Tennessee, only about 8% or 9% of newborns are considered small for gestational age. But I feel like that. The spirit was that should be zero. We shouldn’t have babies small for gestational age. But it’s just a statistical definition.
Antonia: 26:36
We shouldn’t have any short adults either, or even the top 10th percentile. Yeah, if you have that magic wand that you were talking about and you waved it and added a whole pound to every baby that’s born, you would just shift the curve and then there would still be it. You’d shift the line and the cutoff for 10th percentile would just be the curve, and then there would still be. You’d shift the line and the cut off for 10th percentile would just be further up and you’d still have that bottom 10th percentile. You would have just shifted it.
Antonia: 27:04
Because that’s still how we define small for gestational age or really even fetal growth restriction or low birth weight. It’s starting with that bottom 10th percentile. There will always be a bottom 10th percentile if we have a normal distribution. It’s not that being in that 10th percentile compared to the norm automatically means you have worse outcomes. It’s just a neutral descriptor because it’s an easy number for people who do research to just pluck out of the data and I would think even at a certain level of obesity and fetal macrosomia becoming more prevalent, it could even mean feasibly that being in the bottom 10th percentile gives you better outcomes if you shift that whole curve far enough down.
Howard: 27:54
Yeah, I remember.
Antonia: 27:55
You’re just. The norm is massive babies.
Howard: 27:58
Yeah, I remember you mentioned a while back that in low income countries without access, routine access to cesarean being underweight might be the only way that a woman and her baby avoid obstructed labors and survive birth.
Howard: 28:10
It’s incredibly context dependent and it shifts and it’s a shifting target. But don’t miss the irony that if my county here had a 5% rate of low birth weight babies compared to the rest of the US, for example, those folks might be happy who have this sort of percentile fallacy, but it would probably reflect overall a more unhealthy population due to the babies in the community being too large due to maternal obesity or diabetes. So this is an example of the percentile fallacy and it probably helps again to raise money or get folks motivated about some intervention, but it misses the point of any actual problems that need to be addressed. The real problem that we want to weed out is pathologic fetal growth restriction leading to fetal demise or other complications, and that’s also why I think we need to push a little bit more to use SGA in the antenatal period, because you’re just saying automatically when you say fetal growth restriction, that 10% of babies have a pathology and that’s not what we really mean to say.
Antonia: 29:06
All right, that’s some good food for thought, but let’s move on. So there is a new guideline regarding ankyloglossia that’s been released over this past summer from the American Academy of Pediatrics.
Howard: 29:18
I might just say tongue tie for this one.
Antonia: 29:20
Okay, I guess that’s easier to say than ankyloglossia, so that’s fine.
Howard: 29:24
Ankyloglossia is a tongue twister.
Antonia: 29:26
Yeah, that’s a nice dad joke. Nerdy pun there for everyone.
Howard: 29:30
It takes an air to know one.
Antonia: 29:32
Yeah, okay, okay. For everyone. It takes an air to know one yeah, okay, okay. So one of the things that’s happened with this is the diagnosis of ankyloglossia, or tongue tie, has increased nearly 20 fold since roughly the year 2000. The traditional rates of this diagnosis had previously been around one to 2%, but in some communities now it’s incredibly high. It seems to be like all the rage. It seems like the new favorite of many lactation consultants or maybe pediatric dentists. I think we had a pediatric dentist say you’re a guy, you might have a little one there we could fix. So it seems like it’s becoming almost like this thriving industry.
