Is it time to trash the stethoscope? The age of ultrasound

Is it time to trash the stethoscope? The age of ultrasound

2016-11-11T18:39:33+00:00

stethoscopeIs the physical exam a relic of the past, because our tools are relics of a prior era?

It is important to do and teach a thorough physical exam. I cautioned against the overreliance on diagnostic testing in lieu of a physical exam, which can be initially burdensome and prolonged. But perhaps our difficulty with the physical exam is not the exam itself, but the tools that we have at our disposal to perform an exam, rather than the exam itself.

Let’s talk about the stethoscope

As a child, I often had the image of a doctor that included a long white coat, benevolent smile, black bag filled to the brim with tools, and of course the ubiquitous stethoscope. However, as a doctor now, I find myself less excited about the stethoscope. Often it’s a nuisance that gets caught on bed poles in the ED and wrangles my neck. (It may be useful, however, as Trick of the Trade tip as a tourniquet for the EJ exam.)

Out with the old, in with the new!

The old-school doctor had the stethoscope and all 5 senses (except hopefully taste) to assist with physical exams. The present-day doctor now has something else around the neck, the portable ultrasound! Portable ultrasound has opened up a field of ultrasonography called Point of Care Ultrasound that appeals directly toward the needs of EM. According to NEJM , “point-of-care ultrasonography is defined as ultrasonography brought to the patient and performed by the provider in real time.”

It enhances patient evaluation and examination in almost every organ system, including diagnosis of pneumothorax, cholecystitis, ectopic pregnancies, and extremity fractures. Using an ultrasound to enhance the physical exam in these cases makes the diagnostic process more efficient. Sonography allows the examiner to go beyond the 4 senses (minus taste) and perform a useful exam.

Even medical schools agree!

Medical schools have also recognized the importance of ultrasound and have integrated it into traditional curriculum. Just as there were physical exam courses, there are now ultrasound courses to teach students how to perform exams. Dr. Laleh Gharahbaghian (@SonoSpot) just conducted a successful course for medical students in northern California on point of care ultrasound.

Now what?

The question now remains, if ultrasound is so great, is there ANY use for the stethoscope? Can we throw away the stethoscope and only use the ultrasound for patient examinations?

My first thought is that we are comparing apples to oranges. I feel that ultrasound does not simply replace the stethoscope. It blows ultrasound out of the water! We can do a more thorough exam with ultrasound than we could ever do with the stethoscope. So it isn’t a fair comparison. That being said, there are pros and cons to consider. 

Pros and cons of ultrasound use

PRO         CON
Repeatable         Costly
Shareable         Operative dependent
Portable         Interpreter dependent

The future

There will be a time, when medical students will receive a portable ultrasound with their new white coats. Physical exam courses will be based upon how to ultrasound each organ system with the supplementation of the traditional auscultation and percussion. And our patients will benefit for it.
 
I still always wear my stethoscope around my neck for every shift, and obligingly use it on every patient that I see. It is a part of my routine exam– emphasis on the word routine. But I can’t wait until the day when I get my own portable ultrasound, and it will fill that groove around my neck!

It is time to recycle your stethoscope, or am I being too premature?

 
Disclosure
My fiance works for Siemens ultrasound and used to work for GE ultrasound
 
References

  1. Iverson K, Haritos D, Thomas R, Kannikeswaran N. The effect of bedside ultrasound on diagnosis and management of soft tissue infections in a pediatric ED. Am J Emerg Med 2011. PMID 22100468
  2. Summers SM, Scruggs W, Menchine MD, et al. A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis. Ann Emerg Med 2010; 56:114-22. PMID 20138397
  3. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med 2010;17:11-7. PMID 20078434
  4. Stein JC, Wang R, Adler N, Boscardin J, Jacoby VL, Won G, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Ann Emerg Med 2010;56:674-83. PMID 20828874
Source:  Image 1

Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University
  • I too am a huge fan of using the ultrasound in real time in the ED. I agree it provides mountains more useful information about the patient than the stethoscope. However, I do not feel the stethoscope should be relegated to medical museums. We must never forget the healing power of laying hands on the patient. It makes a human connection with the patient. We are not just machine operators that pour cold ultrasound gel on the patient. Ultrasound should be part of daily practice, but we need to maintain our skills and not rely on machines. What happens when the video laryngoscope doesn’t work? What happens when the one ultrasound machine in your department is being used for placing a central line when the unstable dyspneic patient rolls in? The day is coming when everyone will have their little portable ultrasounds with them as medical students. We must remember that it is just another tool that makes us better doctors.

