Tuesday, June 3, 2014

Is ultrasonography overrated? A radiologist thinks so

In response to an article in the New England Journal of Medicine that discussed whether bedside ultrasonography (US) should be taught to medical students, radiologist Dr. Saurabh Jha recommended that clinicians do a proper history and physical instead of point-of-care ultrasound.

His post appeared on the KevinMD website.

As if a radiologist advising doctors to do an H&P wasn't shocking enough, Dr. Jha then confessed that he thinks "ultrasound images look like a satellite picture of a snow blizzard."

He worried that rather than finding hidden pathology, indiscriminate use of US by inexperienced physicians will simply lead to more and more testing.

Even seasoned radiologists tend to overcall abnormalities on US said Dr. Jha. This leads to increased use of other imaging studies, most of which turn out to be normal. Using US to avoid the risks of ionizing radiation often results in patients having CT scans anyway.

In the comments section of the post, Dr. Jha emphasized that he was talking about situations where the pretest probability of finding something wrong is very low. Directed US based on clinical indications is obviously of value.

Emergency medicine physicians who
Photo via Dr. Ryan Radecki (@emlitofnote)
commented listed several instances which bedside US can be useful such as in identifying pericardial effusions and fluid or blood in the abdomen of trauma patients.

Ultrasound is clearly the test of choice for right upper quadrant abdominal pain. There is nothing better for identifying gallstones, but thickening of the gallbladder wall and fluid surrounding the gallbladder are best seen with US done in the radiology department.

Probing all body cavities with a transducer for no specific indications is another matter.

Is there still a role for a good history and physical examination in modern medicine? Yes.

Is US a useful test? Yes, in the proper context, it can be very helpful.

Should every medical student be taught how to do bedside US? I don't think so. A course is just the beginning. Learning how to perform US requires a lot of repetitions. Many medical specialists will never use it.

I agree with Dr. Jha that the time should be used to "Teach them to organize their thoughts coherently."

What's your opinion?

Note: These folks also tweeted the photo.@EM_Educator @MDaware @EBMGoneWild @choo_ek


nicmiller said...

I'm an M1 at an institution that does teach students u/s from from the first block onward. The push has come largely from the ED attendings, who think everyone should learn it. I've really enjoyed the opportunity to learn from the beginning, and it has a strong correlation to functional anatomy, which can be really helpful in the preclinical years. M1s and up have open access to an u/s lab where we can go scan each other whenever we want. We also have an annual U/S challenge event for all the med students, and as a result many of us are well versed in FAST, Parasternal long/short axis/apical scans, even endoluminal, venous access, etc. I definitely love the opportunity to practice it whenever we want. My opinion is that our time in u/s is frequently well spent as we get to mingle with attendings and residents who gently pimp us on anatomy and disorders, etc.

Skeptical Scalpel said...

Nic, thanks for commenting. That's a good point about the functional anatomy which I had not thought about.

Is everyone in your class is as enthusiastic as you are about ultrasound? What percentage of your class frequents the US practice lab?

Anonymous said...

Full disclosure, I am a medical student. Luckily I have had the opportunity to be at an institution where I have gained exposure to ultrasound, be it in an informal, extra-curricular manner. Why do I value ultrasound? Simple: it makes me better. It has deepened my understanding of anatomy, physiology and clinical medicine. It has emphasized to me why the history and physical exam is so important -- interestingly the opposite of the argument made in this blog post. I very distinctly remember a case of massive PE during a PEA arrest. The right ventricular strain was obvious to me, even at my level of training. Talk about being humbled by a disease I was now able to better appreciate (anatomically, physiologically) by watching that heart struggle right before my very eyes. Whenever I run through PE risk factors with a patient, or exam a patient for DVT or PE, I think about that case.

Anonymous said...

The use of anatomy in medical school curricula to reinforce NORMAL anatomy, vascular function, soft-tissue evaluation can be invaluable for students who are trying to learn from the stiff, dis-colored cadaver (for which I don't recommend ultrasound). Learning on standardized patients or each other (within limits) could help redefine how we teach anatomy at the MS1, MS2, and GME levels.

artiger said...

I started to comment before looking at KevinMD, but I went ahead and checked it out. I largely agree with nicmiller above.

One thing I have wondered about for a while is our tendency to lump history and physical together. I view them as 2 separate skill sets. I've felt for a while that good history taking is the most important step of the encounter, and that it can be more easily mastered than physical exam. Furthermore, I view directed ultrasound as an extension of the exam (though not a substitute for it).

As an example: "You say your right upper rib cage started hurting after you ate that BBQ sandwich? OK. Let me feel just under your rib cage. Oh, that's pretty tender, huh? Let me pull out my pocket transducer and take a quick look. Hmmm, I think I see some stones, and that GB wall looks a little thick. Mrs. Scalpel, it is starting to look like you have a diseased GB. Let's get a more definitive study to be sure."

In other words, I think BASIC ultrasound skills should be taught as an extension of physical exam, with it all being directed by good history taking.