Howard: 30:12
Yeah, and well, anytime you see the rates of diagnosis increase significantly over time, whether that’s rates of breast cancer or colon cancer, autism or diabetes, or small for gestational age fetuses among twin pregnancies, or you have to ask yourself whether we’re seeing a true increase in the rate of disease or simply the rate of diagnosis itself. It’s possible for the rate of diagnosis to go up appropriately, while the rate of disease could go up appropriately, while the rate of disease could actually be declining or remaining unchanged at least. And this might happen due to increased awareness of the condition or, say, a newly available diagnostic test or a diagnostic criteria has changed, and so we might be labeling more people as having a certain condition, even though in an absolute sense, if you could know it, the real rate of that condition existing is declining or is being stable that might be spurred by, maybe, a new treatment or intervention that can now help more people with the diagnosis that previously there wasn’t treatment for.
Antonia: 31:20
So we see that a lot in medicine. One example is hepatitis C. Before we had direct acting antiviral treatments for that, we really didn’t emphasize screening as much as we do today, because there just wasn’t a good treatment, so why screen? But now we recommend routine screening for it with every pregnant patient at the new visit, and so the rate of diagnosis has increased a lot, even as the absolute rate of hepatitis C infection is declining due to that treatment.
Howard: 31:51
Yeah, there’s a lot of examples like that. So autism, too, has become a lot more normalized, and there’s all kinds of kids now getting identified and great because they have more resources and more treatments and things like that. And in prior generations a lot more autistic and neurodivergent children were just kept in the same conventional school setting as everyone else. There wasn’t really interventions and they fell behind and it was deemed somehow a poor discipline or a poor parenting problem or something else and they didn’t have an awareness and it went under diagnosed.
Antonia: 32:19
Yeah, I would definitely agree that my son that’s autistic is in a preschool program for autism and he’s just doing really well. And I don’t know if we would have figured this out for him and his with his exact presentation even 10 or 20 years ago. He might have just been like what’s wrong with him, kind of thing. But now we know.
Howard: 32:40
So catching more cases of a given condition can be wonderful, but it’s also possible that something is being overdiagnosed.
Howard: 32:47
So you see an increase in misdiagnosis and overtreatment while the absolute rate of the disease or pathology is actually unchanged, and we see that perhaps more commonly than the other more favorable kind examples we just mentioned.
Howard: 33:00
This is especially true if someone is able to make money off of it or it seems to explain a common problem that a lot of folks are frustrated by.
Howard: 33:08
So we also may see increased rates of inappropriate diagnosis or misdiagnosis or overdiagnosis due to the adoption of a new testing modality or regimen that somebody may make money off of. For example, we’re seeing a lot more postpartum hypertension now, not because there’s more of it, but because we’re checking women’s blood pressures at one to two weeks postpartum or even using home blood pressure monitoring that a lot of companies have sold to us, and so we’re just finding something that was likely always there but we didn’t know about, and whether that changes outcomes is a different question and actually the question to consider, and so we have to Figure that out, for example, for these extra blood pressure checks that we’re doing in the postpartum period. Whether we’re actually going to change morbidity or mortality. I don’t think we know that yet and we can talk about that later. But in the case of tongue ties, it’s very unlikely that the actual rate of tongue tie in the United States has increased 20-fold in the last 20 years. So we were either grossly underdiagnosing it before or now we’re grossly overdiagnosing it.
Antonia: 34:09
I think that’s why they’ve come out with this new guideline now to try to address the criteria and understand, more importantly, which newborns actually benefit from these surgical procedures that are being popularized, often by lactation consultants or dentists, and often who charge cash for these procedures consultants or dentists, and often who charge cash for these procedures, and probably in most cases, with newborns that don’t end up benefiting from it because they never needed it in the first place.
Howard: 34:35
Right. Well, breastfeeding is a great example of something that most people struggle with, at least initially, and so these patients become very vulnerable for anything that might make their struggle a little easier, and there’s a big market out there that’s ready to sell them interventions, and it doesn’t even really matter if they help or not, because a frustrated mother will try anything if she’s desperate enough, and most of this advice doesn’t come directly from physicians, but it comes from the sort of meta-medical community, which does include lactation consultants, but doulas and the mom groups on the internet or in social media. So everything from cookies to various secretagogues and galactagogues, and herbs and vitamins and supplements and, well, multiple oral surgeries for your newborn child.
