Trying to Stop a Disruptive Train

Apr 04 2014 Published by under Life of a Physician

My week involved a lot of work with patients as some hemolytic-uremic syndrome came to town. While driving to and fro and using the restroom, I have read some tweets. At one point in a discourse, we talked about "antique" portions of the physical exam.

For example, in medical school they taught us to percuss heart borders. Percussion involves tapping on the chest and listening for the difference between the air-filled lungs and the relatively solid heart as shown in the video:

I cannot remember the last time I percussed a heart. Children do not hold still and quiet for such nonsense, and we get much more information from a chest xray. The latter also provides a lasting objective record of the findings that can be shared with subsequent physicians (or legal professionals). Most of the medical students I queried had no idea what I was talking about.

Many medical schools now incorporate inexpensive portable ultrasound machines into their curriculum. I envy these students who will be able to hear a murmur and figure out what it means on-the-spot. I know several pediatric nephrologists who have trained to perform their own ultrasound exams in the clinic. Unfortunately, its use is not spreading as fast or as far as it should.

Why? Hospital privileges.

When a doctor establishes a practice in a clinical facility, they usually have to be approved by a group at that place to make sure they are competent. I could apply for privileges for many procedures, but then I have to document my proficiency. Generally, they want to know what training you have and how many of the procedure you completed in the past 1-5 years. Imaging studies have fallen under the procedures heading. All those formal ultrasounds in the radiology suite generate lots of income for facilities.

They may not want us doing our own, even when we have the capability to record and store our images for the record.

The nice thing about disruptive technologies is that they are usually hard to stop. Eventually pocket ultrasound may replace even more of those "artisanal" physical exam skills. And that's OK if it makes for better care.

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