The Stethoscope’s Quiet Eclipse

December 5, 2011

Laennec and the stethoscopeMy concerns about the stethoscope’s future began at lunch recently among a group of doctors where it was suggested that the revered icon had evolved as an ornament of clinical medicine – an iconic relic of medicine’s past.  Others around the table held firmly to the idea of the stethoscope as a critical diagnostic tool.  The contrast was striking.

The more I looked the more I found that the stethoscope’s story and the views of those doctors at lunch reflect a profession in transition.  The role of the stethoscope in modern practice raises the question:  How does the physical exam fare against the inevitable tide of diagnostic technology?

In the context of 21st century medicine it’s hard to appreciate the impact of the stethoscope’s 1816 invention by R.T.H Laennec.  At the time disease was defined by subjective symptoms (1).  The appreciation of body sounds and the ultimate correlation of those sounds with objective pathologic lesions set the stage for modern diagnostic medicine.  The stethoscope initiated a shift in the way we think about patients and disease.  This was the moment doctors went from observing patients to examining them.

But more than revolutionizing how we see disease, the stethoscope had a powerful effect on defining the medical profession.  It changed the way we see ourselves.  For those powerless to understand what was evolving within body cavities, the stethoscope put control in the hands of the physician.  And the bedside is where it happened.  Doctors practiced the art of medicine with their hands, ears and hard-worn skill established in the man-to-man clinical teaching of medicine.  The generations that followed spawned giants like Osler who’s capacity for bedside magic was legendary.

As a profession we had arrived.  But technology changes things.

Technology and the eclipse of auscultation

Initially a physician’s ability to diagnose and treat a patient was tightly dependent upon the subtle qualities of sound.  But as technology evolved, our dependency on bedside diagnosis lessened.  The rise of new diagnostic tools made physicians less dependent upon auscultation.  Ultrasound ultimately offered a qualitative cardiac exam superior to anything offered through a tube.  While the modern physician sees their stethoscope as a diagnostic tool, other more sensitive diagnostic modalities have dulled our capacity to understand clinical sounds.

It seems that the last generation that was truly dependent upon the stethoscope reached extinction at some point during the last century.  In 1993 Mangione reported in the Annals of Internal Medicine that only 37% of major cardiology teaching programs offer formal instruction in auscultation (2).  The median stethoscope accuracy among cardiology trainees in that study was 22% and that of medical residents was 19%.  Perhaps most revealing was the fact that a medical resident’s capacity to use a stethoscope was no better than that of the third year medical students.  Since Mangione’s publication in 1993 it would appear that there has been an increase in formal training of cardiopulmonary auscultation although the numbers fall short of what one would expect for a critical diagnostic tool (3).  So it would appear that if we wanted to learn auscultation it wouldn’t be an exaggeration to suggest there are few available to teach us.  And even if we learned it’s likely that we wouldn’t exercise our skill.

Of course the stethoscope is useful as are reflex hammers and tuning forks.  But it’s important to discriminate the stethoscope as a critical tool of diagnosis from the stethoscope as an instrument of simple, front line diagnostics.  For example, we have few equally cost effective tools to identify bronchospasm or a simple pleural rub.  It’s hard to imagine that an anesthesiologist would use anything other than a stethoscope to confirm appropriate placement of an endotracheal tube.  But these tasks cannot be compared to the critical decisions made using auscultation when it was the core diagnostic tool available to clinicians.

The stethoscope as an evocative object

What’s remarkable is that the stethoscope’s demise has been rather quiet.  Few physicians willingly acknowledge the modern eclipse of auscultation.  Perhaps our relationship with the stethoscope is emotional.  Like a comfortable piece of furniture in our environment, we seek comfort in our tools.  As futurist Kevin Kelly tells us, some of our hardest-working technology will ultimately achieve “beautiful uselessness.” (4)

MIT sociologist Sherry Turkle calls coveted pieces of technology “evocative objects.”  Beyond their instrumental power, simple pieces of technology like the stethoscope can serve as “companions to our emotional lives or as provocations to thought.”  Or as Turkle suggests, “We think with the objects we love; we love the objects we think with.” (5)

The argument for the stethoscope’s lasting power reflects the endemic insecurity of the 21st century doctor.  We pine for a simpler time.  Despite the changes happening around us, we wax nostalgic for the days when the ability to listen and feel offered the final word in a patient’s story.  We want to be connected to patients.  We want patients to depend upon us.   We resist the inevitability of technology because we want to remain relevant.  Despite where technology takes us, the stethoscope will represent an evocative symbol of what once was.

