Dr. Miwa Geiger and Michele Cafone discuss the multidiscipliary approach to the fetal heart program team. This in-depth review will provide an update on this topic.
Dr. Theresa Tacy discusses the topic of education in fetal cardiology and the training of future generations of sonographers and fetal/perinatal cardiac experts. This in-depth review will provide an update on this topic for your clinical practice.
Dr. Erin Paul discusses the topic of healthcare disparities in fetal cardiac diagnosis and care. This in-depth review will provide an update on this topic for your clinical practice.
Mhm. Yeah I'm sorry I'm not I'm not carrying that dr paul. Yeah. Hi everyone Welcome back to session two comprehensive fetal heart care. It's more than just the heart. I'm dr Aaron paul an assistant professor of pediatrics and fetal cardiologists here at Mount Sinai, joining me as a moderator is dr Stephanie Levasseur, Associate professor of pediatrics. Medical director of fetal cardiology and non invasive imaging at new york presbyterian morgan Stanley Children's Hospital. Please note that there's been a slight change in our session. Unfortunately Dr Srivastava is not able to join us. Um And dr. T. C. We'll get we'll dive a little deeper in a discussion of education and fetal cardiology. Um That will leave the session length unchanged. Our first talk of the session will be given by dr Michaela Geiger. She is the director of the fetal heart program at Mount Sinai and Michelle Can phone the clinical program Director of the Federal heart program. Their talk is entitled multidisciplinary approach. The fuel heart program team, Doctor Theresa Tasty, Professor of pediatrics and medical Director of fetal cardiology at Lucile Packard Children's Hospital at stanford will then discuss education and fetal cardiology training. Future generations of stenographers and fetal perinatal cardiac experts and dr Aaron paul will then close the session with healthcare disparities and fetal cardiac diagnosis and care. How do we serve our patients better? Well then have time for discussion after the presentations. Okay. Hi everyone, thank you for attending this year's Mount Sinai fetal cardiology symposium virtually this second session is going to focus on comprehensive care for the fetus. And in our first talk, Michelle, ca phone or feel heart program coordinator and I will talk a little bit about composing a fetal heart program from a multidisciplinary approach. We have no financial disclosures keep in mind. This is a subjective discussion based on experience and our observations and is not evidence based since practice models and resources are really variable. Take some of this with a grain of salt and see if maybe you can adapt it to your program. And keep in mind that fetal heart center development is evolving and requires periodic updating. So the goals of the field heart program in this to describe it that we'd like to describe in this talk, our number one obviously to provide optimal patient care. The fetus is the patient or also caring for a family. So in doing that first and foremost, we want to provide an accurate cardiac diagnosis which will help us optimize the perinatal plant. And once we've done that, we can attempt to have coordinated care managed by the fetal heart program coordinator in our case, Michelle, our nurse practitioner, who can help guide the parent along the pathway until delivery. And ideally this does involve multiple disciplines. The counseling should be compassionate up to date in terms of um up to date outcomes and and prognosis and should be educational for both the family and any trainees involved and as much as possible we think it should be unbiased. The fetal heart program should also provide family support. Another is processing to the field heart program is research and education um and having a field heart program. It gives us the opportunity to keep a database which allows us to do research um either prospectively or retrospectively and also focused on quality improvement in assessing areas we may have um misdiagnoses or mismanaged occassion. It also allows for us to educate our trainees both in pediatric cardiology as well as maternal fetal medicine and neonatology. So as pediatric cardiologist, we think of pediatric cardiology and fetal cardiology as being the core to fetal detection of fetal cardiac diagnosis. But we all know that other um disciplines are involved in the care. So obviously we're dependent on good screeners are obstetrician or M. F. M. Colleagues, but really the geneticist social workers, surgeons as well as interventional cardiologists, neonatologists all play a role in this patient's care after delivery. So ideally would like to involve all of these services even before the delivery. So going focusing on pediatric cardiology or fetal cardiology who wasn't aware of the fetal heart program. So important is the staff pediatric cardiologist obviously, but really skilled stenographers who are trained in fetal echo specifically. We want to have both uh sort of junior mid level and senior staff involved with the diagnosis. So this applies for both stenographers and pediatric cardiologists. If junior staff are evaluated a patient, we want to make sure that their senior staff to give a lifeline or back them up if they have any questions or just want to be um reassured about what they are, how they're going to counsel a family. Um And then the fetal heart program coordinator is really the lifeline of the program. She or he provides communication along the way to the different teams. Technologically we need to have up to date equipment for the assessment of fatal cardiovascular physiology. Um ideally you have the ability to do both early scans earlier and maybe in the first trimester, extending all the way to late gestation because we do get referrals later in gestation. So you may have different settings depending on your gestational age and you do your watch your vendors whichever platforms you're using uh to help you come in and optimize your grayscale and color settings because these are different um for people cardiology um than stay obstetrics. Also, if you're going to see complex patients, you want to have the ability to perform maternal hyper oxygenation testing. And finally, we do recommend having a dedicated outpatient fetal scanning area and in separate waiting room from the pediatric group, um as well as separate scanning rooms, rooms that are separate from scanning and counseling. You don't want to really council where while you're doing the ultrasound. So once the pediatric or fetal cardiologist has made a diagnosis, we're going to counsel the family and as best as possible try to anticipate post natal physiology. So in doing that, we are trying to develop a management plan and then we have our other disciplines getting involved. So we involve O. B. M. F. M, possibly the interventional iStar surgeons, if we think there's some potential for instability after delivery. And so while we're doing the fetal echo and counseling, the family were also making a plan for who needs to be president of the delivery and what the immediate post natal needs of the fetus will be. So obviously there's a spectrum, some will be completely stable and do not need anything. And if you are at a Children's hospital and you're diagnosing such a patient in this patient can deliver at a local hospital. Uh, if you have someone who you anticipate to be uh ductal dependent, then you can arrange for uh innocent to be uh innocent, prosecuted to be started um, at your local hospital as well. But if you have uh stay at Mount Sinai, like we do a large delivery unit where um we see both critical and noncritical lesions. We can communicate with our nick you who we want prosecution and started. So this kind of goes into these level of care. Um, assignments that various groups have looked at. So a chop in Jack right text book, he mentions the delivery classification scale, which similarly goes through four different levels of severity. And as you can see in this class, the first level is no hemo dynamic instability than dr dependent than likely needing an intervention in the first admission and then the impact which is where you have potential for severe hemo dynamically him Oh dynamic instability which may make you need a to have