Bedside ultrasound: Simplifying diagnoses or complicating clinician-patient relationships?
Usually we await a radiologist's procedure, judgment, and documentation before getting these results. Sometimes we're offered a quick preliminary read, but it often can take days or even weeks before a final report appears on your desk. In particularly well-equipped clinics, an in-office ultrasound can yield quicker results, but these are rare outside of hospitals or obstetrical settings and can be expensive to maintain.
But what if all clinicians were equipped with ultrasound technology? What if a portable ultrasound was as ubiquitous as a stethoscope or a reflex hammer?
That's exactly what's happening at the medical school at University of California, Irvine, where all med students are being trained in the routine use of bedside ultrasound. As the program's champion, Dr. Chris Fox, explained in a radio interview, "I can see a lot more with that device, with the ultrasound machine, than I could ever feel or listen to with my stethoscope.”
Of course he can! Who can possibly distinguish fascia from fat from mass from organ with their bare hands alone? Who has the secret x-ray powers to assess whether a breast mass is a cyst or a malignancy? Ultrasound undoubtedly has the capacity to assess anatomical differences indistinguishable with mere human senses.
Dr. Fox and his colleagues are attempting to bring more advanced technology to the bedside, and with it, they hope, more accurate diagnostic specificity. They're trying to enable better, more efficient patient care – something we all value and strive for.
Then why does this prospect make me so uneasy?
First, no one knows if the experiment will work. UC Irvine is the first medical school to integrate bedside ultrasound into its curriculum, and the school hasn't proffered any specific plan to track student or patient outcomes with the new approach. The bedside ultrasound may simply lead to more ordering of diagnostic ultrasounds or result in one more piece of evidence to corroborate a diagnosis that could already have been reached through a history, physical and labs.
Even if the new curriculum does work – if the newly minted MDs indeed are better at evaluating and diagnosing than their sonogram-less counterparts – at what cost will we have we bought this progress? The financial cost of the machines, the training and the maintenance is considerable (comparable to a luxury car, according to the NPR story). The likelihood of false positive findings, especially with brand new clinicians, is high and the prospect of costly follow-up daunting.
Furthermore, as the senior associate chairman for the theory and practice of medicine at Stanford University Dr. Abraham Verghese, has so articulately argued in a recent New York Times article, the physical exam is already a disappearing art. Few of us learn – let alone remember years into practice – the finer points of the neurological exam or the myriad ways to assess for peritonitis.
As new technologies are introduced, especially into routine practice, these important skills run the risk of disappearing even more quickly. In the race to adopt and integrate new technology, we need to stop and check we are substantively improving patient care and that we don't accidentally discard part of what makes us valuable clinicians in the first place.
Dr. Fox claims that the ultrasound fosters a connection between clinician and patient: “It's not just looking at a still image on the screen. It's generating the image yourself, interacting with your patient in that intimate way – that is 'bedside ultrasound.'”
As someone who has conducted hundreds of exams and hundreds of ultrasounds, I'm not sure I agree. Accustomed as I am to walking around, as Dr. Fox puts it, “with the Internet in [my] pocket,” I think something is lost when a screen is placed between you and your patient. A relationship mediated by sound waves and grainy images does differ meaningfully from one conducted eye-to-eye or hand-to-person. Which is better? That should be up to each clinician – and, really, each patient – to determine.