Some medical specialists have recently voiced their strong preference for a compact hand-held ultrasound device as a bedside diagnostic tool, replacing the conventional stethoscope. This may fuel a discussion and debate over the pros and cons.
Both the stethoscope (steth) and the ultrasound device are based on sound. Sounds conducted and slightly augmented by the steth are audible to the human ear. The other is in the inaudible range.
The steth is much more important than the white coat, tuning fork, knee hammer, tongue depressor, torch and the rest — even all of them put together. A functionally competent, quality steth consistently proves to be a great asset, serving with unfailing accuracy in the hands of an expert with discerning ears. Over time its relevance, utility and contribution to bedside diagnosis has not declined at all.
Ultrasound devices, popularised over the past six decades, are like very many new imaging modalities no doubt most useful and welcome additions to the medical field, useful in diagnostic procedures and therapeutic interventions.
Over a period of five decades I have closely observed my great mentor diagnosing with astounding precision a multitude of complex medical conditions with exhaustive thoroughness. In every clinical session he used to demonstrate patiently and painstakingly with his own steth, himself holding the chest piece firmly in place, to tens of undergraduates and post-graduates, eliciting and interpreting the subtle characteristics and variations of cardiac sounds and murmurs and breath sounds and adventitious sounds. It was a treat to get groomed by that colossus at the bed-side. He used to explain in detail the intricate nuances of auscultation over varied body sites — over narrowed arteries, humming veins, turbulent vessels, dilated intestines and even over areas of unusual silence.
In the mid-1970s, an honorary professor of a premier medical institute vehemently attacked the role of the steth as a diagnostic tool in defining lung disorders, amid a large gathering of post-graduates. He went on to uncharitably remark that the steth has become simply redundant and deserves to be thrown out. As a relatively young assistant professor, I was pretty peeved and provoked at this frontal attack on a hapless instrument. When I could no longer remain a passive spectator, I got involved in launching a counter-view. But the pleasant and sportive professor kept his cool and warmly remarked, “You are a good student of an ideal teacher.” I instantly fell silent, feeling sad to have confronted a senior.
A renowned physician from a far-off land, in his own wisdom, preferred to have a harsh dig at the astute clinicians. This, I had read some 40 years back. It ran something like this. “Some senior physicians, despite their increasing age and increasing deafness proudly proclaim they are able to make out four heart sounds, five clicks and six murmurs during the various phases of a single cardiac cycle in a time span of less than one second.”
This unkind cut could have caused a ripple of instant fun, but to record this in a book meant for postgraduates was a real disservice to clinical medicine.
Over the years I have seen highly experienced physicians diagnosing hosts of illnesses with a well elicited history, alone. With unwavering mindfulness, they smell illnesses and feel ailments. They keenly observe, percuss to feel and intently listen, distinctly dissecting the normal from the abnormal.
Concise history-taking and systematic physical examination, consisting of inspection, palpation, percussion and auscultation, done in a methodical way are even today pretty much relevant. A steth serves, with perfect efficiency, the process of auscultation.
It is good that we are leaning more and more towards technology, but more is not always better. Let us not end up doing too much too soon. It invariably ends up putting a lot of stress.
For all its excellent contribution, so consistently extended over two centuries, the steth, the defining symbol of the doctor, should not be sentenced to solitary confinement in a vault or a museum.
This simple and the cost effective instrument can seldom become obsolete to necessitate a replacement.
(Dr. V. Gurumoorthy is a former Professor of Medicine. e-mail: firstname.lastname@example.org)