Ultrasound imaging in the general practitioner's office – a literature review

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VOLUME 16 , ISSUE 64 (March 2016) > List of articles

Ultrasound imaging in the general practitioner's office – a literature review

Alicja Genc * / Małgorzata Ryk / Magdalena Suwała / Tatiana Żurakowska / Wojciech Kosiak

Keywords : general practitioners, ultrasonography, ultrasound imaging, medical imaging

Citation Information : Journal of Ultrasonography. Volume 16, Issue 64, Pages 78-86, DOI: https://doi.org/10.15557/JoU.2016.0008

License : (CC BY-NC-ND 3.0)

Received Date : 06-July-2015 / Accepted: 07-September-2015 / Published Online: 29-March-2016

ARTICLE

ABSTRACT

Aim

The aim of this paper is to review the Polish medical literature pertaining to the usage of ultrasound imaging in general practice as well as to present advantages, disadvantages and utility associated with conducting ultrasound examinations by general practitioners based on selected publications.

Material and methods

The analysis involved 15 articles found in Polish medical literature published in 1994–2013 in 9 medical journals. These publications were obtained using various data bases, such as Polish Medical Bibliography, Google Scholar as well as websites of “Lekarz Rodzinny” and “Ultrasonografia.”

Results

Of 15 available publications, 5 papers present the usage of ultrasound imaging by a primary care physician for general purposes, 4 discuss the usage of abdominal scans, 3 – imaging of the neck and lymph nodes, 1 – lungs, and 2 discuss its usage for specific disease entities. In over 70% of the papers, the financial aspect associated with the usage of this modality in general practice is mentioned. More than a half of the publications draw attention to the possibility of using point-of-care ultrasound examinations. Advantages of ultrasonography most often mentioned by the authors include: good effects of screening, safety, short duration and low cost. The authors of eight publications also indicate disadvantages associated with ultrasound imaging used by a general practitioner.

Conclusions

In the Polish literature, there are relatively few papers on the role of ultrasonography in the office of a primary care physician. This modality is more and more often becoming a tool that helps primary care physicians to establish diagnoses, accelerates the initiation of treatment and directs the further diagnostic process.

Cel

Celem pracy był przegląd piśmiennictwa polskiego opisującego wykorzystanie badania ultrasonograficznego w gabinecie lekarza rodzinnego oraz przedstawienie zalet, wad i przydatności wykonywania samodzielnego badania ultrasonograficznego przez lekarzy rodzinnych, na podstawie analizy wybranych artykułów.

Materiał i metoda

Analiza objęła 15 artykułów wyszukanych w polskim piśmiennictwie, opublikowanych w latach 1994–2013 w 9 czasopismach medycznych. Publikacje znaleziono za pomocą różnych baz danych, takich jak Polska Bibliografia Lekarska, Google Scholar, strony internetowe pism „Lekarz Rodzinny" i „Ultrasonografia".

Wyniki

Z 15 dostępnych publikacji 5 stanowiły artykuły przedstawiające zastosowanie ultrasonografii w gabinecie lekarza rodzinnego w wymiarze ogólnym, w 4 opisano wykorzystanie badania jamy brzusznej, w 3 – szyi i węzłów chłonnych, w 1 – płuc oraz w 2 omówiono badanie w konkretnych jednostkach chorobowych. W ponad 70% prac poruszony został aspekt ekonomiczny związany z zastosowaniem ultrasonografii w gabinecie lekarza rodzinnego. W ponad połowie artykułów zwrócono uwagę na możliwość wykorzystania badań ultrasonograficznych typu point-of-care. Wśród zalet ultrasonografii najczęściej wymieniano korzystne badanie przesiewowe, bezpieczeństwo, krótki czas trwania, niski koszt badania. Autorzy ośmiu publikacji wskazali również wady związane ze stosowaniem USG w gabinecie lekarza rodzinnego.

Wnioski

W polskim piśmiennictwie dostępnych jest niewiele publikacji opisujących rolę ultrasonografii w gabinecie lekarza pierwszego kontaktu. Ultrasonograf coraz częściej staje się narzędziem ułatwiającym lekarzowi podstawowej opieki zdrowotnej postawienie diagnozy, przyspiesza też rozpoczęcie leczenia pacjentów i ukierunkowuje dalszą diagnostykę.

