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Tuesday, May 20, 2014

Pocket ultrasound machines: 'Why doesn't everyone have one?'

For about 2 years now a tiny ultrasound machine has been part of my standard physical exam tools as I take care of patients in the hospital and in the outpatient clinic. In November 2011, I first picked up an ultrasound transducer in a continuing medical education course on bedside ultrasound for emergency physicians. I am an internist, not an emergency physician, but I was interested in bedside ultrasound and it was the emergency physicians who were giving the most interesting course. It was transforming for me. I was able to see internal anatomy and physiology and eventually, with lots of practice, I was able to make diagnoses more quickly and accurately. I bought a pocket ultrasound machine so I could make bedside ultrasound a seamless part of my practice

It was an unexpected and welcome bonus that my patients and their families loved it. I would share the moving ultrasound pictures with them, often having them hold the machine so I could point out how beautiful their internal organs were and what we could see that helped give us a clue about their disease process. Many of these same patients also got full, detailed ultrasounds or other imaging by radiology technicians, but since the technicians aren’t supposed to discuss findings with the patients and often they couldn’t see the screen, it wasn’t nearly as gratifying.

The most common comment I get from patients is, “Wow, that’s really cool!” ”I agree!” I answer. Then they will ask, “Why doesn’t everyone have one of these things?”

That is kind of a difficult question. “They’re pretty expensive,” I usually say. They are. At least for now. The little machines (I use Vscan, by GE) retail for over $8,000, though you can buy them cheaper used or overseas. Physicians balk at spending this amount of money on a piece of equipment. Most of the expensive gadgets we use are owned by hospitals or by our group practices. Musicians, however, who make a fraction of what we do, buy their own musical instruments, which often cost in excess of $10,000. I’m not sure the cost ought to be a serious consideration.

Other doctors often ask me if I bill for my exams. I don’t, because billing and the detailed documentation and posturing that would be necessary to prove to an insurance company that an ultrasound was necessary would take more time than I have. I report the results in my narrative of the physical exam, much as I do the findings of my ears or my hands or eyes. There are billing codes for limited ultrasounds, and if I were able to record and store my images easily I could probably boost my revenue, but that would make me feel just a little bit conflicted every time I did it. I would have to tell the patient that I was charging for it, which would probably make them feel conflicted as well, or maybe choose to forgo the exam, which would mean that I would know less about what was going on and would be more likely to make a mistake.

“It also takes a long time to learn,” I add. I have spent hundreds of hours in learning from good teachers, mostly in person, but also online. I have done many thousands of exams and have reviewed a fair number with experts. But it is actually pretty quick to get good enough to be sure of a handful of different things that make a huge difference in making clinical decisions. After that, much like most of the things we do in medicine, learning expands exponentially with on-the-job experience. Many students in medical school now are learning how to use ultrasound at the bedside as part of their standard training, which is really the best way to do it.

“When did those things come out? I’ve never seen anything like it!” say my patients. The little pocket model I have has been available for at least 5 years, and there have been portable ultrasounds for considerably longer. The company that makes mine has not been aggressive in marketing it, even though it is potentially as huge a deal as the introduction of the stethoscope, and other ultrasound companies have been incredibly slow in developing competitive models. Maybe it’s just difficult to develop the technology, but I think it’s a little less wholesome than that.

Ultrasound is a huge part of what radiology departments in hospitals and clinics do. It has grown as we have become aware of the dangers patients are incurring with the expanding use of imaging based on X-rays, such as CT scans. Full scale ultrasound exams are performed by radiology technicians using machines costing hundreds of thousands of dollars, are read by radiologists or cardiologists and billed out for thousands of dollars each. If physicians at the bedside are doing these exams for free, or even for cheap, this has the potential to negatively impact huge revenue centers. It is not in the financial interests of the whole industry for the manufacturers to produce an awesome pocket machine. A bedside ultrasound, which takes minutes, is hardly the same as a full scale ultrasound or echocardiogram which can take almost an hour to perform by a technician who does only this. In some cases we may order more ultrasounds because of what we see, or think we see, at the bedside, but for some questions our brief and focused exam will be enough and will supplant imaging by the radiology department.

There is also abundant controversy about adding routine ultrasound to the way we practice medicine. It is a “disruptive technology” which means that it potentially changes things in far reaching ways, many of which can’t be adequately predicted. We may see things inside patients that are best left unseen or are difficult to interpret. We may thus end up chasing findings that are nothing and costing patients more money and anxiety than we should. I have not found this to be true, however. Imaging of all kinds, especially the detailed kind that comes out of radiology departments, is often misleading and anxiety provoking. Think about the majority of mammogram abnormalities that turn out to be nothing or adrenal “incidentalomas,” the small meaningless lumps we see on the adrenal glands when CT scanning the abdomen. Combining bedside imaging with examining the patient, talking to them and reviewing laboratory data has been much less likely to lead me to misdiagnoses than to appropriate ones.

Many older physicians are trying to adjust to changes that make them feel that they are losing the profession that they used to practice skillfully in the past. We are asked to learn to use computer systems to document patient visits, review medical histories and order treatments. We start to become data entry technicians, and we aren’t very good at it. We are asked to learn continually changing algorithms for treating a myriad of diseases. We are required to provide excellent preventive medicine for our patients so they don’t have heart attacks or strokes or get cancer, when research on the proper way to do this makes what was wise 1 day stupid the next. On top of this people like me with our tiny little ultrasound machines come along and say “Hey, there’s this other thing you should do too.” But I would love for my overworked and stressed out colleagues to know that this is different. Data entry is not inherently fun. Robots or trained monkeys could probably stay on top of the preventive to-do list better than we do, and algorithms don’t give us much job satisfaction, even if they do help us deliver evidence based treatments. Bedside ultrasound, though, is terrifically fun and despite the time and effort required, brings back some of the joy of being a real doctor. I say this after a quarter of a century of practicing internal medicine. I am an “older physician.”

So, “Yes,” I tell my patients. “I agree. It is incredibly cool. We are looking at the inside of your body together and learning things. It’s unusual now, but I’m pretty sure it’s not going to be too long before it’s part of what most of us do.”

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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1 Comments:

Anonymous Anonymous said...

Great read! It is always great to hear from other medical professionals who are as passionate about ultrasound as we are at the University of California, Irvine!

Some of us medical students at UCI are traveling to Panama this summer to perform and teach ultrasound in rural island communities. We set up a fundraising campaign so we can bring medical supplies to the community. With enough support, we hope to purchase an ultrasound machine to leave in Panama! Please check out our project here: https://www.indiegogo.com/projects/ultrasound-in-rural-panama/x/7062514#home

May 24, 2014 at 8:58 PM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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