  • Great post. Ultimately I think of this like the debate for direct laryngoscopy vs visual laryngoscopy…….well kind of, but the point of the analogy is yes video laryngoscopy helps first pass intubation, decreases complications, etc……but not every hospital can afford it or is savvy in it. Much like the stethoscope versus the ultrasound. I agree that the time is coming that ultrasound will be and should be used as a portable tool (many studies showing benefit to patients without harm), but the more senses a physician uses the better a diagnostician he or she becomes. Great job on this write up, a lot more things that could be discussed.

  • When US is as portable as a stethoscope, I think the technology will explode. I know it’s “there” in that they have these devices but they are not ubiquitous (as mentioned, some EDs don’t even have any US machine). When my smart phone can check someone’s ECG, do cardiac US and I don’t have to sacrifice immediacy, my stethoscope will officially disappear (assuming I can always borrow a nurse’s in a pinch).

  • Anonymous

    My stethoscope is already in the trash!…or someone else’s pocket — I don’t know because I lost it nearly two years ago and haven’t looked back!

    Of course, I work in an academic ED, so someone else is “listening” for me.

    Note to CMS: I ALWAYS borrow a resident’s or nurse’s when I do my own physical exam and would NEVER commit fraud.

    Note to everyone else: I am more interested in good patient care than checking useless boxes — so as soon as my evaluation of the aortic valve (and to a lesser extent, the mitral) gets just a bit better, I will always be “faking” it when I place the stethoscope on a patient’s chest. [I still actually listen a bit in syncope patient’s and peds asthma]

    HH

  • Thanks for all the comments so far, I wrote this post because I wanted to emphasis just really how much better our physical exams can be when we use ultrasound!

    • Very true. Anything we can use to make our practice better if more than welcome.

  • I use US on a regular basis in ED, but still remember proper technique for many so ancient things, like drawing the Damoiseau line based on percussion and auscultation, examining the fluid in abdomen just by percussion, even estimating the heart silhouette with percussion only. Point is- we became just plain lazy and prefer to stick to new gimmics, but our teachers did lot of that just using their hands, ears, and brain

  • This comment has been removed by the author.

  • Great post, Nikita. I know that you intentionally wrote it to be controversial and it indeed worked to generate some thoughtful comments seen above. Stethoscopes still have a minor role in the physical exam, while the US is gradually replacing its essential functions (except for perhaps detecting wheezing). On twitter, someone mentioned using CO2 capnography to indirectly detect wheezing and obstructive pulm disease pathology.

    I bet in about 5-10 years, US will be standard of care for many parts of the physical exam, especially as their costs go down and their design improves (portability, quick start up, attachment to your mobile device). I think stethoscopes will be relegated to being a second-line tool, if US or capnography is not readily available. Just my opinion.

    Thanks to everyone for commenting. Love the dissenting opinions.

  • This is so true Nikita! There are many schools doing this: Dave Bahner is an amazing EM Physician who has incorporated it into all 4 years of the med school curriculum at Ohio State: http://www.osuultrasound.com/ , and here’s Univ S. Carolina who’s doing it too: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3064888/.
    The future is bright indeed!!!

  • Great post. I am all for using ultrasound over stethoscope in the future, though theres one physical exam finding I have yet to see an ultrasound information on: Wheezing.

    Im sure someone much smarter than me will find some way of using dopper or color flow in the future to make this happen.

  • Great post & comments — one thing I want to borrow (steal) from Bret Nelson is that while US gets a bad rap for being “operator dependent” and “interpreter dependent,” so is everything else. We’ve all seen x-rays that weren’t aligned properly, or CTs that mistimed the dye-load. And I’m pretty sure we’ve all missed a small PTX because we say a big infiltrate. Stethoscopy is no different, either. US is by no means unique in it’s operator & interpreter dependency.

  • Hi Seth… you raise an excellent point that I really hadn’t considered prior to this, you are right EVERYTHING is operator / interpreter dependent… and I suppose that is why medicine is an ART!

  • Ultrasound has already replaced stethoscope, even in third worls, like here in Egypt, where chinese portable ultrasounds made it available for us, as a sonologist i am proud owner of two portable machines not just for emergency ultrasound but also for my ultrasound clinic

    • Wow, in many ways you are on the cutting edge of medicine. Was the transition difficult to make? Thanks for sharing your experiences from Egypt.

  • Love this post Nikita! Just saw it today – catching up after a vacay – If you can see the pneumothorax, pleural effusion, pulm edema, pneumonia, valve dysfunction, pericardial effusion, bowel persitalsis, etc and more… why do you need to hear it? 🙂 I do still carry around my stethoscope because machines are too expensive, too heavy, and too big to truly replace the stethoscope for all physicians, but maybe one day… and I imagine one day soon!