Antonia: 35:20
Yeah, so maybe instead of all these questionable, maybe placebo type treatments, the moms just need a little more actual support or reassurance and objective information. Almost all of those things that you listed have been studied in clinical trials and do not work to increase milk supply or infant’s weight. But most moms do struggle in the first couple weeks with breastfeeding, no matter what they do, until they and their babies get the hang of it, and most of them also find that things just over time will get easier, just by giving it time and continuing to just stick with it. Keep, maybe keep trying different positions, conservative options, you could say. But if they also ate the lactation cookies or supplements, they might attribute those improvements to those cookies too, especially if they paid a lot of money for it. And so some of that probably happens with those tongue tie release procedures as well.
Howard: 36:26
Well, the idea is that these tongue ties restrict the tongue’s range of motion and degree of motion, and the most common tongue tie that people think about is the lingual frenulum. But there are other ties as well that are being cut out of these infants’ mouths and the promise that it’s going to help breastfeeding and also speech and other things.
Antonia: 36:47
Well, this new article from the AAP reviews the literature and the problems with diagnostic criteria and the influence of internet and social media on the rates of diagnosis, as well as the cost of these procedures and just some of the unknown research questions that we still have. And they do come away with some conclusions that we can review here. But I would encourage everyone to read this article and especially look at the visuals they have. It’s free to access and it was created by a group of pediatricians and lactation consultants and dentists and pediatric ENT doctors and some other relevant experts. So it’s a good multidisciplinary document. But let’s go through. I think they have nine recommendations and conclusions here. Their first one is just a reminder that tongue tie is a normal variation of oral anatomy. It can be symptomatic if that lingual frenulum causes enough restriction of the tongue’s movement to interfere with breastfeeding. That is not improved with just normal lactation support. And the point of this is just that if you see a tongue tie, it doesn’t mean that it needs to be cut.
Howard: 38:05
Right. Some people are saying that if there is a tongue tie, then the patient should undergo frenotomy regardless because it can cause problems in the future with speech or even obstructive sleep apnea, and that simply is not true, and it’s not a reason to cut a tongue tie that isn’t causing significant breastfeeding difficulty, which doesn’t respond to normal treatments. Now the next conclusion or point that they make is that we shouldn’t use the term posterior ankyloglossia or posterior tongue tie, because there’s no clear definition of this and it’s not a reason to have a surgical intervention.
Antonia: 38:38
Yeah, they point out that the lingual frenulum actually does not connect to the posterior tongue, as people probably think it does, and the mere appearance of this frenulum cannot be used to diagnose ankyloglossia.
Antonia: 38:53
One of the issues is that the tongue and a frenulum, if that’s present, look different during the feeding itself. They’re in a different position, and so when you’re just, when they’re just laying there and their mouth is open and you’re looking at it, seeing that anatomy is misleading, you really would need to see it in action, which I know it’s a little bit harder to do. But that’s the anatomy. That matters is what is their position during feeding, and you have to have some very specific types of feeding difficulties again that are not improving with lactation support, not just an anatomic appearance when you’re just looking at their open mouth, not feeding. Okay. Their third conclusion is that labial and buccal frenulums or ties, are unrelated to breastfeeding mechanics. Therefore they don’t require surgical intervention, even if there is breastfeeding problems, because they won’t fix the problems. And another point they make is that sucking blisters, like on the baby’s hands, for example, are normal for newborns and do not suggest that there’s any kind of problem.
Howard: 40:01
Yeah, that’s some of the other ties that you see commonly and being treated, and, just as a rule of thumb, if you have a provider recommending that those other ties are a problem for breastfeeding, or that sucking blisters indicate that there is a problem, then you should probably find a new provider, whether that’s a lactation consultant or a pediatrician or whatever. These are very non-evidence-based ideas, okay, well, their next conclusion is that breastfeeding difficulties arise from a complex interrelationship of issues, and then you have to consider all the reasons for breastfeeding difficulty, with a multidisciplinary team evaluating the problem, before you go to surgery. Most breastfeeding difficulties are not going to be related to tongue ties.
