Why physicians will use mobile ultrasound instead of stethoscopes in the future

Recently, the Wall Street Journal did a great piece on how mobile technology is being used in medicine. They looked at the major avenues of use — from the hospital to personal to emergency care settings.

They gave an example of how a cardiologist has stopped carrying a stethoscope, and now just uses mobile ultrasound, a modality we have highlighted numerous times in the past.

Dr. Topol, a cardiologist in San Diego, carries with him instead a portable ultrasound device roughly the size of a cellphone. When he puts it to a patient’s chest, the device allows him to peer directly into the heart. The patient looks, too; together, they check out the muscle, the valves, the rhythm, the blood flow.

“Why would I listen to ‘lub dub’ when I can see everything?” Dr. Topol says.

As mentioned in our article on mobile ultrasound, research continues to show how the modality can be used to improve outcomes, such as with central line procedures.

With the continued improvements in ultrasound mobility, will physicians be required to become more proficient in the modality?

I would argue yes. For cardiac sounds, it will replace the stethoscope in the future, and it will eventually become a part of medical school curriculums once pricing goes down — right now the price point is $8,000.  The value added by ultrasound is tremendous.  The ability to look at not only cardiac pathology, but abdominal, eye, venous, arterial, and more.

Would a cardiologist be able to use a mobile ultrasound tool better than a primary care physician to look for cardiac abnormalities? Of course, but thats the case with a stethoscope as well.  Most physicians today are proficient with a stethoscope — not masters — and the same paradigm could be applied to a mobile ultrasound tool.

Furthermore, since ultrasound uses sound waves, and not radiation, more physicians proficient in ultrasound could lead to less x-rays or CT scans.  Recent data on cumulative doses of patient radiation exposure highlights the need for ultrasound use when possible.

Although you can use ultrasound to look at pulmonary pathology, such as a pneumothorax — sound still plays a key role.  Hearing the interval improvements in a patient’s expiratory or inspiratory wheezing is essential when treating a patient with acute exacerbation of COPD.

While there are cases the stethoscope would be useful, especially in regards to certain pulmonary sounds, it’s not outlandish to think mobile ultrasound could be the essential tool physicians carry around, while the stethoscope becomes relegated to PRN use.

We’d love to hear what you think in our comments section, whether you agree or disagree.

Author:

Iltifat Husain, MD

Founder, Editor-in-Chief of iMedicalApps.com. Emergency Medicine Faculty and Director of Mobile App curriculum at Wake Forest School of Medicine.

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18 Responses to Why physicians will use mobile ultrasound instead of stethoscopes in the future

  1. MedGadget Dan May 5, 2011 at 8:06 am #

    I’d agree, I’ve been evaluating the GE and Siemens palm-sized devices for a bit (I like the Siemens much more because GE seems to be intentionally crippling their capabilities in order to not cannibalize their laptop-based ultrasound market) and think the current generation could already be used in place of the stethoscope for cardiac and abdominal exams. I’d like to see battery life go up and price point go down however, but they aren’t deal breakers. I think the pulmonary exam could be a somewhat trivial fix as well, the ultrasound probe already acts as a microphone for the sound waves it produces. I can envision a “listen only” setting that only transmits the low frequency noises to an audio jack on the device.

    • Iltifat Husain May 5, 2011 at 9:20 am #

      The GE and Siemens comparison is really interesting. One would think
      as everything is going mobile that GE would be smarter.

      Using the ultrasound probe as a microphone would make so much sense –
      then you really would have no use for a stethoscope.

      Really interesting points Dan, thanks for sharing!

  2. MedGadget Dan May 5, 2011 at 9:45 am #

    If I were to guess I think that the difference between the GE and Siemens strategies has to do with the fact that GE has several laptop-based systems it sells and Siemens has none. While Siemens can try to capture any and all mobile market-share with the P10, it might be that the VScan group at GE has to avoid stepping on the toes of their laptop system colleagues.
    Either way, since ultrasound is a relatively cheap medical imaging technology to produce and utilize (compared to other medical imaging tech) I think in the next few years we will see products from smaller companies that don’t need to concern themselves with internal competition.

    • Iltifat Husain May 5, 2011 at 9:50 am #

      Yea — I’m assuming one of those small companies you are referring to
      is Mobisante, with their smartphone connected ultrasound peripheral?

