As Clifton Meador’s observes in “Unheard Hearts,” these days most doctors rarely listen to a patient’s heart.
“Physicians do carry stethoscopes and it certainly is a badge that shows they are a physician, but the sad thing is a large percentage of them don’t know how to use it and use it improperly when they do,” says Michael Criley, professor emeritus of medicine and radiological sciences and the University of California, Los Angeles’ David Geffen School of Medicine.
In a recent interview with Cardiovascular Business, Criley explains: “When two-dimensional echocardiography became available in the mid-1970s it could have, and should have, provided a noninvasive way of seeing what the heart chambers and valves were doing when extra sounds or murmurs were created, but instead replaced bedside auscultation [listening to the heart].
Reading what Criley had to say, and thinking about Meador’s piece, it struck me that this is all part of what some call “the depersonalization of medicine.”
By and large, 21st century doctors do not lay hands on their patients. As psychiatry resident Christine Montross pointed out in a New York Times op-ed: a few years ago: “Today’s doctors rarely do thorough physical exams.” Instead, they rely on “diagnostic tests and imaging studies.”
Meanwhile, in medical schools, Montross reveals, “virtual gross anatomy” lets students avoid the “messy” business of dissecting a real body. “This is a mistake,” says Montross.
Listening to the Heart
Criley’s theory that the stethoscope has become little more than a badge of honor is based on a study of physicians’ cardiac examinations.. . Criley was the lead author on a study that investigated these exams, published in the the December 2010 issue of Clinical Cardiology.
The research involved a multimedia test administered at 19 U.S. teaching centers to more than 500 trainees and faculty. Results showed that cardiac exam test cores increased with age.
Does this mean that experience leads to better scores? “Not quite,” says Criley. He explains that more senior faculty members were trained in an era of superior cardiac auscultation training.
“While some educational programs may stress cardiac auscultation skills (listening to teh heart with a stethoscope) more than others, since bedside exam skills are not tested on board exams for internal medicaine and cardiology, overall emphasis may be lacking,” Criley told Cardiovascular Business.
“It’s not going to be on the test, so why study it?”
Criley believes that imaging has its uses but should not be a substitute for a physician at a bedside. Echo and CT should be combined with the cardiac exam, and listening to the heart can help rule out certain conditions: “If you are just saying ‘I think I hear a murmur, maybe I should get an echo,’ that is a very wimpy way to go about it.”
An effective bedside investigation also involves attending to visual cues, says Criley. He gives some examples:
- Cyanosis: Blue tinged lips, tongue or mucous membranes could indicate a right-to-left shunt in the heart
- Slow-rising, late peaking carotid pulse: This change in pulsation can indicate aortic stenosis, a condition affecting 10 percent of people over the age of 65 years.
- Corrigan’s pulse: A bounding carotid pulse where the arteries appear to jump out of the neck is indicative of aortic regurgitation. Sometimes the patient’s head bobs up and down.
Touching, listening and truly seeing the patient—these are the sensory arts that may be lost if physicians become too dependent on “reading” tests.
When a Computerized Image Replaces the Med Student’s Cadaver
Writing about the “virtual” gross anatomy classes that substitute “sophisticated imaging and computer programs” for cadavers, Montross acknowledges that “dissecting a human body is smelly and expensive.”
But, she argues, doctors-in-training need to learn to cope. Someday that medical student will need to “keep his cool when a baby is lodged wrong in a mother’s birth canal; when a bone breaks through a patient’s skin; when someone’s face is burned beyond recognition,” writes Dr. Montross. “Doctors do have normal reactions to these situations; the composure that we strive to keep under stressful circumstances is not innate. It has to be learned.”
Using computerized body replicas distances medical students from the human element in medicine” she argues, while “the dissection of cadavers . . . gives young doctors an appreciation for the wonders of the human body in a way that no virtual image can match.”
Maggie, this is a fascinating (albeit a bit sad) perspective on this trend towards depersonalization. But first – could we please stop using stethoscopes as necklaces, doctors? I saw a conference photo the other day of a dermatologist wearing a stethoscope while speaking onstage. A dermatologist!
“…senior faculty members were trained in an era of superior cardiac auscultation training.” Bingo! This issue of how medical students are being trained is an important one.
I had a firsthand opportunity to witness this issue in action when I was in the middle of having a heart attack. The cardiologist who was called down to the E.R. immediately administered a 30-second non-invasive cardiac assessment that I later learned is known as an “abdominojugular test” (pressing hard on my abdomen with both hands while observing an abnormal jugular pulse just below my ear lobe with the help of a small flashlight).
Healthy people undergoing this test will have a temporary increase in the internal jugular pulse for just a heartbeat or two before the venous pressure returns back to normal. But a skilled physician can observe in the heart patient’s earlobe pulse the characteristic double flicker of a sustained elevated jugular venous pressure – a sign of active or impending heart failure.
