The Stethoscope

A Love Letter to Obsolescence

The TV commercial for a health insurance company pictured a handsome young physician pressing his stethoscope against a patient’s chest. The patient, also devastatingly handsome, is sporting not one but two layers—a T-shirt and a sweater. I nearly choked on my cocktail. Back in my medical school days, attempting such a maneuver would have earned me either an invitation to repeat the year or a helpful suggestion to explore an alternative career, such as interpretive dance.

We were indoctrinated to place the device against naked skin. We even learned the art of warming the diaphragm first, lest our patients experience the trauma of cold metal and shiver themselves into a diagnosis of hypothermia. Such were the quaint customs of a bygone era.

Abraham Vergheese, in My Own Country: A Doctor’s Story, recounts the same ritual of physical examination with which we were indoctrinated: inspection, palpation, percussion, and, finally, auscultation. If you were conscientious and observant, you already knew what you were likely to hear. Today’s students are skilled in none of these skills.

We learned the difference between all the sounds emanating from the lungs and what they meant - rales, rhonchi, crepitus, crackles, stridor, and wheezes. Heart sounds were a particular challenge, but we all bought a one-hour 33 rpm vinyl record made by one of the cardiologists, and spent hours learning the clicks and whooshes. It was similar to learning bird songs, but even more challenging when the heart rate reached 180 beats per minute. This was during the golden age of rheumatic heart disease, when diagnosing valve problems was an actual marketable skill. The only technology available to us was a chest X-ray and an electrocardiogram. We had to rely on our senses, including our eyes, ears, fingers, and nose. We became excellent diagnosticians, or else found another profession. One person in our class became a movie director, while another pursued a career in accounting.

Those halcyon days of clinical diagnosis are long gone. Amazing new technology replaced our ears. Imaging and interventional radiology have revolutionized the evaluation of heart disease. So the question is, why do physicians still cling to the symbol of the stethoscope when almost no one knows what it is for? At this point, it’s basically medical cosplay.

Even blood pressure measurement has succumbed to technology, though it is so fraught with inaccuracies that many readings are almost useless. The new guidelines have once again shifted the goalposts. Every country has different criteria, so you can literally cross a border and transform from “dangerously hypertensive” to “perfectly normal”—no medication required. That is inexpensive medical tourism.

In reality, the entire charade of the physical examination remains mainly as a means to pay the bill. My nephrologist looks at my ankles through my socks and then scribes - no edema, pokes at my belly through my clothes, listens to my lungs through three layers of clothing, and checks the box - ‘comprehensive examination’. That will be $220. It’s a bad joke performed daily by physicians and patients who are engaged in mutual delusion.

My internist, bless his heart, still makes me undress for my annual well-check-up. He provides one of those humiliating paper gowns that tears if you breathe wrong, then leaves me to contemplate my life choices while I wait. Being in his fifties, he actually conducts a halfway decent examination, though he confessed—in a moment of brutal honesty—that he rarely expects to find anything significant. This doesn’t stop him from ordering approximately 50 blood, urine, and stool tests, plus a few X-rays for good measure. If you have one symptom? That’s a referral to three specialists, just in case.

He’s one of the few holdouts in his practice who still performs this ritual, mainly because his patient population is geriatric and expects to get their money’s worth. At least they leave feeling thoroughly examined, which is really all that matters in our modern healthcare theater.

Even when performed with aplomb and great care, the physical examination traditionally accounted for approximately 5% of diagnostic information. The patient’s history remains king, but that’s been reduced to checking boxes on a computer screen. At the same time, the physician nods sympathetically and tries to remember if they’re supposed to make eye contact or stare at the monitor.

Many physicians have fully embraced the “test everything, examine nothing” approach, which is precisely why algorithms are threatening their employment, and patients are about as satisfied as airline passengers in the middle seat.

Perhaps the physical examination’s last remaining purpose is to “build the doctor-patient relationship.” What a romantic notion. That is similar to saying that the primary purpose of a first date is to practice small talk. What a devastating commentary on what was once a cherished and valuable skill.

Like the lancet of old, used for blood letting, it is time to retire the stethoscope as a medical symbol. It has far outlived its use. It needs to be replaced with something more appropriate for our era. Perhaps a laptop? A billing software icon? An image of a referral form? Or a picture of a shrug emoji. At least that would be honest.

Rest in peace, dear stethoscope. You had a good run. Now you’re just cheap jewelry. We no longer need to see it draped around the neck or drooping suggestively from the lab coat pocket.