A Stethoscope’s Place in Today's Clinical Workflow

Dr. Adam Saltman, Chief Medical Officer, Eko

September 15, 2020

Vasudevan and colleagues, in the June issue of the American Journal of Medicine, published an interesting article, Persistent Value of the Stethoscope in the Age of COVID-19, advocating for the venerable, humble stethoscope. Originally invented to satisfy the demands of a modest European society, the stethoscope has changed little in form or function over the last 200 years, and as such has become the undisputed symbol of the healthcare provider. My own, very unscientific sample of 100 Google images of “doctor” and “nurse” reveals that 96% are wearing stethoscopes, and my experience in academic medicine has reinforced that – even if many don’t actually use it, they do wear it!

CORE Digital Stethoscope
The CORE Digital Stethoscope functions in both acoustic and digital modes.

Which raises this perplexing question: Why don’t healthcare providers use their stethoscopes? And by that, I mean, really USE it, not just wear it for one second as a formality, but listen carefully and purposefully, to extract information and make a decision? The answer, I fear, is complex and sad.

It is complex because of the slow, steady, and insidious progress of medical technology. Think about it: Why would I waste my time listening to a patient’s heart, lungs, bowels, and blood vessels when I can just order ‘A Test?’ Yes, it’s an expensive test, and yes, I can’t get it right now, and yes, the patient is inconvenienced, and yes, the patient gets another bill, and yes, the results rely often on another professional’s interpretation and opinion, BUT it sure is convenient! And besides, if I don’t get ‘The Test’, if anything goes wrong with this patient, I may be criticized and even sued.

And it is sad because, as a physician and teacher, I see this mindset directly driving up the cost of healthcare. I see it degrading the physician-patient encounter. I see it as creating a vicious cycle where those who have lost their skills cannot teach their students. And, most of all, I see it eroding the healthcare provider’s ability to perform a proper and valuable physical examination. (Which is not just auscultation, but also inspection, palpation, percussion; the four cornerstones of the physical exam.)

Medical and nursing students and residents today less and less often lay hands on their patients. They do not perform proper bedside investigative maneuvers. They do not know how to interpret the findings. “Just get a CT scan” is the approach. Entire libraries have been written on the technique and interpretation of physical examination. There are at least two professional societies dedicated to those skills (The Society of Bedside Medicine and the Directors of Clinical Skills Courses). And I know that there is a rudimentary nod to physical examination training during schooling. But these skills are not reinforced and so are quickly forgotten!

I can remember many times being laughed at when I brought my residents to a patient’s bedside, took out my stethoscope, and showed them how auscultation could demonstrate that a patient had fluid in his chest. Without ordering an x-ray or a CT scan. And then how you could treat that patient from those findings alone. And when I showed them how the x-ray (that somebody ordered) actually added nothing to what we found on exam, there was much nodding, silence, and looking at the ground. I hope that for a few, I helped them find respect for, and the use of, a tried and true skill. But I can’t move the needle alone.

In their article, Vasudevan et al offered a view of the value of stethoscopes from the perspective of infection control. They argued quite correctly that stethoscopes are fomites - inanimate objects that serve as vectors for infection. And it was true until wireless stethoscopes such as the Eko CORE and DUO were invented, healthcare providers had to touch the stethoscope with their bare or gloved hand, and go from patient to patient with a device that was difficult to clean effectively. But the ability to physically disconnect a wireless stethoscope from its tubing, leaving only the technology element and the chestpiece, put those into a sterile bag that can be changed between patients, and then listen to body sounds via wireless earbuds has overcome that concern.

At Eko, we hear every day from happy, satisfied customers about how they’ve been able to maintain their isolation, keep their PPE intact, and enjoy the sense of security that they are protecting themselves and their patients from harm by leveraging this functionality.

Beyond infection control, these technology benefits carry over to telemedicine, something that a few months ago was a boutique method of healthcare delivery but has exploded during the COVID-19 pandemic. The CORE and the DUO allow patients to stay safely at home while the provider experiences truly high quality auscultation during a virtual physical examination. The live streaming function in our software allows for the capture, storage, and transmission of high quality heart, lung and bowel sounds, getting the practitioner as close to the bedside as they can be without being in the room.

Wireless stethoscope
Eko stethoscopes allow to perform wireless auscultation while wearing PPE.

But there still remains this issue of ‘The Test’. What to do with that? I am sad to report that it has been proven that physicians today, even experts, actually do rather poorly at identifying pathologic body sounds (something even more worrisome because most listeners consider themselves at least “very good”!).1–3 And so as a realist I must conclude that the ‘Expert Listener’ has joined the ranks of the ‘Mechanical Typist’. But not for lack of hardware; this time, it is because of lack of practice.

We will not reverse this trend just by shouting from the rooftops; there are too many pressures to just get ‘The Test’. And those pressures won’t go away until the cost of ‘The Test’ becomes too great, and health economic forces make it less available. Instead, we must make auscultation rise to the modern practitioner’s needs. It must become more consistent, more valuable, and more useful. The stethoscope must provide practitioners with the same level of comfort and confidence they get from ordering ‘The Test’, and it must prove to them better performance than they – and ‘The Test’ – can achieve without it.

This is what we strive for at Eko. We aim to change the way healthcare is practiced. So that ‘The Test’ isn’t necessary. So that patients don’t need to travel to get their healthcare. So that the diagnosis is achieved and treatment starts more quickly. And so that our chronic disease management becomes better at prolonging and enhancing the quality of a patient’s life. All while lowering the cost of care without sacrificing the quality of care.

We see as central to that future an AI-enabled clinical workflow where the practitioner uses Eko tools that are familiar, inexpensive, ubiquitous, can be used in person or remotely, require little if any training, and deliver expert, specialist-level decision support. It’s a tall order, and the challenges are many, but that is what will move the needle!

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1. Gardezi SKM, Myerson SG, Chambers J, et al. Cardiac auscultation poorly predicts the presence of valvular heart disease in asymptomatic primary care patients. Heart Br Card Soc. 2018;104(22):1832-1835. doi:10.1136/heartjnl-2018-313082

2. Hafke-Dys H, Bręborowicz A, Kleka P, Kociński J, Biniakowski A. The accuracy of lung auscultation in the practice of physicians and medical students. PloS One. 2019;14(8):e0220606. doi:10.1371/journal.pone.0220606

3. Shub C. Echocardiography or auscultation? How to evaluate systolic murmurs. Can Fam Physician. 2003;49:163-167.

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