  • I feel the greatest use of the stethoscope is it gives me time to think. Also listening for a wheeze is the other important utility. Also be careful about using an US to r/o PTX if there is concern about pleurodesis.

  • As point of care ultrasound continues to penetrate all areas of medicine in this country we must be careful with the terminology we use to describe what we do. After all, we are the leaders in this industry. Statements such as ” ultrasound is an extension of the physical exam” and trendy analogies like “ultrasound is the stethoscope of the 21t century” continue to be used with increased frequency by ultrasound vendors, simulation companies, physician colleagues, specialty societies like RDMS, hospital administrators and medical student educators. While it may seem logical to use this language in the academic / medical student education setting it can have negative impact in the clinical sector. Our colleagues practicing in the community do not use this technology as a stethoscope but a diagnostic study separate from the physical exam. The results are archived and documented in the patient’s medical record. Insurance companies want nothing more than to bundle our ultrasound codes with the standard E&M codes so as not to reimburse us for our hard work. If they see what we do as part of the physical exam or a glorified stethoscope they will have all the ammunition they need.

    It is critically important that we draw the distinction between ultrasound used in the education and clinical setting. I realize this is an academic blog but I felt compelled to post this here as we all have a part to play in this game. Medical students should fully understand what the role of this powerful technology is as they are the future. We will not be able to purge the language but it is time we try and contain it. I believe we should still carry our stethoscopes around no matter how cumbersome they may be. Thanks for listening.

    Rajesh Geria MD
    Chair, ACEP Emergency Ultrasound Section
    @geriasonomd

    • Hi Rajesh: We’re honored to have you comment on this blog. You certainly bring insightful and unique considerations to this discussion. My thoughts:

      1. Community vs academic uses of ultrasound: In my mind, the overarching question is — SHOULD bedside ultrasound be considered as critical skill set for emergency physicians, much like intubation and suturing? If so, we should make this a uniform practice for all EDs- not just academia and education.e It’s my belief that it should become a core skill set in the next 5-10 years. I’m not sure if I’m just the crazy one to think this.

      2. Billing: I’m not sure if we should change our message from the perspective of E&M codes and billing. I’m all for having physicians getting appropriately paid for their services, but not sure if re-labeling how US is used is the best approach. Perhaps a better way is to focus on insurance companies rather than having physicians try to relabel how things are used or not used. Maybe US can be in its own billable coding set, outside of the traditional physical exam?

      Just my 2 cents. Perhaps I’m naive in my thoughts. Interesting discussion.

    • Michelle, thank you allowing me to voice my opinions in this forum.

      1) Ultrasound is absolutley a critical skill for emergency physicians as evidenced by the recent RRC milestones plan. Making it uniform practice in all ED’s would be ideal but it is easier said than done espeically on the community practice side. One of the biggest reasons for this is lack of ultrasound expertise / leadership and formalized QA process. As a section we are trying to give community EP’s the tools they need to suceed in this area.

      2) Ultrasound does have it’s own billable coding set but we continue to face denials and codes continue to be bundled. I am not saying that the reason for bundling and denials are a direct result of calling ultrasound an extention of the physcial exam but the language does not help our cause. In the end it is really about delivering quality patient care. IF we are truly using ultrasound as a diagnostic tool we should be archiving and documenting findings in the medical record. This is far more important than the reimbursement argument.

      RG

  • Anon

    I accept that ultrasound is inextricable from the future of our practice and I make every effort to use it when I can. I work mostly in the community now but will be back in the academic scene soon so I will be spending four weeks of vacation time updating my skills. Not all physicians in the community can do this. Moreover, if a community physician never trained with ultrasound– it will take them much longer to feel comfortable with that skill and once they learn it they will have to maintain their competency. This is not an easy feat !

    I am very concerned with the notion that a physician is “faking” auscultation. A stethoscope is absolutely necessary at the bedside for listening to bowel sounds, etc.. Shame on you ! Yes, I may be an “old fogey” but my old ears have picked up murmurs, rubs and pneumothoraces faster than any physician can power up their ultrasound machine.

  • You will always need a stethoscope. Not only to be identified as a physician 😉

    I love ultrasound but I think we need the whole picture. How can we assess bowel activity better and faster than with a stethoscope?

    • njoshi8

      Thank you for your rely Daniel! Bowel activity and pulm function is definitely an area that is tricky to just ultrasound. Of course the answer is somewhere in the middle ground, but its important to recognize the rise of ultrasound. Thanks again!

  • maateeq

    Its possible to combine both products in one pocket ultrasound that can work as stethoscope as well..