a surgeon and equal on standby. Similarly married Donofrio at B. C. Children's also developed a schematic with using level of care. But essentially it's very similar. There's four different levels and these are levels are basically used as ways to communicate with your team on what things need to be prepared for the delivery of a fetus. Okay, so moving on to the timeline that we generally are schematic that we use in the fetal heart program here, we know that these things may happen in a different time, but usually in the second trimester and AM FM identifies a problem with the fetal heart referred to a pediatric cardiologist and then may get genetic counseling that may happen in a different order. Um so those things are very intertwined in the initial stages. The pediatric cardiologist will determine the level of acuity or severity and what the perinatal needs might be. And then from there, a patient will usually have the opportunity to decide about continuing the pregnancy um or potentially doing comfort care. And once those decisions have made, we're kind of in this middle stage where uh the fetus is evaluated approximately every four weeks depending on your institution, but we usually do every four weeks transfer of obstetric care to our unit. If we think that there will be a critical lesion and involve social work at that time, we're constantly assessing for changes in the physiology to reassess the level of acuity during this time as we know some lesions can progress. And then as we're getting into the third trimester we really try to fine tune the delivery plan, the location and type of delivery and what staff need to be present. And then as we near towards the last two months of the pregnancy, we try to coordinate consultations with our different teams, cardiothoracic surgery, interventional cardiology. If we anticipate um balloons attached to me for example is going to be necessary. Uh nick you and social work as well as other specialties if there are other extra cardiac anomalies. And recently we've tried to do a multidisciplinary day where we have all of these consultations in one day kind of an all day affair for the patient in which all the different services can communicate in front of the patient. And the patient feels that they have an individualized delivery plan that's made specifically for them. They can also see us communicating um if we're all there together in the same room. So there are some limitations to this now with Covid but we're trying to do this move forward with this plan for any complex patients in our unit. So a very crucial part of this as I mentioned is the fetal heart program coordinator role and Michelle, who up until recently was our coordinator has done an amazing job to fill that role and she's everywhere in communicating with all of these patients. So are there many responsibilities. Um But primarily she arranges foetal echo consul appointments, is present for the counseling and provide resources for families after the consultation and keeps in constant touch with the families. Um She usually follows up a few days after the initial consult is made to touch based on where they are and how they're feeling. If they have additional questions that they didn't get to ask the doctor when they were there. She coordinates any follow up appointments. And if obstetric care needs to be transferred, she takes care of that sends weekly communications to all the different teams regarding the upcoming deliveries as well as keeps our database updated. So our database contains information about each mom diagnosis and ultimately gets updated with the post natal outcomes. And your research for you. Coordinator may or may not be involved in research but can definitely help with some of your keeping up your research protocols. So now I'm going to just spend a few minutes asking Michelle a few questions um from her perspective as a coordinator for the last four years. Hi, Michel my. Okay. So what are some common questions that families ask when the doctor has left the room after counseling? Yeah. So the most common question I get is what do other families do in this situation? And I always reassure them that you know, they don't have to make a decision. Now they have time to go home digest the information, talk with their other loved ones and support families, whether that be other family members or friends and then come to a decision after speaking with everybody. Um and then the other most common question I get is what's going to happen in the delivery room. So I usually try and tell them, prepare them as much as possible. Let them know that the new york scientologist will be present in the room. Um And Covid we used to do tours, but unfortunately now we um, I do send them like nick you a little video with some pictures so that they can be the most prepared um after the baby's here. What is the hardest part of your job? Do you find the hardest part is having clear, constant concise communication? Um So making sure that everybody is aware of the delivery plan and making sure that everybody who needs to be present knows the plan and knows where to be and where to go um when this baby is here. Okay. And what kind of feedback have you received from patients regarding the fetal heart program? So the best feedback I get is everything that you said happened, what happened? Um and that just means that the parents were fully prepared. The team was fully prepared. Um and that just means that we all did a great job. Okay, thank you Michel. So we'll come back here in a minute. So as you may see from Michelle's responses, um coordinating especially the complex cases requires a really good communication. Um and so we're going to suggest some communication options um and some may work that are in different circumstances or clinical settings. So um we often will do a weekly multidisciplinary meeting that usually involves the neonatologist, the maternal fetal medicine specialists as well as ourselves, uh and sometimes some other specialists if they have extra cardiac anomalies. So we uh would do a weekly uh weekly meeting where we discussed the upcoming cases. We also send out a weekly email list of the active cases. So again, anyone who's delivering in the next month or two, we have an email where the plan is kind of listed in a spreadsheet. Um And then ideally you do have this multidisciplinary clinic model where each patient um meets with all the different groups on the same day and they can actually observe us formulating this plan. And really communication is probably the best in that situation was everyone's in the same room at the same time and it gets documented in the patient's chart. Um Other options would be some kind of form which we're probably going to formulate our center where we have check boxes of in our notes at the last visit, foetal echo visit, who's going, we recommend induction for who can go to the nursery versus the nicu who needs pressing plant and etcetera. Um And then finally, a lot of times you end up doing some individual emailing slash texting about the plan because someone's delivering in the next two days and it's the cath lab gonna be ready, etcetera. Um Well that's sometimes necessary. I really would caution against that because inevitably when that baby is actually delivering a different person is actually on call or something like that. So I would caution a little bit about individual emailing and texting regarding patient care. But I think all of these options are good, but really try to optimize communication in these complex cases. So Michelle is going to talk a little bit more about family and parent support. So once a family gets a diagnosis, we usually always refer them to social work who can provide extra emotional support, logistical and financial support. We here at Mount Sinai have a mentoring program called the fetal Heart to Heart Program where it matches families who are pending delivery with the congenital heart disease diagnosis to a family who has gone through it already. Um and it's a wonderful support group for families we have in person support groups and online support groups that we work for them two. And then we also have resources that we refer like outside websites and educational materials. Mhm. And then finally the fetal heart program um does really