Antonia: 40:43
Yeah, and what you might see in the community is, let’s say, a complaint of painful breastfeeding and then, whoever provider it is, takes a quick look in the mouth, they see that lingual frenulum. When the baby’s mouth is just open, dentist for a laser procedure, without even thinking about letting, let alone reviewing, all of the other potential issues that might be causing that painful latch. And so most of these sorts of diagnoses are going to be inappropriate in that example and most of those procedures that stem from the inappropriate diagnoses then are not actually going to be helpful. They’re not actually going to be helpful. They’re not actually going to make a difference. If people experience an improvement in their breastfeeding afterwards, there’s a good chance it would have improved anyway without that procedure. All right, the next recommendation they discussed is that newborns who do possibly have symptomatic tongue tie need close monitoring and follow-up and evaluation of weight gain, for example, to see how things progress and make sure that they’re feeding enough both before and then after if they do go through that procedure.
Howard: 41:57
Yeah, and that also reiterates that this isn’t something you diagnose at one visit. This has to play out after time and conservative measures Okay. The next recommendation is that you can offer surgical intervention once other causes of breastfeeding dysfunction and pain have been evaluated, and that frenotomy may decrease maternal nipple pain in appropriately selected mother-baby dyads, and that treatment of this pain may, of course, promote breastfeeding success. Now they do not recommend that a laser be used, and there’s no evidence that the laser provides any advantage to just a surgical snip scissors.
Antonia: 42:32
Yeah, that might be another clue. If you’re dealing with someone who seems to only be recommending lasers for these tongue ties, you’re probably not seeing the right person. Their next recommendation here is that these procedures should be performed by trained and privileged providers and that the pediatrician be involved in recommending the patient to the right provider, which is often going to be a pediatric ear, nose and throat doctor. The general pediatrician themselves may do the procedure as well if they’re appropriately trained and credentialed, but they are clearly trying to instill some gatekeeping here in this guidance so that patients aren’t just routinely shuffled off to maybe an exploitative dentist or physician who is just doling out laser procedures to every single baby that gets brought into their office.
Howard: 43:28
Yeah, definitely Okay. The next recommendation is that postoperative stretching exercises should not be recommended and, finally, that we need more research to standardize our approach to this problem and measure the impact these interventions are having on long-term outcomes.
Antonia: 43:43
They provide a nice algorithm for addressing the suspected tongue tie, and that includes a list of other infant and maternal conditions that need to be evaluated before concluding that breastfeeding dysfunction is related to a suspected tongue tie.
Howard: 43:58
It was also interesting that they noted that most of the appropriate procedures are covered by insurance, and so it should be very unusual that patients with insurance have to pay cash for these procedures, but that’s what I see happening almost exclusively in my community.
Antonia: 44:13
Yeah, so if someone out there is at a cash only practice, then just turn away. That should be a red flag. All right, we do have time for a listener question. We received actually a three-page letter from a listener who is not an OBGYN but is a physician. We don’t have time to read all of it line by line, but we can summarize what she said and get to the main part of her question.
Antonia: 44:39
So she told a story of how she made an appointment with a new gynecologist who she hadn’t been followed by before, for a pap smear and to get an IUD inserted. First they gave her a form to sign that was essentially an agreement to pay for her pap smear in case her insurance didn’t cover it, and the form stated that ACOG no longer recommends yearly pap smears but that the providers in this office strongly believe in them and that they recommended that she get one and get one every year, and that she should sign this form agreeing to pay for it if her insurance does not. So that was already an interesting thing. I hadn’t heard of this before. So then she had also made sure that she could get the same day IUD placement. She vetted out what kind of clinics do that and what don’t, and this was a clinic that does it and she made the appointment accordingly and because she had never been pregnant before, she decided that she wants a Kyleena. It’s a smaller IUD. She first met with the physician in his office even though she had been taken to wait in the exam room, and then she was pulled from the exam room to talk with him in his office and she felt like this was an intimidating experience. But when she met with him he strongly recommended that she get a Lyletta IUD instead and that there was no difference between that versus the Kyleena. The only difference was a quote licensing deal. And then they.