The fate of the stethoscope begs the broader question of what it is that doctors will do as technology advances.   As we lose our stethoscope and other components of the physical exam, how will we be defined?  The stethoscope’s eclipse does not predict the end of the profession it represents but instead foreshadows a dramatic change in how physicians are defined.  Just as with the stethoscope, physicians will be shaped by the relationship they share with the technology they create.

  1. Duffin, J.  1989.  The Cardiology of R.T.H Laennec.  Medical History. 33: 42-71.
  2. Mangione, S., L. Z. Nieman, E. Gracely, and D. Kaye. 1993. The teaching and practice of cardiac auscultation during internal medicine and cardiology training: a nationwide survey. Ann. Intern. Med. 119: 47-54.
  3. Mangione, S. Duffy, FD.  2003 The Teaching of chest auscultation during primary care training: Has anything changed in the 1990s.  Chest.  124(4):1430-6.
  4. Kelly, Kevin.  What Technology Wants (Viking, 2010).
  5. Turkle, Sherry.  Evocative Objects: Things We Think With (The MIT Press, 2011)
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{ 12 comments }

Jay Hochman December 5, 2011 at 2:32 pm

Bryan,
This a terrific post. I think that the medical history between doctor and patient remains quite powerful in making useful decisions. The technology has changed considerably and largely affects the physical exam. In cardiology, the stethoscope is overshadowed by multiple other imaging modalities. In gastroenterology, endoscopy is ubiquitous. One of my colleagues remarked that some “scope first, think later.” And, this is the downside of some of the technology. In many cases, excessive testing creates more questions than it solves or solves questions that didn’t need an invasive test to answer.

As Francis Peabody noted, ‘The secret of the care of the patient is in the caring of the patient.” (JAMA 1927; 88: 877-882). So while technology is important, I think listening, even without a stethoscope, is still what patients need the most from their doctors.

DrV December 5, 2011 at 4:12 pm

Indeed. I suspect that as technology becomes more advanced, this need or connection between doctor and patient will better defined and potentially more meaningful. Thanks for chiming in, Jay.

Bob West December 5, 2011 at 3:34 pm

Need to get a copy of this into every medical student’s hands! (Too late for most practicing Docs.. )

Chris Porter MD December 6, 2011 at 1:04 am

Spot on.

Lost my last stethoscope about three years into practice. Considered buying a new one but realized a loaner scope is within reach anywhere a surgeon could possibly need one.

Beyond tool and evocative object, the stethoscope was also a symbol of corruption for me. I was grateful for the gift when they gave me one on the first day of med school, but didn’t realize who “they” were until residency. Then, I resented the sleight of hand on the part of drug company who’d provided it.

DrV December 6, 2011 at 9:10 am

And clearly we all use stethoscopes … I use my nurse’s. And I had forgotten about the stethoscope ‘gift.’ Not sure that’s done/allowed anymore but you’ve given me fodder for another post….

Mark December 6, 2011 at 1:30 am

Thank you for a very interesting and thought-provoking article.

In contrast to the idea that diagnostic technology can render either clinical examination in general, or auscultation in particular, redundant some may argue that it is becoming ever more important to have examined the patient in order to contextualise the imaging findings and being able to separate the ever increasing number of incidental findings with the actual pathology.

I would also note that although most of us who are accessing web 2.0 resources such as this blog are probably working in well developed, high technology healthcare systems. Worldwide, we may be the minority and many will continue to rely on clinical examination and stethoscopes for many years to come.

Best wishes,

Mark.

DrV December 6, 2011 at 9:14 am

Indeed, Mark. This doesn’t necessarily apply in the developing world although I will submit that the fastest advances in mobile technology are coming out of Africa and India – born of necessity.

Will Sargent December 6, 2011 at 2:29 am

Great post.
However, You can’t stare through the patients torso with intense bewilderment holding a crystal probe.

Freelance MD December 6, 2011 at 5:16 pm

The physician of tomorrow will be managing technology and only dealing with patients through that filter. It makes it difficult to see where the physician exam will fit.

Jan December 6, 2011 at 6:13 pm

Since many physicians seem to auscultation through clothing these days (shudder), they might as well,throw their ornaments away.

Jan December 6, 2011 at 6:14 pm

Umm, that should be auscultate – darn autocorrect.

Dave Miller December 14, 2011 at 4:00 am

As a medical student, I was initially amazed (and my preceptors impressed) at the acumen with which I picked out interesting auscultation findings on physical exam. As one who is interested in rural primary care, especially in resource-poor areas, auscultation is a skill that I constantly work on. I am a firm believer that Laennec’s humble tube is far from obsolete but should be embraced with renewed enthusiasm as we seek to reduce unnecessary testing and imaging and reign in health care costs. Imagine diagnosing pneumonia simply by auscultation, without the expense (and radiation exposure) of a chest x-ray. Certainly within our scope of training and it only takes a little more time to get it right.

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