contribute to both research and education as well, ideally. Um If you have a database and you're following a number of patients, why not use that to um advance our field. So the fetal cardiac database um depending on where you are, can be an Excel spreadsheet. There's other um platforms to do this now. But basically you want to link the maternal information the diagnoses with searchable fields, um gestational age et cetera, who the referring was. You can use this to go back and forth when managing the patient. And then years later you can also do some retrospective research on some of these patients. If you've kept the data clean, you can also link the post natal information to the mom. So sometimes uh that information between the baby and the mom gets lost if we don't keep track of this. Um So it does lend itself to research as well as um quality um assurance or quality investigation, diagnostic accuracy, appropriateness of management. Um If we want to see if we're managing things correctly, um we can look back at our database and finally we can contribute to multi center projects that there are other centers doing a specific lesion. We know that um these diagnoses are relatively rare. So keeping track of how many cases we've had. Um and then contributing that data can really help um contribute to large studies through the fetal heart society and other organizations. Um And we also want to improve education. So not only are pediatric cardiology fellows who are interested in fetal echo, but we can also help educate maternal fetal medicine trainees and uh nick you fellows. Um Sometimes the AM FM. Fellows will scan with us and being in on the counseling. We also provide um frequent died at six on different lesions. Um and then have the fellows do case presentations on different cardiac lesions. So in summary comprehensive care at the fetal heart program ideally provides really optimal patient care as its number one priority, ideally we use multidisciplinary planning to plan each complex delivery and we know that communication is key and that this is something that constantly needs work. Um no matter what center you're at um ideally would also promote education and research. And I think if you really focus on those two things, patient care, education and research, you ultimately have very satisfied patients and this will allow for you to grow your program. Thank you. Hi everyone. My topic today is education and fetal cardiology training future generations of Sinaga furs and fetal and perinatal experts. I'm very pleased to give this talk. And I'd like to thank the organizers of the conference for asking me to do so. When anyone is learning to become a fetal cardiologist, they are learning in three different spheres concurrently. And I think of those spheres as being sphere of scanning during what you're requiring the new physical skill of of sonography. The second of those skills being interpreting learning to apply your medical knowledge to look at scans. And today a lot of that medical knowledge is coming from uh the digital media also the role of cognitive bias and it's uh its role in making errors while interpreting their scans. Unless but not least lee the role of counseling, which in the past has focused largely on transmitting a lot of medical information to the parents. And now lately has been shifting towards recognizing the need to learn communication skills, trauma management, emotional support and medical decision making guidance while also giving all that information to the parents. So now we're going to delve into each of these topics. The first being learning the fetal cardiac scanning skill set. And there are goals in the process of learning how to scan. One is knowing the elements of a comprehensive scan. Your labs talk about their protocols and, and, you know, hammer that in. And the real reason is that when one sits down to start a scan, they need to know what the goals are for the skin and for the imaging. And uh, so, knowing the elements of comprehensive skin is essential. Understanding image optimization methods either through probe or machine manipulation is definitely a large part of learning how to scan and then something that's a little less recognized, at least by me until maybe several years ago is becoming aware of standard probe manipulation sequences in fetal echo. And what I mean by that is you start to learn through years of experience that when you have one image, if you take that is a standard view and you take a couple of small adjustments in your view that are consistent. You go from one standard image to the next standard image. And as you learn these manipulations, you become more efficient in your scanning largely those seem to be at least in me subconscious until I made a lot of effort to start learning and documenting what they were and teaching them to others. Experience stenographers. No, these very well. And we probably all are acquiring the same basic sets of maneuvers in our um scanning repertoire to implement training of scanning. Really the bedrock of that has been forever has been live scanning on patients and receiving immediate case based feedback from your attending. There's been an increasing role of simulation and education of eco um mostly to date in the natal T. E. And trans thoracic, but fetal echo simulation is available. Um the quality metrics is very useful not only for quality, but as a teaching tool for the fellows again in the past and continuing in the future, fetal case in QA conferences and other kind of conferences are very useful not only for um you know, just now learning clinical medicine, but also you can add the bend of talking about um the images and how one could adjust the you or whatever to improve the scanning and also provide that added value to the fellows attending these conferences at our lab Packard, the main people who who are in training, who are learning um the comprehensive foetal echo process. Our third year fellows interested in fetal echo as and echo in general as a career as well as our fourth year advanced imaging fellows. The categorical fellows learned very basic uh you know, trans verse a four chamber view and how to get that. And beyond that, they focus really on the body of knowledge associated with fetal cardiology and not so much the physical skill set of scanning. I've become increasingly enamored of QA tools as a tool not only for quality assessment but also for education. And I think that they can guide the fellow learning how to skin by knowing by which rule of thumb or metric they will be assessed down the road. However, QA process has long been viewed as a very uh painful process and so in order to make it less painful at Packard, we designed this QA tab for we have it for both the trans thoracic and for fetal echo and the fetal echo. QA tab incorporates the three a CPC fetal metrics of study comprehensiveness, image quality and diagnostic diagnostic accuracy. And it includes the intra societal accreditation commission questions that are that they request submission of on a regular basis. The reviews are assigned by the Lead Tech and then the results are queried and sent. Um two Q. Net and I A. C. So this allows a much more streamlined QA process but then also gives us really nice data for feedback for the stenographers which we and for the fellows which we have employed just in minor ways so far but do plan on expanding in the future. The use of simulators in teaching echo scanning has been used for quite some time. Um I do believe that the use of fetal simulators are rather new, but in general I think that we should explore possibilities who are teaching in a simulated environment. So echo simulation has positives and negatives and this is talking about, you know, the trans thoracic, neonatal and T. E. Skins that people have more experience with. Uh So the the use of simulation addresses the reduced procedural instruction time that learners have at this point in time. Uh and as work hours have been appropriately decreased over time, they have to maximize their efficiency in learning. And so echo simulation addresses that minimizes patient risk and helps them develop a skill through practice and repetition. Uh And I think that can really be useful in the acquisition of the skill set of scanning. Also, what's very interesting