- Opinion Piece
Is the age of the stethoscope over?
Have we forgotten the art and science of a physical examination, including the use of a stethoscope – the age old emblem of medicine? What is its place in a post COVID19 primary care that operates on total triage and remote assessment? Eric Topol, an eminent american doctor, cardiologist, and thinker whose work I admire enormously, recently posited that the era of the stethoscope for listening to the heart is over - he argued: why listen when you can see inside the human heart using a handheld portable ultrasound device?
At medical school, detecting a heart murmur and classifying it seemed a mystery: defying generations of medical students who struggled with the 'lub-dub' cadence of heart sounds plus or minus murmurs, prosthetic clicks. Assessing murmurs accurately was a key part of Finals and of membership examinations.
In my view, we ignore the basics of medicine, such as the patient history and examination, at our peril. Now there are too many tests, X-rays, and scans without sufficient attention to basics which leads to overdiagnosis and unnecessary treatments. It is tempting to go straight to tests, often expensive and involving radiation exposure. The myriad test results can be challenging to separate the wheat from the chaff. I have a mantra: treat the patient and not the test result.
The use of a stethoscope can be game changer. I vividly remember when Brian called me because he unexpectedly became dizzy and lightheaded during a football game. I was new in practice and eager. This was in the halcyon days of general practice when things were relaxed. I asked him to pop down at the end of the evening surgery. The only finding was a systolic murmur, but all the vital signs were stable. We sent an urgent referral to the local cardiologist, whom we knew by his first name. He was diagnosed with aortic stenosis within a few days and was cured surgically. The stethoscope here literally saved Brian's life. 32 years later I still see him in the anticoagulant clinic.
I remember Hannah, a new-born baby in whom I discovered a harsh systolic murmur at the 24-hour check of the kind and severity I had not heard before. Naturally, I was concerned and pleaded with the on-call paediatrician for early assessment. Despite resistance the referral was eventually accepted. Pulmonary stenosis was diagnosed, which required surgical intervention—full marks to the value of the stethoscope. And during a busy, frantic Monday morning clinic, I remember finding a murmur in an elderly patient with non-specific symptoms who was found to have infective endocarditis.
But the clinical life of a GP is never straightforward, with unexpected diagnoses, developments, and surprises. So, I will never forget Bob. I was Bob's GP for many years. He was a heavy smoker with a formal diagnosis of chronic obstructive pulmonary disease. In his 70s, he had frequent infective exacerbations that responded well to steroids and antibiotics. During a particularly severe exacerbation, he was admitted to the hospital by the out-of-hours service. He sadly died during the admission. When I received the notification, I was shocked to find out the cause of death was severe aortic stenosis. Could his 'silent' aortic stenosis have been detected earlier? And in retrospect, was his fatigue a sign of his undiagnosed heart valve disease (HVD)? Did the symptoms of wheezing mask the murmur detection?
So, we must do better with earlier detection of heart valve disease: our clinical assessment models must evolve to ensure faster diagnosis and safety netting. My thinking has evolved. What if we combine good medicine and clinical judgment with the judicious use of innovative technology?
Specialists have warned that heart valve disease is going undetected in the UK (1), with 300000 people having potentially fatal valve disease. NICE has also produced an excellent guideline, recently reviewed in Guidelines in Practice (2)
In an important report in July 2021, the All-Parliamentary Policy Group (APPG) for heart valve disease (3) recommended annual stethoscope checks for all those aged 65 or over. This seems sensible if done opportunistically, as most people in this age group are likely to be seen at least once per year in primary care. But there are barriers, particularly with the current crisis in general practice. How often do we have the luxury of time in general practice with its 7–10-minute consultation to conduct a heart examination? And as my examples show, even auscultation may be falsely reassuring, especially in comorbidity.
The stethoscope underwent very little change despite Laennec's invention 200 years ago. Can new technology, such as digital stethoscopes, help? These reduce noise and increase amplification. There are also portable handheld Ultrasound devices that show images and blood flow on a smartphone - looking 'inside' the heart. I believe using such technology may have helped Bob. Handheld digital and ultrasound stethoscopes may support clinicians using automation and artificial intelligence (4). Indeed, the APPG recommended that the NHS undertake studies into digital stethoscopes to assess their impact on aiding the detection of HVD in primary care, perhaps as part of community diagnostic hubs.
So don't through away your stethoscope just yet. It is mighty! Instead, use it more! -especially in people over the age of 65. We are doing great in projects on atrial fibrillation, hypertension, heart failure, and lipid management but heart valve disease has become the Cinderella of cardiovascular disease.
So is the age of the stethoscope over? Definitely not! We need to use it more but we also need to augment its use through the use of digital and ultrasound instruments used at the point of care.
General Practice Based Primary Care has thrived because it has evolved and adapted with grassroots innovation such as computerisation: Can it now respond to the challenge of faster diagnosis more broadly? Future models of care may comprise a three-part process of history, examination, and 'bedside' or Point of Care testing/ /imaging.
Sir Mayur Lakhani CBE is a practicing GP in Leicestershire, an ICS/ICB Board Member, Former President of the Royal College of GPs, and Chair of the Faculty of Medical Leadership and Management (FMLM). This article is written in a personal capacity
- Uncovering the treatable burden of severe aortic stenosis in the UK | Open Heart http://dx.doi.org/10.1136/openhrt-2021-001783
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