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Is the Stethoscope Becoming an Outdated Diagnostic Tool?

      During the past hundred years, the 3 major symbols representing the bedside physician have been the “black bag,” the white coat, and the stethoscope. It was a badge of honor during my second year of medical school to obtain all 3 items in anticipation of seeing patients on the hospital wards after the preclinical lecture hall experience. The stethoscope dangling from the pocket of the white coat or wrapped around the back of the neck meant to the outside world that you were now a member of the healing profession.
      The “black bag” is no longer a physician symbol because house calls are no longer part of routine clinical care. Will the stethoscope also meet the same fate, given that handheld ultrasound devices have now become available to better define cardiac anatomy, hemodynamics, and pathophysiology?
      • Liebo M.J.
      • Isreal R.L.
      • Lillie E.O.
      • et al.
      Is pocket mobile echocardiography the next-generation stethoscope? A cross-sectional comparison of rapidly acquired images with standard transthoracic echocardiography.
      Since the time of its introduction in 1816, the stethoscope has been an invaluable bedside tool for auscultating heart sounds.
      • Weinbergo F.
      The history of the stethoscope.
      During the golden age of early 19th century French medicine, with the use of the stethoscope, the physical examination became an integral part of clinical assessment.
      • Nuland S.B.
      Rene Laennec, inventor of the stethoscope.
      Dr. René Laennec would become the leading proponent of this diagnostic approach. Laennec was a student of Dr. Jean-Nicolas Corvisart at the Charité in Paris, one of the leading teaching hospitals in Europe.
      • Nuland S.B.
      Rene Laennec, inventor of the stethoscope.
      Subsequently, as an attending physician at the Necker-Enfants Malades Hospital in Paris, Laennec introduced a cylindrical device, open at each end, to auscultate the thorax. He called this device a stethoscope, whose name derived from the Greek word for chest, stethos, and the word for observer, skopos.
      • Nuland S.B.
      Rene Laennec, inventor of the stethoscope.
      With his discovery, Laennec, an accomplished musician, was able to differentiate various diseases of the chest by physical examination and correlate his findings with autopsy studies.
      • Nuland S.B.
      Rene Laennec, inventor of the stethoscope.
      He reported on his work with the early stethoscope in the classic text De l'Auscultation Médiate,

      Laennec RTH. De l'Auscultation Médiate. London: T.G. Underwood; 1821 (French); Birmingham, AL: Classics of Medicine Library; 1979 (English).

      which was published in 2 editions. Ultimately, the cylindrical stethoscope was improved upon by Dr. George Cammann 40 years later, after the introduction of rubber, by introducing a device having hearing pieces that fit into the examiner's ears.
      • Peck P.
      Dr. Cammann and the binaural stethoscope.
      Other refinements included the bell to discern low-pitched sounds, and the diaphragm, to better hear high-pitched sounds. Most recently electronic stethoscopes with microphone amplifiers have become available. For almost 200 years the stethoscope, the first bedside diagnostic tool, has remained a central part of the thoracic examination. Many of the great clinicians made their reputations as masters of auscultation. Whether these physicians actually heard everything they claimed to hear was always a question.
      During my career in academic cardiology, the introduction of ultrasound devices has provided the ability to visualize both anatomic structures of the heart and to assess myocardial function, technologies going well beyond the capabilities of the stethoscope. Most recently handheld ultrasound devices, which can fit into the pocket of a physician's white coat, have demonstrated the ability to make more accurate diagnoses at the bedside when compared with standard examination using the stethoscope.
      • Mehta M.
      • Jacobson T.
      • Peters D.
      • et al.
      Handheld ultrasound versus physical examination in patients referred for transthoracic echocardiography for a suspected cardiac condition.
      In some medical schools students are being trained to use these handheld devices as part of their curriculum.
      • Panoulas V.F.
      • Daigeler A.L.
      • Malaweer A.S.
      • et al.
      Pocket-size hand-held cardiac ultrasound as an adjunct to clinical examination in the hands of medical students and junior doctors.
      Physicians working in the emergency room and critical care units are being trained on this technology.
      • Testuz A.
      • Muller H.
      • Keller P.F.
      • et al.
      Diagnostic accuracy of pocket-size handheld echocardiographs used by cardiologists in the acute care setting.
      Primary care physicians are also potential operators of these handheld devices.
      • Alpert J.S.
      • Mladenovic J.
      • Hellmann D.B.
      Should a hand-carried ultrasound machine become standard equipment for every internist?.
      • Rosenthal E.
      The odd math of medical tests: one scan, two prices, both high.
      The stethoscope may indeed be replaced by handheld ultrasound devices, at least for cardiac examination. It will still be necessary to use the stethoscope for pulmonary examination and for auscultation of the abdomen to hear bowel sounds and bruits.
      At present the handheld devices are expensive when compared with the cost of a stethoscope. However, their use could save money for the healthcare system if the need for conventional ultrasound studies or other diagnostic tests can be lowered.
      • Mehta M.
      • Jacobson T.
      • Peters D.
      • et al.
      Handheld ultrasound versus physical examination in patients referred for transthoracic echocardiography for a suspected cardiac condition.
      • Rosenthal E.
      The odd math of medical tests: one scan, two prices, both high.
      We may also see a return of the “black bag,” to store the handheld ultrasound devices when they are not being used.

