Some Come To Bury The Stethoscope, Some To Praise It

Is the stethoscope still an essential tool of modern medicine or is it an obsolete low-tech vestige of an antiquated era? There is, to say the least, a wide variety of opinions on the topic.

On the one hand, technology enthusiasts argue that the stethoscope should be replaced by portable ultrasound devices. “The stethoscope’s 200th birthday should also be its funeral,” Eric Topol (Scripps Translational Science Institute) recently tweeted.

Two Mt. Sinai physicians, Jagat Narula and Bret Nelson, agree. Last year they wrote that ultrasound “has become the stethoscope of the 21st century…. there is evidence that ultrasound is more accurate even than chest x-ray in the detection of pneumothorax, pleural effusion, and perhaps even pneumonia. Ultrasound allows visualization of cardiac valve function, contractility, and pericardial effusions with greater accuracy than listening with the stethoscope. And beyond the heart and lungs lie dozens of other organs and structures- well-described in the literature of point of care ultrasound- which are opaque to the abilities of the stethoscope.”

On the other hand, another Mt. Sinai physician, the distinguished cardiologist Valentin Fuster, disagrees with his colleagues. In an editorial in the Journal of the American College of Cardiology Fuster warns against over-reliance on advanced technologies like ultrasound: “As clinicians, we need to continue to interact with our patients, listen to their histories, their lifestyles, and their bodies— the last of which is where auscultation continues to play a dynamic role in our daily practices.” Stethoscopes, he writes, “allow us to physically listen to the sounds of the body.” He cites several clinical scenarios in which the stethoscope “remains essential.”

Fuster points out additional limitations to ultrasound, including the risk of misdiagnosis, false positive, and false negative findings by poorly trained users. He concludes with a question: “what if a physician comes upon a sick person in the street and hasn’t received the proper training for a physical exam? Does she or he have to abandon that sick individual? We cannot teach our medical students to become reliant upon advanced technologies without which they become useless.”

Brian Choi, a cardiologist at George Washington University who trained at Mt. Sinai, took a more balanced position, noting that “stethoscope versus ultrasound is a traditional time-honored debate between the masters and the techy newbies.”

Dr Ryan Junior

Future physician Sabrina Ryan developing her auscultatory skills on Lambie. Will they still be useful when she becomes a doctor?(Photo courtesy of Dr. John Ryan)

John Ryan (University of Utah), father of the young stethoscope student pictured above, said that “the demise of the stethoscope is overstated.” He notes that cardiology clinics often “get referrals for ‘new murmurs’, which can vary in pathology from being innocuous flow murmurs to sinister diseases such as aortic stenosis. The variability is remarkable even though we have 200 years of experience with this device and have training programs that emphasize their use. I would be concerned that if point of care hand-held echocardiograms are to propagate without adequate training, we will be seeing a lot more referrals for ‘new regurgitant lesions’, which reflect normal pathology, for example trivial mitral or tricuspid regurgitation.”

Ryan said that in addition to its role in the heart, the stethoscope “plays important roles in diagnosing and triaging acute lung diseases, such as asthma exacerbation, pneumothorax, and then also plays a role in assessing acute abdominal pathology.”

“If my girl does decide to go to medical school (or become a vet),” Ryan concluded, “I think the stethoscope will continue to play a role in her training and in her career. For now at least, Lambie is safe and was reassured that she had an innocent flow murmur.”

 

Narula: The Case For Ultrasound

Responding to the Fuster editorial, Narula sent the following argument in favor of ultrasound.

