Medical Matters: A Doctor without a stethoscope?

Stethoscopes have become a fashion item. Unlike when I started out as a junior doctor – when we carried our stethoscopes folded up in the pockets of a white coat – the current trend is to wear the diagnostic instrument around your neck.

The trend was summed up nicely by a letter writer to The Irish Times who said: "Seeing a middle-aged man wearing a suit and a stethoscope in the car park of a Dublin general hospital, I was caused to reflect on hospital doctors and their ubiquitous stethoscope scarves."

I suspect the "stethoscope as scarf trend" started in the US. Certainly from the time Michael Crichton's ER became the flagship medical soap, there has really been only one way to wear your stethoscope as a hospital doctor. But that may be all about to change, if recent predictions in a medical journal come to pass.

Parisian medic René Laennec invented the stethoscope in the early 1800s. The original consisted of a wooden tube and was more like an ear trumpet than the current design.

Listened to with just one ear, the original stethoscope resembled the monoaural instrument still used today to listen for a foetal heartbeat in women who are pregnant. The first flexible-tube stethoscope appeared about 1840, still with a single earpiece. The double tube, binaural instrument we recognise today appeared in the 1850s.

Evolution of medicine
Medical historians see the invention of the stethoscope as a key point in the evolution of medicine. Not only did it represent a huge step forward for diagnosis, but for the first time symptoms could be linked to clinical findings in a particular body system.

According to a recent editorial in the Journal of the World Heart Federation , we may be on the cusp of another evolutionary moment. Two cardiologists from the Mount Sinai school of medicine in New York say the world of medicine could be experiencing the final days of the stethoscope due to rapid developments with ultrasound devices.

They point out that several manufacturers now offer hand-held ultrasound machines slightly larger than a deck of cards.

“Mounting evidence suggests that compared with the stethoscope, ultrasound technology can reduce complications, assist in emergency procedures and improve diagnostic accuracy.”

They believe ultrasound can diagnose heart, lung and other conditions with more accuracy than the 200-year-old stethoscope. However, they acknowledge that the latest portable ultrasound devices cost several thousand euros compared with just hundreds of euros for even the most expensive stethoscope.

And to their credit they accept that a major switch to ultrasound is not financially feasible for those practising in developing countries.

Has point-of-care ultrasound proved its worth in scientific studies?

A clinic-based study of first-year medical students instructed in the use of ultrasound demonstrated they were able to detect pathology in 75 per cent of patients with known cardiac disease, where specialist cardiologists using stethoscopes could detect only 49 per cent.

Pocket-sized ultrasound devices were used by GPs in Norway to assess left ventricular function in patients with suspected heart failure.

Some 92 patients were assessed by GPs as well as cardiologists, and the measurements obtained with ultrasound by GPs correlated well with those obtained by the specialists.

This is how the editorial writers see the future: “Medical students will train with portable devices during their pre-clinical years, and witness living anatomy and physiology previously available only through simulation. Their mentors will increasingly use point-of-care ultrasound in clinical environments to diagnose illness and guide procedures. They will see more efficient use of comprehensive, consultative ultrasound as well . . . not limited by physical examination alone.”

Personally, I would be sorry to see the stethoscope disappear. Perhaps, just as vinyl records are seen by some as producing the truest sound, might some clinicians cling to the familiar acoustics of the stethoscope?

Not to mention their value as scarves.

mhouston@irishtimes.com
muirishouston.com