Forget ultrasound: Do a proper history and physical instead


A recent editorial in the New England Journal of Medicine lauded, albeit cautiously, point-of-care ultrasound that has risen to such an extent that it is now becoming an integral part of medical education.

Could the availability of ultrasound revolutionize clinical medicine in much the same way Laennec’s stethoscope broke the acoustic barrier?

Certainly this possibility can’t be ruled out. But I am not so sanguine. One thing I’m sure about: Indiscriminate use of ultrasound at the bedside will increase the utilization of imaging.

Ultrasound is tough. I’m not saying this as a protectionist radiologist (I don’t particularly like ultrasound), but as a radiologist who has read lots of CT scans and MRIs for what is supposedly found on ultrasound. Nearly always these findings turn out to be giant balls of “nothingoma.”

Ultrasound images look like a satellite picture of a snow blizzard in action. If you stare at them for long enough you’ll imagine all sorts of things and, much like what the boggart does to Harry Potter, these blizzards reveal the diagnosis you fear most.

I recall my training in ultrasound. For the first few weeks I saw nothing. And then I saw only pathology. Well what I thought was pathology. Until I realized there’s a fine line (or acoustic interface, if you wish to be clever) between normality and pathology. It’s a strange fact of ultrasound that appreciation of normality and its undulating and inconstant form takes longer than appreciation of frank pathology. An experienced operator is one who can boldly say “normal”.

But even seasoned operators overcall. Often I read confirmatory imaging for diagnoses raised on echocardiogram (ultrasound of the heart). These are not for trivial allegations. They include entities such as aortic dissection and cardiac mass.

In fact there’s a joke, based on a truism. What’s the most common finding in cardiac MRI done for mass? The echocardiographer’s acoustic shadow (imagination).

The thought of medical students, interns and residents flashing high frequency ultrasound probes towards the liver, aorta and pancreas in all and sundry is, quite frankly, scary. This is not because they’ll miss pathology but because they’ll find pathology where none exists. And in bulk.

And when they do they’ll have to pursue the finding. Meaning you can’t say “this might be a liver abscess, but never mind I’ll come back to it another day.” Once documented in the mind this means a confirmatory CT scan or MRI. These confirmatory scans are delightfully easy to read because they’re almost always normal and one knows a priori that they’ll likely be normal.

Look, I’m not saying that ultrasound should only be performed by experts. To be honest, anyone can become proficient in ultrasound with 3 months of practice and after having read a couple of books. Even if radiologists went around the floor scanning every patient there’d be a queue for “confirmatory” CT for liver abscess or renal cancer.

I’m saying that this innocuous instrument that boasts “trust me, I disperse no radiation” or “trust me I don’t operate at nearly thirty thousand times the earth’s magnetic field” is deceptively dangerous. Because it’s seductively innocent but can be dangerously imprecise. It sets up perfect grounds for creating Victims of Medical Imaging Technology (VOMIT), who end up having radiation nonetheless.

We’re constantly searching for innovation and disruption in healthcare in general and medical education in particular. It’s understandable to laud novelty and disdain orthodoxy. It’s, therefore, with hesitancy I propose another disruptive technology. It’s cheap and effective. The only problem is it’s been around for some time. It’s not novel. It’s an ancient art. It’s called the “history and physical examination.”

Teach medical students to perform a physical examination. Teach them about Rovsing’s sign, guarding and rigidity. Teach them to palpate pulses. Teach them to ask about history of presenting complaint. Teach them the importance of questions such as “why did you decide to come to the emergency department at midnight on Saturday when you’ve had this pain for three months,” over the robotic recital of review of systems. Teach them to organize their thoughts coherently so that they don’t sound like the audio version of Robbins Basic Pathology, but through their exposition shines insight and strategy.

These skills seem not as exciting as putting in a central line or making sense of acoustic blizzards. But they’re important if done right. They’re consequential when done wrong.

You’re probably wondering what moral basis is there for a radiologist to make this plea. So removed from the patient. So engrossed in technology. I’m not even a “proper” doctor.

You’re right.

Yet I beg: Please perform a decent history and physical. Because when this ancient art is not done right by “proper” doctors, I’m the one left to clear the debris. This costs the tax payer. This hurts your patient.

So forget ultrasound. Focus on a decent history and physical.

Saurabh Jha is a radiologist and can be reached on Twitter @RogueRad


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