about using simulation to teach echo is it isolates your teaching to teaching not only the physical skill and standard manipulations, but also spatial concepts. And it removes all the environmental distractions and machine learning that one must do and really is a unique opportunity to focus on the three D spatial concepts that one must understand when when performing echo, either trans thoracic, T. E. Or fetal, the negatives are, it's a really artificial aspect and sometimes it can be hard for learners to really engage or accept the process as really being valid to um informing their scanning skills. Also teaching, using simulation is a really interesting new skill and a lot of people just who are educators really just don't like it or don't see its value as well. Um Or and again, I think that the the idea that you can train about relationships in three D. And the transition of three D. To two D. Relationship is really fascinating and unique opportunity and simulated environments and one of the negative aspects is the cost of setting up simulation um program not only an initial cost but in um upkeep and maintenance. So there are vendors that provide simulation in fetal echo. And as you can see it's really just an add on to the mannequin that is used for at least in this case for T. E. Or trans thoracic. And it is comprised of an admin belly with sensors that are included within that kind of silicone esque mess. And the output that you see here is typical for simulated um environments with the inclusion of the echo view the interview as well as you know, the probe position. So this is from a company called Symbiont IX. There may be others out there but I thought it was interesting that these fetal simulators are out there at this point. And again I would say we don't have this yet at Packard. So moving on to how to learn how to interpret fetal echoes as part of the process of becoming a fatal cardiologist. The main process of learning to interpret includes the massive effort to learn all the medical information and clinical information that there is about fetal cardiology. And so while one could talk about that forever, I thought I'd focus on the you know, the relatively new emerging trend towards learning clinical medicine in a digital age and in a digital environment and how it is really our responsibility as educators to learn how to present digital media in a way that is effective and efficient um and also to guide our learners towards quality digital products or webinars or whatever that are available on the internet. The other aspect of learning interpreting that isn't discussed a ton. I don't think yet at this point in time in fetal echo is understanding cognitive bias. Uh So I'm just gonna cover a couple slides of that uh later on. Mhm. Yeah, there's been a real increase over the last several years in the use of digital platforms for medical education. And the event of Covid really accelerated that trend. And I'm talking about this because I think that as the shift occurs towards providing online educational videos, it's important for us to learn from the body of literature about how to create effective digital media uh that we should be part of that process of learning it. So, for example, this paper talks about effective educational videos and provides three principles to follow in that effort. And those principles are managing cognitive load enhancing student engagement and facilitating active learning. So I'm going on to manage cognitively code. What we see are that we are to edit information so that we are not providing any extraneous information that is interfering with the absorption of essential and important details. We want to use the two channels of both visual and auditory channels to input information for acquisition and processing, and then we want to chunk our information into easily digestible six minute videos. So one talk might be multiple types of chapters, but each are about six minute videos in length. So as we move on towards enhancing student engagement, The suggestions towards this end again suggests the multiple videos about six minutes or less. That's just a guideline. Um, you want to package these videos in topics that highlight their relevance to the course. You want to use conversational language and create a relationship with the listeners whenever possible, and to speak actually relatively fast so that you're not droning on and on, but also not talking so fast that the fact that they can't even comprehend what you're speaking about, and lastly, how do we facilitate active learning? We ask interactive questions and we give the learner control over the questions. So what that means is we're not just asking a question and then answering our own question in the course of the talk, but actually giving them the opportunity to respond to the question in real time and to use guiding questions too, actually inform our our educational content. So when we're creating or we're in the process right now of creating um a series of educational talks, there's about 25 of them, I believe, for the fetal heart society, conjunction with Lucile Packard and with the Educational committee. And so we have about um 15 minute lectures each, so they're relatively short and they're chunked into three different topics if you will, as you can read there. Um the topping some background information, the middle being eco information and the last being counseling outcomes and a provider sheet link where possible. And so these three chunks are you know, roughly maybe six minutes each. Um and then after each segment there are questions and what those questions look like are provided here. So um looking on the right side of the screen, you're going to see an example of, you know, the normal fetal echo and some information. And then the question pops up here about uh you know, asking a question about the content. The respondent then answers the question And it provides you feedback about whether or not it's right or not and may provide an explanation about what that is. So in the process of creating this, the group of hackers created these these these um these presentations as well as a full of 200 questions. And right now we're in the process of reviewing the questions and then kind of making sure that our content is organized as recommended and then interspersing these questions in creating a pre and post test. So this should be hopefully uh an effort to have a really interactive experience during the course of going through these 25 ish talks that were um that are going to be uploaded on the website. Yeah. And the second part of interpreting that we mentioned was the role of cognitive bias in the errors, in the creation of errors. And uh we are in the process of preparing a manuscript where uh, we looked at several metrics in fetal echo. We looked at the comprehensiveness metric and score and what its role was in um, in a relationship or association with error was. And I'm not going to talk about the whole study, but I just wanted to point out that when we looked at the type of errors that we had In 304 fetal patients with critical congenital heart disease, we had 40 for moderate to severe errors. And in those errors, there are 59 contributors. And here you can see the bulk of ours was cognitive. Um, now we described it as we thought it was a cognitive error. If upon review of the study, we could see clearly that the problem was there, but that it was missed. And then we try to determine why. So that to us as something didn't compute there was an error in cognition. And then we tried to look at what exactly was that, that contributor. Now we know that the Mount Sinai group has published a very similar paper, um and it was mainly focused on looking at the diagnostic accuracy and the contributors. And so in your study, uh there was 222 fetal patients with critical CHD defined as needing heart surgery or an intervention post birth. You had 14 moderate to severe errors and your cognitive errors were remarkably less than ours. And so here you had more technical errors or primary contributors to error rather as compared to the cognitive. So be interesting to explore why there is that difference between our two groups. I'm going to guess that there might be a variation methods in determining the primary contributor. So