Ultrasound and Physical Examinations for Obese Patients—Reply

In Reply: We agree with Dr Dixon that technological advances, such as sonoscopes, may be able to alleviate some of the limitations of the physical examination for obese patients. However, we have concerns about the potential widespread use of the sonoscope in routine clinical practice. For example, handheld ultrasound machines have not yet been well studied, especially in the generalist's hands. The quality of an imaging test depends on the performance and the interpretation, and sonography is a difficult imaging technique to master.¹ If an examiner has a suspicion about an abnormality on physical examination, it may be preferable to order an ultrasound study performed by someone who is properly trained. Another problem with sonoscopes is the cost. Although the price of a handheld device has decreased over the past several years (in 2003 the cost was more than $15 000 compared with present-day costs that range from $4000 to $10 000),² the cost remains high. For many clinical settings, the marginal benefit of the added diagnostic information likely does not justify the added cost of the device, the time it adds to the physical examination, or the cost of false-positive and incidental findings requiring additional follow-up.