Introduction

The history of ultrasonography (USG) dates back to the beginning of the 19th century when physical principles that form the basics of this imaging method were discovered. As early as in 1822, Jean-Daniel Colladen analyzed the speed of sound in the waters of Lake Geneva using an “underwater bell.” In 1877, Lord Rayleigh proposed a theory of acoustic wave propagation, and in 1880 Pierre and Jacques Curie discovered the piezoelectric effect(1). The accomplishments of physics in this field have been explored for nearly 200 years, and new imaging techniques have been introduced: ranging from ocean bottom mapping, through the creation of a reflectoscope, to examining internal organs in people. These advances have allowed us to diagnose lesions in the brain, heart, parenchymal organs, vessels or even lungs and bowels. This method is continuously perfected and more and more eagerly used by clinicians of various specialties. Thanks to its simplicity and when its basic principles have been mastered, ultrasonography becomes a tool that can be used in everyday medical practice and, more importantly, also in general practitioner (GP) offices. An ultrasound scanner is more and more frequently used as a stethoscope of the 21st century(24). The widespread usage of this method in primary health care would combine physical examination, interview and imaging, thanks to which redundant diagnostic processes could be avoided in certain cases, and patients would be provided with faster diagnoses(4). Point-of-care US examination, i.e. a scan performed by a doctor who is not a radiologist in their office or at patient's bedside in order to identify a specific clinical problem, enables one to practice modern and effective medicine(2).

Aim

The aim of this paper is to review the Polish medical literature pertaining to the usage of ultrasound imaging in general practice as well as to present advantages, disadvantages and utility associated with conducting ultrasound examinations by primary care physicians based on selected publications.

Material and methods

The material for this review consisted of 15 articles published in 1994–2013 in the following medical journals (Tab. 1):

  • “Developmental Period Medicine”;

  • “Family Medicine and Primary Care Review”;

  • “Gabinet Prywatny”;

  • “Journal of Ultrasonography”;

  • “Lekarz Rodzinny”;

  • “Nowa Klinika”;

  • “Problemy Medycyny Rodzinnej”;

  • “Ultrasonografia”;

  • “Ultrasonografia Polska.”

Tab. 1

Publications found in selected medical journals

JournalIssueYearTitleAuthor
“Developmental Period Medicine”17 (2)2013“Value of ultra-sound of lymph nodes in children and adolescents in the family doc-tor's office and in pediatric practice – own investiga-tions”Tomasz Batko, Wojciech Kosiak
“Family Medicine and Primary Care Review”10 (3)2008“New tech-nologies in ultra-sound imaging - usefulness in family medicine practice”Maciej Piskunowicz, Wojciech Kosiak, Dominik Świętoń
11 (1)2009“The role and usefulness of ultrasound in the diagnosis of ab-dominal pain in general practice”Maria Magdalena Bujnowska-Fedak, Ewa Krawiecka-Jaworska
11 (1)2009“The usefulness of ultrasound of the neck region, in particular the thyroid gland and lymph nodes, in general practice”Ewa Krawiecka-Jaworska, Maria Magdalena Bujnowska-Fedak
12 (2)2010“Sonography as modern stetho-scope in every-day practice of family doctors”Wojciech Kosiak
14 (2)2012“Ultrasound diagnostics in primary care - for and against”Wojciech Kosiak, Magdalena Kryger
“Gabinet Prywatny”12005“Professional sonography in a general practitioner's office”Wiesław Jakubowski
“Journal of Ultrasonography”13 (54)2013“Relevance of ultrasound examination in general practice. A case report of a patient with autosomal dominant polycystic kidney disease”Izabela Cwojdzińska-Jankowska, Anna Plewa
“Lekarz Rodzinny”7 (9)2002“Ultrasonography in general practice. Assessment of selected abdominal organs”Witold Gajewicz
“Nowa Klinika”8 (12)2001“Abdominal ultrasound (US) in general practice”Andrzej Rakoczy
“Problemy Medycyny Rodzinnej”14 (3)2012“The importance of General Practitioner in diagnosis and treatment of a mass in the neck”Stanisław Bień
“Ultrasonografia”42000“Ultrasound examinations in primary health care – doctor training possibilities and needs”Maciej Latalski, Irena Woźnica, Katarzyna Bełtowska
312007“Carpal tunnel syndrome in family physician practice. Value of sonographic assessment vs electromyography”Teresa Mazurczak-Pluta, Stanisław Pomianowski, Kazimierz Szopiński
382009“Usefulness of ultrasonography examinations made by a general practitioner”Luiza Sowińska-Neuman
“Ultrasonografia Polska”4 (4)1994“Problems associated with sonography in a general practitioner's office”Wiesław Jakubowski