would be useful to look more later. Uh now types of cognitive errors abound, there is a whole science for this because cognitive errors are created in every area of human experience. Um in this one codex, they document 188 different forms of cognitive bias. So I'm just putting it out there that it's an important effect and role in our interpretation. And the question then is what does awareness, do, does it have any impact on it? And the creation of errors? And there are de biasing strategies that do do work? Uh to work. One must fully appreciate the contribution of cognitive biases to errors in medicine, recognized that errors can be avoided and be optimistic that solutions to reduce bias work. And I think awareness is really fascinating when there are many tools out there to see if you have a form of bias. Here is an implicit bias. There's a and this is a project out of Harvard and there are multiple apps that either described biases or give you exercise to overcome biases. And I think that just just speaks to the increasing awareness of the role of bias in our world and in our specific world, the role in diagnostic accuracy in fetal echo. So we talked in the beginning about counseling, being the third realm of education in learning fetal cardiology. And in the past we always focused, I believe on mainly providing medical information to the parents and that is of course very important and central to the counseling process. But I think it's become increasingly um recognized that it also involves learning important communication skills, methods of trauma management, providing emotional support and medical decision making guidance. And in case you're thinking that I'm really making an overplay for being a superior empath. I want to kind of go over the role of stress and trauma on the brain's ability to receive information because it addresses that enraging or very at least very annoying event where we spend an hour and a half talking to a family and they walk away with no understanding of who they talked to and what was said and uh and some of our mitigation, some of the ways that we can best kind of stop that process from happening again is lies in empathy and communication skills. So when we look at the unstructured brain, we see here, the prefrontal cortex is in the light blue. And what happens is if you look at the brain stem, it provides norepinephrine and dopamine producing cells. And what that does is that opens channels in the prefrontal cortex to allow effective neuro transmission. And so the prefrontal cortex is working. It's kind of helping to moderate moderate the limbic system and keep emotions kind of without effort in control. And the brain is able to process information as it comes. Yeah and when this brain is stressed, what happens is the the brain stem provides elevated levels of norepinephrine and dopamine which literally shut down transmission in the prefrontal cortex. And so the olympic system runs amok and it is unchecked. And so that subconscious um management of all those emotions and impulses is gone. And what must happen then is the patients must consciously sit there and say don't cry, don't cry, keep it under control. She's trying to tell you something this is really important. But in all that time much less effort is can be expended towards listening to the very important information and life changing information that you're giving them 30s. And studies have shown that if you're able to show just the slightest amount of empathy that that really um kind of dampens the stress response and patients do walk away with more information retained. So it's really a very effective way of improving the effectiveness of your counseling session. So every fatal counseling session does not become a crisis. And I don't advocate that every fetal cardiologist is as skilled as a social worker or psychologist in this area. But I do want to exert that the smallest amount of learning about crises, trauma empathy, et cetera as well as internal reflection, will be immensely useful when counseling families in every situation. So if we can educate ourselves about the topics of breaking bad news, how people deal with uncertainty and how they assess risk in their process of decision making is useful, but also as equally as important as internal reflection on what are your reserves for providing empathy and emotional support to people. Um, and how can you deal with what tools you do have naturally to provide? Whatever you can to these families. And also, when are you recognizing and experiencing stress? And what processes can you do to mitigate negative effects from that? One place that has really done a lot of work with this is the Alberta health services in Canada. They put together this booklet that's over a hunt, that is 102 pages long and it's quite rich in resources. Here's example of one page where they are providing information about how you can show compassion for others and for yourself and includes some questions. It's very practical and useful. So there's all kinds of resources like this out there on the Internet, uh, and and the more we can track them down and employ them and our training, the better off our education for our fellows will be another useful resource that I was recently directed to. I had to do with medical decision making. And this is at the british Columbia Children's Hospital in their medical ethics department. They have a website that it has not only, uh, worksheet that I'm going to describe and you see here, but also some resources for physicians. So what this is is a two page worksheet for families and making medical decisions. And on the left, it has a lot of prompting questions, uh, and on the right, it gives them space to answer these questions. And, and, and the whole goal is to help them discern the medical decision, um, that that they feel is right for them and their family. So, uh, you know, I think overall it's important for us to understand or to define for us what are the elements of counseling that are important and valuable to us? # 2? What are the resources that are out there that we can use to help in our education. And number three I employ them in the education of our fellows in the counseling process. So overall I'm proposing that there is an emerging paradigm for education and fetal cardiology that expands opportunities for hands on training, teaches strategic scanning, expands the role of Q. A. Acknowledges that digital learning is everywhere and teachers should work on discovering literature on the methods of providing quality digital learning environments and should engage in cognitive bias discussions regularly in the echo lab. And I do believe that counseling education formalization is something that has been started in other in some institutions but should probably be an effort of the fetal cardiology community in the future. Thank you very much. Hi, I'm dr Aaron Paul. I'm a pediatric cardiologist here at Mount Sinai Kravis Children's Hospital. Today I've been asked to discuss healthier disparities and fetal cardiac diagnosis and care and to address how we can best serve our patients. Yeah. Yes. When you talk about disparities in health care, we're talking about differences in health associated with social economic and environmental disadvantage. Today we're going to focus on the impact of social determinants of health, on rates of prenatal diagnosis of congenital heart disease. There's a small but growing body of literature on this topic. And all the papers I'm going to review have a presumptive value placed on prenatal diagnosis and most of the papers focus on critical congenital heart disease, defined as a feed of Then infant needing intervention within the 1st 30 days of life. Either surgical or cath based. And the reason for presumptive value being placed on criminal diagnosis is because this helps families with decision making about continuing or interrupting a pregnancy, delivering planning for both the safety of the mother and infant. There has been a mortality benefit demonstrated for a couple of fatal diagnoses and morbidity benefit as well. We're going to focus on what factors are associated with rates of regional diagnosis on the from the day we have and some forthcoming publications and also discuss what interventions may be possible to address