Stethoscope

While diagnostic technology continues to advance, the stethoscope remains the primary tool used at the bedside for the physical exam.

One of the most critical aspects of a physician’s role is the ability to diagnose patients correctly. If they cannot identify a patient’s disease with accuracy, they cannot effectively treat the patient — and may even cause greater harm.

Take a look back at medicine in 1816. A physician is evaluating a patient with shortness of breath. The common practice of the time was to listen to sounds from the heart, lungs, or other organs by placement of the practitioner’s ear on the patient’s chest. At the time, many criticized this technique as providing little insight into the patient’s condition, as well as being out of usual social standards.

Later that same year, a French physician named Dr. Rene Laennec invented the stethoscope, which dramatically improved the physicians' ability to listen to the patient's chest. He spent the remainder of his career learning how the stethoscope could detect various chest problems, and educating on the utility of this new technology. The accumulation of his works resides in his text De l’Auscultation Médiate, which is one of the most widely translated medical texts in history.

Now, just over 200 years later, it is incredible to think that this technology has not been reinvented — especially when you compare the advances humankind has made in other areas. We have gone from the horse and carriage to cars that can practically drive themselves, from the notepad to the electronic tablet, and can now communicate anywhere on the globe regardless of language or distance. In healthcare as well, we have drastically altered our ability to monitor and treat our patients.

While diagnostic technology continues to advance, the stethoscope remains the primary tool used at the bedside for the physical exam — despite its widely known inaccuracies.

For example, a recent study demonstrated troubling results regarding the ability of the stethoscope to detect common cardiac events with a reported accuracy of 20 to 40 percent. Even amongst cardiologists, the accuracy of the stethoscope is poor.

Accepting these shortcomings is imperative for us to innovate. When you compare the scrutiny that we require all modern medical monitors to achieve for their accuracy, why do we not seek a similar level of accuracy when we discuss the tools we use for our physical exam? Fortunately, technological advances have recently allowed for new technology to be considered for the physical exam: point-of-care ultrasound (POCUS).

The utility of POCUS has been demonstrated for nearly every type of physical exam including cardiac, pulmonary, neurologic, pulmonary and abdominal.

Sadly, the utility for POCUS to facilitate acute care management has mostly been used in emergency medicine (EM). This has been viewed with some criticism given the fact that patients have the same diseases or disorders in multiple patient care settings. From a patient care standpoint, why should the skillset for bedside evaluation change merely because they transition from the emergency room to a different acute care setting?

Fortunately, the use of POCUS to improve patient care in non-EM environments is starting to emerge rapidly. Recent research has demonstrated a positive clinical impact in these new environments as well. While it is encouraging to see the growth of POCUS, there is much more that can be developed. The certification and educational processes for the non-ED setting are currently limited — but the concept is growing.

A collaboration of academic programs including Loma Linda University Medical Center, UCI Medical Center and UCLA Medical Center are working together to help address the need for education and training on this topic through research and workshops.

One such curriculum termed F.O.R.E.S.I.G.H.T. (Focused perioperative Risk Evaluation Sonography Involving Gastro abdominal Hemodynamic and Transthoracic ultrasound) has been published as an effective strategy for education. This curriculum is now online, and is free to access. Additionally, training workshops on this curriculum are now available as well.

This is just one initiative to further the development of POCUS. Additional online resources available for education on POCUS include those from the Society of Critical Care Medicine and American Institute of Ultrasound.

While these resources serve a key role, the responsibility is on all acute care specialties to develop structured guidelines, endorsed educational pathways, and credentialing processes to incorporate this new assessment tool into everyday practice.

To draw back to the works of Dr. Laennec, in 1834 (18 years after his innovation), the Times of London reported that the medical profession was unlikely ever to start using the stethoscope, “because its beneficial application requires much time and gives a good bit of trouble.”

Clearly, Dr. Laennec’s efforts have proven this statement to be false. Now, we are at the same crossroads with the stethoscope and point-of-care ultrasound.

—Davinder Ramsingh, MD, is an anesthesiologist at Loma Linda University Medical Center.