Is the physical exam a relic of the past, because our tools are relics of a prior era?
It is important to do and teach a thorough physical exam. I cautioned against the overreliance on diagnostic testing in lieu of a physical exam, which can be initially burdensome and prolonged. But perhaps our difficulty with the physical exam is not the exam itself, but the tools that we have at our disposal to perform an exam, rather than the exam itself.
Let’s talk about the stethoscope
As a child, I often had the image of a doctor that included a long white coat, benevolent smile, black bag filled to the brim with tools, and of course the ubiquitous stethoscope. However, as a doctor now, I find myself less excited about the stethoscope. Often it’s a nuisance that gets caught on bed poles in the ED and wrangles my neck. (It may be useful, however, as Trick of the Trade tip as a tourniquet for the EJ exam.)
Out with the old, in with the new!
The old-school doctor had the stethoscope and all 5 senses (except hopefully taste) to assist with physical exams. The present-day doctor now has something else around the neck, the portable ultrasound! Portable ultrasound has opened up a field of ultrasonography called Point of Care Ultrasound that appeals directly toward the needs of EM. According to NEJM , “point-of-care ultrasonography is defined as ultrasonography brought to the patient and performed by the provider in real time.”
It enhances patient evaluation and examination in almost every organ system, including diagnosis of pneumothorax, cholecystitis, ectopic pregnancies, and extremity fractures. Using an ultrasound to enhance the physical exam in these cases makes the diagnostic process more efficient. Sonography allows the examiner to go beyond the 4 senses (minus taste) and perform a useful exam.
Even medical schools agree!
Medical schools have also recognized the importance of ultrasound and have integrated it into traditional curriculum. Just as there were physical exam courses, there are now ultrasound courses to teach students how to perform exams. Dr. Laleh Gharahbaghian (@SonoSpot) just conducted a successful course for medical students in northern California on point of care ultrasound.
Now what?
The question now remains, if ultrasound is so great, is there ANY use for the stethoscope? Can we throw away the stethoscope and only use the ultrasound for patient examinations?
My first thought is that we are comparing apples to oranges. I feel that ultrasound does not simply replace the stethoscope. It blows ultrasound out of the water! We can do a more thorough exam with ultrasound than we could ever do with the stethoscope. So it isn’t a fair comparison. That being said, there are pros and cons to consider.
Pros and cons of ultrasound use
| PRO | CON | ||||
| Repeatable | Costly | ||||
| Shareable | Operative dependent | ||||
| Portable | Interpreter dependent |
The future
It is time to recycle your stethoscope, or am I being too premature?
My fiance works for Siemens ultrasound and used to work for GE ultrasound
- Iverson K, Haritos D, Thomas R, Kannikeswaran N. The effect of bedside ultrasound on diagnosis and management of soft tissue infections in a pediatric ED. Am J Emerg Med 2011. PMID 22100468
- Summers SM, Scruggs W, Menchine MD, et al. A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis. Ann Emerg Med 2010; 56:114-22. PMID 20138397
- Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med 2010;17:11-7. PMID 20078434
- Stein JC, Wang R, Adler N, Boscardin J, Jacoby VL, Won G, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Ann Emerg Med 2010;56:674-83. PMID 20828874
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