this disparity. The available data we have is uniformly retrospective with a wide variability and sample size. They're single centered data that from defect registries we have the sts surgical database, fatal heart society and Medicaid data. The majority did show improvement in prenatal diagnosis rates over the course of the studies and most employees census block deal data to evaluate socioeconomic position, so not individual level. D. The first study will review is the single center study from Boston retrospectively looking at a little over 400 units between 2003 and 2006. In this study, there was a 50 prenatal diagnosis rate that was higher in fetuses with hypoplastic left heart syndrome and lower in those with transposition. And that's a theme. We'll see across a number of publications In this study, private insurance and higher socioeconomic position were associated with prenatal diagnosis, whereas distance to the site and race we're not. But in this cohort, only 25 of the patients had raced. Known. This is a figure from the study with the number of patients on the Y axis and the socioeconomic chortled on the X axis and the prenatal diagnosis rates here in the hatch bars and showing an increasing rate of prenatal diagnosis with increasing socio economic portal. The next study used data from the Utah birth defects state registry, also retrospective, larger number of neonatal. Almost 1500 and here, the prenatal diagnosis rate was about 39%. Only a quarter of the patients with congenital heart disease had a fetal echocardiogram. And if you were looking at just those who had a fetal echo is a very high pick up rate of about 97 detection here. Prenatal diagnosis was associated with family history of congenital heart disease, having your ultrasound in a high risk clinic and having your skin interpreted by a maternal fetal medicine doctor. And you also had a higher likelihood of making the diagnosis. If there were other concerns about the fetus, like other extra cardiac defects, the number of ultrasounds, you had also increased your rate. There's a lower detection with needing additional views to other than the four Chamber view and individual and geographic measures of socioeconomic status did not have a statistical signal in this study. Moving on to our surgical database data, this study showed an impressive variation and prenatal diagnosis rates by geography across the United States. This study included infants who were under six months of age who had undergone surgery. It was also retrospective Centers where this data piece. The prenatal diagnosis was missing more than 15 of the time those centers were excluded from the study. This was the largest study with over 31,000 patients included, and the overall prenatal diagnosis rate was just 34%. This did increase over the study period. It was higher for those having the Union L surgery and even higher, almost 60% in those needing just a four chamber view to make the fetal diagnosis. There was also a higher rate if there were non cardiac abnormalities noted in the fetus and significant variability across the US. So this figure shows the 10 U. S. Department of Health and Human services regions and you can see the great deal of variability in the prenatal diagnosis rates that are on top of the region. So here there's the 24%, the lowest in the group in region six which includes Texas and um the highest in region three. Whereas as high as 46%, the reasons for this variability are still largely unknown. The next study comes from fetal heart society data looking specifically at fetuses with transposition and hypoplastic left heart syndrome. This was presented as an abstract at PCC in 2020 19 and there were over 1000 fetuses with hypoplastic left heart syndrome. There there was a prenatal diagnosis rate of 92% and this was again by foetal echo and transposition. The prenatal diagnosis rate was around 60 and having lower wealth and income was associated with a lower prenatal diagnosis rate. Also being farther from the hospital is associated with a lower rate. In the case of transposition. In this study, race, ethnicity and insurance did not come out as a statistical association. This is a a table from the study showing that you're the lower neighborhood summary score portal went along with a lower chance of having a prenatal diagnosis. This work has since been accepted for publication. We look forward to seeing it. And there's future work being done by dr john klein geo mapping this data and also evaluating neurodevelopmental outcomes. Yes, turning to Medicaid analytic extract data. Campbell almost recently looked again retrospectively at claim coats And found 4700 maternal fetal diets. And in that group there is a prenatal diagnosis rate of just 28%. This did increase over the study period and hear factors associated with a prenatal diagnosis included maternal diabetes, higher median income, higher Sinaga for labour quote meaning a higher density of stenographers in the area where the patients lived and had their care and the year of delivery. There is a higher rate of diagnosis. Again, if you needed to rape. Other than a fortune review, it was less likely that you had a prenatal diagnosis. It's a great figure from the paper showing that here in the dark bars as the routine ultrasound rate increased between years 2007 and 2012, the rate of prenatal diagnosis also increased. And then on this graph we see on the Y axis, that prenatal diagnosis rate and on the X axis, the income dis ill. And you can see that there's increasing prenatal diagnosis rates with increasing income, decide. The last study we're going to review is in uh their single center study looking retrospectively at just over 500 Munich who in their fetal diagnosis rate was around 61% here, factors associated with the post natal diagnosis. We're having no other anomalies in the fetus living in higher poverty, living in less dense communities or rural areas needing a view other than a fortune review again, and there was a larger disparity between rural and urban communities when you needed more than a 14 review. So to talk about that more specifically here on the Y axis, we have the prenatal diagnosis rate and on the X axis we have the view required to make that particular diagnosis. Um The darker bars are the um urban communities and the white bars of the rural communities. And you can see that the prenatal diagnosis rate did not differ if you needed, just a four chamber view. However, there is a higher statistically significantly higher rate of female diagnosis in urban communities when an outflow track you with required compared to rural communities. Now when I turn to some future work. So this um is a collaborative run by Dr Brett Anderson out of Colombia. The new york and general heart surgeons collaborative for longitudinal outcomes and utilization of resources. And this collaborative includes 10 of the 11 surgical centers in new york. And it's using a novel linkage method that links together and Medicaid claims data and also each individual centres, sts and new york Clinical registry data from 2006 to 2019. And this uniquely marries claims data to clinical data and allows for longitudinal outcome, health expenditure and disparities outcome analysis. Dr. Joyce who will be spearheading the effort looking at um fetal maternal die ads from this dataset. And what's really unique is that through this we will have access to individual data rather than zip code level or census block data and we can evaluate the number of prenatal care encounters um the mother and child had and in their posting of course. Okay, so after looking back at all the papers we just reviewed, there are clearly disparities. There is variability from paper to paper in terms of what disparities have a statistically significant association with higher or lower prenatal diagnosis rates In general having private insurance, higher socioeconomic status and having a diagnosis you can see in a 14 review were all associated with higher rates of regional diagnosis, whereas lower wealth needing additional views being further from the hospital and in a rural community was associated with lower rates of prenatal diagnosis. So part Two of our focus today is possible interventions. What can we do to decrease these disparities? And there are many lessons from the