The publications were found in the following data bases:

The key words used while searching for the publications were: ultrasonography, general practitioner, ultrasonography family physician, ultrasonography usage, ultrasonography office, ultrasound imaging, family medicine, medical imaging

Results

Fifteen publications were found in the available data bases. Five of them present the usage of ultrasonography by a primary care physician for general purposes(1, 2, 57), 4 discuss the usage of abdominal scans(811), 3 – imaging of the neck and lymph nodes(4, 12, 13), 1 – lungs(3), and 2 discuss its usage for specific disease entities(14, 15). Moreover, the role of ultrasonography is discussed with respect to the following conditions: carpal tunnel syndrome, polycystic kidney disease, thyroid lesions, enlarged lymph nodes, palpable neck tumors, abdominal pain and auscultatory changes in the lungs.

Individual articles draw attention to general advantages of ultrasonography, particularly in terms of its usage in the office of a general practitioner. The authors emphasize its positive role in primary diagnosis and its usefulness but also problems concerning its application. The publications mention issues associated with training doctors in terms of basic principles of ultrasonography, equipment applied and financial aspects (Tab. 2).

Tab. 2

Problems discussed in the selected 15 articles on the usage of ultrasonography in the office of a general practitioner

ProblemNumber of articles that mention a given problem (%)
Usage of US93
Financial aspect73
Point-of-care principle 53
Equipment47
Education of doctors40
Comparison with other imaging methods27
US – a stethoscope of the 21st century27
Case report7

These results demonstrate that the greatest advantage of performing ultrasound examinations in general practice is the fact that it is a good screening tool in the diagnosis of numerous conditions. The authors frequently underline shorter duration of a diagnostic process as well as safety, non-invasiveness, rapid examination, low cost and ready accessibility. One fifth of the publications mention an important aspect of US uniqueness as the only clinical imaging modality. By combining the interview, physical examination and real-time imaging, ultrasonography constitutes a whole, which can be clearly used in general practice(24). Additional advantages of this modality are: increased value of examination and quality improvement of daily medical care (Tab. 3).

Tab. 3

Advantages of ultrasonography mentioned in the selected 15 articles on the usage of ultrasonography in the office of a general practitioner

ProsNumber of articles that mention given pros (%)
Positive effects of screening examinations80
Shorter diagnosis67
Safety60
Painlessness60
Non-invasiveness53
Rapid examination47
Accessibility47
Low cost47
Financial benefits for the health care system40
Quality improvement of everyday medical care27
Technique and interpretation are easy to master20
Features of a clinical examination20
Follow-up after treatment13

The authors do not list many disadvantages of ultrasound imaging. Some emphasize that it cannot be a solitary examination, has to be combined with clinical assessment and, without a doubt, requires experience(8). Moreover, it is also noted that patients must be adequately prepared for abdominal or pelvic scans. One of the articles draws particular attention to high costs of modern techniques, such as elastography or contrast-enhanced ultrasound, which are not needed for a basic screening scan(1) (Tab. 4).

