Disclosure: Dr. Som reports no conflicts of interest regarding the content herein.
Recently there has been an ongoing impetus in the medical literature emphasizing the need for a paradigm shift in the approach to physical examination, in particular, the cardiac auscultation. A recent example is the October 2014 JACC article, “Handheld Ultrasound Versus Physical Examination in Patients Referred for Transthoracic Echocardiography for a Suspected Cardiac Condition” by Mehta et al1 and the accompanying editorial by Marwick et al2, in which they have run an obituary of the stethoscope. I have used handheld ultrasounds, mostly in the periprocedure settings; it is such a beautiful technology for various reasons as elucidated in the contemporary literature. Yet the prospect of forgoing the ubiquitous stethoscope is a chance I will not be willing to take while I am still the physician-in-the-trenches. It is analogous to giving up the white coat, since there are now “data” to support that it might even be “harmful”, although no data to support that giving it up improves patient safety and therefore contributes to better patient care. The skill of clinical auscultation represents the quintessential synergy of two hundred years of shared knowledge and wisdom in the art and science of physical diagnosis, which is often distilled into a quick, one-minute physical exam to give a real-time working diagnosis. This is at the very least therapeutic, but more so, relevant in our current cost-conscious healthcare environment. However, the fate of the handheld ultrasound technology will rest in our definitions of what to do in cases of incidental findings along with the medico-legal implications of an act of omission based on this handheld technology, which has often been called an extension of the physical examination itself. Is it sufficient to merely document the pertinent handheld ultrasound findings in the chart, similar to physical examination findings, or do we need to archive the digital images and/or write formal reports? Hopefully, in time, as its use is expected to become more commonplace, new practice protocols3 and society guidelines will be published. However, till that point and beyond, the essence of the humble stethoscope is the fact that it will always remain the initial screening tool at the point of first medical contact — a beacon of the arrival of the doctor.
- Mehta M, Jacobson T, Peters D, Le E, Chadderdon S, Allen AJ, Caughey AB, Kaul S. Handheld ultrasound versus physical examination in patients referred for transthoracic echocardiography for a suspected cardiac condition. JACC Cardiovasc Imaging. 2014 Oct; 7(10): 983-990. doi: 10.1016/j.jcmg.2014.05.011.
- Marwick TH, Chandrashekhar Y, Narula J. Handheld ultrasound: accurate diagnosis at a lower cost? JACC Cardiovasc Imaging. 2014 Oct; 7(10): 1069-1071. doi: 10.1016/j.jcmg.2014.07.008.
- Kimura BJ, Yogo N, O’Connell CW, Phan JN, Showalter BK, Wolfson T. Cardiopulmonary limited ultrasound examination for “quick-look” bedside application. Am J Cardiol. 2011 Aug 15; 108(4):586-590. doi: 10.1016/j.amjcard.2011.03.091.