broader disparity literature that we can build on. An important theme is that we have to first identify disparities, design specific interventions and measure their effectiveness. This, of course, requires a multi factual approach at the patient level, the clinical encounter level and a systems level, not just within your hospital system, but within our communities and society at large. We can also think about other disease models that have leveraged a number of resources like adult cardiology and diabetes that have used community outreach and education for both providers and patients, phone calls, assistance with coordination and transition of care and also increasing diversity of care providers, given that we all have implicit, which is unconscious bias. Having more diversity in our provider group can help. So now focusing more specifically on the disparity and prenatal diagnosis for fetuses with congenital heart disease. A great step that has been taken over the fast past few years is that we now have more uniform screening guidelines from issue as a cog in A. I. Um that established that a fetal echo program requires a four chamber view and also outflow tract views. Um and um also specifies that for a detailed obstetric ultrasound that would be performed for a woman with more high risk features like having a diagnosis of diabetes. That would also include a or to conduct an arch views the systemic veins that in a ventricular septum. So it's a great foundation. Once you establish what should be included in that fetal echo, then you have to think about well how can we best implement that? So what's the best way to train stenographers and obstetricians? And there have been publications about training programs in the United Kingdom and the training programs have very variable structure somewhere a short intensive period. Others were 2 1/2 days spread out over a year. Um Common themes where that providers needed the time and access to training and they needed ongoing feedback throughout their training and then subsequent practice. They also importantly needed access to fetal echoes if a concern was identified, Okay, the next area for possible intervention is a large one which includes access to care in general and thinking about insurance coverage. Just having insurance isn't enough. Um You also need insurance that covers in an affordable way for you what we consider to be standard of care. So the affordable care Act, for example, does not cover all the radiologic certificate services um that we often do in a pregnancy. It does cover without co pays all the USPS, T. F. A. And B. Preventive recommendations. But that how that mid gestation ultrasound is not included in those records commendations. There's variable out of pocket deductibles and coinsurance is for patients and maternal fetal medicine care is actually not covered by a number of private, major insurers. There is also variable reimbursement to providers from private versus public insurance. And this does set up an inherent conflict for hospitals in terms of what patient populations recording and what patient populations are allowed or can afford to see. Um Next we can think about how can we get more sonography as we saw in that paper that having an increased labor quotient and increased density of stenographers, I was actually associated with a higher rate of professional diagnosis. And there are ways in which we could incentivize training and then relocation to areas with a lower regional density of stenographers. We need reliable transportation for our patients. And you can think of that from a community structure in terms of public transportation or a hospital system. In terms of providing transportation to visits from the hospital. Having paid time off is incredibly valuable. So there's a much greater cost to patients. You have to come to their appointment and not get paid for that day. Tell medicine programs have great promise in terms of bringing care to more remote areas and we'll hear more about that from dr kuna leader um conquering CHD and M. P. C. Q. I see have both done a lot of Q. I. Work and advocacy in terms of providing equitable counseling to patients and also encouraging patients even by giving them a list of questions that they're supposed to ask about transparency of outcomes at sites that they are considering having surgery at. We also need to communicate with our patients clearly by having the appropriate interpretation systems. Yeah. So in terms of health care disparities and fetal cardiac diagnosis, they are present. And the data we review today showed that disparity has been associated with your insurer, the number of ultrasounds you had. How many cinematographers there are in your area, what your diagnosis is as a patient. If there were extra cardiac findings for that fetus, what your socioeconomic position is, where you live and what's what views are required to make the diagnosis in terms of how we can serve our patients better. I just reviewed a number of possible interventions, but some take home points. We can continue to prioritize investment in this area of research at our individual institutions and as part of our societies, um we can continue to identify disparities tailor interventions and then study the effectiveness of those interventions. We can develop interdisciplinary models partnerships with O. B. M. F. M. And pediatric cardiology to make sure we're all comfortable with this foundation of our four chamber and outflow track to be used to make these diagnoses and we can participate in advocacy to ensure that our patients have a global insurance coverage for what we consider to be routine and standard care. Thank you very much for listening. I'm happy to take questions at the Q. And A. Or directly at my email here. Thank you. Thank you. Everyone proceeds really. Um great uh talks on topics that are really critical for our our great field. Um I do have a question I'd like to start. Uh we do have one question, Please don't have yet to send us questions in the Q. And A. I have a question for dr Geiger um understanding that there are many elements of a great fetal program um and that some of those elements are actually quite difficult to get together. Um Which ones do you think are most important to prioritize for someone who would like to build a great program? Yeah, that's a great question. Um and highlights just, you know, we're all seeing patients in different settings um you know, somewhere in private practice or community hospitals. And so I think in terms of um sort of the outcome and just management um and trying to optimize your post natal thermodynamics, um communication with your obstetricians and your M. F. M. S. I think is that the key is extremely important to understand that the O. B. S. Or M. F. S. That are delivering the fetus with critical heart disease, understand um what you anticipate the condition that for the baby to be in after delivery. Um And that they're kind of on the same page when they counsel families about um you know why they're choosing a certain delivery mode or location. Um So I think that's really key and unfortunately you know um it doesn't cost money but communication is a problem um in all different areas of medicine. Um And it's something that you know we certainly struggle with all the time. It was you know someone doesn't tell this one person and everything else falls apart. So I think it's something that we all need to work on and even though um you may not have the resources to have a nurse practitioner or um a psychologist or you know even a separate counseling room to make sure that you communicate with the patient well and the Obi caring for us. And manicure I should also add because obviously they're going to take care of the baby after birth though I think that's the most important if you're going to have to prioritize. Um There so there is a question from the group for Michelle can phone um can you speak more about your role as an mp in the coordinator position and how does this differ from an RN. Um And you practice anywhere else in the cardiology clinic? Okay. Hi it's Michelle. Um So I um I use my and my masters to help answer follow up questions and use it in the counseling and then uh for program development at Mount Sinai. I did not see follow up patients in the clinic