Antonia: 46:13
She went back to the exam room where he proceeded to do a complete physical exam and she described all the little components of it and it the way she described it. He didn’t do any of those exam maneuvers correctly or thoroughly. Do any of those exam maneuvers correctly or thoroughly, and none of the exam items were indicated they weren’t necessary by her specific risk factors or complaints or especially her age. And she really had to push back and fight to get the Kyleena IUD till the very end, which she finally did, but it seemed like he was really trying to do everything in his power not to give her the Kyleena and give her the Lyletta instead. So he gets the Kyleena and he did clamp the tenaculum on the cervix and then let it hang there for a while as he fiddled around with the other instruments and finally got the iud in.
Antonia: 47:03
Then he told her that he recommended she have an ultrasound because when he felt her abdomen he thought he felt stool and he recommended she have an ultrasound because when he felt her abdomen he thought he felt stool and he wanted to do an ultrasound to examine her for constipation, which she didn’t complain of. She knows that she doesn’t have constipation. So finally, after all that, then he has her come back to his office so that he could then describe to her the side effects and the expectations of the IUD, which that part was something she felt. Maybe he should have done that part up front before placing it, so that, well, this was all paraphrased from our listener but signed pressured in Pittsburgh. So, like I said, three pages long, a lot of detail. But I think that summary gets the highlights of the experience and she wondered if we might have any comment about it. So I know I have a few thoughts. What about you?
Howard: 47:54
Well, these sorts of things are really great and I’ve seen some letters like this before from folks and I think we can all learn a lot from listening to patients and their expectations and impressions and experiences.
Howard: 48:06
So there’s a lot to potentially comment on here, but let me get the low-hanging fruit first.
Howard: 48:10
I guess Our patients are educated more and more about what parts of the physical exam are recommended and are necessary, and particularly for a physician, like this letter writer is.
Howard: 48:21
It’s amazing that people think sticking a stethoscope to the heart for three or four seconds or pressing gently on the abdomen of a person who has no abdominal complaints is something that’s indicated, appreciated or necessary, and then to tell this person is a surgeon, to tell a general surgeon that she might need an ultrasound for a possible constipation honestly defies comprehension. Obgyns have to stop this nonsense of doing exams on people that aren’t indicated and that and they need to spend the time that’s scheduled for these preventative visits, at these appointments to deal with important things like family history of breast or ovarian cancer and mood and substance abuse screening, other indicated screenings and counselings that should be taking place which actually make a potential difference in people’s lives, but instead they make people think that if they don’t come back every year and have someone listen to their heart for three seconds and press on their belly for four seconds, that they’re going to die or that these unnecessary exams serve some purpose. It’s dishonest and it’s arguably fraudulent.
Antonia: 49:22
The thing that stuck out to me first was that whole thing about agreeing to pay for unindicated pap smears. I think that was just outrageous the way she described it. I was actually excited to learn that some of the commercial insurers are finally taking action and are not paying for unindicated pap smears. In the past they have, and I think that’s one reason why a lot of people were still getting them. Particularly Blue Cross, blue Shield here in Tennessee is not going to pay for them if they’re outside of the ASCCP guidelines. So good for them. I think that’s going to well.
Antonia: 50:00
It’s going to change my practice a little bit, because I have a lot of patients that are demanding it Now that they know that insurance won’t pay for it.
