Shari Welch, MDI was one of the first "guys" in my group to learn and become certified to use bedside ultrasound in my department. As a night warrior I envisioned the possibility of getting imaging answers at 2 am where there was no opportunity to do so with my radiology department. The little sonosite was telling me stories at 2 am that were important: The pregnancy is in the uterus, the aorta has a normal diameter, the gallbladder has stones, there is no free fluid in Morrison's pouch. The questions I asked of ultrasound were one sentence long and the answers were monosyllabic. I thought of the sonosite as another tool to aid me in physical diagnosis, much like the stethoscope. In most instances I planned for a definitive formal ultrasound study later and I had no fantasy that billing for bedside ultrasound would make me a rich woman. My ED group's bedside ultrasound utilization coexisted peacefully alongside the ultrasound department and the radiologists.
Fast forward a decade and it is hard to recognize where we are. ACEP's Emergency Ultrasound Section has developed guidelines for performing and documenting ED ultrasounds that are quite exhaustive. These reports should include the indications for the ultrasound, the positioning of the patient, the views used, measurements like common bile duct thickness and a "qualitative assessment of the wall and pericholecystic regions". The documentation for these bedside exams is now often as long as the chart for the ED visit itself and we find we are also responsible for the storing of images. Many groups continue to invest more money and time in the equipment and software to do this. They also need equipment maintenance which is more involved with the complicated new generation machines, and ongoing quality control and improvements which require more documentation still. To date the majority of ED's do not bill for ED ultrasound and relations with Radiologists are less than friendly over the issue. Where is the return on this investment?
For those committed and enthusiastic about bedside ultrasound including Dr. Mallon, I have three more questions:
First, is the emergency physician ever as good at this as the ultrasonographer and radiologist that do it all day? We may want to think of obstetricians doing their own ultrasounds in the office and billing for them as our model. But those physicians are doing one type of study over and over and eventually they do develop an expertise. When emergency medicine residency trained docs are allowed to be honest, they often express a lack of confidence in their skills and do not want their study to be the definitive study. Personally and ten years into it, the "chocolate chip cookie" ovaries are still confusing geography to me. As with fiberoptic laryngoscopy, are we doing enough of these various and infrequently performed studies to be clever and completely competent? In academic settings certain faculty are dedicated to achieving, teaching and maintaining this skill set, but is that a viable plan for most practitioners in busy general practices?
Second, what are the liability implications for us if we perform, document, store the images and bill for these studies? If an emergency physician performs a first trimester ultrasound is he in it for the game with this pregnant patient? What if in his travels with the ultrasound probe he misses abnormalities of the pancreas or liver that are consequential? Where does the liability of the ED physician begin and end?
The Third question is the most critical: In terms of patient flow and work flow, is this the right thing to do? Is there data to demonstrate that an ED practitioner is in fact better off performing, documenting, storing and billing for an ultrasound, as opposed to seeing the next patient? Does the bedside ultrasound process in its current iteration improve efficiency and flow or impede it? Emergency medicine is a zero sum game. A physician engrossed in ultrasound processes is not seeing and evaluating a new patient, reviewing other patients' data, writing prescriptions, talking to consultants and families and he is not performing the myriad other tasks that require his attention.
I believe emergency medicine has misstepped in this regard. I envisioned that smart little sonosite eventually living in my pocket. I would carry it with me and use it to do procedures and answer those one sentence questions with mono-syllabic answers at 2 am. I would use it to diagnose fractures and abscesses and blood clots. Like Xray-vision- in- a -pocket, it would make me a better clinician. I never wanted to store images or generate bills. I never wanted to measure the common bile duct. I never wanted to be an Ultrasound Tech!
Wednesday, October 28, 2009
Reader Comments (3)
Thanks, Shari - I'm with you there!
You are right - ED ultrasound should be used much like a stethoscope - an extension of the physical examination that allows us to formulate a diagnosis and management plan. Our skill is cognitive - we are not an investigative specialty.
My most fulfilling use of ultrasound is in showing a moving foetus to a relieved pregnant woman. If she has pain and bleeding in the first trimester, this is all she wants to see - then I let her go on her way to get a formal one. I always tell her that I can't tell the gender or size or whether there is any abnormality - all of the women have been happy enough to see a live foetus.
My ultrasound colleagues are very supportive of our practice - we aren't trying to compete with them.
I guess the best way to think about it is to consider how we feel when our own skills as doctors or as EPs are discounted. Could you do my job with a few weeks' training and a certificate? To me, it comes down to this - if you want to do the job, do the (full) training.
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