The Dinosaur called Stethoscopus Antiquatus

Many years ago, when I was a resident in Urology, there was a patient whose condition was presenting a problem to the staff. He had a “kidney” stone positioned at an awkward location along the path from the kidney to the bladder. This path is a small natural tube called the ureter. Previous attempts at retrieving the stone from the ureter were made using endoscopic devices, both from above and below. The endoscopic approach involves snaking in a specialized tube that can allow for the grabbing or local shattering [using ultrasound or sound waves] of the stone.

In the midst of this discussion about how to get at the stone, one of the senior Urologists noted that years before, this would have been simply managed. In the past, he said, the patient would have had an incision made on his flank and the stone would have been directly removed from its location midway in the ureter. So why not continue to do it this way? Because complications from using this direct, open approach were sometimes so bad that the patient could lose the kidney on the side where the stone was. This was rare with the endoscopic approach. So, while modern medicine had and still has its drawbacks, overall it was and still is clearly a far more successful approach, at least to this particular problem.

Many people I know have had their gallbladders removed using the relatively newer laparoscopic approach. In this approach, small incisions are made on the abdomen and specialized viewing and operating tubes are placed into the abdomen. It is astonishing what can be done through these tubes. More importantly, this approach yields much better results in terms of patient recovery and reduced complication rates. I have heard the joke a number of times that soon, surgeons will be called “tubologists.”

Both of these types of cases demonstrate something that doctors are actually very uncomfortable with. As time moves on, old techniques are put aside and replaced by newer techniques most often founded on new technologies. It is actually quite traumatic for some physicians to have to learn a fundamentally new way of practicing medicine. One would think that all doctors would be excited at the possibility of practicing better medicine, faster and with fewer complications. On the other hand, tell certain doctors who are already 50 years old, that in the next few years they will be expected to manage a mobile phone sized ultrasound device that will replace many other tools they presently use, and those doctors will already start planning retirement.

Change is hard. Doctors very much want to be expert at what they do. By definition, the moment a major change is implemented, no doctor can claim to have decades of experience with the new approach. I’m in fact always surprised that salespeople don’t understand how sensitive an issue this is and how much resistance they may face when showing off new and improved technologies to doctors.

I was just reading an article about an FDA approved digital stethoscope, from Eko Devices. Before discussing this whole field of digital stethoscopy, let’s ask the obvious question. Why create a digital version? Is this just because the trend today is to computerize everything?

The stethoscope is an amazing device that allows a properly trained physician to diagnose heart, lung, abdominal and vascular problems. Stethoscopes are so strongly associated with the practice of medicine, that patients expect practically every doctor to have one slung around their neck and shoulders.

Stethoscopes are actually very problematic. Let’s just start with the fact that stethoscopes can be an ideal way for bad bacteria to hop from one patient to the next. The stethoscope itself is used on multiple patients, sometimes over years of a doctor’s practice. So, it is understandable how (without proper cleaning) a stethoscope could become a reservoir of all kinds of microorganisms. Also, as a doctor leans in to listen, the doctor’s clothes and tie make close contact with the patient. This is also a great way for bacteria to be transferred from one patient to another.

As I noted above, interpreting the sounds that one hears via a stethoscope requires significant training. And as alternative tools become available, the use of a stethoscope becomes less and less worthwhile. For example, a well trained physician can determine that the heart of a patient has a physical abnormality all by virtue of the types of sounds emanating from the chest. But an echocardiogram not only can identify the physical abnormality, it can totally visualize the entire heart, both the healthy and sick portions (which can be very important for deciding on treatment). In formal studies, even expert cardiologists did not come close to matching the ability of echocardiograms to identify heart problems. So here’s the question: why bother using a stethoscope when an echocardiogram is so easily ordered?

Over time, the skill of listening to the heart (and other parts of the body) is being lost, for the reason I noted above. When the professors themselves will have studied in an era when stethoscopes are rarely used, who will teach the medical students what to listen for?

In comes the digital stethoscope. The moment the listening part of the stethoscope is computerized, everything changes. Firstly, the sounds can be transmitted in any number of ways to a recording source. The digitally recorded sound can travel via regular long earphones to the doctor, via Bluetooth to a phone or tablet or pair of speakers, via WiFi to the cloud for permanent storage in the electronic medical chart for later review and comparison and so on. Once the sounds from the patient have been recorded, they can be processed by the mobile supercomputer in your pocket, and a diagnosis can be made. No more guessing. No more arguments over the interpretation of the sounds. This is game-changing.

In many ways, this is equivalent to the automated interpretation of radiological studies, which will become standard in the years to come. I personally enjoy looking at an X-ray and being able to identify a fracture. I feel that I am contributing my skill to the welfare of the patient. But soon enough, computers will interpret the films on their own and even suggest the most appropriate treatment, both to the doctor seeing the patient in the ER as well as to the orthopedic surgeon who might have to operate on the case.

In the article I noted above, one doctor laments the loss of personal contact between doctor and patient as digital tools push these two farther and farther apart. The comment is as follows: “a stethoscope exam is an opportunity to create a bond between doctor and patient. You can’t trust someone who won’t touch you.”

Allow me a moment to get up on my soapbox. There you go. Now… “GET OVER YOURSELVES.” Now, allow me a moment to get down from my soapbox (it takes me longer these days than it used to).

I continue to be astonished at the Paleolithic attitude that doctors have about health care. Digital stethoscopy also makes it possible for remote health care workers (even in the United States) to get a second opinion about a case. With EKG, echocardiogram and now heart sounds, all stored digitally in the cloud and/or EMR, local and remote doctors will be able to care for patients better, not worse.

And as to the loss of personal contact, it was predicted that the regular old telephone would destroy communities. People would no longer need to know their neighbors or to interact physically with anyone outside of their home. All I know is, that due to the astounding technologies we have today, I am able to hear and see my family members and friends from across the world. In the past, getting on a boat for America [or for Israel] meant saying goodbye. Outside of letters, with their turnaround time of 1 to 2 months, communication simply did not exist. I can’t speak for everyone, but I don’t need my doctor to physically touch me in order  to have a professional, yet personable relationship with me.

Over the years, I have received many phone calls from people looking to better understand their medical condition. In some cases, I was being asked about life-critical healthcare decisions. I have no measuring stick by which to prove that I managed to have an effective doctor-patient interaction with the person I was speaking to. All I have is feedback from the patient him or herself, as well as their families. The issue is listening. It doesn’t matter whether you’re listening directly to the patient or via a stethoscope to his or her heart. Even from halfway across the world, if you take the time to listen, you will create a doctor-patient relationship that is the envy of many people.

Physicians have to become more and more forward thinking and flexible in their attitudes towards medical practice. It should no longer be an exceptional situation to think outside the box. Physicians should constantly be thinking about how to utilize technology to enhance the doctor-patient interaction. With a fundamental switch in the attitude of physicians, I could even imagine there being a special email address to which doctors could immediately send a summary of a new idea that just popped into their heads. Then, later on in the day, technical staff could sit with the physician to flush out the idea and pass it on to biomedical engineers who would bring it to life. When I was designing my electronic medical record system, I would often get requests for features that could be implemented in the software within 1 to 2 days. This short turnaround time further encouraged the staff to share more ideas such that the project constantly was being pushed forward by all of its physician-users. This is how things should happen. And this is what doctors have to embrace.

Thanks for listening.

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.