I'm not so sure of that.
Why should a primary care doctor (who's probably already strapped for cash) spend upwards of $30,000 for a device that he can't get reimbursed for using, that potentially increases his malpractice exposure (if he relies on his own interpretations as opposed to sending patients with positive findings out for definitive studies), that takes extra time to employ (you'll argue that this is "minimal," but I can tell you that every minute is precious in most primary care offices), and that rarely adds anything beyond that which can be ascertained through a good history and physical exam?
If you accept the way things are today, I agree with you.
But what if... (so imagine a world...)... what if we started training PGY-1 FM resident the use of ultrasound during residency. And, on every rotation they go on they take their ultrasound machine and learn how to ultrasound *in conjunction* to their regular work up.
What if... FM residencies expand and start a outpatient ultrasound fellowship to further skills and research. And not only would that include diagnostic ultrasound, but also interventional ultrasound (like ultrasound-guided amniocentesis, thoracentesis, central line placement, joint injection, breast biopsy/aspiration). I mean, these are things that FM residencies do now anyways, so why not bring it the PGY-1 level.
Your training argument goes away. We don't get reimbursed now for the Patient-Centered Medical Home... so why are we pushing so hard for it? Because if you build it, (we hope) it will pay. And so should demonstrating value in office ultrasound in the amount of cost-savings we can gain from unnecessary CT's and MRI's.
Malpractice exposure is fluid issue. FM, IM, Pedi, and ER residents learn how to read chest x-rays only for them to be "overread" by a radiologist. Does that increase the exposure for the doctor who makes the initial impression? I don't think so. OB/Gyns who send their OB ultrasounds to radiology for a "formal" ultrasound or a "formal" biophysical profile do the same thing to hedge their malpractice. No reason why an FP who has an equivocal ultrasound can't send for a "formal" ultrasound or a more advanced imaging (like MRI). If FM residents learn how to interpret ultrasound during residency x 3 years, this malpractice issue really goes away too. I trust an OB/Gyn doc interpreting my OB ultrasounds more so than a radiology TECH (and remotely, after-the-fact, with no clue where the probe is pointed/located... a radiologist signing off). But that's because it's an OB doctor who knows OB and does OB *and* trains 4 years with an ultrasound probe in hand. That beats a tech who couldn't give a damn anyday. But our medical system won't pay an OB doctor to provide the formal interpretation for ultrasounds in the hospital because he/she isn't a radiologist and may not have privileges to do so... because such an act is the turf of a radiologist... BUT, in the outpatient setting, an OB/Gyn can get paid for interpreting an ultrasound they perform... (figure that one out...)
I actually think my malpractice exposure would decrease because I'm not shooting at the hip with a "hand palpating for a positive Murphy's sign" and then placing a referral for insurance to approve my order for ultrasound and then scheduling the patient for an outpatient ultrasound 2-3 weeks later to be done by a tech because that's the first opening when he gets back from vacation.
If I had the skill to do it, I would do it, bam bam, nail the diagnosis, and move on to treatment. Patients come to the doctor for answers. None of this, hey, let's wait for the natural history of the disease to progress to elucidate the diagnosis with more certainty. Or, this willy-nilly ordering of CT or MRI because I can't get a good history or physical exam.
Diagnostic ultrasound, done by a PHYSICIAN, at the bedside in conjunction with a H&P with properly formulated DDX can be incredibly powerful.
The fact that you can use an ultrasound machine for virtually any body organ spreads the cost of the machine out over several service lines. In economics, they call it Economies of Scope (as opposed to Scale). And so, yes, while it is expensive, it can be used for multiple purposes for multiple organs in multiple types of patients (like pedi or OB) who have multiple range of resources (cheaper than an MRI and doesn't require 1 hour in a claustrophobic tube).
But it must be in good technical hands. But that's why we're doctors. And that's why we go to medical school. And that's why we train in residency. There's no reason why we can't be good in ultrasound. If we can train residents to do c-sections, relocate broken bones, insert central lines, run codes, intubate, perform colonoscopies, read CXR, etc. etc., we sure hell can train them to do ultrasounds.
The question is, do we have the political will do make it happen?... That's the real question.