but other centers may use their mps in that fashion. That's really helpful, shifting gears a little bit dr Tracy. It was really notable um how cognitive errors made up the majority of errors that you talked about in that prepared manuscript when when you're looking at fetal cardiac diagnosis for yourself or for your trainees on a day to day basis, what techniques do you use to avoid cognitive ice to use checklists or a protocol, not just as you perform a scan, but as you interpret a skin, what kind of tools can you tell us about? Yeah, thanks very much for that question. Um, I don't think we have it really like set, you know, for how what's the best way to do it. One thing that we do is we talk a lot about the referring diagnosis and try and also trying to get people to not lock in or anchor to that diagnosis and we talk about that a lot in case review sessions. When we're talking about, let's say we've uncovered an error. Our study only looked at initial cases our initial echoes. Um, and, you know, lots of times when you do a first echo, the diagnosis changes on the second echo. And those changes in diagnoses can lead to an opportunity to explore what happened in the first one and really delving into it. Looking at what the indication was, looking at what, you know, family history was looking for things that could have contributed to cognitive bias, I think is again a really interesting process. So I think it's just trying to talk about it. Look at it. Always consider it as a source of error. I would say acknowledging it. Being more aware, perhaps give you more cognitive flexibility the next time you see something. Yeah, absolutely, absolutely. I think that's a good way to describe it. And just um, I think a lot of us are not aware of them because they are subconscious. So we're trying to like unearth them and make them conscious. I I see another question. Do the, do the panelists want me to? Um, it's in the chat section. Gonna go ahead and do that. Sure. Um, so comment on my part of the process for simulated versus real life field counselor. And this could go to anybody it says can go to anyone on the panel. Um, and how often should training during training? She fellows participate in simulated versus real life counseling. Two fellows to counsel families for critical or severe. So first regarding stimulated, we do that just once with each fellow just because we don't have a lot of, it takes a lot of time and we record them as well for later kind of review. And um, uh I think the once enough is good for the, for the fellows to get that feedback. They love getting the feedback of, well, when you said this, you know, this is my reaction and so forth. So we could probably, it would be nice to do it more than that. But it's also good for the fellows to have like a dry run if you will. Uh they experienced like, oh I said that really, that was horrible when I said that. And so it's really a good experience for them to kind of test out counseling and I'll just answer this last part and then open it up to the panel. Do we allow fellows to counsel families? We pretty much will allow the fourth year fellow to do the counseling with us present in the room and we, we explain to the parents what the various roles are are. But sometimes if there is a third year who is interested in to spend a lot of time with us and we know that they are really good at this, you know? Certainly that's up for modification. Um But that's about it. Um We have explored the idea of having fellows kind of zoom in and listen to a counseling session because you don't want to have so many people in a room that's very intimidating for a family. So those are just my responses and I thought I'd leave it up for opening up to everyone else, see what they have to say, dr moon Grady, your hand is raised. Yeah. Thank you terry. That was um really great uh talked all of the work that you've done in this is just amazing um to add to what we do. Um I would say that the third year fellows pretty much don't uh don't independently counsel patients um unless it's something very simple like belvoir pulmonary stenosis or that they scanned and then we'll let them give it a try if we've seen them council post natal patients and they've done well. And the fourth year, uh of course I do need to start doing some counseling. We also do a simulation with um you know, with feedback at least once per year that all the fellas take part in, so they have an opportunity to get that kind of feedback. Um And then the the additional thing that I have done is have um uh palliative care specialists or psychologists come and talk to our group of fellows at least once a year about two things one. Um And sometimes I do the talking to one is about grief and touches on uh what what terry was talking about, how difficult it is for for these families to hear anything when they are in the acute phase of of grief. And uh the other is uh from the other side of it is how hard it is for us to do the counseling. Um And the you know the catchwords compassion, fatigue and all of that. But you may even bring some of your own personal um uh feelings into the room unintentionally and so um being really mindful that that this is very difficult for everyone involved or can be um uh and giving them that background uh for for counseling. So those are some other things that we've done and zoom has changed everything they can now they can watch all of these counseling sessions without having to worry about. Are they making a face or you know, they can just be a fly on the wall. So um I encourage people to do that. There's a thank you. There's an interesting added question which kind of goes in the same direction about ways that individual providers can get feedback on their performance. Um So if you have uh nurse practitioner who's there all the time and you see all the different providers, I'm sure she has an idea, I'm sure she has an idea of what, you know, makes sense and what works and what doesn't work if you all entertained getting some feedback um from from this person. We um we didn't do it formally. Um And actually I think it's an interesting dynamic, right? Because um there is probably and Michelle can speak up, but, you know, I'm sure she has her thoughts on how we all council and how the Fellows council and even experienced attendings. And it's interesting because there's one attending there, you're not observing, other attending. So you as an attending, you don't know how the other attendings council except for what you hear from the council, the coordinator or fellows. Um but we do, I mean, we do periodically ask Michelle, you know, how did that go? Was I too pessimistic? Uh, you know, I try to ask for that feedback just so I get a sense of how I've been doing and I know I've changed how I've counseled over the last, you know, 10 years. And so, um I think it's very important to get some of that feedback, but the person that is doing that maybe a little bit hesitant to give you that feedback because they work with you every day and, you know, they don't want to criticize you, but I think, um even if we don't do this, but you can develop a form of like how each session went. Um and then going back to the other question. Um We have this similar thing that we have mainly the 4th year do the counseling, third years, can we do allow observation especially if someone's going to go into this or private practice even, but they're going to do fetal um definitely joined with the counseling if the parents if their family gives permission. Um and then sometimes am FM fellows join us. Um But we do have the fourth year fellow, particularly the latter half of the year do counseling. We go through where we do. We have a small puddle about what we're going to discuss and what the important parts are and then obviously you can chime in if there's um any additional information. Thank you all so much for this discussion. Um That's unfortunately the close of session to, it's such a treat to be able to talk to another like this. Um It's lunchtime on the East Coast and brunch on the West Coast. But please join us again at 1 15. Please go visit the exhibit hall now. Um But session three, which is advances in fetal cardiology. Okay. It's the heart Begins at 1 15. See you then. Thank you everyone. Okay. Mhm. Yeah. Yeah. Yeah.
