A few months ago, a young cardiologist told me that he rarely listens to hearts anymore. In a strange way, I was not surprised.

He went on to tell me that he gets all the information he needs from echocardiograms, EKGs, MRIs, and catherizations. In the ICU, he can even measure cardiac output within seconds. He told me that these devices tell him vastly more than listening to out-of-date sounds via a long rubber tube attached to his ear.

There was even an element of disdain. He said, “There is absolutely nothing that listening to hearts can tell me that I don’t already know from technology. I have no need to listen. So I don’t do it much anymore.”

I began to wonder. I called my longtime friend and colleague, also a cardiologist. I knew him to be one of the best heart listeners. I asked him if he still listens to hearts. He answered, “Of course I do. I could not practice medicine if I didn’t. But you know every week, several patients tell me when I listen to their hearts that I am the first doctor ever to do that. Can you imagine that?”

Playing the devil’s advocate, I challenged my friend to tell me what he learned from listening to hearts.

He answered, “How could anyone not want to hear those murmurs, sometimes ever so soft, like whispers? Murmurs from the heart, even very faint ones, are trying to tell us significant things. Some sounds are very localized, even hidden or obscured by layers of air. And then there is the rhythm and the beat and the cadence that you cannot hear on the paper strip of the EKG. Also, careful listening is the only way to appreciate the rubs of friction if there are any. The devices are important, but the heart has its own spoken and unspoken language if you know how to listen.

My cardiologist friend continued, “I don’t know how to say it. But something real important happens between me and the patient when I listen. Over a long period of time, I can get to know each heart and its peculiar and individual sounds and rhythms. I do believe if you put a blindfold on me I could tell one heart from another.”

Then I really began to wonder. How many of us no longer listen to hearts? How many hearts go unheard each day?

And the really big question: what becomes of the unheard heart?

Clifton Meador, MD is currently a professor at both Vanderbilt School of Medicine and Meharry Medical College and directs programs of the Vanderbilt-Meharry Alliance. He is perhaps best-known for “The Art and Science of Nondisease” and “The Last Well Person,” both published in the New England Journal of Medicine, and “A Lament for Invalids,” published in the Journal of the American Medical Association. The articles are satiric treatments of the excesses of medical practice. He is the author of six books, including the best-selling medical book, A Little Book of Doctors’ Rules. This post first appeared on Maggie Mahar’s Health Beat Blog

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10 Responses for “The Unheard Heart: A Metaphor For Medicine In the Digital Age”

  1. steve says:

    With the literature on functional status we have now, the yield from a stethoscope has dropped. With poor function, you pretty much need an echo no matter what you hear. With good functional status, you dont need an echo, but it is unclear that there is any value then in listening. OTOH, listening to the lungs continues to be of value, although even there if you do a good history you are mostly confirming what you already suspect.

    Steve

  2. Andy Mawson says:

    One could almost consider listening to the heart via a stethoscope as a vestigial anomaly from the ‘analog’ age of medicine. That position could be considered a pejorative one. However, while we know that a digital recording contains masses of data, the output it provides lacks some ephemeral authenticity. Analog sound is warm and full of the sub-harmonics a digital sample simply can’t hear. Perhaps auscultation gives us a purer, fuller, representation of the patient’s theme song.

  3. Andy Mawson says:

    Another thought occurs. Placing a stethoscope against a patient’s chest requires a closeness and intimacy that perhaps we are losing. Granted, the exercise always seems some what awkward, patient’s eyes averted, physician’s eyes focused on a space beyond the tip of their own nose as they focus their attention; but the closeness is loaded with an unspoken message from clinician to patient that says “I’m here, and I care. Everything is going to be all right”. Those digital monitors that may be out of the sight of our patient may tell us everything WE need to know – but they tell our patient’s nothing.

  4. I really don’t want to divert this to politics, but the first thing that came to my mind when reading this post was the clip they keep showing now on TV of President Obama comforting a lady after the storm in New Jersey.
    It doesn’t look like your run of the mill disaster photo ops. He is really hugging her tight; his eyes are closed; he is rubbing her back, looking into her eyes and speaking softly tells her that she will be OK. It’s a real human moment. It’s like kissing a toddler’s booboo to make it better….
    Now what’s the purpose of that? She probably needs food, shelter and a certain amount of cash to be “OK” again, not some outdated touchy feely thing, or does she?
    Something was transferred during that brief moment from one human being to the other. Something not measurable and quantifiable by machines. Something that gives the one in need strength to fight on and something that increases the capability of the giver to give more of the same.
    As long as we don’t have tangible, technical solutions to all needs, this ephemeral something exchanged between people will maintain its value, and sometimes it is exchanged through a stethoscope.

