POCUS puts focus on the patient encounter

One of the most important changes for internal medicine has been the acceptance of point-of-care ultrasound (POCUS). Emergency physicians realized that they needed it to screen for surgical problems after trauma. But internists didn't quite get it. Jenny Mladenovic, MD, MBA, MACP, was a really important part of its acceptance. She felt like internal medicine needed to be turned around so that we got back to the bedside, to paying attention to patients, and we needed to improve our game. She saw that ultrasound could be an important part of that.

There began to be an avalanche of people involved in it, partly because the pocket machines got quite a bit cheaper. The beginning of exponential growth looks very slow, but we're beginning to see the steeper part of that curve. It's been picked up by a lot of organizations as important, and ACP was on the forefront of that. Now, we have classes, ACP has conferences, and people sign up for them and are very enthusiastic, and they want more.

When I first picked up POCUS, I was a hospitalist. I had transitioned from my traditional practice to doing mostly locum tenens hospital medicine. Usually, there's a lot of acuity in the patients of a locum tenens hospitalist, which was excellent for learning. In 2019, I went back to doing outpatient medicine, and I became a consulting internist for a community health center. During that whole time, I had been teaching POCUS internationally. I started going overseas to Africa and teaching people through a couple of different projects. Once I knew ultrasound, I could teach people who really, really needed it, in resource-poor settings, who had the machines but didn't know how to use them.

Now, I use POCUS as an outpatient physician, which means that I don't necessarily use it on every single patient like I did as a hospitalist. But I will use it three or four times every day for a patient whose problem has anything to do with heart, lungs, pain in the abdomen, lumps or bumps, or swellings. I'll do what we now call the PEARLS exam. Michael S. Wagner, MD, FACP, and I put together this acronym as a way to teach other people to do a full ultrasound exam. It allows me to get a much better idea of what's going on with the patient. It takes me an extra four minutes, the patient feels the ultrasound probe for less than two of them, and we often arrive at a diagnosis. Patients love it.

Anybody who has studied medicine understands the concepts of “pearls”—little snippets of wisdom, often from our best teachers. But in this case it's actually just an acronym for Parasternal, Epigastric, Apical heart and Anterior lung, Right upper quadrant, Left upper quadrant, and Suprapubic. If you put your transducer in those locations, and you look for specific views, you have this myriad of data that you couldn't get by physical exam, because the sensitivity and specificity of our physical exam is poor for these conditions. Things like pleural effusions, pericardial effusions, left ventricular function, bladder distension, ascites, and hydronephrosis. Those are some of the most important conditions to identify and POCUS can accurately rule them in or out.

It is not exhaustive. But it is an excellent way to get people's hands on an ultrasound machine and start reaping the benefits for their patients. And once they become comfortable using it, it becomes an extension of the doctors' hands.

An internal medicine doctor needs to do all of these things, listen to the patient, pay attention to the patient, do a good physical exam, gather an excellent history, and produce some kind of a story that includes a hypothesis that we will then test further. I'm watching medicine get farther and farther away from that, in fact, a lot of us become just the AI for digesting a bunch of data. And we're not even great AIs. Meanwhile, we're not doing as good a job as we should connecting to the patient.

Ultrasound brings us back to the bedside, and it causes us to touch the patient, again, to interact with what's actually going on with that person as opposed to our preconceived notions that we have when we first walk into the room. I see that so often; people have their note half-written before they hit the patient's door. They spend five minutes feeding some of their data into their preconceived hypothesis, and then go out, not realizing that the patient had a different story entirely. When you do ultrasound, not only do you actually get the data from looking at the patient's insides, but you're actually quiet for a little while, giving the patient a chance to talk. Some of my most amazing diagnoses have to do with just stopping talking for a moment while I'm doing the ultrasound.