Hanging up the stethoscope

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You are never - or you shouldn't - completely get away from the medical foundations of your training. No, you're not going to be doing physical exams all day every day, but you should be able to do a basic physical exam, know how to identify common physical exam abnormalities, and know what to do with that information. Depending on what you end up doing, you will not "hang up the stethoscope" - things like C/L psychiatry, interventional psychiatry, neuropsychiatry, etc. are areas where a physical exam is important and relevant.

I had some misgivings about going into psychiatry because I felt like much of the knowledge that I just spent 3+ years trying to learn seemed to be going to waste. That really isn't the case - even if I'm not an internist.
 
No regrets. Still use my stethoscope.

We utilize different aspects of medicine more frequently than you would think. Derm, rads, path, ortho, etc will all hang up aspects of their “stethoscope” yet we all have high job satisfaction scores.
 
TexasPhysician said:
No regrets. Still use my stethoscope.

We utilize different aspects of medicine more frequently than you would think. Derm, rads, path, ortho, etc will all hang up aspects of their “stethoscope” yet we all have high job satisfaction scores.
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I find it very interesting that this stethoscope fascination is applied so specifically to psychiatry. My SO is a specialty surgeon who has her stethoscope buried in our closet after she finished her gen surg time. I've spent copious time with her co-residents when we were in training and with her attendings and I have not heard a single one complain or bemoan their very focused physical exam that does not include a stethoscope. In fact most want to touch patients as little as possible unless its during surgery.
 
Nope. Have not used it since my internal medicine pgy 1 year! Also one of the biggest draws of child psych is that kids are generally healthy and don't have medical problems! Goodbye forever CHF, COPD, dementia etc etc
 
Honestly, I lost one of the screw on ear pieces off my stethoscope about 25 years ago and I have never bothered to replace it. The fact that it is in my desk still is kind of weird but I don't think that is because I would miss it. There are many things I don't miss, rectal abscesses are a bright example that will inform you as to the general reasons.
 
I still use my medical training, and have found at times I know more than the PCP about the patient.

And literally about the stethoscope, still have mine although I rarely use it. I do recommend that all of you poor medstudents at the end of the year look to the garbage cans and dumpters where well-to-do spoiled students regularly throw away their stethoscopes or Netter's anatomy, grab as many as you can that are still clean, and sell them on Ebay.

While I was a medstudent I'd regularly "dumpster dive" at the end of the semester (it was the garbage room of the dorm and it was clean) and I'd often times be able to fish out at least 20 Netters and maybe a dozen stethoscopes selling all of them without problems for about $50 each on Ebay. There was usually far more than I could grab but lack of time, space and energy, I couldn't take anymore.
 
I've had to use my mine during medicine overnight call during PGY-2. In private practice, I've used it a few times when patients presented with subjective SOB or pre-syncope (panic v. hysteria v. something medical) before referring them to urgent care/ED. What I heard was probably secondary to having them feel I was doing my due diligence and that I took their physical concern seriously.
 
In private practice, esp. for psychopharm heavy practices, stethoscope is not unusual. I have one in my office--you need to document physical exam findings for things like outpatient detox, etc. I don't use it often, obviously.

I think psychiatry these days are very heavily medicalized.
 
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Only used for H&P aspect of an ECT consult.

Otherwise not used at all. Not even in outpatient office now, and my practice is heavy on psychopharm. Never used it for addiction specific work either...

Currently its just at home for wheezing kids.
 
I’m just saving mine for kids inevitable Halloween costumes.

Thinking of that old thing makes me smile as I remember on my first day of surgery rotation anxiously presenting on rounds that I may have heard a crackle.

Attending pretends to pimp me by asking me how to differentiate chest sounds and says “Wrong, order a chest xray”.