Tab. 4

Disadvantages of ultrasonography mentioned in the selected 15 articles on the usage of ultrasonography in the office of a general practitioner

ConsNumber of articles that mention given cons (%)
Necessity to confirm US with other examinations33
Subjective, depends on examiner's experience33
High qualifications of medical staff are needed20
Patients must be adequately prepared for scans20
Adequate equipment20
High cost of modern techniques7

Discussion

An ultrasound examination is one of the most common additional examinations. It is the first choice in most diagnostic algorithms used by a general practitioner. The action of ultrasounds is considered safe – to date, they have not been proven negative or harmful. That is why examinations can be repeated many times and the course of a given disease can be closely monitored(9). Moreover, US is non-invasive, painless, readily accessible and less expensive than other imaging examinations(8, 12, 14). It is characterized by high specificity and sensitivity(2). By contrast with CT and MRI, it enables dynamic real-time imaging, thus facilitating image interpretation. Stable images, however, are used to illustrate changes and create documentation but are not the main basis for establishing diagnoses(8).

Ultrasound imaging enables direct contact between the doctor and patient during the examination, which can be conducted in various planes and patient positions. This is particularly useful in patients in a serious general condition, in whom conducting lung US is easier than chest X-ray(3).

Due to technological advances, there is equipment of better and better quality, and the portability and compactness of certain models enables doctors to reach patients during home visits, e.g. bedridden ones, disabled or elderly etc.(3)

US is used for specialist diagnosis, screening or procedures, such as abscess drainage or intraarticular administration of medications(2). It seems that it can play a role in periodical check-ups, enabling patient monitoring(3).

The authors of the analyzed publications draw attention to various positive effects associated with using ultrasonography by primary care physicians. A general practitioner knows the patient, is familiar with clinical signs, medical history and has access to results of all additional examinations, including US, thanks to which they can assume a global attitude to the patient's disease(3, 12). A US examination conducted in a GP's office would allow rapid diagnoses to be established and immediate decisions to be taken concerning whether or not the patient requires specialist consultation or hospitalization(5). This is particularly important in life-threatening conditions(3), such as pneumothorax, pneumonia, dyspnea or presence of fluid collections in body cavities. A US examination could shorten the time needed to confirm or rule out clinical signs(3, 13), which would enable the identification of silent pathologies (e.g. impalpable thyroid nodules or polycystic kidney disease) (13, 15), reduce patient's stress and shorten the time of waiting for a consultation with a specialist. Moreover, a point-of-care US examination conducted by a family physician(2) does not prolong the visit since, e.g. the duration of lung examination with ultrasound is comparable to that with a stethoscope(3). The term point-of-care ultrasonography means carrying out and interpreting ultrasound findings while making therapeutic decisions in order to confirm a suspicious pathology. The GP's knowledge concerning US would reduce the number of inadequate referrals and improve correct interpretation of results(2).

Photographic documentation would enable primary care physicians to make rapid comparisons between current and previous US results(3). This would enable detection of subtle lesions, which could prove crucial in increasing the detectability of diseases in their early stages. Additionally, a primary care physician could periodically monitor healthy patients and control the efficacy of treatment or follow changes resulting from the disease(10). Thanks to screening ultrasound examinations, an early diagnosis of a disease can contribute to a decrease in the percentage of advanced conditions that lead to disability. The problem of late carpal tunnel syndrome diagnosis can serve as an example(14).

It must be remembered that ultrasound imaging is an additional examination and it should not be the only basis for decision-making(8). US is characterized by certain limitations, e.g. it makes it possible to detect a cancerous lesion, but it cannot evaluate it in terms of malignancy(12).

The value of ultrasound mainly depends on three factors: equipment, patient and examiner.

When selecting ultrasound equipment, one should bear in mind the guidelines of the Polish Ultrasound Society since the age and class of equipment affect image quality(9). Moderate-class equipment is completely sufficient for general practitioner offices.

Moreover, the quality of an examination is affected by the general condition of a patient, the condition of abdominal wall (wounds, scars, stretch marks) and proper preparation of patients by adequate diet, antiflatulent agents (intestinal gas can make abdominal structures less accessible) as well as proper degree to which the urinary bladder is filled(9). Insufficient knowledge of primary care physicians concerning ultrasonography, or sometimes the lack of such knowledge, results in inaccurate referrals and poor skills in interpreting US findings(8). The author of one article, published in 2002, emphasizes that skills of doctors who perform US examinations in accordance with the guidelines of the Polish Ultrasound Society and Polish Medical Society of Radiology should be confirmed with adequate certificates(9). A US examination is always subjective, and its results and further diagnostic process depend on qualifications and experience of the examiner and their professional approach(12). That is why it is concluded that the issue of ultrasonographic education is crucial.

