Dear MFM

As a patient’s MFM you are her lifeline – literally.

You have the knowledge, access, and ability to implement the resources necessary to give her pregnancy the best chance for a positive outcome.

We describe the MFM as the leaders of the monochorionic health care team. Your advanced training, experience and, again, access to vital resources often positions you as the Big Decision Maker. 

And with great privilege comes great responsibility.

The responsibility we’re focusing on here is the doctor-patient relationship. More specifically, ensuring trust within that relationship.

“Improving the doctor-patient relationship” is tired rhetoric which has become associated with things like patient satisfaction scores and value-based pay. It’s hard to uniformly define this “relationship” and even harder to establish it with every single person.

For this reason, its importance is often lost and it can be seen as yet another thing you must try to control for while also providing quality health care – which is your actual duty.

In our world, however, there are no words that I can pen to adequately describe how vital this relationship is to the mother. And we’re not referring to establishing some friendship-like relationship, or even being perceived as likable, quite frankly.

Instead, we encourage monochorionic patients to become “BBFF’s” with their MFM.

What is the MFM BBFF connection?

“BBFF” represents “Brain, Bladder, Fluid, Flow”. We tell them that their MFM should be someone who’s going to follow the rules for you, take care of you, tell you everything you need to know and support you through it all.

Central to being the patient’s “BBFF” – or establishing the “doctor-patient relationship” as we perceive it – is providing evidence-based medicine which relies on current science, guidelines, and recommendations. Additionally, this evidence-based medicine must be delivered timely, compassionately, and without bias.

This is where trust in you begins for the patient.

Being told that you will not deviate from outdated monochorionic clinical guidelines that have not been reaffirmed or rewritten in over five years (e.g., ACOG/SMFM’s 2013 “TTTS” publication) – erodes trust.

You cannot say you will not consider the over 12 years of evidence showing profound value for routine MCA-PSV Doppler testing for TAPS, because you wouldn’t know what to do with the findings, or because interventions for TAPS are not completely understood, or because TAPS will present with other symptoms which will be visible first – erodes trust.

Being told that bi-weekly visits with you will stop around 24 weeks because major monochorionic risks are gone by then – erodes trust.

What you can do as an MFM

to establish and preserve a trusting relationship with your monochorionic patients is quite simple –

Be comprehensive

Adopt and implement a monochorionic ultrasound screening protocol that is supported by the current science1,2. Perform all of the tests all of the time. It is essential to perform them when they should be performed. Use modern equipment and techniques, and be sure you’re interpreting the findings accurately3,4. When in doubt, reach out to your colleagues for second opinions or advice.

Be informative

Inform the patient about the screenings you will be performing and why. Effectively communicate all ultrasound findings to the patient. You must phrase and rephrase the findings until you are confident that she understands what she is being told. Explain normative findings as thoroughly as abnormal findings. Tell her where her placenta is located and how each umbilical cord is inserted. Always ask her if she has additional questions and let her know when she will be seeing you next and which screenings she can expect at that appointment.

Be unbiased

If abnormal findings occur (TTTS, TAPS, sIUGR, sudden fetal demise, etc.), present her with all treatment options, their associated pros and cons, and all known outcomes. When the best treatment option is not obvious, tell her that. Don’t ever be afraid to tell her that you don’t know. Do not sugarcoat her scenario but deliver the reality with compassion; the most caring thing you can do is give her time and the ability to hear from you over and over again what’s happening and what she can possibly do about it. Do not rush her to leave and “call with any questions.”

Tell her where she can learn more about her diagnosis and connect her to leading experts from whom she can seek additional opinions. Tell her that the choice of whether or not to intervene, and how, is completely hers. Support her in what she chooses, even when you adamantly disagree. Sometimes support is silence.

Be an advocate for change

Recognize the impact that your country’s governing body may be having on monochorionic prenatal care via their published clinical guidelines or recommendations (e.g., ACOG and SMFM). Understand how these guidelines may be restricting your patients’ choice and autonomy. Where you see flaws, be vocal about improvement. Lead the change. Your patients are only so powerful one-at-a-time. It is people like you who can initiate systemic changes.

by Dr Lauren Nicholas

  1. Khalil, Asma, et al. “ISUOG Practice Guidelines: role of ultrasound in twin pregnancy.” Ultrasound in Obstetrics & Gynecology 47.2 (2016): 247-263.    
  2. Papanna, R.; Johnson, A.; Wilkins-Haug, L. Twin-Twin Transfusion Syndrome and Twin Anemia Polycythemia Sequence: Pathogenesis and Diagnosis.