Ok, get ready for another rant….. I know, I just keep ‘em comin’, but this needs to be discussed. I know you’ve heard it before: “Ultrasound is an extension of the physical exam.” I heard it before too – when I was first learning it, when someone was trying to explain it’s use in patient care. But, the fact of the matter is, it’s so much more. Just because it’s in the bedside clinicians’ hands, and not a radiologists hands, doesn’t mean it’s not an equally important diagnostic tool. More than that, its a tool used when procedures are performed that has proven to minimize complications and thus affecting patient safety. It answers the questions that even the best and most complete physical exam (which is unfortunately hardly ever done) cannot.
ACEP 2012 in Denver, CO was amazing…. and I still plan to post all that I learned from that conference, but one of the statements that were said in the Emergency US management course that is so clear to me yet seems to be hard to grasp by others is that “Ultrasound is NOT an extension of the physical exam, so stop saying it is. It answers clinical questions.” - Now, when I heard from my friend who attended the course that this was said, I knew it already, and it makes complete sense to me, but, interestingly, it appeared that those conducting the course felt it important enough to state it clearly and concisely – as they heard this statement spreading, needing clarification. It was apparently spoken about by basically every leader in bedside ultrasound before, during, and after the course.
Ok, let’s talk about this. The physical exam is an evaluation of the patient; a use of ultrasound is to evaluate the patient – there is a difference. A physician will perform their history and physical exam, then think of what is needed for diagnosis, work up, management, and treatment. Sometimes, but not all the time, that involves bedside ultrasound (just like any other imaging modality that is chosen to be ordered to work up a patient, except it will be a focused study). Ultrasound CAN extend the physical exam, but Ultrasound is a diagnostic tool; Ultrasound is used for procedural guidance; Ultrasound is an expensive machine that is used as a procedure in overcoming physical exam limitations (like a chest XRay done to evaluate whether the crackles you hear on your physical exam is pneumonia or an effusion). It does answer clinical questions. Why this matters, and why am I going on this rant? Well, one reason is that the statement “ultrasound is an extension of the physical exam” is a simple statement that gets a lot of attention but it’s not complete, and some would argue that it’s just plain wrong, for the reasons stated above, but allow me to explain further. It is true that soon after the physical exam, a bedside ultrasound can be performed after an indication presents itself, but just because it’s temporally related or performed by the same physician who does the history and physical exam, doesn’t mean it’s an extension of it. It’s a focused study to answer a clinical question, answers that cannot be obtained by the physical exam (instead of the chest Xray, using ultrasound to differentiate pneumonia from effusion). Is an IV line or lab test an extension of the physical exam (which is sometimes performed at the same time as the history and physical, and sometimes by the physician when the nurse or phlebotomist is unavailable or the nurse is unable to get the IV)? Is an echo done by a cardiologist right after they performed a history and physical exam an extension of their physical exam? Is an ultrasound performed to evaluate the fetus of a pregnant mother by the same OBGYN doctor who just performed the physical exam an extension of the physical exam? Is a CT scan an extension of the physical exam (which can be ordered right after the physical exam)? No. Another important reason is that if it was considered by us physicians simply as an extension of the physical exam, then the risk of eliminating reimbursement from insurance companies for performing this procedure, this important diagnostic and procedural tool, exists. If the physician is using it as an extension of the physical exam, you cannot bill for it because it is an extension of the Evaluation and Management (E/M) examination. If a physican is using it for an accepted medical necessity for diagnostic or procedural purposes with appropriate documentation and image archiving abilities (which I would argue is the way we should be using it), then we can bill for it (however small that charge actually is, but let’s not go there), giving us the funds to purchase more machines and hire more ultrasound-savvy physicians to teach others who will then use this tool to ultimately save a life…..
I do get why some people say it to others: it sounds good, minimizes the fear of learning it, makes it sound easy, and is encouraging to others to believe in its utility. The intent is good. But, it’s just not enough – it’s not an extension of the physical exam, but it is an amazing imaging tool that diagnoses, helps manage, and minimizes complications of procedures of patients.
Ultrasound does not, and should not, replace the physical exam. “There is a natural synergy between the physical exam and the ultrasound machine. They should not be enemies, but instead should be allies. It can extend your evaluation of the patient, and add to your physical exam. But, it is also a diagnostic tool that is equivalent to a standard ultrasound. When it only was used for a few applications, it was thought to be an extension of the physical exam, but now with all that we know about it, it’s not simply an extension of the physical exam, it is much more.” – Dr. Michael Blaivas to the World Congress of Ultrasound in Medical Education.