Summary of main findings
In this study, we found that most patients felt they were well informed about the purpose and the results of the POCUS examinations. However, only half of the patients felt very informed or informed to some extent about the difference between a GP POCUS and an imaging-specialist’s ultrasound examination. Almost all (99%) patients reported that POCUS was integrated naturally into the GP consultation and 45% reported that POCUS may even have improved the doctor-patient relationship.
POCUS use had a large influence on patient reassurance: 92% felt more thoroughly examined, 85% felt they had been taken more seriously, and 86% felt more secure after being examined using POCUS. Eighty-eight percent reported an increased understanding of their health problem and 65% had an increased trust in the GP’s assessment of their health problem after the use of POCUS. Although we found that the majority of GPs reported an increased confidence in their diagnosis after POCUS, no strong association was found between the GPs’ increased confidence and the patients’ sense of reassurance.
Finally, we found that the vast majority of patients said that POCUS use improved their experience of the level of service and quality of care in general practice, and no patients reported having a negative experience with the use of POCUS in general practice.
Strengths and limitations
The questionnaire was developed based on extensive preceding qualitative work. However, the items originated from interviews with GPs and not patients. Hence, it is possible that interviews with patients preceding this study would have revealed aspects of the patient experience that we did not include. Nevertheless, all dimensions of the items in the questionnaire were pilot-tested with patients giving some assurance that they were relevant to patient experience.
Although, we had a 97% participation rate, we had expected to include more patients. The participating GPs reported that the study registrations were time consuming and, therefore, fewer patients were examined with POCUS during the study period. A larger sample may have provided more diversity in the results.
Generalisability may have been compromised as the GPs performing POCUS in this study are likely to constitute a selected sub-group of GPs with a special interest in ultrasonography. These GPs choose to use POCUS in their daily work without receiving a fee or remuneration for the extra service or their time. It is possible that the GPs’ enthusiasm for the technology affected the consultations and created a more positive atmosphere, which may have influenced patients’ experiences. Hence, it is unknown if similar results would be found in a larger or more diverse group of GPs.
To avoid recall bias, patients completed the questionnaires in the clinic’s waiting room immediately after their consultation, but this may have affected their responses. The high response rate could reflect the inability of some patients to say ‘no’ to participation, as the questionnaire was presented to them by the GP. Hence, we cannot reject some potential response bias where patients’ answers are in favour of their GPs.
This was a first descriptive study examining patient experiences with the use of POCUS in general practice, and as such we did not adjust for possible confounders. However, the distribution of data was strongly unidirectional. The lack of a comparator in our study design makes us unable to determine whether our findings are, in fact, a result of the use of POCUS or a more general expression of loyalty, trust and satisfaction with the GP. However, the phrasing of the questions was specifically designed to elicit the impact of POCUS.
Findings in context
Despite a growing number of publications describing the use of POCUS in general practice, little attention has been given to patients’ perspectives on the use of the technology [
12]. Previous studies have explored patient experiences with POCUS in general practice using questionnaires administered immediately after the consultation [
16], after 15 to 30 days [
15], and after three [
13] or four [
17] months following the examination. Although using various designs and items to measure patients’ experiences, all studies reported that POCUS aligned well with patient preferences.
Accordingly, we found an overall positive experience with the GPs’ use of POCUS assessed immediately after the consultation. Three previous studies from general practice found that patients preferred having the examination performed at the GP’s office rather than going to the hospital [
15‐
17]. Using discrete-choice methodology, one of the studies from a rural general practice [
16] even found that patients were willing to trade off diagnostic accuracy to have the examination performed locally at the GP’s office. Hence, the high patient satisfaction reported in the present study may be explained merely by the availability of the test and patient expectations that the GP will take an active diagnostic approach in the consultation [
26‐
29]. However, a POCUS examination is not a replacement for the traditional comprehensive ultrasound examination performed by an imaging-specialist [
30,
31]. POCUS examinations are typically restricted to ruling in or ruling out a specific condition e.g. the presence or absence of a gallbladder stone, without exploring the surrounding areas. The premise for POCUS is that it is an abbreviated procedure, acceptable for the purpose. POCUS is superior to traditional ultrasound examinations in terms of accessibility, speed and availability, but it is inferior in terms of range and its ability to rule out disease [
30]. Awareness of the limitations and communicating the differences between the two examinations is important to avoid false expectations about what the examinations can provide. We found that not all patients reported having received such information. This might confirm the findings from the preceding qualitative study [
22], where GPs reported that, despite informing patients about the limitations of POCUS, they felt unsure about whether patients understood the differences between a specialist’s and a generalist’s examination. A perception gap between the information provided and the patients’ understanding of the information has been found regarding other tests too [
32].
The GPs in our study all used POCUS on a weekly basis. However, their training and usage varied a lot, resulting in different competence levels [
33]. Our study did not compare how this might have affected the patients’ perceptions of trust and confidence in the examination. Another possible explanation for high patient satisfaction with POCUS use is the reliance on diagnostic tests. Patients have been found to appreciate the use of point-of-care tests in general practice [
27] and to put a lot of emphasis on diagnostic tests [
26,
34,
35]without necessarily understanding their limitations, pitfalls and the potential unintended harms [
34]. Studies have found that for some diseases reliance on the traditional physical examination of patients is questionable [
36,
37]and patients, as well as doctors, may be aware of this. The mere availability of a diagnostic test may lead to wish-fulfilling medicine, where diagnostic examinations are performed upon patient request to meet patient expectations or to provide reassurance [
38]. GPs undertaking POCUS must be aware of this risk and communicate their medical reasoning to patients. However, providing reassurance for patients is both important and common in general practice [
39] and GPs have been found to use diagnostic tests to reassure themselves and patients [
35,
40]. Measuring dimensions of reassurance immediately after the consultation, we found that patients felt an increased trust in their GP and a sense of security. However, studies have suggested that the immediate reassuring value of pregnancy-related ultrasound is not long-lasting [
34,
41]and evidence does not support long-term reassurance by diagnostic tests [
42,
43].
The diagnostic accuracy of a test and the pre-test probability of a condition have to be taken into account before GPs and patients can actually be assured that a diagnostic test (including POCUS) can, with reasonable certainty, rule in or rule out a condition [
45]. GPs performing POCUS must be aware of this and the potential false reassurance that having a POCUS examination may provide for patients and themselves. Likewise, GPs must consider the risk of overdiagnosis, overdetection and possibly overtreatment following the introduction of an additional test [
12,
45,
46]. Hence, GPs must continue to practice generalist medicine up to a certain level before handing the patient over to secondary care, informing patients about the limitations and risks of point-of-care examinations and referring patients to imaging specialists in case of doubt.
Implications
The increasing pressure on general practice in terms of more elderly and multi-morbid patients and more treatments transferred to primary care calls for faster and more precise diagnoses at the GP’s office. POCUS may be a valuable tool in this respect, but prudence must be exercised to ensure the quality of the examinations performed by GPs and the correct allocation of health care resources. The availability of high-resolution, affordable and portable ultrasound devices, together with the introduction of POCUS training in medical schools [
47,
48] and residency programmes [
49], makes it plausible that POCUS will be more commonly used in general practice in the future. This study suggests that patients appreciate POCUS use in general practice, however, a thorough evaluation of POCUS use should include an evaluation of experience of care, population prognoses and health and cost of care [
50]. Although recent studies describing the use of focused POCUS in general practice have reported promising results [
12], more high-quality research is needed to evaluate the diagnostic precision and impact of POCUS use in general practice including the patients’ prognoses and the impact on the health care sector as a whole.