Turns to fresh intern “Give me your algorithm for reading a tough chest X-ray”

“Wrong, order a CT”
 
Merovinge said:
I find it very interesting that this stethoscope fascination is applied so specifically to psychiatry. My SO is a specialty surgeon who has her stethoscope buried in our closet after she finished her gen surg time. I've spent copious time with her co-residents when we were in training and with her attendings and I have not heard a single one complain or bemoan their very focused physical exam that does not include a stethoscope. In fact most want to touch patients as little as possible unless its during surgery.
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yeah idk why the lack of physical exam thing in general is so heavily directed towards psychitary usually (probably because it's viewed as more 'non-medical' than other specialities). Radiologists and pathologists definitely haven't touched a patient (besides procedures if you're IR and a dead patient in autopsy for pathology) for years. Ophtho literally just does eye exams all day (not saying they don't need to know a lot about neuroanatomy and eye anatomy). All our psychiatry inpatients have to have a physical exam and neuro exam on admission that the residents have to do. Is it the best physical? Probably not but probably better than the ortho magical one stethoscope position that can simultaneously auscultate the lungs, heart and bowels all at once....
 
My residency makes us take our own patients' vitals. I actually only ever properly learned to do a manual blood pressure in residency. Med school showed it to us maybe once. So I use the stethoscope every day.
 
I just use one of those automatic cuff BP devices. It takes about 30 seconds. Whenever I did it manually it'd take at least a few minutes, also while the machine is doing it I can put in their other vitals making the entire thing take about 3 minutes vs about 7 minutes.
 
calvnandhobbs68 said:
yeah idk why the lack of physical exam thing in general is so heavily directed towards psychitary usually (probably because it's viewed as more 'non-medical' than other specialities). Radiologists and pathologists definitely haven't touched a patient (besides procedures if you're IR and a dead patient in autopsy for pathology) for years. Ophtho literally just does eye exams all day (not saying they don't need to know a lot about neuroanatomy and eye anatomy).
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Yeah these threads make me wonder why some people view doing general physical exams (IM, FM, Peds) as somehow the baseline and that specialties who do focused or little physical exam (Psych, Path, Surg specialties, Derm, Radiology) are somehow aberrations. Almost all of the sought after fields fall in the latter category.
 
Sushirolls said:
Only used for H&P aspect of an ECT consult.

Otherwise not used at all. Not even in outpatient office now, and my practice is heavy on psychopharm. Never used it for addiction specific work either...

Currently its just at home for wheezing kids.
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why do you need it for a wheezing kid? What info would it provide and what would be the value of that info?
 
Wheezing not so much, but more for colds that just aren't remitting. i.e. is this a possible bacterial or PNA process that truly warrants dragging the kid into Peds office. Most everything is viral, so I want to be a little more concerned with auscultation findings to say its warranted. Waste of every one's time to go into Peds and get the classic 'reassurance prescription' for a viral Dx.
 
Sushirolls said:
Wheezing not so much, but more for colds that just aren't remitting. i.e. is this a possible bacterial or PNA process that truly warrants dragging the kid into Peds office. Most everything is viral, so I want to be a little more concerned with auscultation findings to say its warranted. Waste of every one's time to go into Peds and get the classic 'reassurance prescription' for a viral Dx.
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I’ll be honest being 10 years out as a psychiatrist I would not be comfortable diagnosing anything related to kids or pulmonary symptoms lol..I mean obviously as a physician you can appreciate serious symptoms but to distinguish wheezing vs stridor vs crackles vs who knows what I wouldn’t know what I was doing and wouldn’t even remember the significance of such symptoms or the proper treatment or next step
 
Didn't say I was diagnosing, that's what the Pediatrician is for. Just an extra parental tool to add pros/cons in deciding when to bring my child into Pediatrician office.

Drag your own kid(s) into the Peds office if you wish for every cold, but you'll quickly realize that you don't have enough sick days to cover every cough/phlegm/nasal drip, etc.
 
psychapp121 said:
I’ll be honest being 10 years out as a psychiatrist I would not be comfortable diagnosing anything related to kids or pulmonary symptoms lol..I mean obviously as a physician you can appreciate serious symptoms but to distinguish wheezing vs stridor vs crackles vs who knows what I wouldn’t know what I was doing and wouldn’t even remember the significance of such symptoms or the proper treatment or next step
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I sure as hell wouldn't diagnose anybody else's kid, but I have one asthmatic kid and it's really helpful to be able to monitor her, make sure she is responding to therapy, decide whether or not she needs to be seen, etc. I am... pretty sure I could still tell a wheeze from a crackle, but luckily I haven't seen much pneumonia around my house so haven't had to make that call anytime recently. The stethoscope is good for checking bowel sounds in kids with constipation or tummy ache too. You don't have to be a physical exam whiz, just looking for something vs nothing is useful info. The main decision you are making is whether or not to seek treatment. Obviously you aren't going to do full workup/dx/tx at home.
 