Antonia: 50:08
I think they’re going to they’re probably not going to demand it as much anymore. So anyway, this doctor our listener told us about must have already had the problem of surprise billing and insurance companies telling his patients that we’re not going to pay for this annual PAP anymore, and so now he’s having them sign a waiver, and she actually sent us a copy too. So something like this, in my opinion, should get reported to. If there’s an inspector general or something equivalent to that, I’d say at an absolute minimum, if someone’s going to have a form like this in their clinic, it should say something along the lines of like to the patient. If you insist on getting an extra pap smear that is outside of the well-researched, established guidelines and standard of care that have no proven benefit to you, then you will have to accept the possible additional cost. But we do not recommend this. But the letter that this patient showed us was the exact opposite of that.
Howard: 51:11
You’re definitely a dreamer, but I love it.
Howard: 51:13
Yeah Well, I have to say these sorts of docs are going to be really upset in the near future when pap smears and that physical exam aspect of the visit goes away completely. In fact, by this fall we will have in the United States or we already have it in Europe but in the United States, or we already have it in Europe but in the United States we’ll have FDA-approved HPV screening tests that are patient-collected so that no pelvic exam at all is necessary in order to do the appropriate cervical cancer screening per the American Cancer Society guidelines, which recommend HPV primary screening. In fact, the New York Times ran a piece about this on August 15th, announcing to patients that they can receive cervical cancer screenings going forward after this fall without having a pelvic exam at all.
Antonia: 51:54
Yeah, it’s pretty exciting. It reminds me of how there’s that colo guard, so instead of doing a colonoscopy you can just send in a sample. So I’ll be excited to see how that turns out. I have a New York Times subscription but this was actually one of the doc. I also am on the Doximity app.
Antonia: 52:12
This was one of the articles that they sent out in their email blast and on the Doximity website and that one was interesting because there’s a place for reader comments and some of the readers and commenters on Doximity are probably not listeners of this podcast, I should say on Doximity, are probably not listeners of this podcast. I should say it’s interesting to see gynecologists’ responses to this new self-collected HPV screening announcement. So the New York Times piece emphasized stories of women who were made very uncomfortable in their pelvic exams and it promoted this new screening as a way to rid women of those uncomfortable experiences and this really could lead to more broad screening and better access to detection of pre-cancers. But apparently one. There were more than one of these, but one example on the doximity was one older male physician who you can look at their profiles this is a department chair at an academic school. Really poo pooed this whole idea. He essentially said in his comment that women shouldn’t be uncomfortable with pelvic exams. If they are, they just need a new gynecologist. And the point of pelvic exams goes far beyond just screening for cervical cancer. So obviously this is someone who is still into this whole routine asymptomatic screening pelvic exam thing that has already been credibly shown to be really no value. And that kind of comment seemed to be a theme at least on Doximity.
Antonia: 53:46
Another person called it a lazy approach to health care, so lazy to not stick speculums up vaginas if you can, if you don’t have to. And then, and they said this is just another attempt to minimize health care quality, okay. Another commenter thought it’s a cheap ploy by insurance companies to save money. Another commenter told a story of a vulvar melanoma that he discovered on a supposedly routine asymptomatic screening pelvic exam. And, by the way, vulvar vaginal melanomas literally have an incidence of one in a million. So I guess congratulations to him for finding that one. But it’s not the reason we do pelvic exams to find one in a million type of diseases. There were some other commenters at least who pushed back. They acknowledged that HPV primary screening is the future, is superior to the current pap smear, and some also saw value in decreasing costs and increasing access and improving patient experience. But unfortunately that was not the majority of comments on this. Most of them were defending the unnecessary pelvic exams.
