The death of the stethoscope, killed in cold blood by point-of-care ultrasound (POCUS), is trendy as a punchy twitter-bite. Its time to stop eulogizing now and consider the science.
For the last few years, we have been actively teaching medical students how to use point of care cardiac ultrasound and have seen first hand how new doctors take to this technology like fish to water. This generation of med students are shipped with texting thumbs attuned and smartphones implanted. It is only natural that this level of inborn technical savvy disrupts knowledge delivery and the diagnostic method. We fully agree that Laennec’s listening tube is ripe for a modern overhaul and have conducted meticulous study into how point of care ultrasound (POCUS) enhances the physical exam (Cawthorn and Johri).
But during the course of our investigations we have realized that POCUS is more powerful than the stethoscope, and as the saying goes, with this greater power comes greater responsibility. Let’s not jump blindly on the bandwagon. There are definitely cases where too much power in the hands of an inexperienced operator can lead to patient harm. Quality, training, and sober reflection are paramount.
The dirty secret is that negative studies don’t get published by medical journals. No one wants to talk about medical error. We commend the Canadian Journal of Cardiology for giving our study a chance, despite the fact that the majority of POCUS studies in the literature are overwhelmingly positive. An educator that is truly interested in teaching point of care ultrasound to her students must not only profess the advantages but also the LIMITATIONS of the technology.
In our study (Wilkinson and Johri) we were surprised to find an increased rate of confidence in the diagnosis of certain findings by physicians using cardiac POCUS. Of most concern was the increased rate of false positives- or an incorrectly placed increased level of confidence in a finding that was not present.
Very few, if any studies have dared to look at how medical error may be increased when POCUS is applied to the physical exam- this does not fit with the prevailing wisdom that all new shiny toys must be better than what we did before.
I am not a dinosaur or a hold out. I teach cardiac POCUS on a daily basis. But I am also a cardiologist that cares for patients and understands the impact false positives (or negatives) can have on our system of follow up testing and intervention.
We must take POCUS for what it is- not a diagnostic test but a way to enhance the bedside exam. We need to teach it better and not shy away from its limitations. Your patient wants you to do more than a weekend course before you start making critical decisions. 1
That POCUS has changed medicine is old news. Its time to move beyond cheerleading and now ask questions: is the use of POCUS increasing the rate of incorrect diagnosis at my center? Is it leading to more or less follow-up and/or incorrect testing? Who is checking my work? Is there a quality control mechanism at my center? Does my patient understand the limitations of what I am doing?
POCUS is powerful stuff. It needs to be taught within a competency based framework. We are contributing by publishing the POCUS Journal, launching this February 2016. Join us to figure out the best way to teach and maintain quality.
Want more editorialization by Dr. Johri? Read this article: Generation iUltrasound
Want to contribute a POCUS case (any any discipline)? Goto VascNet.com and email us
- Actual feedback from some patients- they may think they have had a full diagnostic echocardiogram, whereas in fact a POCUS exam was performed with limited archiving and continuous quality control practices in place. Where did you document findings?