tr said:
I sure as hell wouldn't diagnose anybody else's kid, but I have one asthmatic kid and it's really helpful to be able to monitor her, make sure she is responding to therapy, decide whether or not she needs to be seen, etc. I am... pretty sure I could still tell a wheeze from a crackle, but luckily I haven't seen much pneumonia around my house so haven't had to make that call anytime recently. The stethoscope is good for checking bowel sounds in kids with constipation or tummy ache too. You don't have to be a physical exam whiz, just looking for something vs nothing is useful info. The main decision you are making is whether or not to seek treatment. Obviously you aren't going to do full workup/dx/tx at home.
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What useful information does listening to bowel sounds give you?
 
Thought you all might find this interesting:

(deleting link), just Google "tytocare" —it's an otoscope, camera, stethocope, etc that shares pictures, sound, etc. with a doctor remotely

Works with a lot of the low cost online services like LiveHealth.

I don't personally have a use for it, but I'm all for keeping contagious people out of public spaces.
 
Depending on the virus, "contagious people" can be contagious before symptoms, during, or after. However, society directs their ire towards those exhibiting active symptoms.
 
whopper said:
I just use one of those automatic cuff BP devices. It takes about 30 seconds. Whenever I did it manually it'd take at least a few minutes, also while the machine is doing it I can put in their other vitals making the entire thing take about 3 minutes vs about 7 minutes.
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Yeah, that would be nice, but I'm just a resident, so they don't have enough hospital-owned machines to give them to us. I found a portable layperson's BP machine, but it kept giving unrealistically high numbers. I ended up trusting my own ears better.

It's actually kind of cool to hear the loud pulse between the systolic and diastolic markers, and I can do it in under a minute now. I get height and weight if I need to (mostly for kids on stimulants) as we walk from the waiting room.
 
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Sushirolls said:
Depending on the virus, "contagious people" can be contagious before symptoms, during, or after. However, society directs their ire towards those exhibiting active symptoms.
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I understand.

But if a person has symptoms it's knowable. There's an incubation period where they might be a vector, but if you're around family and friends or a close-knit work environment you know that they've recently been around someone who's been sick and you can take more precautions. I mean for me personally, it really just comes down to thanksgiving and christmas. Those are the two times of year I have family who come to see me and who have first visited other family, including children in daycare. I ask not just about what symptoms the family who come to see me have but about the symptoms of those they've been with recently and on the way here. I'm pretty much a hermit for the most part otherwise, and so the only other real issue comes with visits to doctors' offices.

For years doctors' offices and urgent cares and ERs have been offering their services for cold/flu season, like actually advertising it. My own PCP *loves* giving out Tamiflu. Why? I have no idea. I've given him all the research on its efficacy and side effects, and he can't give away enough of it. So far his office has not had one confirmed case of flu (his nurse told she thinks the machine is broken because she's seen cases that absolutely seem like flu come back negative), but he's given out Tamiflu regardless. He tried to give it to me as a prophylactic because I had come into the office and could catch it there. I think there's a broken system whereby doctors have entreated generally well people to come into the office for colds and flus, and now that there's Tamiflu they have a medical justification for it: Get here within 24-48 hours so we can test and treat you. I think it just makes doctors' offices ground zero for catching viruses, and it makes it so an entire quarter of the year the doctor's office becomes somewhat iffy for seeing them for something more long-term/chronic. Maybe it's just me to be so avoidant. I have POTS and if I get the flu, it really does a number to me (tachycardia worse than usual), plus strangely induces Paxil brain zaps (the ones you get when suddenly stopping Paxil).