      References

        • Liebo M.J.
        • Isreal R.L.
        • Lillie E.O.
        • et al.
        Is pocket mobile echocardiography the next-generation stethoscope? A cross-sectional comparison of rapidly acquired images with standard transthoracic echocardiography.
        Ann Intern Med. 2011; 155: 33-38
        • Weinbergo F.
        The history of the stethoscope.
        Can Fam Physician. 1993; 34: 2223-2224
        • Nuland S.B.
        Rene Laennec, inventor of the stethoscope.
        in: Doctors. Vintage Books, New York1988: 200-235
      1. Laennec RTH. De l'Auscultation Médiate. London: T.G. Underwood; 1821 (French); Birmingham, AL: Classics of Medicine Library; 1979 (English).

        • Peck P.
        Dr. Cammann and the binaural stethoscope.
        J Kansas Med Soc. 1963; 64: 121-129
        • Mehta M.
        • Jacobson T.
        • Peters D.
        • et al.
        Handheld ultrasound versus physical examination in patients referred for transthoracic echocardiography for a suspected cardiac condition.
        JACC Cardiovasc Imaging. 2014; 7: 983-990
        • Panoulas V.F.
        • Daigeler A.L.
        • Malaweer A.S.
        • et al.
        Pocket-size hand-held cardiac ultrasound as an adjunct to clinical examination in the hands of medical students and junior doctors.
        Eur Heart J Cardiovasc Imaging. 2013; 14: 323-330
        • Testuz A.
        • Muller H.
        • Keller P.F.
        • et al.
        Diagnostic accuracy of pocket-size handheld echocardiographs used by cardiologists in the acute care setting.
        Eur Heart J Cardiovasc Imaging. 2013; 14: 38-42
        • Alpert J.S.
        • Mladenovic J.
        • Hellmann D.B.
        Should a hand-carried ultrasound machine become standard equipment for every internist?.
        Am J Med. 2009; 122: 1-3
        • Rosenthal E.
        The odd math of medical tests: one scan, two prices, both high.
        The New York Times. December 16, 2014; (A22): 1

      Linked Article

      • Stethoscope: A Still-Relevant Tool and Medical Companion
        The American Journal of MedicineVol. 129Issue 5
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          We read with interest the editorial by Frishman1 entitled “Is the Stethoscope Becoming an Outdated Diagnostic Tool?” published in The American Journal of Medicine. The stethoscope and the semantics of auscultatory findings were invented more than 200 years ago by the French physician R.T. Laennec (Traité de l'Auscultation Médiate, Paris, 1819); over the years, very few changes have been made to either the stethoscope itself or the way in which it is used. More recently, we have seen advances in the techniques used to process auscultatory signals, as well as in the analysis and clarification of the resulting sounds.
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