Jakubowski emphasizes that acquiring the ability to conduct ultrasound examinations properly requires a systematic approach, everyday training under professional supervision and the usage of appropriate equipment. According to Jakubowski, this takes at least 12 months(6). Despite such a long period of time needed to master the specifics of ultrasound imaging, a survey conducted by Latalski, Woźnica and Bełtowska among doctors demonstrates that there is a considerable demand for such courses(7). They would enable doctors to perfect their skills in interpreting US findings in the most common pathologies encountered in a GP's office on a daily basis. Moreover, GPs assess their own knowledge as insufficient and, therefore, they must frequently seek assistance of more experienced colleagues. They believe that such courses should be primarily practical and conducted by qualified ultrasonographers(7). Many surveyed doctors draw attention to high costs of specialist trainings(7). Furthermore, a comment to the publication of Sowińska-Neuman includes the opinion that the financial aspect should encourage general practitioners to conduct US examinations in their own offices. Performing such scans is less expensive than referring patients to other centers(11). Moreover, doctors should possess knowledge about available ultrasound equipment in order to be able to purchase adequate systems(1).

Conclusions

  1. Despite the fact that primary care physicians constitute a large group, there are few papers in the Polish literature on the role of ultrasonography in general practice.

  2. Most authors unanimously agree that performing ultrasound scans by GPs themselves accelerates diagnoses and enables adequate treatment to be rapidly implemented or the patient to be referred to a proper specialist.

  3. Several basic problems remain to be solved, namely: education of general practitioners, the manner of their training and making them aware of the benefits associated with the availability of an ultrasound system in their office.

Conflict of interest

Authors do not report any financial or personal connections with other persons or organizations, which might negatively affect the contents of this publication and/or claim authorship rights to this publication.

References


  1. Piskunowicz M,Kosiak W,Świętoń D,Nowe technologie w obrazowaniu ultrasonograficznym – ich przydatność w gabinecie ultrasonograficznym lekarza rodzinnego Fam Med Prim Care Rev 2008 10 1014 1016
  2. Kosiak W,Kryger M,Ultrasonografia w gabinecie lekarza rodzinnego – za i przeciw Fam Med Prim Care Rev 2012 14 249 250
  3. Kosiak W,Ultrasonograf stetoskopem lekarza rodzinnego Fam Med Prim Care Rev 2010 12 389 393
  4. Batko T,Kosiak W,Zastosowanie badań ultrasonograficznych węzłów chłonnych u dzieci i młodzieży w gabinecie lekarza rodzinnego i pediatry – na podstawie doświadczeń własnych Developmental Period Medicine 2013 17 137 142
    [PUBMED]
  5. Jakubowski W,Problemy związane z ultrasonografią w gabinecie lekarza domowego Ultrasonografia Polska 1994 4 102 103
  6. Jakubowski W,Profesjonalna ultrasonografia w gabinecie lekarza rodzinnego Gabinet Prywatny 2005 1 35 38
  7. Latalski M,Woźnica I,Bełtowska K,Badania ultrasonograficzne w podstawowej opiece zdrowotnej – możliwości realizacji i potrzeby szkoleniowe lekarzy Ultrasonografia 2000 4 47 52
  8. Rakoczy A,Znaczenie ultrasonografii (USG) jamy brzusznej w praktyce lekarza podstawowej opieki zdrowotnej Nowa Klinika 2001 8 1165 1168
  9. Gajewicz W,Ultrasonografia w praktyce lekarza rodzinnego. Diagnostyka wybranych narządów jamy brzusznej Lek Rodz 2002 7 74 79
  10. Bujnowska-Fedak MM,Krawiecka-Jaworska E,Rola i przydatność badania ultrasonograficznego w rozpoznawaniu bólów brzucha w praktyce lekarza rodzinnego Fam Med Prim Care Rev 2009 11 21 25
  11. Sowińska-Neuman L,Umiejętność samodzielnego wykonywania badań ultrasonograficznych w praktyce lekarza rodzinnego Ultrasonografia 2009 38 51 54
  12. Bień S,The importance of General Practitioner in diagnosis and treatment of a mass in the neck Probl Med Rodz 2012 14 49 55
  13. Bujnowska-Fedak MM,Krawiecka-Jaworska E,Przydatność badań ultrasonograficznych szyi, w szczególności tarczycy i węzłów chłonnych, w praktyce lekarza rodzinnego Fam Med Prim Care Rev 2009 11 37 41
  14. Mazurczak-Pluta T,Pomianowski S,Szopiński K,Zespół kanału nadgarstka w praktyce lekarza rodzinnego. Znaczenie badania ultrasonograficznego w odniesieniu do elektromiografii Ultrasonografia 2007 31 73 84
  15. Cwojdzińska-Jankowska I,Plewa A,J Ultrason 2013 13 344 349
    [PUBMED] [CROSSREF]
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REFERENCES

