The Stethoscope will Remain Amidst Modern Improvements
In 1816, a physician named Rene Theophile Hyacinthe Laënnec invented the stethoscope1. He wanted a closer look into the inner workings of the human body, but had difficulty with his contemporary tools. Common practice at the time was immediate auscultation, which consisted of the physician listening with their ear directly on the patient's chest. Problems of modesty and impracticality led Laënnec to develop a rudimentary stethoscope, initially a “tightly rolled sheet of paper”, ultimately progressing into the modern day version2. Laënnec published his work in his 1819 book, De l’Auscultation Médiate ou Traité du Diagnostic des Maladies des Poumons et du Cœur (On Mediate Auscultation or Treatise on the Diagnosis of the Diseases of the Lungs and Heart)3. The stethoscope allowed better study of the un-dead patient’s body in a time where autopsy was the best way of looking within4.
However, in recent years there has been a movement to retire the stethoscope in favor of more advanced technologies such as Handheld Ultrasounds5. After all, an ultrasound device provides much more objective and permanent information whereas auscultation traditionally remains a transient measurement, vanishing when the stethoscope leaves the surface of the chest (this is ignoring the latest technologies that allow for stethoscope recording due to somewhat severe cost limitations and other barriers at present.). In the case of the ultrasound, if there is a dispute about the diagnosis, at least the clinicians are looking at the same information. In contrast, using a stethoscope is an acquired skill, often requiring many years of advanced practice to hone the ability to differentiate subtle sounds. With a stethoscope, physicians aren’t debating the patient’s symptoms, but instead what they’re hearing.
However, I will argue that, while the stethoscope is on the verge of being replaced, it won’t be anytime soon. The stethoscope represents an icon of medicine, but it’s much more than that. It represents a connection that patients and doctors have felt for two hundred years. I remember when I was a boy, going to the doctor’s office for an annual checkup; the doctor would blow warm air onto the cold metal of his tool in order to make his examination as painless as possible. In the same vein, stethoscopes represent an intimacy that so often is evaporating in today’s medical system. Even back to Ancient Greece and Hippocrates, immediate auscultation was a main examination mechanism6. With Laënnic’s invention, the physical exam became more precise and scientific, allowing for sounds emanating from the human body to be heard for the first time7. Yet, despite the distance between ears and chest that a stethoscope allows, it’s hard for a doctor not to be close to their patient during auscultation. It’s a common practice today for a doctor to place his hand on a patient’s shoulder to feel a deep breath; perhaps a physician might close her eyes to immerse herself in the sounds she is hearing. These are without doubt signs of closeness and comfort. Contrast this with the new Ultrasound devices that come with feet of cable; this longer distance, although it makes no difference for the device, is a barrier for the human contact that provides a feeling of care and trust.
In addition to intimacy, a stethoscope provides immediacy. There is hardly a faster maneuver than a doctor swinging his stethoscope from around his neck onto a patient’s chest. Perhaps you can imagine the sense of urgency in the emergency department of a hospital when a car-crash victim speeds through the doors with doctors, nurses, and EMTs running alongside the bed taking vital signs or administering drugs. In situations such as these, it would be a waste of precious time to power on a handheld ultrasound (or other similar device) and prepare the apparatus for measurement. Here, speed is paramount–this is provided by the simple, mechanical stethoscope.
Stethoscopes make more sense in practical matters, too. In more routine cases, such as pneumonia, it would be pointless to perform an examination with a device that costs upwards of $10,000, when a simple listen with a $25 stethoscope might work8. Indeed, auscultation is one of the first skills taught in medical school–often times a simple listen is enough to rule out serious diseases or to signify that a patient is doing worse than previously thought. Although ultrasound devices may allow for higher precision in certain cases–particularly those with greater complexity–these gadgets can suffer from the same problems that all electronic tools might have: battery considerations, technical support, calibrations, etc. Nothing compares to the strictly mechanical propagation and amplification of sounds through a rubber tube directly into the ear canal.
Yet, perhaps the failure to depart from the stethoscope represents a question of human ability. A well-documented phenomenon is inattentional blindness, or when people “fail to notice salient unexpected objects when their attention is otherwise occupied.”9 Basically, it’s easy to miss things you’re not looking for. In a study from 2013, radiologists were tested for their ability to see a small gorilla digitally placed onto scans of patients with lung nodules. Shockingly, while the radiologists were busy looking for lung nodules in a timed experiment, the large majority failed to notice the gorilla, which obviously does not belong on such a scan10. These physicians, specifically tasked with identifying lung nodules, were blind to such an overtly out-of-place feature on the scans. Although inattentional blindness is not exclusive to the visual system, perhaps it’s easier to filter visual information because you can direct your eyes to very specific locations, potentially avoiding something right in front of you. With auditory information, however, it’s more difficult to direct your attention to any one feature, making it harder to miss “obvious” features like in the visual case. Here, stethoscopes may prevent physicians from being too focused on finding what they expect, so that they are more receptive to any abnormal sounds.
Although the stethoscope has been around for two hundred years, its use seems to be declining. Of course, medicine should progress in time with key advancements in scientific tools; however, I believe the stethoscope will stay around for the foreseeable future. It’s important to remember that medicine is not strictly a science–healing is a human endeavor. There’s something indescribable about human interactions that gives comfort, a comfort that cannot be achieved without such contact. In addition to practical constraints, cost considerations, and human biases the stethoscope will continue to allow physicians to practice to the best of their training and abilities. I agree with the late Dr. Carolyn Reed of the Medical University of South Carolina when she writes that modern, “tests, machines, and procedures can not supplant listening, experience, and intuitiveness.”11
1. Ariel Roguin, “Rene Theophile Hyacinthe Laënnec (1781–1826): The Man Behind the Stethoscope,” Clinical Medicine and Research 4, no. 3 (September 2006): 230.
3. Ibid., 231.
4. Jonathan Sterne, The Audible Past: Cultural Origins of Sound Reproduction (Durham: Duke University Press, 2003), 99.
5. Taunya English, “The End of the Stethoscope?,” The Atlantic, March 3, 2016, https://www.theatlantic.com/health/archive/2016/03/end-of-stethoscope/471888/.
6. H. Kenneth Walker, “The Origins of the History and Physical Examination,” in Clinical Methods: The History, Physical, and Laboratory Examinations, ed. H. Kenneth Walker, W. Dallas Hall, and J. Willis Hurst, 3rd ed. (Boston: Butterworths, 1990), http://www.ncbi.nlm.nih.gov/books/NBK458/.
8. “The Stethoscope: Timeless Tool Or Outdated Relic?,” NPR.org, accessed December 21, 2016, http://www.npr.org/sections/health-shots/2016/02/26/467212821/the-stethoscope-timeless-tool-or-outdated-relic.
9. Carina Kreitz et al., “Inattentional Blindness and Individual Differences in Cognitive Abilities,” PLoS ONE 10, no. 8 (August 10, 2015): 1, doi:10.1371/journal.pone.0134675.
10. Trafton Drew, Melissa L. H. Vo, and Jeremy M. Wolfe, “‘The Invisible Gorilla Strikes Again: Sustained Inattentional Blindness in Expert Observers,’” Psychological Science 24, no. 9 (September 2013): 1848–53, doi:10.1177/0956797613479386.
11. Reed, Carolyn E. “Patient Versus Customer, Technology Versus Touch: Where Has Humanism Gone?” The Annals of Thoracic Surgery 85, no. 5 (May 2008): 1511–14. doi:10.1016/j.athoracsur.2008.02.053.