Nice stethoscope. Now, learn to use it

The stethoscope may be an icon of the medical profession. But as a tool of the trade, many veteran physicians fear it is becoming a useless prop of doctorhood.

As physicians rely on more accurate and expensive tests of cardiac function, including echocardiography, the art of listening to the heart has fallen on hard times. In recent years, a spate of studies has shown that as few as 20% of new doctors and 40% of practicing primary-care doctors can discern the difference between a healthy and a sick heart just by listening to the chorus of whooshes, lub-dubs, gallops and rubs that compose the distinctive music of the human heart.

But a handful of veteran physicians are struggling to revive the dying art of cardiac auscultation, or examining the heart with a stethoscope. They may fault the advance of technology for what they believe is a decline in doctors’ skills, but these defenders of the stethoscope are no Luddites. They are banking on computer-generated heart sounds, virtual patients, CD-ROMs and that ever-present student friend the iPod to help a new generation of doctors overcome what Dr. Michael Barrett of Temple University recently called their “woeful lack of stethoscope skills.”

By honing those skills in the next generation, defenders of the stethoscope hope to shore up physicians’ first line of diagnosis, to stem the growth of healthcare costs and to preserve the purpose and integrity of one of medicine’s most revered rituals -- the laying on of hands (not to mention hard metal) to treat patients.

“A lot of people have talked about the lost soul of medicine, how medicine has changed,” says Dr. Salvatore Mangione of Thomas Jefferson Medical College in Philadelphia, who in 2000 co-wrote an editorial on declining stethoscope skills in the American Journal of Medicine. “The demise of the bedside examination and the refuge we seek in powerful technology is a symptom of that -- we’re becoming more technicians and less healers.”

At UCLA’s Harbor medical campus, Dr. John Michael Criley has been collecting heart sounds, diagnostic images and patient histories for almost five decades. For years, he hauled his jumble of recordings, images, videotapes and scribbled notes into his lecture rooms, until one day a student asked him, “Dr. Criley, wouldn’t it be easier to put this all on a CD-ROM?”

He did, and the result is something that Criley calls a “weapon of mass instruction.” His teaching CD-ROM lets students see “virtual patients” complete with the physical signs -- a heaving chest or pulsating neck -- of heart disease, and to hear their hearts’ sounds.

“These are things that should be in your armamentarium as you enter the bedside with a stethoscope in your hand,” Criley says. “Let’s face it, every physician, even proctologists have a stethoscope in their pocket. You shouldn’t have one if you don’t have the correct knowledge.”

In a study published recently in the American Journal of Medicine, Barrett, a cardiologist, detailed his method of teaching third-year medical students to discern a heart murmur or a weakened heart muscle by the telltale sounds that such abnormalities make.

Early in that year -- during which they’re expected to hone their clinical skills -- medical students could, on average, recognize six abnormal heartbeats four times out of 10, Barrett found. Using computer-generated “templates” of diseased heart sounds, which are free of background noise or pesky distractions such as chest hair or fat layers, Barrett had 80 students listen to each of six sounds at least 500 times. (Most students promptly converted the CDs to MP3 files and downloaded them to their iPods, he said.)

By year’s end, the “intensive repetition” group raised its ability to recognize those sounds to 89% of the time. A control group that had received regular classroom instruction and the same level of hands-on experience during clinical rounds showed no improvement in the ability to discern abnormal heart sounds.

“We used to say you’ll learn it on the wards,” Barrett says. “They weren’t learning it on the wards,” he added, and that weakness follows many doctors into daily practice. As a result, Barrett says, studies of stethoscope proficiency among practicing internists suggest their ability to detect and diagnose heart disease with a stethoscope alone is “basically at a level of guessing.”

To compensate for their lack of skills, experts say, physicians are now quick to order high-tech heart tests such as the echocardiograph-- basically ultrasound imaging of the beating heart that can cost up to $1,000 a shot.

Dr. Howard Weitz, a Jefferson University cardiologist, says high-tech tests not only compensate for poor stethoscope skills, but they also perpetuate them. Physicians do not become proficient, and they pass on to new generations of student-doctors that listening to the heart through the stethoscope is not a skill worth taking the time and trouble to hone. “For many,” he says, the device slung around the neck or tucked into the pocket of a crisp white coat “has become useless.”

“The stethoscope is really a symbol of medicine. And to have a symbol of medicine become a vestigial device is very surprising,” Weitz says. “I’m not saying it’s more important than technology, but it has a role in picking the best technology to follow up with.”

In the coming years, new policies may help turn the ebbing tide of stethoscope skills in practicing physicians and those in training. Starting in 2000, internal medicine doctors who renew their board certification in the specialty (a step required every 10 years) have had to pass an examination of stethoscope skills.

At the same time, new technologies continue to raise the question of whether it is worth the time and trouble to polish doctors’ stethoscope skills. In addition to the ubiquitous echocardiograph, a small New Hampshire firm called Biosignetics Inc. is readying for market a stethoscope-like device equipped with software that would translate a patient’s heartbeat into a storable visual display and compare it with a vast bank of normal and abnormal heart sounds. The software would recognize abnormalities and spell out their likely significance almost instantly.