Skeptical Scalpel said...

Both Anons, thanks for commenting. It looks like at least some of you are getting something out of your ultrasound experience. Neither Dr. Jha nor I were aware of this. As I asked above, am I just hearing from the disciples or are most med students having the same positive experiences as you three?

Chris Byrne said...

I just recently graduated from Western University (London, Canada) and have been involved with various educational initiatives at the medical student level there. Two years ago, our group of students started the "Point of Care Ultrasound Interest Group" within the medical student club system here. Membership has grown to such an extent that it is among the largest interest groups at the medical school (ahead of, for example, the Surgery Interest Group), with nearly 50 per cent of the student body registered as members. Interest group events (typically evening workshops, not part of official curriculum) fill up quickly and sometimes have substantial wait lists.

Our group also organized a more intensive two-day medical student ultrasound symposium. It was held for the first time in August 2013 (can read about here: http://westernsono.ca/2013/08/26/western-medical-student-ultrasound-symposium-a-memorable-weekend/). Last year's symposium was attended by 35 students (limited by resources), with representation from five of Canada's 17 medical schools. Registration for this year's symposium (can read about here: http://westernsono.ca/2014/05/01/registration-open-for-2nd-annual-western-medical-student-point-of-care-ultrasound-pocus-symposium/) opened up recently. The organizers were concerned about registration this year as they did not have the one-time grants that supported last year's symposium. Last year's initiative won two "innovator" grants, one of which was from the Canadian Federation of Medical Students, which provides representation for all medical students in Canada at the national level. As a result, the registration cost burden on students more than doubled to $329. Keep in mind this event takes place in late August, over the weekend. Students are paying to essentially dedicate one of their last summer vacation weekends to an ultrasound education event organized by other medial students. This year registration filled in 5 days, with a wait list double of what the symposium is capable of supporting. It seems that at our institution, medical students are very interested in learning ultrasound.

Our group of medical students presented three abstracts related to the interest group and symposium "grassroots" initiatives at the Canadian Association of Emergency Physicians conference in Ottawa over the past few days and are working on a subsequent manuscript. We feel we are somewhat unique in that what is being done has been entirely student-driven (with generous support of enthusiastic faculty, of course). I wish I could link you to the abstracts, but they are not yet online. If interested, you can check out this poster, which was presented at the Association of American Colleges: https://westernsono.files.wordpress.com/2014/06/aamc2013-agrassrootsinitiativeinpoint-of-careultrasoundeducationposter.pdf

Chris Byrne

Skeptical Scalpel said...

Artiger, sorry I missed your comment earlier.

Your example is not convincing. The patient you describe is going to get a US in the radiology department anyway. What does your pocket US add to the workup besides costs?

Chris, congratulations on accomplishing so much on your own.

I would point out that if you survey attendees at a POCUS symposium about the value of POCUS, you are likely to get favorable responses about POCUS.

Chris Porter MD said...

I learned bedside U/S on the job, starting with vascular access in ICU, then FAST for trauma. Since, I've used it to find fluid collections under erythema when I couldn't feel a fluctuant abscess and once in Africa to confirm an early pregnancy. Placing a central line without US now seems 'blind'.

As far as teaching to med students, an US probe seems as rational as a stethoscope and at least as teachable than that thing for looking in ears and eyes.

Chris Porter MD said...

PS - I think bedside laparoscopy by ED physicians should be taught next.

Skeptical Scalpel said...

Chris, ED docs doing bedside laparoscopy is in line with my recent post on interventional nephrologists. http://www.physiciansweekly.com/interventional-medicine/

Tom O'Graphy said...

I understand what you say : I'm a (unofficial) newbie in US, work in ED and really enthusiastic about this stuff. So I will easily screen many of my patients with US. If I found nothing wrong, it's ok I will stop (but before that I didn't order CT or anything else). If I find something strange or if I'm not sure (even if clinical exam is ok) I'll probably order a "real" echo or a CT scan.
The challenge will be : which patients not to screen with US, if clinical exam is ok.
On the other end, sometimes we need US exam by radiologists and have real difficulties to have exam in the day (it becomes impossible to have these at night or on holiday). So temptation is strong to do radiologists job even if I know I'll never be as accurate as an US radiologist.
I disagree with the expression of "modern stethoscope" because the interpretation of US is not easy and need real effort compared to listening of human body sounds. I find some of my colleagues not ready for this and maybe never.

artiger said...

Scalpel, my example was a rather poor one. My only excuse was that my daughter halfway had my attention while I was composing the post.

I guess what I was trying to say is that like many others here, basic ultrasound seems like an exam skill that should be taught to students (and residents), but not for the purpose of raising the cost of an encounter. It should just serve as a guide to help determine if/which more definitive studies are necessary.

Skeptical Scalpel said...

Tom, good comments. I agree that learning sonography is difficult.

