Listen More

My first posting on this blog explained why I chose to name it “Auscultation.”  I wrote that I wanted to promote a conversation, and that listening was essential to doing so. I went on to write: “With an obvious nod to my being a cardiologist, I believe auscultation has long been an act that defines us as physicians and connects us in a profound way with our patients. The act of leaning in, touching the patient, listening, concentrating, and interpreting is a powerful metaphor for the entire clinical encounter: getting close to the patient and listening.”

It is therefore no wonder that I was really pleased to read “The Physical Examination and the Fifth Maneuver” by Thomas Metkus in a recent issue of the Journal of the American College of Cardiology. The piece appeared in the “fellows in training and early career page” in the Journal, which regularly features articles by trainees about their experiences, and was a mature and robust defense of the importance of developing auscultatory skills. Metkus alludes to Osler’s model of physical diagnosis, the first four maneuvers of which are inspection, percussion, palpation and auscultation. The fifth – and arguably most important – is cognition, the intellectual exercise of putting it all together.

Metkus acknowledges that cardiac auscultation has, pardon the pun, taken a beating. It seems passé in an age of ubiquitous echocardiography to make a diagnosis or assessment based only on what one can hear with a stethoscope, but he makes a compelling case for doing so, based on 3 principles:

  1. Cardiac auscultation is critically important in taking care of patients. No technology is perfect, and relying solely on echocardiography to the exclusion of auscultation is a little like relying only on your car’s GPS enabled navigation system, without any regard to where you really are.
  2. Accurate and precise diagnoses with cardiac physical examinations. Yes, it is possible, with diligence and practice, to sort out a patient’s condition with a stethoscope.
  3. When you examine a patient, you examine a person. This was my favorite reason. Listening to a beating heart “up close and personal” is fundamentally different from interpreting echocardiographic images. It creates a special connection between the patient and the examiner, which itself is therapeutic.

We should also remember that the physical exam is the second part of the clinical encounter. The first, and more important, is learning the patient’s story….by listening.

What do you think?

3 thoughts on “Listen More

  1. I work in radiation medicine. Since becoming a nurse practitioner, I seldom take a pulse; at least not with my fingers. I learn so much more about my patients when I put my stethoscope to their chests. We have packed many a patient off to the emergency department because a-fib was suspected. It just sounds different than tachycardia from dehydration. Of course we listen to the patient’s descriptions of how they are feeling. Some patients have asked if I heard the murmur (something they may have forgotten to add to their history). I agree with cognition being the fifth maneuver. I’ve always called it listening between the lines.

  2. Please read a comment in AnnIntMed., from (?) tittled “Shirts and Skins” for opinions from
    a young physician and his physician father. Dr. Arnold Katz, one of my Cardiology professors
    during my 3 years at UCONN Health Center(UCHC) once told me, “Only use echocardiology,
    et cetera, to confirm bedside diagnoses and to measure their severity(if you can’t from bedside examination.” Another cardiology attending there asked residents and fellows names and significances of our examination findings. I worked as an intensivist in a (medium-large)
    RI hosp;ital for ~6 years. I never saw my boss use a stethoscope at a patient’s bedside; I never saw him palpate pulses, examine for decubiti; or ‘lay his hands’ on a patient. His notes were ‘copied and pasted’ from nursing and respiratory therapist’s notes, diagnostic imaging reports(He view Chest X-rays, some CT scans, and personally reviewed laboratory results. None of the above was documented in progress notes; he used Critical Care CPT codes….

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