So I guess what I should have said was: If people are going to go the doctor for contagious, self-limiting conditions, I'd prefer they do it from home even if it is kind of pointless either way. I know it doesn't 100% prevent illnesses from entering doctors' offices, but I think it would take a good bite out of it. Plus it seems like (in my experience) doctors are going to diagnosis flu based on clinical symptoms regardless of test results and have set opinions on Tamiflu regardless of the situation, so seems a lot could be done via telehealth.
 
psychapp121 said:
I’ll be honest being 10 years out as a psychiatrist I would not be comfortable diagnosing anything related to kids or pulmonary symptoms lol..I mean obviously as a physician you can appreciate serious symptoms but to distinguish wheezing vs stridor vs crackles vs who knows what I wouldn’t know what I was doing and wouldn’t even remember the significance of such symptoms or the proper treatment or next step
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Shouldn’t need a stethoscope or be a pediatrician to recognize stridor...
 
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reca said:
What useful information does listening to bowel sounds give you?
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For an inpatient/CL psychiatrist, increased bowel sounds help differentiate serotonin syndrome from NMS, anticholinergic toxicity, malignant hyperthermia, etc.
 
Performing physical exams is sometimes required for inpatient psych jobs, although not usually all the time- Often there is a Family practice provider during the week but on weekend call performing PE's on new patients may be a duty of the psychiatrist.
 
reca said:
You're going to make a clinical decision about these based on bowel sounds?
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I didn't say anything about making a clinical decision based on bowel sounds alone. I suggested that this piece could help differentiate specific pathologies, as an example for when bowel sounds may provide useful information since the question was posed.
 
Is an inpatient psychiatrist even treating those conditions? If you suspect nms or serotonin syndrome based on vitals/labs you’re not gonna be checking bowel sounds, you’re gonna be calling medicine/icu to get the pt the f away from you
 
psychapp121 said:
Is an inpatient psychiatrist even treating those conditions? If you suspect nms or serotonin syndrome based on vitals/labs you’re not gonna be checking bowel sounds, you’re gonna be calling medicine/icu to get the pt the f away from you
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theoretically, in academic environments, consult psychiatrists help to make these diagnoses. In real life, you are right
 
psychapp121 said:
Is an inpatient psychiatrist even treating those conditions? If you suspect nms or serotonin syndrome based on vitals/labs you’re not gonna be checking bowel sounds, you’re gonna be calling medicine/icu to get the pt the f away from you
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We get consulted for those questions all the time on CL.
Ours is also a med-psych unit, so we tend to not call medicine right away for everything.
 
psychapp121 said:
Is an inpatient psychiatrist even treating those conditions? If you suspect nms or serotonin syndrome based on vitals/labs you’re not gonna be checking bowel sounds, you’re gonna be calling medicine/icu to get the pt the f away from you
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Also, there are no diagnostic labs for serotonin syndrome or NMS, and you can't differentiate them by vitals. So it helps to know basic physical exam elements to help guide your diagnosis. Bowel sounds is one of those.

Whether you actually do those things in real life/your own practice is one thing. But it doesn't negate the fact that there is a role for them in psychiatry, and not all of us immediately hang up our stethoscope. That's all.
 
Doctorows said:
Also, there are no diagnostic labs for serotonin syndrome or NMS, and you can't differentiate them by vitals. So it helps to know basic physical exam elements to help guide your diagnosis. Bowel sounds is one of those.

Whether you actually do those things in real life/your own practice is one thing. But it doesn't negate the fact that there is a role for them in psychiatry, and not all of us immediately hang up our stethoscope. That's all.
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those are diagnosed by medicine not psychiatry for the vast majority of us..if someone is on offending meds with consistent vitals signs clinical symptoms..I’m not doing a physical exam..I’m calling medicine or icu to get that guy the hell off the psych unit..if he’s already on medicine..they’re not calling psych to evaluate the pt..lol
 
psychapp121 said:
those are diagnosed by medicine not psychiatry for the vast majority of us..if someone is on offending meds with consistent vitals signs clinical symptoms..I’m not doing a physical exam..I’m calling medicine or icu to get that guy the hell off the psych unit..if he’s already on medicine..they’re not calling psych to evaluate the pt..lol
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They most definitely call psych to evaluate the patient. Every single time. Unless there is no psych CL service to call, of course.
People are often on multiple different classes of medications, so it isn't always easy to know just based on presumed offending medication. Vitals will be out of whack for both, clinical symptoms similar - altered, febrile. No definitive labs. Physical exam is actually crucial as both are clinical diagnoses.

