Author:Orient, Jane M.

STOCK PHOTOS of "health-care workers" who attend patients--physicians no longer are distinguishable--usually feature a stethoscope draped around the neck. Some, however, such as cardiologist Eric Topol--author of Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again--consider the stethoscope obsolete, nothing more than a pair of "rubber tubes."

The most-important part of the stethoscope is the part between the ears, but some think that will be replaced by artificial intelligence, and the rubber tubes by sophisticated electronic gizmos costing at least 10 times as much as the humble stethoscope.

High tech is wonderful and increasingly capable but, if the stethoscope is dying, so is the art of clinical medicine. The proper use of the stethoscope requires the doctor to touch and listen to the patient, while spending some time with a living person, not a computer. Patient and physician must cooperate: "Stop breathing," "Take a big deep breath," "Lean forward," and so on.

It may be true, as Northwestern University cardiologist James Thomas says, that graduates in internal medicine and emergency medicine miss as many as half of murmurs using a stethoscope. There are several reasons for this. One is not taking enough time to listen in a quiet room, and failing to have the patient perform the special maneuvers required to bring out an otherwise inaudible murmur (lean forward and exhale fully, turn onto your left side, squat then stand up, etc.).

The other is inadequate training. There are excellent recordings of heart sounds and murmurs, which of course would take time away from the time-devouring electronic medical record or "systems-based" medicine--and a recording is not the same thing as a live patient. Much of today's teaching in physical diagnosis may be by "patient instructors"--paid actors pretending to be patients, who are evaluating the students as the students examine them. Rounds may be in a conference room, focused on the electronic record, instead of at the bedside.

In the old days, all the members of the team got to examine a real patient who had an interesting finding, with the patient's permission and under the supervision of an attending physician. It seemed to me that patients usually enjoyed being the center of attention and the star of the show, and hearing the professor discuss his or her case. We learned how to help patients to sit up, and about hairy chests, layers of extra insulation, noisy lung sounds...

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