The death of the stethoscope: murmurs of discontent
Technology-creep is to blame for mediocre physical diagnosis skills, says one gastroenterologist
From the December 1998 ACP-ASIM Observer, copyright © 1998 by the American College of Physicians-American Society of Internal Medicine.
By Michael Kirsch, FACP
No instrument is more closely linked to the medical profession than the stethoscope. This simple device has been connecting doctors to patients since its invention in 1816. In a sense, the stethoscope is an umbilical cord through which physicians transmit true healing to their patients.
Having been on both ends of the stethoscope, I understand how patients feel as their doctor presses the instrument firmly against the skin and quietly listens to various internal clicks and rumbles. Although no words are spoken, a message of caring and concern is communicated.
Why, then, have today's doctors abandoned their ability to use stethoscopes?
A study published in the Sept. 3, 1997, issue of The Journal of the American Medical Association found that medical students, interns and residents accurately identified only about one fifth of abnormal cardiac sounds. Moreover, there was little improvement seen in the residents' skills as they advanced in their training programs.
The culprit here is likely technology-creep, which has permeated not only cardiology, but the entire medical field. Every medical specialty can cite examples of technology stultifying physical diagnostic techniques and history-taking skills. Even psychiatry, perhaps the least techno-dominated medical specialty, may surrender important bedside diagnostic acumen if PET brain scans and their offspring assume a routine role in managing mental illness.
My own specialty of gastroenterology is no exception. Like the stethoscope, the art of abdominal examination has been supplanted by a variety of radiologic imaging techniques. These days, abdominal CT scanning and ultrasound have largely replaced the probing hands of yesterday's experienced diagnosticians. Contrary to classic medical teaching, which dictates that we see the patient first, doctors routinely review scan results before ever conducting a physical exam.
This trend raises disturbing questions about who will be capable of teaching the next generation of doctors the nuances and the value of physical diagnosis. It is not enough for physician role models and mentors to preach palpation and percussion to young physicians while they practice medicine in the fast lane. Should we lament the disappearance of anachronistic diagnostic skills and techniques, or celebrate today's superior technological advances?
In the foreseeable future, doctors will practice telemedicine, a hands-off style of medicine whereby physicians in New York can treat patients they have never met in California. Virtual reality technology will soon allow surgeons to operate on patients using computer controls from a distant location. This futuristic style of medicine is crowding out old-fashioned healing.
Technology has its price. Let's remember that technology, like many good medicines, has serious side effects. For example, having prior knowledge of radiology results prejudices the doctor's bedside physical examination, because the physician knows the finding in advance. This perpetuates a cycle of mediocrity in our physical examination skills. Physical diagnosis, while still practiced, has been devalued.
If I were experiencing abdominal pain on a desert island (or even in a doctor's office), I would want to see a gray-haired gastroenterologist rather than a fresh recruit. Of course, the hoary practitioner may not be conversant with the latest generation of endoscopic gadgetry, but he would probably still remember how to examine an abdomen. Every abdomen—and this holds true with all aspects of the physical examination—should be examined as if a significant finding is waiting to be uncovered.
The erosion of our physical diagnostic skills is a predictable and inevitable outcome of today's technological medicine. Techno-medicine is routinely criticized for its high cost and false-positive test results that can lead to a tidal wave of additional tests. Medical technology, however, also threatens the doctor-patient relationship.
Doctors have been taught for generations that the patient's medical history is paramount. Our reliance on technology, however, impairs our ability and our enthusiasm to obtain this information. In the midst of questioning a patient with intestinal symptoms, for example, I have caught myself mentally reviewing my procedure schedule to determine when a colonoscopy can be arranged.
This premature intrusion of techno-thought interferes with what should be a methodical inquiry of the patient's history. The hypothetical doctor on the desert island, not facing this distraction, can focus exclusively on listening to the patient and might actually solve the clinical problem the old-fashioned way.
Technology may also serve as a convenient "exit strategy," allowing physicians to circumvent uncomfortable or frustrating discussions with patients. For example, it's a lot easier to order a stress test than it is to sit down and discuss stress management with a patient.
Yet it is the health of the doctor-patient relationship that often determines whether healing will occur. This relationship is largely forged when patients are being interviewed and examined. Doctors who still use their ears and hands as their primary diagnostic instruments establish and nurture strong connections with their patients. The rest of us have allowed technology to become another wedge that divides us from our patients.
I am not crusading against progress. We all applaud the extraordinary benefits that medical technology has brought to our lives. However, we must also recognize that technology threatens important humanistic elements of the doctor-patient relationship. Our embrace of medical technology has taken us too far away from the bedside.
Patients want a doctor to whom they can talk. They beseech us to listen to them. How can we learn to do this better? Perhaps the stethoscopes dangling around our necks or stuffed into our pockets can remind us of this mission. The stethoscope, after all, is a listening instrument. Let it show us doctors again how to truly listen and not just hear.
Dr. Kirsch, a practicing gastroenterologist and freelance author, lives in Highland Heights, Ohio.
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