Clinical Ultrasonography - under utilized

Table of Contents

Only an estimated 20-25 % of the global population has access to ultrasonography (US). The others must do without - for their lifetime, in whatsoever disease and condition, even in a childbearing period. This non-access undoubtedly is an under use of US, this magnificent tool, with all its unique properties. No irradiation, easy to apply, quite easy to learn, superb local resolution, real time, innovative (e.g. contrast enhanced US -CEUS), portable and affordable, and relatively inexpensive. US makes (very) much of computed tomography (CT) examinations simply superfluous, and this not only in abdominal indications. Making clinical US available for all citizens of the global village, performed by well trained medical doctors - this is a rewarding aim, e.g. for global healthcare organizations.

Considering this all - and in my opinion -, an "under use" of clinical US is obvious. And a true need for improvement is evident.

Let me remain a bit more with the happy few of 20-25 %. Organization of US services varies considerably from country to country, due to differently defined attendant circumstances. I do not really want to emphasize that in some countries radiologists consider US to be their natural property, sometimes leaving it to technicians, simultaneously advancing a view that US is too difficult a matter to be carried out by e.g. surgeons or gastroenterologists. This is - again in my perception - an old fashioned approach. Clinical US is a self-evident important component in many (sub-) speciality performed applications, as in gynaecology and obstetrics, in cardiology (echocardiography), and in urology. Here, it is self evident for the doctors in charge to have a look themselves at the heart cavities in resting and in exercise, or at all parts of the urinary tract, or at the female pelvis. It all started in clinical US with gynaecology - the great teacher for all subsequent applications. This interdisciplinary exchange of know-how, of technologies, and of new fields of application has made US - parallel and in competition with computed tomography (CT) - an instrument of paradigmatic changes in nearly all diagnostic steps, in nearly all medical (sub-) fields. As just one example, it is no longer the surgeon postoperatively telling what was wrong e.g. in the abdomen - he will be told before where and when to cut, or not to cut. Nevertheless, the number of surgeons performing clinical US on their own preoperatively is still limited - an interesting phenomenon. Obviously, the fine art of cutting without a knife - by sectional real time clinical US - is here not yet really popular or understood. This attitude probably has a number of reasons, again including more psychologically orientated, and including age related learning (non-) capability and willingness.

Organisation of US services depends from local doctors expertise, the systems of insurance, the distribution of money related to clinical US, the numbers of US machines available, to list the more important variables only. Exact information on the present status of many of these details is sparse, and some of topics named are quite delicate and sensitive, as e.g. the financial aspects. Most probably, CT here is more efficacious in many areas of the globe. It moreover has neither to be performed (work) nor to be accounted (responsibility) by the clinician in charge. In my opinion and of course, there is a lot of psychology involved with the acceptance or denial of clinical US. This certainly plays a yet to be defined role in the longstanding substantial lack of clinical US in Anglo-Saxon dominated medicine, as it is apparently practiced and published.

Considering all this - and in my opinion -, an "under use", an unbalanced utilisation of clinical US even with the happy few is reality, and enough place for improvements can be considered.

US examination can be practiced as a matter for the waiting list, for simple imaging only. However, US immediately related to all other clinical data in a given patient - history, physical findings, laboratory values, etc. - and performed in combination with initial physical examination: this is the probably more efficacious usage of US, both in routine, and in any emergency or intensive care setting.

Clinical US is more than real time imaging only - it is an integrative part in sort of a total work of art - a gesamtkunstwerk - in an individualized patient service. This has proven to be truly helpful - and markedly CT saving - both in routine and in emergency patient services in any field of application of clinical ultrasonography.

Lucas Greiner, MD, FRCP
Professor of Internal Medicine and Gastroenterology
ISCUS Director
URL: http://www.flyingfaculty.de and Email: [e-mail]