  5. rbaer says:

    There is a lot of poetic thought about human closeness etc. in this thread and I do not disagree at all – I am the last person who wants to examine (or be examined by) a robot with ultrasound probes. But there arises an interesting question: what parts of the physical exam, if any, are replacable, and which ones are not?
    -cardiovascular: auscultating heart sounds is probably inferior to ultrasound as mentioned above, but keep in mind that the stethoscope is always at hand and requires only a few seconds to minutes
    -pulmonary auscultation: probably dito (inferior but a good screening tool), and keep in mind that a chest CT requires a lot of radiation, and hearing rales can, in the right context, make the case of infiltration or edema
    -abdominal exam: IMO even weaker than the 2 exams above (compared to abd US), but still a good screening tool for organomegaly/ascites/masses/inflammation
    -thyroid/lynph nodes/masses: I think palpation will remain a screening tool
    -orthopedic/joint exam: good functional testing, probably (despite x-ray, CT, MRI) irreplacable
    -neurologic: assesses a lot of function that cannot be assessed by technical exams (gait/balance, tone, reflexes, eye movements) – probably irreplacable. MRIs and other scans are anatomical, not functional exams
    -skin: I am not a dermatologist, but I do not think that the complexity of skin lesions can be captured in 2d photos, let alone be diagbosed reasonably well by expert software
    -eye exam: probably irreplacable

    The more I think about it, the more certain I get that most of the physical exam is to stay for at least the next 3 decades if not half century.

  6. Maggie Mahar says:

    Andy, Margalit, rbear,

    Andy–

    Thaks very much for your comments.
    You wrote:
    “while we know that a digital recording contains masses of data, the output it provides lacks some ephemeral authenticity. Analog sound is warm and full of the sub-harmonics a digital sample simply can’t hear. Perhaps auscultation gives us a purer, fuller, representation of the patient’s theme song.”

    In your second comment, you noted that “Placing a stethoscope against a patient’s chest requires a closeness and intimacy that perhaps we are losing.”

    THCB readers: I urge you take a look at both of Andy’s comments.

    (P.S. Andy, I urge you to comment on HealthBeatBlog (www.healthbeatblog.com) I would appreciate your insights.)

    Margalit–

    You wrote:
    “The first thing that came to my mind when reading this post was the clip they keep showing now on TV of President Obama comforting a lady after the storm in New Jersey.
    It doesn’t look like your run of the mill disaster photo ops. He is really hugging her tight; his eyes are closed; he is rubbing her back, looking into her eyes and speaking softly tells her that she will be OK. It’s a real human moment. It’s like kissing a toddler’s booboo to make it better….
    Now what’s the purpose of that? She probably needs food, shelter and a certain amount of cash to be “OK” again, not some outdated touchy feely thing, or does she?
    Something was transferred during that brief moment from one human being to the other”

    Margalit, Yes, I too, was struck by that photo.

    And your comparison is Spot-On..This is what Clifton Meador is talking about.

    RBEAR:

    Thanks for your comments on specific situations.
    I think both paiients and doctors will be interested.

    You conclude: “The more I think about it, the more certain I get that most of the physical exam is to stay for at least the next 3 decades if not half century.”

    I agree that “hands-on” diagnosis will remain extremely important.

  7. Maggie Mahar says:

    Steve–

    I understand what you are saying.

    But I don’t think Dr. Meador was saying not to use an “echo.”

    He was suggesting that doctors also use a stethoscope–first.

    This can only enhance diagnosis.

  8. Maggie Mahar says:

    Bobby G–

    You wrote “See God’s Hotel”

    I admit I hadn’t heard of it, but since you recommended it, I Googled it. I found this:
    http://www.nytimes.com/2012/05/29/health/29zuger.html

    Remarkable. I hope other readers will take a look at it.

  9. R.J.B.Massay says:

    For those of us in “the third world” it is quite a different issue. The clinical examination directs optimal use of scant technological resources. As mentioned before, the echo never diagnoses the pericardial rub, a cause for post MI pain which I have seen the techies of today treat with nitrate infusion for”ongoing ischaemia”. It never picks up the S4 in the hypertensive patient ( having found that, I do not need your echo to tell me the left atrium is enlarged or that I shall find E:A reversal on doppler). Moreso, before you get to auscultation, imagine the storehouse of clinical information you missed by not looking at the JVP?

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