Demise of the stethoscope

Abstract

Medical practice has undergone a massive drift over the past several years. With the advent of modernization and technical advancements in both diagnostic and therapeutic fields, bedside clinical skills have suffered a setback. Increasing patient load in the hospitals, administrative commitments of the physicians, and need to get superspecialty fellowships are some of the factors which preclude resident teaching, which, in-turn hamper their long-term clinical skills and influence the patient–doctor relationship. In this perspective, I narrate my own experience regarding changing attitude of the younger generation of doctors toward patient care and also describe the role of a mentor in shaping the believes and practices of his medical students. Using real-world examples, I further discuss the obstacles which hamper good medical practice and suggest possible ways to overcome some of them.

On the first day of my internship after the completion of medical school, I got to see a little girl, Emily Grey, in the clinic who complained of a fever of 2-weeks duration. After taking a detailed history, I began her physical examination. While I was auscultating her chest, she smiled at me and asked- “what is this instrument around your neck called, and what is it used for?”. Baffled by her curiosity, I replied- “this is a stethoscope dear, and it is used to listen to body sounds”. She noticed my actions with keen interest during her stay at the clinic. While leaving for home, she waited for a while, turned back, and remarked- “I am deeply touched by the way you examined me. It gave me comfort, warmth, reassurance, and I truly appreciate your efforts. You inspire me to become a doctor. Thank you, sir!.” Her compliments strengthened my confidence and made me realize the value of “the human touch.”

A decade later, while doing my clinics as an attending consultant, an elderly lady walked into my room. I comforted her into the chair. She had high-grade fevers for 3-weeks. I got a call from the emergency room for an urgent consult. I requested my clinic intern, Dr. Justin, to obtain a detailed history, perform a meticulous physical examination, and admit her to the ward while I left for the emergency consult. He called me later and answered hurryingly- “Sir, the elderly lady whom we saw in the clinic today is being worked up in the ward for fever. All investigations have been sent, and the results are awaited.” During post-clinic ward rounds, a ward intern briefed me- “Mrs. Julia Kepner, a 70-year old lady admitted today with a history of fevers and a maculopapular skin rash over her body for 2-weeks. She reports consuming unpasteurized cow milk a month ago. Physical exam reveals a pan-systolic murmur in the mitral area. A possibility of infective endocarditis secondary to Brucella has been considered. While awaiting the test results, she has been started on empirical antibiotics.” “Excellent presentation!” I remarked. “Doctor, what is your name?” I asked. “Dr. Emily Grey,” she replied and added further, “I am one of your old patients. You not only treated but taught me the importance of patient–doctor relationship and the basics of the medical profession.” I was humbled.

While traveling back home that day, a series of thoughts crossed my mind. A striking contrast between the past and present medical practice became quite evident. Several questions arose, the answers to which I tried to seek in this article. Since the “stethoscope” symbolizes the medical profession, I use it as a surrogate for “medical practice” in my article. (1) Is medical practice becoming increasingly more mechanical? Dr. Justin’s response was a testimony of the fact. Nowadays, I see doctors and paramedical staff referring to patients as “he” or “she.” Sadly, doctors often fail to remember the patient’s name, who are treated as mere objects rather than true humans. The loss of sensitivity toward patients has been worsening gradually. (2) Are bedside clinical skills deteriorating? The stethoscope has been a great tool in the diagnosis of various disease conditions, and in addition, serves to build a strong patient–doctor relationship by providing the patient a sense of comfort, warmth, and “human touch.” It represents the medical profession. Recently, I find doctors using it only during their medical school training and internship period. Afterward, a stethoscope is worn as a mere ornament by doctors to glorify themselves. Modern-day diagnostic tools have overpowered the use of this valuable instrument.¹ Hyposkillia denotes an inability of the physician to execute the required clinical skills toward patient care including, an inability to take a comprehensive medical history, conduct thorough examination, formulate a sound management plan, communicate properly, and use appropriate reasoning to help reach the diagnosis. It results primarily from an outburst of high-tech modern diagnostics, which offer an easy and time-saving way to “examine” a patient in this fast-moving world.² In my opinion, the nonusage of the stethoscope represents the demise of the medical practice. It is imperative to supplement machine-based diagnostic tools with bedside examination skills to allow for an accurate diagnosis;¹ moreover, patients feel “owned” if they are examined. This helps build a strong foundation for the treatment.³ (3) “As you sow, so shall you reap.” Today’s incident strengthened my faith in this phrase. Your actions as a teacher or even as a physician would have a lasting impression on your students or patients. Therefore, in this high-tech era of modern medicine, teachers at the medical school or physicians in the hospital must practice what they teach. Their actions are likely to have reciprocal consequences on the future generation of practitioners.

Several possible causes are pictured in my mind to explain this paradigm shift in medical practice. In my opinion, each step of the ladder has constraints. (1) In medical school, I see lesser teaching, particularly bedside teaching these days, which could be related to the disinterest of either student, or teacher, or both. The mounting interest of the medical students toward the super-specialty fellowships at the beginning of their careers could cause disinterest toward the most basic education. Administrative commitments of the teachers often result in their inability to take academic lectures. A strict curriculum in the medical school that includes practical topics like patient–doctor relationships and the importance of bedside examination must be instituted. A high weightage must be accorded to the clinical skills section at the time of exit exams. In case of nonavailability of consultants, either interns or residents could be asked to teach the medical students.⁴ (2) At the hospital, an enormously increasing patient load, administrative responsibilities, medico-legal issues, peer pressure in academics, and research are some of the factors which leave little time for the resident teaching.⁴ Emphasis on limited working hours, absence of accountability toward patient care, and the quest for personal motives are some of the other variables which contribute to the hyposkillia.² Involving interns or residents in patient care in a supervised manner, including daily case notes, treatment decisions, case presentations, and publications could be one way to deal with this difficult issue. Weekly interactive classes like journal clubs, virtual ward rounds with the involvement of the entire department, weekly mortality meetings, clinicopathological meetings, and statistical analysis may also be implemented to allow for a close, unified, and responsible work system. (3) Patient’s appreciation boosts doctor’s confidence. Patients could be encouraged to write their thoughts about the hospital stay, discuss possible flaws in the system, and provide suggestions for the improvisation in a notebook before discharge from the hospital. A review of such patient feedbacks might unveil the hidden fallacies in our system and help us become better doctors with time.

To conclude, I feel that medical practice includes good bedside behavior, astute clinical skills, and a polite but strong patient–doctor relationship.³ As doctors, it is our utmost responsibility to preserve the precious inheritance of our senior colleagues and pass it on a more refined and friendly manner to the subsequent generations of aspiring doctors. While modern diagnostics is a necessity and boon to patient care, age-old bedside basics remain the pillars of contemporary medicine.