The stethoscope is very much alive for master clinicians like Drs. Valentin Fuster, Roman DeSanctis, Paul Wood and Proctor Harvey but my fear is that it is becoming more of a vintage accoutrement for the current generation of trainees. Cardiology fellows and other physicians are not well versed with the use of stethoscope and concerted efforts to make them more facile have not yielded great results. It may be that, as with many arts, some are gifted auscultators; most others need to practice for decades to reach there – a luxury which they don’t have; dwindling teaching skillset, minimum time available for learning physical examination (in face of ever increasing medical knowledge), and the tendency to defer the diagnosis to echocardiography examination has not allowed our trainees to master this art. Finally, conditions in which the stethoscope has a unique value are becoming fewer & fewer and when rigorously tested, it seems to have an inferior performance in most clinical decision needs. Realizing this, there is nearly no clinician who recommends invasive therapy without confirmation (both diagnosis and quantitation) through imaging, mainly echocardiography.

I have been trained in the stethoscope culture and am greatly nostalgic about its role. I am very good at auscultation – in fact, I had to be good since our graduating exam format (in my time in Medical School and Residency) called for us to make a bedside diagnosis; making one mistake with the stethoscope meant failing the exam. But technology have rapidly evolved and I had to reluctantly concede that bedside echocardiography diagnoses many more abnormalities with more certainty than the stethoscope can ever match.

Rene Laennec developed a stethoscope (stethos= chest, scope= to see) with the intention that auscultation would allow a physician to indirectly look into the chest as there was no other means for thoracic examination. Now that we have ultrasound (a true stethoscope), the original name to a listening device seems to be a misnomer; stethoscope should have been called a stethosphone! We have proposed that students use handheld ultrasound for learning physical examination and not use it as definitive diagnostic device. I call them as PUPEDs or Portable Ultrasound as a Physical Examination Device. It allows physicians to spend time with the patients improving patient doctor relationship which has become almost rare. It is not expected to increase the referral to imaging investigations; it will decrease the referral of false positive and increase the numbers of true-positive referrals.
Let me provide an example. A patient presents with shortness of breath. You have a PUPED and you look at leg veins, inferior vena cava, effusion in lungs, pneumonia, rocket lines for heart failure, water around the heart, poorly contracting heart and substantially leaking valves. You have made all diagnosis at the bedside in 10 minutes and can decide whether to send him for a test (which, when, why) or just send him home. You save patient visits and you should save money, and imagine patient satisfaction. Let’s review a non-cardiac example. Midwives in a research study in Ghana evaluate high risk pregnancies with breach presentation, multiple pregnancy, cord around the neck and placenta previa. All these conditions that could result in dire maternal and fetal consequences are referred to hospital. Safe pregnancies can be delivered at home. Midwives have been trained readily and it is easy to evaluate such high-risk ultrasounds.

Seeing is believing. We must move on with new technology; the newer generation is tech-savvy and can easily adapt to this advance.

 

 

 

Comments

  1. Speaking as a cardiologist who specializes in echocardiography and a busy clinician, I believe the stethoscope is not dead and should not be replaced by portable ultrasound.
    Personally, I plan on obtaining and using a portable ultrasound device for my own practice and using it selectively in the near future. However, I fear the consequences of widespread usage of hand-held ultrasound in the poorly trained.
    The issues are going to be false-positive diagnoses and over diagnoses of insignificant abnormalities that experienced and well-trained echocardiographers would not make.
    Minor, physiologic valve leakage, normal variant anatomic anomalies such as fatty infiltration into the right atrium or atrial septum and numerous other variations of normal could lead to vast downstream testing and danger to patients.
    I’ve written about the dangers of including echocardiography as part of cardiovascular screenings (http://theskepticalcardiologist.com/2015/12/13/are-ssm-and-healthfair-cardiovascular-screenings-promoting-wellness-or-unwellness/) and the hand-held devices would be just as bad in the wrong hands.
    I use my stethoscope every day and it is only rarely that I wish I could get a quick echo picture of my patient’s heart.
    The stethoscope is useful for new rubs from pericarditis and new murmurs in patients. It’s often the only way one can detect the murmur of a small VSD. Wheezes and rales heard in the lung are not detected by ultrasound devices.
    Those who would bury the stethoscope, I suspect, do not take the time to listen to their patient’s heart and lungs and to use that information appropriately.

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