JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 67, NO. 9, 2016

ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00

PUBLISHED BY ELSEVIER http://dx.doi.org/10.1016/j.jacc.2016.01.005

EDITOR’S PAGE

The Stethoscope’sPrognosis Very Much Alive and Very Necessary

Valentin Fuster, MD, PHD

rom the first few weeks in my tenure as Currently, there are many circumstances wherein F Editor-in-ChiefoftheJournal, I have been the stethoscope remains essential. While I will not writing about the indispensable integration of consume this Editor’sPagewithmultipledetailed technology and clinical decision-making in the examples, here are a few clinical cases that demon- contemporary practice of cardiovascular medicine strate the necessity of auscultation that I have just (1,2). Although advanced technologies have become encountered in the last 48 h during outpatient visits part of our daily lives as clinicians, we need to make with a fellow or in teaching rounds with the house a clear delineation between wielding these tools to staff: help us determine the best pathway for our patients In a patient with acute chest pain and fever, and relying upon them alone to make these decisions, auscultation revealed a clear pericardial rub, especially in the formation of medical students and whereas the echocardiographic images did not fellows. As clinicians, we need to continue to interact even show pericardial effusion—probably because with our patients and listen to their histories, their itwasintheearlystagesofpericarditis. lifestyles, and their bodies—the last of which is where In a patient with clear pulmonary hypertension, auscultation continues to play a dynamic role in our auscultation revealed a loud P2 of the second heart daily practices. Stethoscopes, which are often disre- sound, when an echocardiogram was unable to garded for newer and flashier technologies such as detect it, because there was not enough regurgitant the echocardiogram, remain so important in evalu- flowthroughthetricuspidvalve. ating and diagnosing our patients because they allow In a patient with a questionable degree of mitral us to physically listen to the sounds of the body. Plus, regurgitation on the basis of an echocardiogram, they are essential in training aspiring physicians. auscultation revealed a third heart sound at the Mosby’s Medical and Nursing Dictionary defines the apex as well as a short mid-diastolic murmur—both physical examination as: “[An] investigation of the indicating that mitral regurgitation was significant. body to determine its state of health using any or In a patient with right-sided chest pain following all of the techniques of inspection, palpation, per- orthopedic surgery, auscultation revealed a right- cussion, auscultation, and olfaction. The physical sided pleural rub, whereas the echocardiogram examination, medical history, and initial laboratory showed a normal right ventricle function. As tests constitute the data base on which a diagnosis is predicted, this patient had a small pulmonary made and on which a plan of treatment is developed” embolism/infarction as assessed by VQ scanning. (3).Thus,aphysicalexaminationisastudyofthe In a patient who was referred to me, an outside patient using one’ssenses,oftenwiththeaidofan echo Doppler report indicated mild to moderate instrument (4),suchasastethoscope.Theuniquely aortic valve regurgitation, as a result of an incom- personal relationship between a physician and a pa- petent bicuspid valve. On auscultation, however, tient stems from the physician’s reliance upon phys- there was an apical S3 sound, as well as an Austin ical touch to diagnose and interact with patients. Flint mid-diastolic murmur, clearly demonstrating that the aortic regurgitation was significant. In a patient age 80 years who was referred for mitral intervention (surgical or catheter-based), an From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York. outlook echo Doppler test was reported as showing JACC VOL. 67, NO. 9, 2016 Fuster 1119 MARCH 8, 2016:1118– 9 Editor’s Page

significant rheumatic mitral valve disease. The lack assessment will require substantially more training” of 3 auscultatory features, aortic valve disease, an (6). In addition, Solomon and Saldana (6) note that

opening snap, and a prominent P2,wereofsuffi- false positive findings may lead to additional and cientevidencetomakethediagnosisofacalcified often unnecessary testing, and false negatives may mitral ring causing mild mitral stenosis, which provide unwarranted reassurance and result in un- would not require the need for intervention. After derdiagnosis. This also leads to unnecessary costs to this case, I told the fellows: “My friends, the the health care system. Last, and of greatest concern, stethoscope is not dead, but you may be if you these “devices can distract students from the core throw it in the basket.” principles of physical diagnosis, especially if intro- duced early in training, and will interpose another Theevidenceofthese6casesinthelast48hofmy layer of technology between doctor and patient” (6). practice alone leads to the following question: should In my view, practically and economically, echo- we train the fellows and house staff just on echocar- cardiography systems are not—and will never be— diography, or should we enhance the present training poised to totally eradicate the stethoscope, as it is not on auscultation and pathophysiology? The answer is possible for every clinician to possess a handheld obvious. Claims that the “stethoscope is dead” (5) are echocardiography within and outside of the United entirely false. In fact, with its new digital capabilities, States. Thus, we cannot discontinue the important the stethoscope is healthier than ever. training that takes place during physical examination, Although there is no doubt that point-of-care whichcanbeaidedthroughtheamplified sounds of a ultrasound training is on the rise among fellows and stethoscope. Let me ask you a question: what if a medical school students, those advances come with physiciancomesuponasickpersoninthestreetand caveats. In a New England Journal of Medicine com- has not received the proper training for a physical mentary, advocating for point-of-care ultrasound examination? Does she or he have to abandon that in medical education, Drs. Solomon and Saldana sick individual? We cannot teach our medical stu- acknowledged: “The risk of misdiagnosis is high dents to become reliant upon advanced technologies when diagnostic ultrasound is used by inexperienced without which they become useless. practitioners. The amount of training required to perform a competent ultrasound examination is not trivial.Although medical students trained in ultra- ADDRESS CORRESPONDENCE TO: Dr. Valentin sonographymaybeabletomakerelativelycrude Fuster, Zena and Michael A. Wiener Cardiovascular diagnoses—determining whether ventricular function Institute, Icahn School of Medicine at Mount Sinai, is normal or reduced, assessing vena cava size, or One Gustave L. Levy Place, New York, New detecting gallstones—more sophisticated anatomical York 10029. E-mail: [email protected].

REFERENCES

1. Fuster V. A second dilemma in cardiovascular 3. Mosby’s Dictionary of Medicine, Nursing & washingtonpost.com/national/health-science/ medicine: personalized medicine versus personal Health Professions. 9th edition. St. Louis, MO: heart-doctors-are-listening-for-clues-to-the- interaction with the patient. J Am Coll Cardiol Mosby/Elsevier, 2009. future-of-their-stethoscopes/2016/01/02/bd73b000- 2014;64:1292–3. a98d-11e5-8058-480b572b4aae_story.html. Accessed 4. Phoon CKL. Must doctors still examine pa- – January 8, 2016. 2. Fuster V. The evolving future of cardiovas- tients? Perspect Biol Med 2000;43:548 61. cular practice technology þ clinicians: a means 5. Bernstein L. Heart doctors are listening for 6. Solomon SD, Saldana F. Point-of-care ultra- to a better end. J Am Coll Cardiol 2015;66: clues to the future of their stethoscopes. The sound in medical education—stop listening and 481–3. Washington Post. Available at: https://www. look. N Engl J Med 2014;370:1083–5.