Howard: 54:56
Well, you just, purposely or not, described the triple aim of health care, which is to lower the cost of health care number one, which this does and then improve the patient experience, which it does by not subjecting people to embarrassing and painful and unneeded exams and improve population health, which it does because the clinical trials clearly indicate that the primary HPV screening approach is superior to what we’re currently doing, and that’s why the American Cancer Society has endorsed this approach and essentially all throughout Europe this is already being done. What all these OBGYNs that commented negatively don’t like is that it well, it disrupts their business model. But, as we’ve discussed before, there’s simply no evidence that these pelvic exams are of any great value.
Howard: 55:39
Yes, you may find that one in a million melanoma, but on the whole you’re doing more harm than good because these exams lead to tons of unnecessary tests and interventions that harm patients. So you feel something. It leads to ultrasound, leads to surgery. It’s all benign for nothing. Some people get harmed by the surgery, etc. We don’t do pelvic exams to screen for melanoma or vulvar cancer or vaginal cancer, and so if you ever find one, it’s just pure luck when somebody sees one of these or pick something up in an asymptomatic patient, and there’s no evidence that an early pickup, prior to symptomatic stage, of most of those diseases even actually improves the outcomes.
Antonia: 56:16
Yeah, back in episode 7.2, we discussed an article and an editorial in the Green Journal showing clearly that these routine pelvic exams are not valuable, and it was a wonderful editorial that made the moral argument for why they need to stop for asymptomatic patients. And I’ll just say the picture of a 70-plus-year year old white male OBGYN arguing that if pelvic exams hurt the woman is just being hyperbolic or hysterical. It just shows how out of touch many physicians are, and especially physicians in power. This person is teaching residents and students, he is making policies for his department and he’s minimizing the patient’s experiences in the women’s stories.
Howard: 57:10
Yeah, and he goes beyond that Maybe a referee of a journal or editors of journals or sit on committees that make opinions. We have this power dynamic issue, just based on age and whatnot, that we should discuss sometime. This reminds me of another letter that recently got that we don’t have time to go into detail today about, but someone asked for references about one-layer closure versus two-layer closure at the time of Cesarean because her department chair told her that it was a violation of the standard of care to do a one-layer closure.
Antonia: 57:42
Oh my gosh. So a violation of his own personal standard of care. I suppose Did you send her the evidence-based cesarean delivery article from a couple years ago that says one-layer closure is what should be done?
Howard: 57:55
I did indeed, and it’s what she specifically asked for, because she remembered that I also sent her a new article from the Gray Journal, which hopefully we’ll discuss in the next couple of episodes. We don’t have time to do it now, but the idea that someone in a leadership position is telling someone younger than them the complete opposite of the truth is so emblematic of the reason why we have so many of the problems in our health care system today.
Antonia: 58:15
Yeah, and our letter writer, the one with the waiver to pay for her unnecessary pap. In her experience she sounds like she met with probably an older doctor, just like this. And the whole thing about taking her from the exam room to his office, back to the exam room, back to the office seems just like a weird power play and it made her uncomfortable and I just couldn’t really figure out why someone would do that. It seems really inefficient, like all the time wasted walking back and forth Like I could understand if you’re just trying to get people out of the exam rooms to clear it, but this kind of walking back and forth thing just doesn’t make any sense.
Howard: 58:58
Yeah, yeah, I can make arguments for and against having someone maybe come to your office. Maybe you need a long discussion and you need your rooms to open up, or something like that. But it’s important, though, still to understand how the patient perceives this, because our job is to do our best to accommodate patients and their expectations and give them the experience they deserve. It’s just a trope of an older male physician treating younger women in an intimidating and pressuring way, and it makes them uncomfortable and they’re tired of it and it needs to stop.
Antonia: 59:27
Yeah, and also, what do you think about the whole thing of where he was trying to push her to get the Lyletta and not the Kyleena that she wanted?
Howard: 59:36
Well, I actually think that’s probably related just the economics of how much money his office would make off of the two. So I predominantly use Lylettas because they are significantly less expensive than the other IEDs. But I also don’t personally make any money from that, whether I do it or not. And if I have a nulligravid patient, like this one was, then I do usually use a Kyleena because it’s just significantly easier to insert and less painful for those patients. Otherwise I use the Lylettas because they’re cheaper.
