Why doesn’t everyone have a pocket ultrasound machine?

Why doesnt everyone have a pocket ultrasound machine?

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 (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 one 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 need to 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 doing the job.

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 is a physician who blogs at Why is American health care so expensive?

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  • JR

    “Musicians, however, who make a fraction of what we do, buy their own musical instruments …”

    Many professional musicians are “supplied” with instruments by instrument companies because it’s a form of free advertising. I know an independent label where everyone in the company uses the same brand of guitar or bass, not by choice, but because they are free.

  • timothyhood

    I can envision an iPhone or iPad version where the wand connects to the lightning port and the software (app) uses the hardware of the device to handle the imaging. Then, it would be really easy to upload the images to the patient’s electronic file, send for review, etc.

  • T H

    What is easier to keep clean and cheaper to replace? The head of a stethoscope or the head of an ultrasound probe?

    I will admit that portable US has its place (E-FAST, FHR, possibly 1st trimester bleeding), but as a replacement of the stethoscope, the hand-held US makes a poor reflex hammer. :-p

    • Janice Boughton

      Right about the reflex hammer, but that was always a lousy way to check reflexes. My pockets contain ultrasound gel, vscan, reflex hammer, stethoscope and otoscope. Started wearing a white coat again to handle all that. The little poison wipes that are all over the hospital can be used to wipe down the probe same as the stethoscope, and there are less nooks and crannies.

      • T H

        You don’t worry about the ‘white coat police’?

        Mainly, I’m being facetious here… and I think the whole thing is a bit of a ‘baby and the bathwater’ issue.

        I used a handheld ultrasound this past weekend as a loaner.
        I must admit: it was very nice.

  • Dave

    Can you talk a bit about how the handheld units compare to full-sized ones as far as image quality, features, etc? I’ve been intrigued by these units since they debuted, but wonder how much has been sacrificed for the sake of size. Maybe I can put it another way: are there instances where, based on your US exam, you have referred the patient for a formal US because the handheld unit wasn’t adequate?

    • Janice Boughton

      When I do a bedside ultrasound I can feel confident, usually, about whether the patient has adequate cardiac function, pericardial effusion or tamponade, whether they have ascites, urinary retention, pleural effusion, hydronephroisis. I sometimes get amazing cardiac images, usually get adequate ones, occasionally can only tell that there is a heart in there somewhere. The images are much less crisp than a machine that is larger, but since I have mine at the bedside, I get much more than a snapshot or a dictated report. It is adequate for cardiac function, pericardial effusion, and has given me information about segmental wall motion abnormalities that hasten a person appropriately to the cath lab. I have often seen things that mean that the person needs a radiology ultrasound, partly because my images and reports don’t go into the radiology section of the chart and also because they do a better job. I have identified unexpected cancers, and always send those for official imaging except if I am in rural Africa.

  • SteveCaley

    I am very cautious about gizmology and medical instrumentalism in general. The implied emphasis today is on increasing the amount of information available, which often is not the problem. One of the traditional canons in medicine has been not to acquire information for consideration that is not influential in the diagnosis and care of the patient. This pearl is as long-gone as Frank Peabody. Differentiating between VSD and MR is much easier with ultrasound; but the clinical relevance of the finding and the urgency of addressing the matter lies at the heart of medical expertise. I would like to see acoustic and visual sonography married to each other in the machines of five years hence.
    That being said, the value of a gizmo is placed by the provider who addresses the question asked. Once one has a gizmo, one can build all sorts of uses for it.
    Finally, to me, a remote ultrasound is almost worthless. The training is in the hand that wields the probe. Grandma might be able to get images that show 3 liters of fluid in the abdomen from chronic ascites, and that’s up from 2.5 liters three weeks ago. What does that do? What additional information does that add, that is of value to the clinician?
    It is as clumsy-sounding as tele-laparoscopy. I have no doubt that tele-laparoscopy for hernia repair CAN be done. But why?
    Gizmos are of use when they are COMPELLINGLY VALUABLE -when a clinician can assert that practice interventions can be done more efficiently, accurately etc. (and, of course, clinicians who are uninvolved with the marketing of the gizmo.) Otherwise, the gizmo merits a listing in “Why is American health care so expensive?”

  • John C. Key MD

    Why doesn’t everyone have a pocket ultrasound machine? Well, because physicians trained in physical diagnosis rarely need them in the vast majority of cases.

    • Mengles

      Sad how a physical exam is being replaced by gadgets.

      • ninguem

        Mengles – Sad how a physical exam is being replaced by gadgets.

