The stethoscope is maybe one of the most iconic items in medicine and health care. Draped around the neck or tucked into a white coat, this instrument symbolizes the knowledge and authority to heal of those wearing it. Invented less than 200 years ago by a French doctor, Rene Laënnec, it was initially a simple tube of paper. Laënnec found the previous method of applying his ear to the chest, especially that of a buxom lass, a bit uncomfortable for both of them. He solved the problem by rolling up a tube of paper to listen to her heart. He was pleased with the improved sound transmission and eventually went on to use a wooden tube, much like the old ear trumpets in order to hear the sounds of the heart.
Of course, the stethoscope has gone through many upgrades and improvements and is now bi-aural instead of mono-aural, fitting into two ears instead of one. The latex tubing and a specially designed diaphragm at the end allow physicians, nurses, EMT’s and others to listen to the various sounds the heart makes, including murmurs, as well as breath sounds, bowel sounds, and the sounds of blood in the vessels. It can also note the crunch of a broken rib, the wheezing of asthma, the rattle of heart failure, the harsh sounds of pneumonia, the size of an organ, fluid levels and can even be used as a reflex hammer if one isn’t available. It is a highly useful medical device but its days may be numbered as illustrated by the following story.
A patient of mine reported she was firing her cardiologist. I asked why as I had referred her to him and he was skillful with a good reputation. She reported that at a recent visit, he never even examined her, not once laying the stethoscope to her chest. By the way, in Greek stethos means chest and scopos means examination.
Well, this was her normal expectation for a full evaluation, a stethoscope being placed on her chest by the heart specialist. I knew the cardiologist had run several sophisticated tests such as an electrocardiogram, echocardiogram, stress test, and cardiac catheterization on this lady. It was unlikely he was going to find out much more by a simple auscultation of her heart. Yet, when it came down to it, she expected it and was upset and even angry that his bedside manner did not include this examination. In her case, high tech could not substitute for high touch.
As medical students and medical residents, before the advent of many of the current tools of cardiology and radiology, we were instructed closely about how to detect which sounds the heart made in health and in sickness. Clicks, rubs, murmurs, gallops, extra heart sounds and the like are still taught to medical students but no longer are as essential to making a diagnosis with the advent of other technical approaches. Recently one of my 2nd year students missed hearing a very loud aortic heart murmur. He could be forgiven because of inexperience. He heard something but wasn’t sure what it was. However, the troubling trend in contemporary medicine is not to believe your own ears, or even eyes or hands, but to depend on objective confirmation by some technology.
It is interesting that in my studies of Asian medicine, the stethoscope is not part of their tradition. Doctors examine the pulse in great detail. They listen to the sound of the voice, notice the color of the face, the tongue, the heat of body, the person’s odor, and so on with great detail. They often make astonishingly accurate diagnoses just by being good observers.
So the loss of the skills of using a stethoscope may be not only a negative to bedside manner but a symbol of an erosion of the powers of observation, so essential to the healing arts.
This may also be a chance for us to re-examine the importance of communication, contact, and compassion in the clinical encounter. A best-care model would have the high touch be aspects of a caring visit be present both before and after the ordering and reporting results of labs, X-rays, and other high tech diagnostics. Optimal care requires both high tech and high touch, and sometimes the old-fashioned symbols of healing.
Dr. Victor S. Sierpina is the WD and Laura Nell Nicholson Family Professor of Integrative Medicine and Professor of Family Medicine at UTMB.