Antonia: 1:00:07
Yeah, I guess he referenced that with the whole licensing deal thing. That really does suggest it was just a reimbursement for him. And she did also say that actually, despite the tenaculum clamp clamping down, the insertion wasn’t really painful at all. But then after the insertion he asked her about her pain level and then made a joke that well, maybe it didn’t hurt because you use that, Kyleena, I would have just rolled my eyes like that. Not a good joke.
Howard: 1:00:34
She went to a physician owned private practice, and so the reality is he probably barely breaks even when he inserts a Kyleena, but may make several hundred dollars when he inserts a Lyletta the Kyleena, which is a perfectly valid.
Antonia: 1:00:46
they’re all valid options, like it should be, whichever IUD a patient wants. So yeah, let’s do it.
Howard: 1:01:06
It certainly doesn’t sound like a shared decision making model, but unfortunately what she’s described in this letter is the norm and probably the most common experience of women in the United States.
Antonia: 1:01:18
I’m sure a lot of our listeners have at least seen things described in that letter and kind of recognize this type of scenario and this type of doctor. Way back in episode 2.1, we discussed the Women’s Preventative Services Initiative recommendations for women’s annual visits, and if you’re following those correctly, you have a lot of work to do at each annual visit and almost none of it involves a physical exam. There’s really no reason at all to casually press on the belly of an asymptomatic person with no complaints or at least no abdominal complaints and tell them they might be constipated when they’re not having any symptoms of constipation and then to try to order an ultrasound to check for constipation. We need to spend that time doing things that matter for the patient and also freeing up that time to see patients who truly need us for actual complaints.
Howard: 1:02:16
Yeah, the irony of it is the lazy way out is having the patient. Yeah, the irony of it is the lazy way out is having the patient already disrobed when you walk into the room and doing a quick two minute unnecessary exam and then telling them to come back in a year. If you actually do the WPSI and do all the issues, we don’t have anywhere near enough time in these visits to do justice to all of those screenings. And then, of course, you’re going to find things that you have to deal with. We’re not paid enough at those visits.
Howard: 1:02:42
So the lazy way out is to do the pap smear and the physical exam and act like you did something for the patient. And the whole thing about ultrasound for constipation is just hilarious really. I wonder if he was actually just worried about his placement. Maybe he thought he perfed her or something but was too proud to admit that that was the reason why he wanted to do an ultrasound, and then, if it was misplaced, he might have tried to blame something she did or something. I don’t know.
Howard: 1:03:06
You can diagnose constipation and localize stool burden with an ultrasound, but it’s almost never clinically necessary or indicated, and it really just illustrates the whole point of why we shouldn’t do unnecessary physical exams. When you do inappropriate and unindicated physicals, you generate a lot of false positive findings that generate a lot of false positive follow-up testing. That generates a lot of unnecessary interventions, and so you end up, on the whole, doing more harm than good, and more people are harmed and helped when you do inappropriate screening exams like yearly pap smears. So we should just be doing things to patients that are indicated and based on high-level evidence and things that show benefit without excessive risk and things that are cost-effective.
Antonia: 1:03:48
This is just like our creed, like our podcast anthem Just do things based on high-level evidence that show benefit without excessive risk. Yeah, there you go.
Howard: 1:03:58
We really just ask people to follow guidelines.
Antonia: 1:04:01
Yeah, that’s right. Okay, so we should wrap up. The Thinking About OBGYN website will have links to the studies that we discussed. Check out our Instagram, send us letters if you want, and we’ll be back in a couple weeks.
Announcer: 1:04:19
Thanks for listening. Find us online at thinkingaboutobgyn.com. Be sure to subscribe. Look for new episodes every two weeks.