        Well……..maybe.

        Makes you wonder if they said the same thing to René Laennec.

  • Mengles

    Exactly. Thank you.

  • http://batman-news.com AT

    most common I would say, obese patients who you can not tell their volume status. dilated non collapsable IVC.
    others:
    1. cholelithiasis/cholecystitis
    2. pulmonary edema
    3. pneumothorax.

  • SteveCaley

    Perfect. I said, “the value of a gizmo is placed by the provider who addresses the question asked.” Perfect use of this device! What I hear is not a very valuable device, but a very valuable physician in knowing what she needs to diagnose a condition. The instrument is an instrument; the value added is by a doctor.

    • Janice Boughton

      The ultrasound is valuable just like getting glasses is valuable when your vision isn’t good. We were never that good at seeing inside a body, but we depended on our flawed physical exam to guide our decisions. With ultrasound we become better at doing what we do because we can see better.

  • ninguem

    Any medical students or residents here?

    Are they teaching ultrasound as a basic diagnostic tool?

    I suspect that will happen, sooner or later.

    It will be like a stethoscope, just different sound frequency.

    • Janice Boughton

      I worked with students where I did my mini-fellowship, at UC Irvine. They start ultrasound in the first part of the first year, as a tool for understanding anatomy and physiology, and continue regular use of ultrasound throughout the 4 years. They are very competent with it by the end of the 2nd year, and not bad by the end of the first year. This is not true in all medical schools, but is increasing. I think they have a similar approach at Oregon Health and Sciences University, also at Columbia, South Carolina.

  • mloren1357

    How often does the portable ultrasound change your impressions based on the initial history and physical exam? Or is it more a confirmation tool?

    • Janice Boughton

      It’s both. I often find myself at a branch of a decision tree, and the ultrasound helps me along. Normal LV or not? Ascites or none? dry or wet? My physical exam skills usually are right, but sometimes are wrong or unhelpful.

  • Janice Boughton

    I find that I discharge patients more quickly based on more diagnostic accuracy and my test ordering is about the same or a little less. Patient satisfaction is much better, and over the course of the 2 years I’ve used it I am confident of several saved lives and lots of saved resources.

  • Janice Boughton

    I always try, and can often see what I need to see, but sometimes it’s useless. Kind of like my physical exam. When there is 20 cm of pannus, I’m not going to be able to detect anything with my exam or my little ultrasound. The depth on the vscan is 16 cm. Surprising how much I can see with that!

  • Janice Boughton

    Patient comes in with renal failure, likely due to volume depletion or ATN, but have to r/o hydronephrosis. Can do! No urine output since the furosemide. Sneak a peak–needs a foley or needs a higher dose? I can know that. Dyspneic. Chest x-ray suggests pleural effusion. Is it atelectasis or a large effusion or just a little one? I know that. I have seen a patient in the ICU where the intensivist ordered a therapeutic thoracentesis based on x-ray and they had close to no pleural effusion. Procedure cancelled, patient saved cost and discomfort. Patient presents with fast A-fib, doesn’t slow much with diltiazem and becomes dyspneic–has unsuspected EF of (I estimate) less than 20%. There is a better drug for him. Tall guy with big belly and h/o hep C. Is it ascites or just a big belly? Physical exam is terrible at that. He gets a therapeutic paracentesis and he has a big belly again near discharge. Does he need to be tapped again? The little machine can tell me that. Overseas it is even more helpful: dyspneic, no x-ray machine. Exam suggests pneumonia. Ultrasound shows moderate pleural effusion, in this population this means likely tuberculosis. Very different management. I think I could go on like this for days. It is surprising how different my practice is with the machine than it was without. I was a very hands on, physical exam doctor, and I still am, but I am more accurate now.

  • Janice Boughton

    I have been combining experience and other imaging and exam to recognize lung pathology. Ultrasound is pretty good for pneumonia, better than chest x-ray for interstitial infiltrates and pulmonary edema. It takes practice. The combination of physical exam, history and ultrasound is powerful and is why it is important to learn this stuff rather than leaving it to the radiologists.

  • Janice Boughton

    Thanks, Dr. B. ER physicians have come further than internists and FP’s in being comfortable with the technology as an extension of physical exam.

  • Janice Boughton

    I just think that we need to be a little bit less entitled with regard to buying our tools and engaging in lifelong learning. Yes it’s all very expensive and time consuming, but we aren’t the only profession that has to do this, and we do make more money than most.

  • buzzkillerjsmith

    This is actually a good idea. I’d like to get up to speed on it.

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