Unless you’re a dermatologist, it is hard to see disease that is more than skin deep. This amazing organ system that protects us from so much, also conceals a great degree of pathology that lies beneath the surface. Though there is a long tradition in medicine of searching for subtle clues that point to the patient's condition, as medical providers we need something that will help peel back the cutaneous layer and reveal the complexity of disease underneath.
Enter radiology. The last century has seen great improvements in the ability to see and understand the inner workings of the human body. The quest to understand anatomy and its relation to disease that began with Galen continues today. Unlike then, we no have the ability to image down to the microscopic level. And this capacity has significantly improved the specificity the care that we can provide for patients.
However, this is a double edge sword. Every imaging study that we use and test that we order takes us that much further away from the patient’s bedside. It is the ability to sit at the bedside, touch the patient, synthesize the findings into a unifying diagnosis all in the context of a therapeutic relationship that is the heart and soul of what it means to be a doctor. And unfortunately, as we fill the exam room with pagers, computers, mandatory metrics, and tests that are performed or analyzed in a remote suite, we lose a little part of that patient-physician connection.
Few would argue that we should return to some former era of healthcare for the sake of medial nostalgia. It is amazing what we can discover, treat, and cure with the labs, imaging and genomics that have come to characterize modern medicine. But how can we maintain this diagnostic specificity and the patient interaction? How can we retain a detailed, real time understanding of what’s happening to our patients while at the same time maintaining or even improving the human connection?
Sonography as a technology has been around for a long time. But ultrasound as a diagnostic tool in medicine was first used in 1942 by a Neurologist named Karl Dussik to assess for brain tumors. Ultrasound began to be used for echocardiography in the 1950’s and OB adopted ultrasound in the 1960’s. In the late 1980’s, a French intensivist began using ultrasound to assess patients in the ICU. Over the last several decades, ultrasound has emerged from the ECHO, OB and radiology suites and has been brought to the bedside in the form of Point-of-care Ultrasound (POCUS).
POCUS (as compared with sonography performed by cardiology, OB or radiology) is fundamentally provider performed and provider interpreted ultrasound at the bedside. The specialist interpretation of an image is exchanged for a comprehensive understanding of the patient's presentation and an ability to interpret the images produced in the context of that clinical presentation. It is the ultimate expression of "Correlate clinically" where the image production, interpretation and correlation happen simultaneously.
Many critics suggest that imaging is too complex to be interpreted by bedside clinicians or that detail is lost when not performed in the hands of an imaging specialist. Much research has shown that a focused assessment of various organ systems and disease states with POCUS in the hands of bedside providers can reach sensitivities and specificities of other forms of imaging. But what is missed by the critics is a realization that POCUS is not designed to supplant conventional imaging. Rather POCUS functions to color the patient's presentation with greater clarity and with more vivid hues.
As we think about modern healthcare, it is amazing to realize the things that we can now do compared with a short 50-100 years ago. But just as every disruptive technology challenges the status quo and forces us to adapt, the marvels of today's diagnostic and documenting tools have challenged the very nature of what it means to be a physician. This begs the earlier question: how do we balance advanced diagnostics with the need to maintain the fundamental connection created by the history and exam? I believe the answer begins with bedside ultrasound.
Comments