Atiger, if an ED doc tells you he ultrasounded the abdomen and saw no gallstones in a patient with RUQ pain, would you believe it or would you get an ultrasound in the radiology department?

artiger said...

If that ED doc was reasonably proficient at bedside ultrasound (which an increasing number are), I'd believe him. Then I'd ask him why he called me if there were no gallstones.

Skeptical Scalpel said...

Don't tell me you've never been consulted for abdominal pain and no gallstones on US. I can't count the times it's happened to me. Conversely, I have been asked to evaluate patients with asymptomatic gallstones found incidentally to "clear" them for discharge.

artiger said...

Sure, it's happened, more than once. My response is "well, work the patient up, and call me if you find something amenable to surgical intervention".

As to asymptomatic gallstones, I don't "clear" patients anymore than I ask cardiologists to "clear patients for surgery" ( a term that not only do I not use, but detest vehemently). I simply state that I do or do not recommend surgical intervention based on the findings.

Justin Hensley said...

Of course a radiologist wouldn't want a reason to decrease billable studies. If an adequately trained emergency physician can decrease length of stay and decrease costs, then why shouldn't we do it?
Of note, the overwhelming majority of pushback on POC U/S has been from radiology, because they worry about decreased income. Similar to EKG interpretation by emergency physicians vs cardiologists.

saurabh jha said...

Thank you Skeptical Scalpel for cross posting my piece.

I agree that US, indeed any cross-sectional imaging, can be an adjunct to learning anatomy. I applaud medical students who not only follow the imaging results of the patients but ask radiologists to point out the relevant pathology. I agree this reinforces learning.

However, this does not extrapolate to US being the new stethoscope. Ubiquitous use of US, even by experienced operators, will result in fishing in low pre test probability ponds, and proliferation of false positives. This is basic Bayesian logic (relationship between prior probability and false positives).

If somebody has right sides lower chest pain which is most likely musculoskeletal in nature and you decide to have a peep in to the gallbladder just to "rule out stones"; if negative that's fine. If positive, now you may well have misattributed the patient's pain to gallstones. Gallstones are common.

In the limited time of medical school US would not be my highest priority. History and physical would, and thanks to the abundance of and ease in obtaining diagnostic imaging this skill is slowly deteriorating. If I were an educationalist my first priority would be to stem and reverse the decline of this basic skill.

If US healthcare has any chances of managing resources it must instill in its physicians a sense of resource stewardship. A decent H & P will go a long way in this endeavor.

Skeptical Scalpel said...

Justin, Justin, interesting points. Is there any proof the ED US has decreased patients' LOS or costs? I wasn't aware of a problem with ED MDs and cardiologists. Everywhere I worked, the ED MD read the study acutely and decided what to do. Then the next day, the EKG was officially read by a cardiologist.

Skeptical Scalpel said...

Dr. Jha, thanks for your input. I expect some further comments on this.

saurabh jha said...

"Of course a radiologist wouldn't want a reason to decrease billable studies"

I would encourage ED to bill for US.

I would also encourage other specialties to act on the findings made on US by ED physicians such as appendicitis, cholecystitis, ruptured ectopic (or no ectopic) rather than ask radiology to repeat the US or get a CT or a HIDA. Although it's not in my jurisdiction to make the case for ED.

The idea that a radiologist might object because of turf issues is a relic of old style thinking. We will be moving away from a FFS model sooner or later. I don't think any radiologist will mind the load of pelvic US being shared with ED physicians.

So by all means Justin Hensley, bill away (just don't forget to save the images and issue a report).

artiger said...

I too appreciate Dr. Jha's comments. I'd like to see physicians actually looking at the radiographic studies that they order. I see people ordering CT's and ultrasounds left and right...not only are they unable to make heads or tails of the actual images, they don't even bother to take a look, just "wait for the report".

Justin Hensley said...

Yes. http://www.ncbi.nlm.nih.gov/pubmed/23283267, http://www.ncbi.nlm.nih.gov/pubmed/10530660, and http://www.medscape.com/viewarticle/813162. I have been in meetings where the discussion is that if we bill for the procedure, then the other "expert" cannot bill for as much (or at all). Argument differs at each institution certainly. At ours, currently, we have to bill for a "limited" US (if at all), otherwise sending pt for a "formal" US (to satisfy consultants) results in no pay for second exam.

saurabh jha said...

ED should bill for the US and save the images and issue a report. It makes little sense not to do so.

The trouble arises when ED does the US but radiology has to repeat the US either because ED is unsure of what they have found, or not found, or the clinical team to which the patient has been referred insists. Repeating a pelvic ultrasound (TV) is not terribly kind to the patient.

If confirmatory imaging (US, CT or nuclear medicine) is obtained for findings made on US by ED, it sort of defeats the purpose.

The idea that an objection to skill mix is made on the grounds of turf is a relic of the old days of unfettered fee for service. As we move to bundled systems it will matter even less. It is unlikely that many radiologists will be upset that ED is performing and billing for pelvic ultrasounds.

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