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.”