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by the American Institute of Ultrasound in Medicine J Ultrasound Med 22:323-325 • 0278-4297
Is It Time for the Sonoscope? If So, Then Let’s Do It Right!Department of Radiology, University of California, San Francisco, San Francisco, California USA I read with interest the editorial by Lennard Greenbaum, MD.1 I have known Dr Greenbaum for many years and value his judgment and devotion to our subspecialty. He believes the time has come for handheld sonographic systems to become the next "scope" used during physical examination. Indeed, for many years now, a number of physicians have referred to sonography as "the stethoscope of the future." In 1988 I wrote an editorial entitled "Ultrasound: The Stethoscope of the Future, Alas."2 I thought that the proper description for this future course of action was the word alas, because I was predicting that if this were to happen, then sonography would meet the same fate as the stethoscope. The following is taken from my original editorial2: Although the stethoscope is one of the most widely employed diagnostic instruments, it is also one of the most poorly used. When I was a medical student, I was profoundly impressed with what could be diagnosed with this simple tool. A professor of cardiology who was one of my teachers—who, incidentally, was somewhat hearing impaired—would, as is customary, examine the patients on service after everyone else had had his or her chance. He would then elaborate on his findings to both our delight and our consternation. We had all used a similar instrument on the identical patient, but the difference in benefit to the patient from his examination compared with ours could not be measured. As I walk about the hospital, I see stethoscopes jauntily draped over the shoulders or hung around the necks of just about everyone: nurses, therapists, medical students, interns, etc. This instrument has become more a badge of dignity than a diagnostic tool. I’m sure the patients don’t know that the bulk of these medical artisans haven’t an inkling as to the power of the tool they so casually display. There probably are some physicians around who still realize what can be diagnosed with a stethoscope, but I would guess that they are few, and they must be dismayed at what they see around them. I can only presume that they would feel sorry for my children—the only humans on whom I still employ my auscultatory skills. What has changed since I wrote my editorial nearly 15 years ago is that "handheld" sonographic devices have become available and at a substantially lower cost than even the prevailing system cost in 1988. Nonetheless, these small sonographic devices, although only a fraction of the cost of more sophisticated current sonographic systems, are still a lot more expensive than a stethoscope. The devices currently range in cost from approximately $15,000 to $50,000. If we were to assume an average unit cost of $20,000 and that each year we graduate approximately 16,000 medical students in the United States,3 then an average additional cost of $320 million per year would be added to the bill for US medical care. If we assume an average life expectancy for a sonographic system of 7 years and started today, then the cost for the first decade of this program would be $4.2 billion. That does not include service contracts, broken transducers, and damage from dropping these systems on the floor. If conservative service contract fees that would cover damage to systems and transducers were applied, this would add a tidy additional $32 million to the annual total, bringing the first decade total to $4.5 billion. (These computations assume that all clinicians would have personal "sonoscopes," just as they have personal stethoscopes. Shared equipment would alter the equation.) Is it reasonable to assume that such a cost can be amortized by adding a small fee to the charges for a physical examination? I would doubt it. Among the recommendations of Dr Greenbaum’s proposal that I applaud is the need to start the educational process with medical students and to have a specific curriculum. It is also crucial that the use of sonography in this setting should not be a separate billable event. Equally important is his recommendation that suspected findings be confirmed by imaging physicians. The problems of sonography’s past have arisen because there were no training requirements for performing sonography. Thus, a practitioner with few skills could purchase a low-cost ultrasound instrument and begin conducting examinations on unwitting patients, then issuing a bill for each application of the transducer. This situation is still rampant today and growing, as far as I can see. The latest groups to pursue this route are emergency department physicians and thyroidologists. Of course, it is somewhat unfair to single out these 2 newest groups when they are simply standing at the end of a long line of individuals who did exactly the same thing. As long as these past problems exist unchecked, Dr Greenbaum’s proposal may simply add fuel to the fire. I would think that we should clean up the old mess before we dip our toe into the next potential mess. This week at our obstetric and gynecologic ultrasound teaching conference, the obstetricians were horrified to learn that emergency department physicians would be looking for ectopic pregnancies with their new ultrasound machine and that Obstetrics and Gynecology would not be consulted until afterward (and probably would not be consulted at all in cases with "negative" findings). I decided not to tell them how, a dozen or so years ago, I was horrified to learn that they would be doing sonography on patients suspected of having ectopic pregnancies (I, like Dr Greenbaum, am a radiologist, if you didn’t know). The bottom line, as I see it, is that the degree of clinician experience and training in sonography is getting worse, not better. Predicting the downstream effect of Dr Greenbaum’s proposal is extraordinarily difficult. Personally, I find it hard to imagine that detecting the "edge of the liver" is a practical application of this powerful and expensive tool. I also find it difficult to imagine that the frequency with which primary care physicians are confronted with patients who have a "pulsatile abdominal mass" indicates a need for a massive expenditure of medical dollars to solve the problem. However, I do know that if they start investigating the gallbladder in a patient with right upper quadrant pain, they are performing the same "sonographic imaging procedure" that I perform. Therein lies the problem: I cannot believe that a clinician with this tool in hand will not overstep the boundaries that Dr Greenbaum is so carefully trying to set. Also, I have a difficult time envisioning this sonographic physical examination. Will the doctor look at the heart instead of ausculting it, image the thyroid instead of palpating it, look for carotid plaques sonographically instead of listening for bruits, and image the abdomen and pelvis instead of palpating for peritoneal signs and masses and listening to the bowel sounds? Will it be necessary for every patient to report for a physical examination after fasting so that the gallbladder can be more clearly seen sonographically? Will each patient need to have a full bladder for the pelvic portion of the examination, or do we propose an endovaginal sonographic examination on every female patient or a transrectal prostatic sonographic examination on every male patient to replace the bimanual pelvic and digital rectal examinations? If any of the above is the intention, then the price will escalate dramatically, because an additional 3 or 4 transducers will be required to complete the "physical" examination. Finally, how do modern clinicians fit this into the 15 minutes currently allotted to obtain a history, examine the patient, develop a plan, and make a disposition? If we look to sonography’s past, we can only view such a future with great trepidation. Is it time for the sonoscope? I really don’t know, but I truly doubt it. However, if the sonoscope’s time has come, then let’s do it right for a change. A well-thought-out study should be conducted at 1 or more major medical schools that would prospectively compare matched groups of students. One group would go through the current standard training in physical examination, and the other would go through a program designed to teach the use of the sonoscope. The 2 groups could then be compared with respect to the time required to complete an examination of a patient, what additional findings were disclosed, and whether this resulted in a change in patient disposition or, more importantly, in outcome. Finally, the study would need to determine whether the new tool generated a greater need for examinations subsequently performed by diagnostic imaging specialists and, if so, what the fiscal impact was for the added examinations. If it is our will to develop the concept of the sonoscope, let’s make our best effort to ensure that it does not meet the fate of the stethoscope. References
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