A Google Images search for “doctor” reveals essentially the same picture: a doctor wearing a crisply ironed white coat with a stethoscope draped, scarf-like, around the neck. The only difference between the images is the actual doctor—man or woman; white or black or Asian. The stethoscope sits like a fashion accessory on all of them, ear pieces over one shoulder, chest piece over the other. I grew up with a pediatrician father and never saw doctors wear their stethoscopes like this until shows like ER and Scrubs. Today, in my hospital, this stethoscope-as-shawl is the standard fashion among doctors who trained from 1990 onward. But older doctors, like my father, still have the ear pieces meet at the back of the neck, like the clasps of a necklace. They project the notion that they were just using the stethoscope and can use it again at a moment’s notice. When children play doctor with each other, they listen to the chest with a toy stethoscope, take a blood pressure with a small hand pump, look into the mouth and eyes with a fake light, administer painless shots, and test reflexes with a plastic hammer. The child doctor touches the child patient throughout the exchange. There is almost no talking and, of course, there is no documentation of exam findings. In my clinic, I devote, at most, 10 percent of my time with patients to the physical exam. The rest of the time is spent talking or typing. Yet patients seem to want the child’s version of a doctor’s visit. Because I specialize in the rarest forms of kidney diseases, most of my new patients are seeking a second or third opinion. In the context of criticizing their previous nephrologists, these patients often tell me that the last doctor didn’t even examine them. “Well, we examine patients in this office,” I say—as much for the patient as for any medical student, resident, or fellow shadowing me. Indeed, for many doctors (myself included), the stethoscope exam has become more ceremony than utility. A colleague, considered one of the best clinicians in the hospital, recently asked me if he could borrow my stethoscope for his clinic. He’d left his in the car. I confessed that I was using an isolation stethoscope, which is a flimsy, disposable, toy-like stethoscope that the hospital stocks for patients who are on isolation for infectious reasons. A doctor could put one end of a paper towel roll against a patient’s chest and the other end against his or her ear and get roughly the same level of auscultation as these isolation stethoscopes provide. “Can I have it?” he asked. “Sure,” I said. “I can just grab another one out of the utility room.” He put the isolation stethoscope around his neck. “Patients expect you to have one of these things,” he said before walking away. The first stethoscope was not that different from a paper towel roll. Its inventor, Rene Theophile Hyacinthe Laënnec, had grown uncomfortable with the technique of immediate auscultation—which is when the doctor places his ear directly on the patient’s chest—and found inspiration in watching Parisian children playing a game in which they sent signals to each other using a long piece of solid wood and a pin. In Laennec’s own (French-translated-into-English) words: In 1816, I was consulted by a young woman laboring under general symptoms of diseased heart, and in whose case percussion and the application of the hand were of little avail on account of the great degree of fatness… I recalled a well-known acoustic phenomenon: if you place your ear against one end of a wood beam, the scratch of a pin at the other end is distinctly available. It occurred to me that this physical property might serve a useful purpose in the case I was dealing with. I then tightly rolled a sheet of paper, one end of which I placed over the precordium and my ear to the other. I was surprised and elated to be able to hear the beating of the heart with far greater clearness than I ever had with direct application of my ear. Two centuries later, a physician who tries to make a diagnosis based on the stethoscope exam is as anachronistic as a baseball scout who watches prospects rather than poring through all of their advanced statistics. During my intern year, I wrote an essay about the dying art of the physical exam that was published in the New England Journal of Medicine. I used myself as an example and confessed that my exams, during early morning hospital rounds, were less than 30 seconds. I divulged the secret of the “intern’s spot,” the magical area on a patient’s chest where breath, heart, and bowel sounds can all be heard in record-short time. And I relayed a case of calciphylaxis, a rare complication of kidney failure in which the skin necroses at a rapid and fatal rate. The smell of dying, rotting skin was unforgettable. The intended message of the piece was that as one part of my patient encounter was dwindling (the expected stethoscope exam) another unexpected part was improving (the equally important olfactory exam). The essay was misinterpreted, though, and has been reprinted in a number of medical school syllabi (including my own) to defend the importance of the stethoscope—and by extension, the full physical exam—to medical students. The stethoscope isn’t a tool, anymore, but a metonym for bedside manner. Today’s medical literature reveals a critical debate about the stethoscope’s place in modern medicine. Can new technology restore the equipment’s place among a doctor’s armamentarium, or should we consign the stethoscope to an old-fashioned doctor’s bag, right next to a tuning fork, as a relic of physicians past? A search of PubMed, the National Library of Medicine’s digital catalogue, for recent articles about stethoscopes results in either performance evaluations of electronic, acoustically enhanced stethoscopes or investigations into how stethoscopes are a route of healthcare-associated infections, transmitting microbiota from patient to patient. These latter articles question, sometimes directly, sometimes indirectly, whether the ceremony of the stethoscope exam should continue if it comes at the cost of nosocomial infections. Some hospitals have encouraged their doctors to stop wearing neckties, long sleeves, and even the white coat itself to prevent such infections. Would these same hospitals someday outlaw the stethoscope, too? When the poet Claudia Rankine wrote about “a truce with the patience of a stethoscope,” she couldn’t have been thinking of the way my colleagues and I use our stethoscopes. My daughter, listening to our 4-year-old neighbor’s heartbeat with her toy stethoscope, is more patient with her doctoring than any doctor I’ve seen in my hospital. “I can hear it,” she says with a smile, her hand cupping our neighbor’s chest. “I can hear your heart,” she whispers to her friend, as if they’ve both shared a magical experience. I witnessed this doctor play just a few weeks after my father had visited to examine my infant son, whom my wife and I had self-diagnosed with croup. We called up my father and let him hear my son’s barking cough over the phone. He agreed with the diagnosis. “He may need steroids,” my father said over the phone. “Do you hear any stridor or wheezing?” Not trusting my or my wife’s physical exam skills, he offered to come over. We promised to feed him lunch as a thank you. “Here you go, Bampa,” my daughter said as he entered our home. She handed him her toy stethoscope, which is one of the plastic, isolation stethoscopes from my hospital. “Let Bampa eat first,” I said. “No, let me examine him first,” my father said, donning the stethoscope, putting in the ear pieces, gearing up like an athlete in pre-game warm-ups. My daughter stood by her grandfather’s leg and looked up in awe at him. That expression on my daughter’s face, and the hope that patients continue to look at their doctors with the same reverence, makes me hesitant to give up my stethoscope. Source
