Ultrasonografie Domeindiscussie
Echografie huisarts
Er vindt op het ogenblik (weer) een debat plaats over de rol van echografie door de huisarts. Om de zoveel tijd komt de discussie weer naar boven. Nu de Volkskrant opensla valt mijn blik op een Opiniestuk van een radioloog uit Amsterdam. Misschien komt het door de titel ” Niet iedereen kan een echo maken” dat ik mij geroepen voel hier over iets te melden? Dat zal vast wel….
Opiniestuk Volkskrant 04 september 2010
Diagnostiek
Toen de auteur als jong internist zijn praktijk begon in Hardenberg (1979), werkte daar ook Dr. Jan Wildschut, gynecoloog van naam en faam. Of het aan hem te danken was weet ik niet, maar er stond een lijvig echo apparaat van een van de eerste generaties (veronderstel ik). Als internist in een klein streekziekenhuis merkte ik dat de belangstelling van de locale radiologen voor echografie toentertijd minimaal was. Begrijpelijk want de apparatuur was uitermate primitief. Een onscherp zwart-wit landschap op een beeldschermpje.Het kwam in mijn gedachte op om af en toe in de spreekkamer zelf de probe te hanteren.Daartoe moest dit enorm grote muisgrijze Echo apparaat met statief en al verreden worden naar mijn polikliniek unit. Ik heb daar spaarzaam gebruik van gemaakt, maar kon toch bijvoorbeeld in spoedsituaties galstenen vaststellen en ook diagnostische puzzels (buikwand hematoom) oplossen. Het beeld was dermate schimmig, dat ik er alleen maar voor “eigen”patiënten (die ik zelf onderzocht) gebruik van maakte. Meestal probeerde ik de diagnose ook op meer traditionele wijze te bevestigen. In een latere fase van mijn loopbaan hoorde ik dat internisten in Duitsland heel vertrouwd waren met de de echografie. Ik heb nog wel overwogen een cursus te volgen, maar toen was de echografie inmiddels stevig in handen van de radiologie. Het was voor de radioloog ook een cashcow geworden….. Inmiddels was de techniek toen zodanig verbeterd, dat de diagnostische opbrengst ook veel hoger was en het er ook om ging anatomische variaties te herkennen en te onderscheiden van pathologie.
Ervaring
Dat vereist toch een brede expertise en routine. Ik kan een heel eind meegaan met de kritische reactie van collega Haanraadts wat betreft de noodzakelijke routine. Voor diagnostiek geldt in wezen hetzelfde als bij ingrepen. Als je er niet voldoende kunt halen (aantallen) en met voldoende moeilijkheidsgraad, kun je er beter afblijven. Dit zou je als indicator moeten inzetten. Maar ook het aantal herhalingsonderzoeken (doublures) vanwege alsnog verwijzing. Wel kan ik mij voorstellen dat aan dit bezwaar wordt tegemoetgekomen door slechts een enkeling binnen een grote groep hiermee te belasten. Daarnaast kun je denken aan ondersteuning op afstand, zoals beschreven bij teleradiologie. Blijft wel staan het punt van de hoge investeringskosten.
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Grappig om te lezen in het Magazine voor de Internist de quote (Dr.Arie Berghout, Maasziekenhuis, Rotterdam) op 13 april 2011 ‘Echografie is allang niet meer voorbehouden aan de radioloog’.
En naast de hoge investeringen: het tegengaan van de perverse prikkel èn het bewijs dat dit betere zorg tegen een lagere zorgconsumptie oplevert. Dus dat het zin heeft….