During my intern year, I wrote an essay about the dying art of the physical exam that was published in the New England Journal of Medicine. I used myself as an example and confessed that my exams, during early morning hospital rounds, were less than 30 seconds. I divulged the secret of the “intern’s spot,” the magical area on a patient’s chest where breath, heart, and bowel sounds can all be heard in record-short time. And I relayed a case of calciphylaxis, a rare complication of kidney failure in which the skin necroses at a rapid and fatal rate. The smell of dying, rotting skin was unforgettable. The intended message of the piece was that as one part of my patient encounter was dwindling (the expected stethoscope exam) another unexpected part was improving (the equally important olfactory exam).
The essay was misinterpreted, though, and has been reprinted in a number of medical school syllabi (including my own) to defend the importance of the stethoscope—and by extension, the full physical exam—to medical students. The stethoscope isn’t a tool, anymore, but a metonym for bedside manner.
Today’s medical literature reveals a critical debate about the stethoscope’s place in modern medicine. Can new technology restore the equipment’s place among a doctor’s armamentarium, or should we consign the stethoscope to an old-fashioned doctor’s bag, right next to a tuning fork, as a relic of physicians past? A search of PubMed, the National Library of Medicine’s digital catalogue, for recent articles about stethoscopes results in either performance evaluations of electronic, acoustically enhanced stethoscopes or investigations into how stethoscopes are a route of healthcare-associated infections, transmitting microbiota from patient to patient. These latter articles question, sometimes directly, sometimes indirectly, whether the ceremony of the stethoscope exam should continue if it comes at the cost of nosocomial infections. Some hospitals have encouraged their doctors to stop wearing neckties, long sleeves, and even the white coat itself to prevent such infections. Would these same hospitals someday outlaw the stethoscope, too?
When the poet Claudia Rankine wrote about “a truce with the patience of a stethoscope,” she couldn’t have been thinking of the way my colleagues and I use our stethoscopes. My daughter, listening to our 4-year-old neighbor’s heartbeat with her toy stethoscope, is more patient with her doctoring than any doctor I’ve seen in my hospital. “I can hear it,” she says with a smile, her hand cupping our neighbor’s chest. “I can hear your heart,” she whispers to her friend, as if they’ve both shared a magical experience.
I witnessed this doctor play just a few weeks after my father had visited to examine my infant son, whom my wife and I had self-diagnosed with croup. We called up my father and let him hear my son’s barking cough over the phone. He agreed with the diagnosis.