Also, serotonin syndrome is not always the classic clear cut severe triad that immediately lands people in the ICU. Symptoms vary widely, as does the severity spectrum, and milder cases actually often go undiagnosed completely. How far along in your training are you?

In any case, I don't mean to derail this thread. I've made my point already.
 
Doctorows said:
They most definitely call psych to evaluate the patient. Every single time. Unless there is no psych CL service to call, of course.
People are often on multiple different classes of medications, so it isn't always easy to know just based on presumed offending medication. Vitals will be out of whack for both, clinical symptoms similar - altered, febrile. No definitive labs. Physical exam is actually crucial as both are clinical diagnoses.

Also, serotonin syndrome is not always the classic clear cut severe triad that immediately lands people in the ICU. Symptoms vary widely, as does the severity spectrum, and milder cases actually often go undiagnosed completely. How far along in your training are you?

In any case, I don't mean to derail this thread. I've made my point already.
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pgy2
 
To redirect the thread a bit, the stethoscope question seems like an example of the stigma against psychiatrists that still persists. As it was said before, there are plenty of other specialties that haven't used the stethoscope in years (derm, radiology, etc), but to my knowledge they're never asked about hanging up the stethoscope.

The stethoscope here is a proxy for "thinking medically," and the subtext is that derm, radiology, etc think medically while psychiatrists don't, and that's just not true. As I mentioned in another thread, I actually would not feel comfortable practicing in a private practice where I don't have immediate access to my patient's full medical record (labs, other specialty notes, other meds they may be on), and being able to easily get vitals, labs and other workups is paramount for being able to practice responsibly. There are many medical conditions that can manifest as depression for instance (OSA and thyroid pathology to name just two), and the side effects of many of our meds are serious business.
 
psychapp121 said:
those are diagnosed by medicine not psychiatry for the vast majority of us..if someone is on offending meds with consistent vitals signs clinical symptoms..I’m not doing a physical exam..I’m calling medicine or icu to get that guy the hell off the psych unit..if he’s already on medicine..they’re not calling psych to evaluate the pt..lol
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Have you done CL? I have diagnosed NMS, serotonin syndrome during CL before the medicine residents did. Thats what a good CL psychiatrist should be able to do and be aware of. You have to be in tuned with your patients, I constantly diagnosed delirium and other sytems the medicine docs missed. Unfortunately you will find that medicine they are already biased towards psychiatric patients and don't talk to them, or rush through them, or take their symptoms seriously or cant detect the nuances of their complaints, not to mention the consults for the non psych patients that end up delirium, stroke, aphasia, etc.
 
I use mine when I cannot find my reflex hammer. But that's usually after I listen to someone's heart, lungs, and bowel sounds. Sometimes I regret hanging it up... because it's at home and I need it.
 
tr said:
Stethoscopes are great. Wait till you have kids. I totally use mine to check for wheezing.
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Yep. I regret selling my otoscope because I feel like my kid's always tugging on his ear. Made a couple hundred dollars at the time, but probably would have saved and a lot more in doctor's visits by the time he's past this stage.
 
Stagg737 said:
Yep. I regret selling my otoscope because I feel like my kid's always tugging on his ear. Made a couple hundred dollars at the time, but probably would have saved and a lot more in doctor's visits by the time he's past this stage.
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Wife's clinic updated their otoscopes last year, so we grabbed an old one. Between that and a good friend who visits a couple times a week who is a pediatrician, we should avoid several unnecessary visits to our regular peds and/or urgent care.
 
The charger handle on my otoscope/ophthalmoscope broke and I never replaced it. Sure regretted that one when my other kid got retinoblastoma and I was trying to see in his eye with a kitchen flashlight. ☹️ You really never know. (He's doing great before anybody asks)
 
Wilf said:
Yeah these threads make me wonder why some people view doing general physical exams (IM, FM, Peds) as somehow the baseline and that specialties who do focused or little physical exam (Psych, Path, Surg specialties, Derm, Radiology) are somehow aberrations. Almost all of the sought after fields fall in the latter category.
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Sorry to be off topic, any way you could check your wall post? I tried to PM you.
 
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