Blog | Friday, May 2, 2014

Death of the stethoscope?

I felt a little sad when I read the “perspective” piece in the New England Journal of Medicine about the introduction of point-of-care ultrasound in medical education.

In it, two cardiologists from the Brigham and Women’s Hospital review the promise and some of the challenges of incorporating hand held ultrasonography into medical education and, more broadly, into medical practice. For those of you unfamiliar with the technology, this is not your father’s ultrasound machine.

The authors cite a number of studies that support the utility of the technology and, rightfully, liken it to an extension of the stethoscope. It is not a big surprise that it allows for more accurate assessments of things like left ventricular systolic performance or liver size than can generally be achieved with physical examination. So what’s the problem?

It is not that I am a Luddite. I have “prescribed” an app for monitoring heart rate; I can take a pretty good single lead ECG with my smartphone; I tweet (@iranash).

I do, however, consider myself a rather old-fashioned kind of physician. I no longer perform any high-tech procedures (I am a “lapsed interventional cardiologist”); I am not an early adopter of newly approved medications; I am a generally skeptical reader of the medical literature; and I believe in the power of listening to patients and doing a good physical examination in forming a therapeutic relationship.

I think my discomfort with point-of-care ultrasound supplanting the stethoscope comes down to a somewhat irrational sense that using it in everyday patient encounters feels a little like cheating. It has taken me years of training and practice to feel confident in my auscultatory skills, and it is not a coincidence that I named this blog “Auscultation.” Those skills are part of what help define me as a physician, and the sadness I feel reflects a decline in their value. Who cares if you can hear an opening snap, if you can see on the screen that the patient has mitral stenosis? I know in my head that it is better for the patient if it is easier to make the right diagnosis. My heart is telling me something else.

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.