I’ve mentioned this test to both cardiologists and E.R. physicians since that day in 2008, and each one has poo-poohed it as “old-fashioned” and too difficult to do correctly unless you have been trained to do so.
Thus the vicious cycle continues: med students are no longer trained appropriately, so the practice drops off, so they aren’t skilled at doing it anymore, so more technology becomes necessary to take the place of hands-on medical practices that really worked in the first place!
Keep up the good work here.
Thats a cute anecdote, but looking for jugular venous distention (JVD) isnt very helpful. It is a simple yes/no answer as to whether a patient has impending heart failure. An echo can give you much more information, and you NEED IT if you have JVD.
What happens if you have a “positive” neck sign for JVD? You get an echo, thats what happens. An echo can not only answer the question “do I have heart failure” it can quantify the exact degree of systolic or diastolic dysfunction. It can show if there are any heart lesions obstructing outflow tracts.
If the physical sign for JVD was enough to BYPASS the echo, then you might have a point that doctors are using too much technology. As it stands though, you still need the echo regardless even if the doctor takes the time to assess for JVD.
I am a D.O. And the son of parents who were both Osteopathic physicians and my son has followed.
One of my memories is discussing medicine with my dad before I entered school. When he started practice in 1933 in Rhode Island he was among a group of D.O.s who met with the medical director of the Rhode island licensing department to petition for full licensure. Even then the august and fearsome man who was in charge spoke about how the “young doctors” in the ‘M.D. Group had forgotten how to touch and examine their patients. Some things never change: the elders pontificate that the youth in the guild no longer do things well.
Someone once said at a spine surgery conference that the mystery was in the history…..so it is with the stethoscope. Heart auscultation may be better with a portable ultrasound device. As a Verghese and Topol suggest. Lungs and and belly..what you hear may be better able to tell apology earlier than imaging. As an orthopedic surgeon I taught my students that osteophony can often tell if there is a fracture when imaging was obscure…before MRI and ct scans. The transmission of sound across a “break” is slower than through the normal limb. A little knowledge of physics helps. Moreover, it is fun and the patients appreciate the bedside attention.
Carolyn & Richard
Carolyn –Thank you,. Your remark about doctors wearing stetheoscopes as necklaces is spot on.
I once spoke at a conference on medical education where a med student stood up and reported that she didn’t feel she was being taught how to diagnose, but merely how to order tests. A doctor from the UK working at her med school had pointed this out to her . . .
My guess is that as medical technology has evolved over time, doctors have become less and less “hands on.”
Certainly, you’re rigiht that patients appreciate the bedside attention.
I couldn’t agree more. So much that is of great value is being lost in the practice of medicine. The art of medicine – observing the patient, the whole patient, with all the senses – is falling by the wayside. It’s a sad commentary on “progress.”
What Criley says is so true – so many tests were developed to enhance what can be observed, so the physician could have more information on which to base a diagnosis. They provide excellent techniques for noninvasively gaining accurate information. But they have instead supplanted and replaced what they were designed to enhance, because they are perceived as “superior” due to their scientific and technological basis, their objectivity. Truth be told, some of these tests also came into fashion because they helped practitioners reap additional financial gain. Technology became mesmerizing. Doctors became enchanted by the ability to obtain objective test results, relying less on their senses and intuition when diagnosing.
In and of themselves, the tests are not the problem….how they are perceived and overutilized is. There is no substitute for the combined cognitive and intuitive abilities of the physician, taking all the tests and observations into consideration, and this is where the human element comes in. The relationship and respect that human touch (literally and figuratively) cultivates in the patient physician relationship cannot be achieved by tests and computerized notes, nor by keeping one’s eyes glued to the computer screen during the exam – if there even is an exam.
I am deeply saddened by what is being lost in the practice of medicine. It is so gratifying to hear from physicians who also appreciate what is being lost, because it is my sincere hope that we can embrace some of these “not so arcane” practices, hold onto them and teach them to the next generation of doctors before they disappear forever, unretrievable. They are the essence of the healing arts. Unfortunately, at this point, they have been relegated to the broom closet, deemed less worthy than graphs, charts, numbers, and pictures. It both depersonalizes medicine, and emphasizes the science to the exclusion of the art.
Not so coincidentally, reducing the overuse and unnecessary use of objective tests can also help reduce healthcare costs. At this time of unbridled growth in healthcare costs, more of a balance is needed in discerning what can be eliminated, and what can be re-introduced. That is exactly what an initiative called “Choosing Wisely” is intended to produce, as a medley of member physician associations each have suggested 5 tests used in their specialty that could be utilized more judiciously. At least it’s a step in the right direction.
Thank you, Maggie, for starting this important dialogue.