Ultrasound-assisted physical examination

To the editor:

I read with some perplexity the article by Siepel and colleagues¹ in the July 2000 issue of JFP. They may have proved their hypothesis that “blending real time diagnostic ultrasound into the physical examination performed by the primary care physician can increase its diagnostic yield with little additional cost.” But the real question is: What difference do any of these findings make in the treatment of the patient?

Of the 72 patients who completed the study and the 27 abnormalities that were discovered, it appears that only 3 of them had an asymptomatic abnormality for which something could be done (urinary retention). None of the other asymptomatic abnormalities required treatment.

It appears to me that performing an ultrasound-assisted physical examination on an otherwise healthy elderly person with no complaints will simply result in more anxiety on the part of the patients and their families, increased risk to the patient with further diagnostic studies that might be required, overall increased cost to the medical care system, and increased perception on the part of the general public that there are all sorts of technological studies that can be done to them when they are feeling well that can detect disease that will need treatment.

It is ironic that in the same issue that this article appears there are 2 brief reports in the Patient-Oriented Evidence that Matters section showing that treatment of carotid stenosis in an asymptomatic patient² and echocardiography to detect left ventricular systolic dysfunction in a patient with a normal electrocardiogram³ are of no value to the patient.

Until a study is performed that shows screening for a particular disease with ultrasound in an asymptomatic patient will yield a diagnosis that can be treated to extend the life of the patient or limit the morbidity of the patient, simply showing that routine ultrasound will yield physical abnormalities seems of little value.

Benjamin N. Friedell, MD
Oneonta Family Practice
New York

REFERENCES

• T, Clifford DS, James PA, Cowan TM. The ultrasound-assisted physical examination in the periodic health evaluation of the elderly. J Fam Pract 2000; 49:628-32.
• J. Does cartoid endarterectomy benefit patients with carotid stenosis but no symptoms? J Fam Pract 2000; 49:600-655.
• CR. Can we reduce the use of echocardiography by using other clinical information to identify patients at very low risk for left ventricular systolic dysfunction? J Fam Pract 2000; 49:655-56.

The preceding letter was referred to Drs Seipel and James who responded as follows:

We thank Dr Friedell for allowing us to emphasize several key points regarding our study. We agree with his observation that the thrust of our article, which investigates an application of ultrasonography in health screening, seems counter to what is often published by our specialty today. Although advanced technology may all too often come between the physician and the patient, it is our contention that this application by the primary care physician in the context of the physical examination (PE) may strengthen the bond between the physician and the patient.

Our first question was whether the ultrasound-assisted physical examination (USA-PE) could improve on the conventional PE in the sense that it more accurately represents the condition of the patient, which is what examinations are supposed to do. Our findings in this small limited descriptive study suggest the USA-PE can indeed find out much more about the patient than the traditional PE.

Second, we hoped to explore in our limited way if the USA-PE could improve outcomes for the population tested. This hypothesis (and Dr Friedell’s concern) is indeed much harder to prove, and we have made no claims to do so. A small group of patients with serious diseases who received prompt treatment with recognized indications appeared to have benefited. There was no likely benefit for the largest group of patients with abnormalities detected who had only incidental findings, such as renal cysts. For the intermediate group with conditions such as 4-cm aortic aneurysms, subcritical carotid artery stenoses, cardiac valvular stenoses, and thyroid nodules, it is difficult to say whether a benefit exists. There may be a benefit to knowing about such things, if such knowledge results in appropriate physician surveillance or patients’ lifestyle changes. We can only speculate, but we feel that it is important for primary care physicians to be raising these questions.

In regard to Dr Friedell’s concerns about patient anxieties that might be raised by the USA-PE, we can only quote an earlier study by our group¹ that appeared to show the opposite effect. In fact, 66% of the patients believed that ultrasound should be part of a routine PE. In conclusion, we feel that USA-PE is a mechanism for us to become more fully informed about our patients.