  1. Piskunowicz M,Kosiak W,Świętoń D,Nowe technologie w obrazowaniu ultrasonograficznym – ich przydatność w gabinecie ultrasonograficznym lekarza rodzinnego Fam Med Prim Care Rev 2008 10 1014 1016
  2. Kosiak W,Kryger M,Ultrasonografia w gabinecie lekarza rodzinnego – za i przeciw Fam Med Prim Care Rev 2012 14 249 250
  3. Kosiak W,Ultrasonograf stetoskopem lekarza rodzinnego Fam Med Prim Care Rev 2010 12 389 393
  4. Batko T,Kosiak W,Zastosowanie badań ultrasonograficznych węzłów chłonnych u dzieci i młodzieży w gabinecie lekarza rodzinnego i pediatry – na podstawie doświadczeń własnych Developmental Period Medicine 2013 17 137 142
    [PUBMED]
  5. Jakubowski W,Problemy związane z ultrasonografią w gabinecie lekarza domowego Ultrasonografia Polska 1994 4 102 103
  6. Jakubowski W,Profesjonalna ultrasonografia w gabinecie lekarza rodzinnego Gabinet Prywatny 2005 1 35 38
  7. Latalski M,Woźnica I,Bełtowska K,Badania ultrasonograficzne w podstawowej opiece zdrowotnej – możliwości realizacji i potrzeby szkoleniowe lekarzy Ultrasonografia 2000 4 47 52
  8. Rakoczy A,Znaczenie ultrasonografii (USG) jamy brzusznej w praktyce lekarza podstawowej opieki zdrowotnej Nowa Klinika 2001 8 1165 1168
  9. Gajewicz W,Ultrasonografia w praktyce lekarza rodzinnego. Diagnostyka wybranych narządów jamy brzusznej Lek Rodz 2002 7 74 79
  10. Bujnowska-Fedak MM,Krawiecka-Jaworska E,Rola i przydatność badania ultrasonograficznego w rozpoznawaniu bólów brzucha w praktyce lekarza rodzinnego Fam Med Prim Care Rev 2009 11 21 25
  11. Sowińska-Neuman L,Umiejętność samodzielnego wykonywania badań ultrasonograficznych w praktyce lekarza rodzinnego Ultrasonografia 2009 38 51 54
  12. Bień S,The importance of General Practitioner in diagnosis and treatment of a mass in the neck Probl Med Rodz 2012 14 49 55
  13. Bujnowska-Fedak MM,Krawiecka-Jaworska E,Przydatność badań ultrasonograficznych szyi, w szczególności tarczycy i węzłów chłonnych, w praktyce lekarza rodzinnego Fam Med Prim Care Rev 2009 11 37 41
  14. Mazurczak-Pluta T,Pomianowski S,Szopiński K,Zespół kanału nadgarstka w praktyce lekarza rodzinnego. Znaczenie badania ultrasonograficznego w odniesieniu do elektromiografii Ultrasonografia 2007 31 73 84
  15. Cwojdzińska-Jankowska I,Plewa A,J Ultrason 2013 13 344 349
    [PUBMED] [CROSSREF]

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