The POCUS Manifesto: Expanding the Limits of Our Physical Exam With Point-of-Care Ultrasound

Book Title: POCUS Manifesto: Expanding the Limits of the Physical Exam With Point-of-Care Ultrasound

Author: Larry Istrail, MD

Publication Details: ZeromSv Publishing, 2021, 208 pp., $34 paperback

The catchy title of this book suggests the manic shouting of a person overcome with the need to spread the point-of-care ultrasound (POCUS) gospel, but unfortunately the applications addressed are limited to cardiopulmonary use in acute care settings. Family medicine POCUS covers so much more, including everything below the diaphragm, the musculoskeletal system, and care for children and for pregnant women. What is broad is the author’s target audience, as he writes to include nurses, students, and therapists. The author explains basic concepts of sensitivities and specificities using analogies about lobsters and tuna to make statistics more relatable to the broader audience. He also compares ultrasound image artifacts to “drug sniffing dogs” that detect the “presence of cocaine in underwear.” The intent may be for shock or entertainment, but as a medical text, the writing is stylistically jarring.

The author is a hospitalist with a profound interest in POCUS medical education and application. He is likely the figure depicted on the brightly colored book cover gripping a stethoscope with the left hand while shining a light into the dark with an ultrasound. POCUS as the modern stethoscope has been written about countless times and is a problematic comparison. The analogy sets up unreasonable expectations toward the ease of use, downplays the learning curve and the affordability of ultrasound, and minimizes the administrative tasks. These understated challenges can present as unexpected barriers for physicians without training or financial and administrative backing. The flashlight, another common comparison, is a better analogy, hinting that POCUS could offer physicians a way forward into the future of medicine out of our medieval past. Like a flashlight, the POCUS transducer shines a light, creating a two-dimensional image, but requires hands-on skills and a strong understanding of orientation and cognitive interpretation of the image produced.

Whether the author venerates or dismisses the physical exam traditions of old is unclear because the book swings between waxing in nostalgia and systematic dismantling of western medical practices. The book reminds us that modern medicine is built on a foundation of sticks, mud, blood, and leeches—a history fit for the Philadelphia Mutter Museum of medical oddities—and then compares it to POCUS, declaring, huzzah, what an improvement! In this day of deemphasis of the physical exam, perhaps any return to the bedside is considered a win. The book highlights the flaws of the traditional physical exam and auscultation skills. Perhaps this is a call to improve medical training so that future physicians have the best of both worlds—astute exam skills and the power of modern technology (ultrasound) to amplify them.

Stronger sections of the book read like a biography on the works of select early adopters of ultrasound, particularly the critical care specialists and cardiologists. The author echoes (pardon the pun) the ideas of current POCUS leaders and uses open-source material. The role of emergency medicine is de-emphasized, and the contributions of family medicine early adopters dating back to the 1980 s are not mentioned. The author does an excellent job describing the physical exam for jugular venous distention (JVD) and its error-prone methods, but the details of the author’s unique methods for performing a POCUS JVD assessment are relegated to a figure caption. One must go to the reference section to learn more. This book particularly highlights the power of POCUS in acute settings, but there is certainly room for family medicine physicians to stake out their claim in the world of POCUS given its diverse applications in the outpatient setting.

The POCUS Manifesto could be a book to recommend to your administrative leadership to support your request for more POCUS. It contains an encyclopedic volume of evidence on its utility and power (albeit primarily cardiopulmonary POCUS). The probability is high that instead of slogging through the dense jungle of declarations on POCUS superiority over the traditional physical exam, administrators will just go ahead and approve your equipment request. Then deciding how this powerful tool can complement your practice will be up to you.