      • MedGadget Dan May 5, 2011 at 10:41 am #

        Yep, they are one. Other than FDA approval barriers to entry are pretty low for medical as I’m pretty sure you can buy the components for the probes and signal drivers pretty reasonably priced from a few suppliers in China. So the difference will be in interface and software until a development like the printable probes mentioned in this recent (small plug) MedGadget story (http://bit.ly/jhx5Om) changes the game again. Exciting times.

  3. Miguel Silva May 5, 2011 at 12:23 pm #

    Having the title of this story in mind, “Why physicians will use mobile ultrasound instead of stethoscopes in the future”, I wouldn’t say “instead of”, but “along with”. It’s an overstatement considering the limitations of ultrasound in the diagnosis of several respiratory and some cardiac conditions, the yet still high price of the equipment at the moment and for the forseeable future (I doubt that the price of mobile ultrasounds will drop to as low as the price of a stethoscope in the next 10 years). Also, let’s not forget the costly effort, both in terms of time and resources to train every medical student to proficiently use an ultrasound. It takes time and experience.

    • Iltifat Husain May 6, 2011 at 5:42 am #

      Great points — I would say that the costs are reducing at a significant scale, even within the last few years. Dan’s above comments also tell of how and why costs will continue to decease significantly.

      In terms of training medical students, one of our below commenters explains how UC-Irvine has already started training their students with ultrasound. They were one of the first medical schools to go to a mobile medical curriculum too, and give all their students iPads. So it’s already being done

  4. Picudoc May 5, 2011 at 2:41 pm #

    I currently take care of ultrasound education in a busy pediatric ICU. As great as it is for giving docs a fundamental understanding of patient physiology, I would lean towards Miguel’s argument that the technologies are complementary.

    One reason is outright cost. We’ve shaved the cost of rubber tubing, a diaphragm, and earpieces to a few dollars. It is hard to imagine the cost of ultrasound use and maintenance can ever prove more economical. It would be a hard sell in austere environs where electricity may not be reliable. For those of us who don’t have to worry about that, with antibiotic resistance rampant the disposable stethoscope is key as well.

    The cardiologist’s argument in the article that US is a more direct route to a diagnosis is sound, since a lot of the cardiologist’s PE is targeted at anatomy and function. There are a lot of small, obese, or anatomically difficult patients however where echo frequently fails us only for the fact that US can’t see through air or bone (except for some head windows). I’ll probably be more able to auscultate those patients. Iltifat, your point about the COPD wheeze is germane as the US will also not meaningfully help me detect bowel sounds, or distinguish asthma from pneumonia, which I see a lot more than US dependent dx like pleural effusion or diaphragm paralysis. Bringing the sensitivity of the transducer into the audible range may help address this, but compared to the cheap coat of stethoscopes is this reasonable?

    That said, a friend of mine practicing in Germany told me she had to perform 600 US studies to attain her certification in general pediatrics. She routinely uses it to complement her practice treating shock and managing ventilators, etc. I agree there is a case for most in clinical practice knowing how to use it, despite the grumblings of some cardiologists. Like a lot of things in medicine though, my opinion is that the stethoscope will not be replaced by it.

  5. Picudoc May 5, 2011 at 2:41 pm #

    I currently take care of ultrasound education in a busy pediatric ICU. As great as it is for giving docs a fundamental understanding of patient physiology, I would lean towards Miguel’s argument that the technologies are complementary.

    One reason is outright cost. We’ve shaved the cost of rubber tubing, a diaphragm, and earpieces to a few dollars. It is hard to imagine the cost of ultrasound use and maintenance can ever prove more economical. It would be a hard sell in austere environs where electricity may not be reliable. For those of us who don’t have to worry about that, with antibiotic resistance rampant the disposable stethoscope is key as well.

    The cardiologist’s argument in the article that US is a more direct route to a diagnosis is sound, since a lot of the cardiologist’s PE is targeted at anatomy and function. There are a lot of small, obese, or anatomically difficult patients however where echo frequently fails us only for the fact that US can’t see through air or bone (except for some head windows). I’ll probably be more able to auscultate those patients. Iltifat, your point about the COPD wheeze is germane as the US will also not meaningfully help me detect bowel sounds, or distinguish asthma from pneumonia, which I see a lot more than US dependent dx like pleural effusion or diaphragm paralysis. Bringing the sensitivity of the transducer into the audible range may help address this, but compared to the cheap coat of stethoscopes is this reasonable?

