See One, Do One, TEACH ONE

Is the Physical Exam a relic of the past because our tools are relics of a prior era in medicine?

A few months ago I wrote a piece about the physical exam and the importance of actually doing a thorough exam and teaching how to do a good exam. I cautioned against the over reliance on blood work and imaging because a physical exam can be burdensome and prolonge. But perhaps the problem with our physical exam is the tools that we have at our disposal to aid in the exam rather than the actual exam itselt.

As a child, I often had the image of a doctor that included a long white coat, benevolent smile, black bag filled to the brim with tools, and of course the ubiquitous stethoscope. However, as a doctor now, I find myself less excited about the stethoscope. Often times it’s a nuisance that gets caught on bed poles in the ED and wrangles my neck, it’s even dangerous to bring around violent and unstable patients as it becomes a means by which harm can befall you. It may not even be necessary as tests like listening for bilateral breath sounds after intubation can be supplemented with visualization of chest rise and end tidal CO2 detection.

And of course there is the ultrasound. Portable ultrasound has opened up a field of ultrasonography called Point of Care Ultrasound that appeals directly toward the needs of emergency medicine. According to NEJM, “point-of-care ultrasonography is defined as ultrasonography brought to the patient and performed by the provider in real time.” In a way, ultrasound has transcended from the category of imaging techniques which is relegated to bulky, heavy, and costly technologies such as CT and MR.

At this point in EM, ultrasound has enhanced patient evaluation and examination in almost every organ system, from diagnosis of pneumothorax, cholecystitis, ectopic pregnancies, and extremity fractures (an article by yours truly). More than that, these studies have shown that EM physicians are just about as proficient with the use of ultrasound for diagnostic purposes as traditional users such as radiologists and orthopedists.

Medical schools have also recognized the importance of ultrasound and have integrated ultrasound into the traditional curriculum. Just as there were courses dedicated towards learning the complex physical exam, there are now courses dedicated towards learning how to obtain and interpret ultrasound images. Dr. Laleh Gharahbaghian just conducted a successful course for medical students in northern California on point of care ultrasound.

The question that now remains, is if ultrasound can be used to ultrasound anything and any organ system, is there any use of the stethoscope? Can we throw away the stethoscope and only use the ultrasound for patient examinations?

My first thought on that is that we are comparing apples to oranges. I personally feel that ultrasound does not simply replace the stethoscope, it blows it out of the water. We can do so much more with ultrasound that we could never do with stethoscope. So it really isn’t a fair comparison. That being said, there are limitations to ultrasound: it is costly, it is operator and interpretor dependent. But there are so many more positives about ultrasound as well, one of the biggest is that the ultrasound is repeatable which makes serial exams meaningful, the results can be shared amongst a group who can visually assess for disease, versus individually trying to “hear” for a disease.

Ultimately, I do feel that the lifespan for stethoscopes has almost come to an end. There will be a time soon, when medical students receive a portable ultrasound with their new white coats at the beginning of their training. Our children will also think of doctors with a kind benevolent smile and with an ultrasound hanging around our necks. And our patients will benefit for it as well. I still always wear my stethoscope around my neck for every shift, and obligingly use it on every patient that I see, from the acutely psychotic to the STEMI seen on EKG. It is a part of my routine exam, emphasis on the word routine. But I can’t wait until the day when I get my own portable ultrasound, and it will fill that groove around my neck that the stethoscope has dug after all these years!

What do you think? It is now time to give the eulogy of the stethoscope, or am I being too premature?

Share your thoughts!

Nikita