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," of Scripps Translational Science Institute in La Jolla, Calif., recently .
Two Mount Sinai physicians, , and , agreed. Last year they wrote that ... 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."
However, another Mount Sinai physician, the distinguished cardiologist , disagrees with his colleagues. In an editorial in the Journal of the American College of Cardiology, Fuster warned 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 wrote, "allow us to physically listen to the sounds of the body." He cited several clinical scenarios in which the stethoscope "remains essential."
Fuster pointed out additional limitations to ultrasound, including the risk of misdiagnosis, false-positive, and false-negative findings by poorly trained users. He concluded: "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."
, a cardiologist at George Washington University in Washington, D.C., who trained at Mount Sinai, took a more balanced position, noting that "stethoscope versus ultrasound is a traditional time-honored debate between the masters and the techy newbies."
Future physician Sabrina Ryan developing her auscultatory skills. Will they still be useful when she becomes a doctor? (Photo courtesy of John Ryan)
, of the University of Utah in Salt Lake City, father of the young stethoscope student pictured here, said that "the demise of the stethoscope is overstated."
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," he noted. "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."
And in addition to its role in the heart, Ryan said, 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 the face of ever increasing medical knowledge), and the tendency to defer the diagnosis to echocardiography examination have not allowed our trainees to master this art. Finally, conditions in which the stethoscope has a unique value are becoming fewer and 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 has 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 -- the 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 PUPEDs, or Portable Ultrasound as a Physical Examination Device. It allows physicians to spend time with the patients improving the patient-doctor relationship, which has become almost rare. It is not expected to increase referrals to imaging investigations; it will decrease the referral of false positives and increase the numbers of true-positive referrals.
"Let me provide an example. A patient presents with shortness of breath. You have [portable ultrasound] 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."