THE WALL STREET JOURNAL.

TUESDAY, JUNE 20, 1995 B1

Doctors Who Perform Fetal Sonograms Often Lack Sufficient Training and Skill

By Heidi Evans

Staff Reporter The Wall Street

Vance Nguyen was born at 10:57 p.m. on a summer evening in 1988. two months premature but healthy, in a San Jose, Calif. hospital. A few minutes later, a nurse blurted out that there appeared to be another baby on its way.

The mother's obstetrician had performed a sonogram in the 17th week of pregnancy and had seen only one fetus. But 30 critical minutes after the nurse’s ominous discovery, an identical twin was delivered by emergency Caesarean section, limp and not breathing. Today, six-year-old David Nguyen lives in a state institution near Fresno, Calif., severely brain-damaged, paralyzed and tube-fed.

The doctor who performed the sonogram, Dung Van Cai, a board-certified obstetrician and gynecologist. had received only a few weeks of ultrasound training as a medical resident years before. Nonetheless, he had a portable ultrasound machine in his office and billed patients $150 a sonogram. In a September 1992 deposition in a malpractice suit brought by the Nguyen family. Dr. Cal said he did "30 to 40 ultrasounds a month," adding $60,000 to his annual income, (The malpractice suit was settled last October for more than $500,000 Dr. Cai didn’t respond to repeated requests for comment.)

Medical experts say there is mounting evidence that 20 years alter ultrasound changed the face of obstetrical care, too many practitioners do it poorly. ‘Sonography is rife with virtually untrained practitioners who are treating this imaging tool like an open cash register drawer," says Roy Filly, a professor of radiology and obstetrics at the University of California Medical Center in San Francisco.

In 1975. fewer than 5% of doctors did ultrasound in their offices, according to Harvey Klein, president of Klein Biomedical Consultants Inc. in New York, Instead, obstetricians referred patients to hospital radiologists. But when ‘real-time" scanning came into the picture in the late 1970s, allowing fetal movement to be observed as it happened, the market boomed. . Mr. Klein estimates that today. 75% of the country’s 39,000 obstetrician-gynecologists have machines and do the tests themselves.

But there is no mandatory training or certification process for physicians who perform sonograms. Many doctors start scanning and billing patients after a week-long course, Others depend on technicians - called sonographers - to perform and interpret the exam-for them, even though the doctor is medically and legally responsible for the diagnosis.

"If you don’t know what you are doing, you can screw up the machine settings and get artifacts, making it look like there is disease or defects when there aren’t." says Lewis H. Nelson III, director of the Bowman Gray School if Medicine's Center for Medical Ultrasound In North Carolina, "Only those people who are trained to do ultrasound should do it."

There are, of course, many obstetricians and radiologists who are skilled and thorough in their scans and keep up with the latest research’ and technological advances.

But when U.S. Healthcare reviewed 420 sonograms voluntarily submitted by its obstetricians and radiologists in the Northeast, the results were startling. Sixty-five percent of the doctors in the study, released in 1992, submitted sonograms that revealed poor image quality and technique and failed to meet minimum standards. In 141 second-trimester sonograms - the sonogram that is most crucial for detecting defects in fetal structures - the heart, brain, spine and kidneys were most often poorly or inadequately imaged.

What's more, many of the doctors were shocked to learn how poorly they had performed, according to Michael R. Clair, director of the HMO’s study.

U.S. Healthcare has since Instituted a certification program for doctors who want to perform ultrasound. But of the 128 obstetrical offices that applied for accreditation between 1992 and 1994, only 36% passed. Radiologists fared better, but 25% of them also failed. As of July 1, the HMO’s obstetricians and radiologists will have 12 more months to pass the test. If they don’t, U.S. Healthcare will no longer reimburse them for sonograms.

Meanwhile, for millions of American women, sonograms have become as much a part of pregnancy as childbirth classes and prenatal vitamins In fetal ultrasound, a hand-held device glides over a woman’s abdomen, creating images by bouncing high-frequency sound waves off fetal organs. An estimated 70% of all pregnant women have at least one ultrasound during pregnancy at a total cost of about $1 billion a year. Noninvasive and presumed to be safe, sonograms are the most important diagnostic tool for detecting congenital defects and monitoring fetal development. If a major defect is seen, women can terminate their pregnancies or deliver in a hospital with specialists who can treat the baby quickly.

The most sophisticated ultrasound equipment can cost as much as $200,000, but portable machines cost as little ‘as $25,000. With doctors charging an average of $200 a scan, a modest Investment can turn a big profit quickly. Physicians who do four scans a day, for example, can add $160,000, after expenses, to their annual income.

The sales pitch is simple. "You give away a valuable source of revenue each time you refer a patient to a hospital or clinic for diagnostic ultrasound testing," reads a brochure by Ultrascan, "a San Francisco mobile ultrasound company.

Manufacturers acknowledge that ‘expertise varies widely among the doctors they sell to. "Sometimes I feel a moral responsibility - whether we should sell equipment to doctors who may not use It as best they could," says Lee Oppegaard, marketing manager of Corometrlx Medical Systems. "However, If we don’t sell to them, then someone else will. At least I know that they will be getting a good piece of equipment."

Copyright 1998-2008, Michael Applebaum, MD, JD, FCLM.  All rights reserved.
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