    That said, a friend of mine practicing in Germany told me she had to perform 600 US studies to attain her certification in general pediatrics. She routinely uses it to complement her practice treating shock and managing ventilators, etc. I agree there is a case for most in clinical practice knowing how to use it, despite the grumblings of some cardiologists. Like a lot of things in medicine though, my opinion is that the stethoscope will not be replaced by it.

    • MedGadget Dan May 5, 2011 at 3:08 pm #

      I’m working on a more comprehensive response over at MedGadget, but I’ll respond to a couple of points you make. I’d argue that ultrasound can already “see” all of the things you mention, half of an ultrasound probe’s function is just a quantitative microphone. The reason these features don’t show up in the B-mode image is that the processing algorithms assume the tissue is the density of water, which bone and air are not, and so calculate reflection times based on that assumption. However, the data is already in the signal, just not processed correctly. This implies a software solution, which is much cheaper than hardware one.

      As for cost, ultrasound tech will follow Moore’s Law; what are the capabilities of the laptop portable’s compared to the cart sized machines of 15 years ago? I don’t think they will be as cheap as a disposable stethoscope, but probably will be as cheap as some of the other things considered “disposable” in an OR or ICU.

      • MedGadget Dan May 5, 2011 at 4:23 pm #

        Reading back over what I wrote I might come off a little too evangelical for ultrasound, which I am not trying to be. I agree with both Picudoc and Dr. Silva that the current generation of mobile ultrasound is not going to replace stethoscopes and I don’t think that stethoscopes will disappear completely from medical practice, but I do think that mobile ultrasound will replace the role that stethoscopes currently have in medical education and in the skill set a graduating medical student is expected to have. What I think is going to happen is that students who don’t have either skill will chose to learn how to do an exam with ultrasound rather than a stethoscope, leading to a gradual decline in use much how slide rules were replaced by calculators. Physicians who already know how to use stethoscopes will learn how to complement their practice with ultrasound, but will probably defer to the listening skills they already have for a few things that they feel they can do quicker and safer.

  6. Martin Hofmann May 5, 2011 at 6:45 pm #

    I’m currently a first year medical student at UC Irvine. First year means the usual: I’m new to the game and have very limited real clinical experience. That said, I would love to see the concept of an ultrasound curriculum explored by more schools.

    We have an ultrasound curriculum that begins in the first year, and it’s been an interesting experience so far. Through our sessions that are complementary to our traditional clinical foundations course, our first-year class has gone from hardly knowing how ultrasound can be used outside of OB/GYN to being able to view each of the major organs.

    The implications of this are potentially great. For one, there’s 104 of us and we’re all learning it together. That’s 104 individuals who, when we’re on our third-year rotations, can take advantage of the best benefits of ultrasound when/if the device is available. If I’m to believe a lot of what I hear about ultrasound, that’s a big win not just for the ultrasound community, but for patients.

    Anyway, just had to throw in my two-cents.

    • Iltifat Husain May 6, 2011 at 6:02 am #

      Really cool — thanks for sharing

  7. Iltifat Husain May 6, 2011 at 6:03 am #

    Really interesting dialogue everyone, thanks for sharing!

  8. Alexander Protonotarios May 7, 2011 at 12:00 am #

    If we let physical exam die, I don’t think we are making a big step forward, though,

  9. J. Christian Fox May 10, 2011 at 12:05 am #

    When a physician examines a patient at the bedside using the physical exam alone they are forced to rely on their mind’s eye to
    imagine
    what organs or tissue below the skin could the culprit of their patient’s ailment. With the advent of portable bedside ultrasound, physicians are now able to
    image
    the organs and tissue directly at the point-of-care creating an immediate impact on patient care. Harnessing this technology transforms the doctor-patient relationship from the time of Hippocrates to the modern day. Physician-performed imaging results in greater clinical self-reliance, and will hopefully one day result in the reduction of unnecessary CT scans thereby causing less radiation exposure. Ultimately, Hippocrates would be proud of the physician who can utilize any simple bedside tool to elaborate on the physical exam, but only if that tool would “first, do no harm”. With the proper training (4 years of medical school) physicians of the future can deliver much more personalized and proactive care in a cost-effective “low tech” sort of way.

  10. Dra Cidalia May 12, 2011 at 2:09 pm #

    I’d love to have one. Waintingfor lower price.

  11. Dra Cidalia May 12, 2011 at 2:12 pm #

    It would be interesting to ue this ddvise to visualize nervous plexus for anesthesia.

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