Blog | Monday, January 4, 2016

Listen more


My first posting on this blog explained why I chose to name it “Auscultation.” I wrote that I wanted to promote a conversation, and that listening was essential to doing so. I went on to write: “With an obvious nod to my being a cardiologist, I believe auscultation has long been an act that defines us as physicians and connects us in a profound way with our patients. The act of leaning in, touching the patient, listening, concentrating, and interpreting is a powerful metaphor for the entire clinical encounter: getting close to the patient and listening.”

It is therefore no wonder that I was really pleased to read “The Physical Examination and the Fifth Maneuver“ by Thomas Metkus in a recent issue of the Journal of the American College of Cardiology. The piece appeared in the “fellows in training and early career page” in the journal, which regularly features articles by trainees about their experiences, and was a mature and robust defense of the importance of developing auscultatory skills. Metkus alludes to Osler's model of physical diagnosis, the first 4 maneuvers of which are inspection, percussion, palpation, and auscultation. The fifth—and arguably most important—is cognition, the intellectual exercise of putting it all together.

Metkus acknowledges that cardiac auscultation has, pardon the pun, taken a beating. It seems passé in an age of ubiquitous echocardiography to make a diagnosis or assessment based only on what one can hear with a stethoscope, but he makes a compelling case for doing so, based on 3 principles:
1. Cardiac auscultation is critically important in taking care of patients. No technology is perfect, and relying solely on echocardiography to the exclusion of auscultation is a little like relying only on your car's GPS enabled navigation system, without any regard to where you really are.
2. Accurate and precise diagnoses with cardiac physical examinations. Yes, it is possible, with diligence and practice, to sort out a patient's condition with a stethoscope.
3. When you examine a patient, you examine a person. This was my favorite reason. Listening to a beating heart “up close and personal” is fundamentally different from interpreting echocardiographic images. It creates a special connection between the patient and the examiner, which itself is therapeutic.

We should also remember that the physical exam is the second part of the clinical encounter. The first, and more important, is learning the patient's story by listening.

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.