Is Stethoscope an Obsolete Instrument?

Ever since the development of a stethoscope by Laennec inFrance in 1816 it has been constantly modified by several persons who includeArthur Leared in 1851 and George Philip Cammann in 1852 to give its presentlook of a 2-piece instrument. A medical doctor looks incomplete without astethoscope hanging and drooping from his shoulders.  Even patients who come with complete work updone including most relevant investigations, which include an ECG, X Ray chest,echocardiography, coronary angiography , MRI and CT scans for an opinion  regarding further treatment or a secondopinion would expect a full clinical examination including auscultation of theheart and chest using a stethoscope.

In fact, I have had several instances when a patientreferred for coronary angiography after a complete work up including a stressechocardiogram or a nuclear scan, and having taken an appointment for admissiongets very disappointed if he is not examined clinically included auscultationof heart using a stethoscope. I also remember a few occasions when patientrefused to get admitted and changed his doctor because of this inadequacy.

   

As a part of medical education in medical schools, studentsafter their basic training in anatomy, physiology and biochemistry are coachedin the art of medicine which involves emphasis on history taking and physicalexamination. The physical examination is a study of the patient using one’ssenses with reliance upon physical touch for interacting with the patient. Forthis taking help of instruments like the stethoscope is an intimate part. Iremember the great feeling I got when I went to hospital wards in my 3rd yearof MBBS training, wearing a stethoscope around my neck and appearing as an iconof our noble profession.

During the last few decades the science of ultrasonographyis rapidly replacing clinical examination and especially listening to theheart. In the field of cardiovascular medicine echocardiography along withdoppler study is a very cost effective and very frequently used method despitethe development of many other sophisticated technologies. Ultrasound machinesover a period of time with the development of fast microprocessors andminiaturization have become really small and can be easily kept in a pocket orhphysicians’ bag. Some machines are of the size of a smart phone and are comingdown in costs very significantly. Trend is changing fast in western countriesand to some extent in urban India where their use is becoming more widespread.Intensivists and anaesthesiologists are using these miniaturized devices aspoint of care ultrasound machines.

Well planned studies have shown that the diagnosticultrasonography performed by first year medical students can be superior tobedside physical examination performed by university certified cardiologists inidentifying cardiac abnormalities. As the use of and training in point of careultrasonography has grown in medical specialities, medical schools are thinkingof starting to make it a part of undergraduate curriculum to instil it as ateaching tool to enhance their diagnostic skills. This could also become anadjunct to traditional teaching of anatomy and physical diagnosis and representa transformative change for medical training. Several medical schools in USAhave started ultrasound training in the undergraduate curriculum starting fromanatomy and physiology in first year itself and continue it into clinicaltraining and correlation with physical examination and problem-orientedtraining. The miniaturizing of these machines is really remarkable and thesemay become even smaller than our current cell phones. Additionally these arelikely to incorporate the facility of amplifying lung sounds, heart sounds,murmurs, bruits and bowel sounds etc.

The down side of these developments is that misdiagnosis ispossible by partially trained newcomers giving sometimes a false sense ofsecurity by under diagnosis or raising unnecessary alarm for a wrong or overdiagnosis. Cardiology residents after full clinical training need at least 6 to8 weeks for getting a basic training in echocardiography. Another issue isthese devices given in the hands of students and residents can distract themfrom the value of learning the basic principles of physical examination.

There are some issues in that as a general rule most newtechnologies start their origin from above downwards in hierarchy. After theaccomplished clinicians and Professors use it or see it being used then only anod is given to the younger physicians and trainees. If however medicalstudents start learning this technology and go armed with this and itsdiagnostic powers their tutors and future examiners are going to desist it andmay call it cheating. This is because the history followed by clinical examinationis traditionally a prelude to investigations like X ray, ECG and then comesechocardiography or ultrasound and Doppler. This is the system practiced in ourteaching institutions both for Doctor of Medicine, DM (University teaching) andDiploma of National Board, (DNB) and also while evaluating students inexaminations.

The issue of replacing the stethoscope with ultrasoundmachines cannot be a debate of any sort in our country where the public healthsystem is very different from the countries where this debate is possible andis on-going. This is because of the widespread availability of technology inthe health sector in those areas. The healthcare system in our country isorganised into primary, secondary, and tertiary levels. At the primary level areSub Centres and Primary Health Centres (PHCs). At the secondary level there areCommunity Health Centres (CHCs) and smaller Sub-District hospitals. Finally,the top level of public care provided by the government is the tertiary level,which consists of Medical Colleges and District/General Hospitals. Ultrasoundor echo machines of very variable quality are available at district hospitalsand General hospitals. The quality of these machines is very variable and theclinicians handling them may not be able to interpret the images very well andneed to refer these patients to higher centres. In this situation awell-trained MBBS doctor after a reasonably good physical examination whichincludes using the stethoscope, coupled with an x ray and ECG reaches a goodworking diagnosis.

This has been going on since a long time. The number ofPrimary Health centres and the secondary and tertiary level centres hasimproved in the last 70 years after we became independent. In spite of this alarge segment of population has to depend upon semi-literate healers who mayhave spent some time observing doctors in dispensaries’ or practitioners ofother systems like Ayurveda, Unani and Homeopathy etc. Most of them invariablyhave not received any formal training and prescribe un necessary drugsespecially antibiotics and at times steroids indiscriminately. This practicecan lead to catastrophises. Making basic and well-trained graduate doctorsavailable in these remote areas should be the priority rather than getting highend equipment without trained users.

There is a unique personal relationship between a physicianand a patient which stems from the physician’s reliance upon physical touch todiagnose and interact with patients. There are case examples where listening tothe heart and lungs clinched the diagnosis even after an echocardiographyreport was available because the machines sometimes hear too much or cannotdifferentiate between different tones which only trained ears can make out. Theamalgamation of clinical signs and different clinical possibilities withjudicious use of machines can be accomplished by artificial intelligencetechniques, so much in vogue these days. The utility of a good physicalexamination and its interpretation based upon physician’s experience should setat rest the debate that Ultrasound and its miniaturizing is the only wayforward.

There is no doubt that these advances are very relevant butnot at the cost of so called “old fashioned” physical examination. Stethoscopeis here to stay for times to come not only in a country like in India but alsoin the most developed countries. In spite of the availability of moderntechnology a basic question that, whether it improves the medical care and iscost effective, needs to be answered. New is not always synonymous with better.

Dr Upendra Kaul is Chairman, Batra Heart Centre, BatraHospital and Medical Research Centre

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