Is listening through a stethoscope a dying art?
For nearly 200 years, doctors have confidently slung stethoscopes around their necks, and listened to hearts flutter, bowels rumble, and blocked arteries swoosh.
But as doctors increasingly rely on technology to diagnose heart disease, a growing chorus of mostly younger cardiologists is questioning the value of the stethoscope.
For many doctors, the low-technology amplification doesn't compare to the high-tech images and more precise data they can gather from an echocardiogram. Over the past seven years, the number of "echoes" ordered nationally has nearly doubled -- from 11 million in 1996 to 21 million in 2003, according to a study published annually by Pennsylvania-based Arlington
Locally, Harvard Pilgrim Health Care reports its doctors ordered 10.5 percent more echoes in the last year alone -- with 8.5 of every 100 patients undergoing the procedure, which yields specific details about the heart's chambers, valves, and blood vessels that a stethoscope cannot supply.
The more doctors depend on echoes, the less they rely on their stethoscopes to decide treatment for patients, and traditionalists worry that this mounting dependence will spawn a generation of medical school graduates who will simply go through the motions of listening to a patient's heart. They will order up an echo every time they hear a heart murmur, click, rub, or gallop through their ears.
"My generation lived and died with the stethoscope," said Dr. Sidney Alexander, 72, who has worked as a cardiologist at the Lahey Clinic since 1963. "The present generation, while loving to have a guy like me around, I'm quite sure does not honor what a good examination can bring. It's become this kind of arcane, somewhat archaic thing."
He and others worry that as doctors' physical exam skills erode, they will miss the signs of a potentially fatal complication, such as an impending ventricular wall rupture in the days following a heart attack. Other diagnoses, like an inflammation of the sac housing the heart, can often be made definitively only with a doctor's ears.
"There are times when your stethoscope absolutely matters," said Dr. Rishi Vohora, 28, a resident at UMass-Memorial Medical Center. "If somebody has a heart attack and is sitting in your [intensive-care unit], you need to know the signs when something is going down. You need to know more than just someone's blood pressure is dropping. You need to be able to examine the patient and be able to figure out what it is."
The stethoscope was invented in 1816 by Rene Laennec, who wanted to listen to a female patient's heart without putting his ear to her chest, as had been the practice since the days of Hippocrates. Instead, the French physician, who also dabbled in making musical instruments, rolled up a piece of paper and put one end to his ear and the other to her chest. Her heartbeat, he discovered, was amplified by the paper, and he quickly began experimenting with more permanent tools to make listening to the heart easier and more convenient. Currently, Alexander often draws crowds of students and residents during his teaching rounds when he asks patients to squat, hold their breath, and strain like they're having a bowel movement so as to accentuate murmurs. "Many echoes are done far more often than need to be."Echocardiogram machines, which were first used in the late 1960s but exploded in popularity in the 1990s, shoot panoramic, almost instant photos of the heart, and have allowed doctors to more accurately diagnose the severity of heart attacks, to discern how well a patient's heart is pumping after having failed, and even to rule out structural heart disease in young, symptomatic athletes.These portable, noninvasive machines emit high-frequency sound waves that render a two-dimensional sketch of the heart, similar to the ultrasound given an expectant mother. Dr. David Samenuk, 34, a Medford-based cardiologist whose fellowship included a year of training in advanced echocardiography, said he believes echoes are superior to even the most seasoned clinician's heart exam.
"I don't care how much experience a doctor has in [listening with a stethoscope], I'll still take an echo over the ears and stethoscope," he said. "I don't think I'm saying anything particularly sacrilegious, either."
Even health insurance companies, which pick up most of the tab for the $250 echoes, hail the test as both relatively cheap and instrumental in the diagnosis of patients with diseases such as diastolic heart failure.
Dr. Bill Corwin, the medical director for the utilization management and clinical policy at Harvard Pilgrim, said there's a potential for overusing the echo, but that hasn't been a problem yet. "I would hope physicians don't think" that every murmur "deserves an echo, because not every murmur deserves [one]."
Alexander and Vohora say they worry that the dependence on echoes will continue to increase as future generations of students are trained by doctors who aren't skilled at listening.
"When you have medical students learning from residents who -- when they were medical students -- didn't know what the heck they were doing, either, you've got a big problem," Vohora said. "Many doctors just don't have the time or willingness to teach bedside rounds anymore. . . . This technology is the new physical exam."
The loss of the stethoscope also means a loss for the doctor-patient relationship, Alexander said. "You very well may end up replacing what the doctor does with his hands and his eyes and his ears. Listening to a patient with a stethoscope has always produced an unspoken bond between a doctor and his patient. It can't be a good thing to lose that." 