Stethoscope question for boards and practicals

[Bushido416]

So I'm starting medical school in a few months and I had a question about what to get. Now I know from previous posts everyone enjoys their Littman Cardiology III's with a passion. That's awesome. However, ever since I was two weeks old until I was about 9 I had chronic ear infections and ruptured both ear drums around 10-20 times. Eventually I had to get a tempanoplasty and before that I had tubes put in. Now I can hear just fine conversations and etc but from time to time when I've been doing medical missions trips or working at the free clinic I'm asked to listen to people to hear a low frequency or a very subtle murmur. Often times I can't hear it or I am barely able to hear the sounds that occur at low frequencies and low decibels. So my question is regarding the electronic stethoscopes.
http://solutions.3m.com/wps/portal/3M/en_US/Littmann/stethoscope/electronic-auscultation/model-3000/
http://solutions.3m.com/wps/portal/3M/en_US/Littmann/stethoscope/electronic-auscultation/model-4100/

I really like the features on both of these and the amplification combined with ambient noise reduction. So anyway my question comes from do you think these will be usable on standardized patient exams for class and board purposes? My view is this is something that every aging cardiologist, pulmonologist, and just anyone extremely concerned they might miss something would like to have. Is this a good choice for me or not? I don't know what specialty I want to pursue or will it be extremely useful in the future. However, I've got a pretty lucrative job on my year off from school and am willing to spend whatever to ensure that this low frequency insensitivity won't prevent me from getting the correct answer for myself as well as my potential patients. Any advice would be appreciated.

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[PeepshowJohnny]

Even if there is an expressed written ban on an school or national exam (and I don't think there is) against using electronic augmentation, I think it'd be a very simple matter for you to produce a form by a physician stating you have a medical need for the device and everything would be okay.

My advice, however, would be to hold off for a bit and pick up your standard stethoscope. It's quite possible your ear problems ARE contributing to your difficulty with murmurs, but even med students (and residents AND attendings) can have difficulty picking up subtle findings. I wouldn't want to spend the money until I got plenty of practice and figured out "Okay, there is absolutely no way I can hear this thing without an electronic stethoscope."

From the way you describe it, you can hear moderate to severe findings which is the only time an attending or resident will bite your head off for not hearing it. So my advice: give it some time, see if practice doesn't make it better on it's own.

 

[smq123]

However, ever since I was two weeks old until I was about 9 I had chronic ear infections and ruptured both ear drums around 10-20 times. Eventually I had to get a tempanoplasty and before that I had tubes put in. Now I can hear just fine conversations and etc but from time to time when I've been doing medical missions trips or working at the free clinic I'm asked to listen to people to hear a low frequency or a very subtle murmur. Often times I can't hear it or I am barely able to hear the sounds that occur at low frequencies and low decibels.

My hearing is fine, and I couldn't hear a lot of that stuff either!

I'm not convinced that your problems lie solely with your ears. To tell you the truth, since you're a premed, it's not fair to tell you to "come and listen to this heart murmur."

A) You're probably not comfortable hearing REGULAR heart sounds - so trying to pick up a murmur is pretty hard. If you're not familiar with "normal," then you're not going to be able to identify "abnormal."

B) You don't know what you're listening for. It's hard to hear something when you don't know what it might sound like. When we, as med students, first learned about abnormal heart sounds, examples of heart murmurs were played over loudspeakers at top volume. That way, we learned what abnormal heart sounds sound like.

However, I've got a pretty lucrative job on my year off from school and am willing to spend whatever to ensure that this low frequency insensitivity won't prevent me from getting the correct answer for myself as well as my potential patients. Any advice would be appreciated.

First of all, when it comes to standardized patients for Step 2 CS, you won't be examining patients who are actually sick. You'll be examining actors who are, generally speaking, perfectly healthy. You just need to go through the motions of how to do a "proper" exam.

They don't test your ability to actually pick up real murmurs or lung findings. On these "standardized patients" exams, they test you on empathy, ability to explain things well, correct medical documentation, and using proper exam technique.

I agree with PeepshowJohnny - if you can, just try using a regular stethoscope for a few months. If you really feel like you're not able to hear well with it, even in a totally quiet room, then switch to an electronic stethoscope.

 

[OrnotMajestic]

OP,

I totally understand. Before starting medical school, I had bilateral auditory canal reconstructions to repair my collapsed ear canals, etc. Due to sequelae of previous ear damage, my tympanograms on my left ear barely register movement, as well as reduced movement on the right. Translation? I can't hear sh**. I used a Littman Cardiology III for my first two rotations, as well as whenever I did "medical stuff" during the first two years, and suffered from your same problems. Physicians would hold the steth on the exact spot to hear "crackles" or "murmurs" or ANYTHING...and I wouldn't hear anything that wasn't blaring loud. At first I thought that I was a crappy med student who couldn't distinguish any subtleties of physical exam findings (and of course, this will remain true to some extent, as I'm still learning and still WILL be learning)...but I knew it wasn't just that. SO, I borrowed an attending's electronic steth, used it for a day....and immediately bought one the next day.

I got the Littmann 3000 Electronic Stethoscope (didn't need the recording capabilities) and I've never been happier. I can turn it WAAAAAY up and use the bell portion and hear some BOOMING mitral valve regurges, I pick up subtle rales in patient's lungs, etc etc. While many people here are giving you good advice (get a cheaper, standard one to use for now...). BUT, to be honest, if you already KNOW you can't hear, just get it. Why by a $120 old steth, barely use it, then buy a $300 one later (like I did)? Pointless. Regardless of specialty you go into, it's important to be able to hear and learn. $300 towards your career is peanuts compared to what you spend on tuition, especially when I feel that it has been some of the best money that I've spent on my clinical years.

Anyways, I love my Littmann, and I can't recommend it enough! Good luck to you!

*EDIT* Also, don't worry about Step 2 CS and stuff. If they are really picky about it, just borrow a friend's standard steth for the day. Not like standardized patients have actual pathology you need to hear.

 

[swtiepie711]

I totally understand (also a multiply tube pt & tympanoplasty). I bought cardio III since my most recent hearing test just showed some hearing loss in the super high freq, but then I'm been struggling all year with my steth. I bought the Cardio 3000 from Allheart.com and I have 1 month to use it & then return it. I'd reocmmend waiting until starting school & then trying that.

 

[MattD]

First of all, when it comes to standardized patients for Step 2 CS, you won't be examining patients who are actually sick. You'll be examining actors who are, generally speaking, perfectly healthy. You just need to go through the motions of how to do a "proper" exam.

They don't test your ability to actually pick up real murmurs or lung findings. On these "standardized patients" exams, they test you on empathy, ability to explain things well, correct medical documentation, and using proper exam technique.

I agree with PeepshowJohnny - if you can, just try using a regular stethoscope for a few months. If you really feel like you're not able to hear well with it, even in a totally quiet room, then switch to an electronic stethoscope.

Precisely. None of your SPs will have a murmur in the first place, so for the test it doesn't matter. If it turns out you have a genuine need for the amplifying scope, just get it and use it, give your patients the best possible care. The things are pretty cool actually, my attending (pulm) recently got one, and today we were all iffy on whether a funny sound we were hearing was a murmur. He cranked up the isolation and volume circuits, listened, and identified exactly what (wasn't) there. Pretty neat.

 

[DocPsychosis]

I'm no expert, but I'm pretty sure the Americans with Disabilities Act should require testing agencies to allow you to use aids within reason (i.e. what you mentioned) since they won't give you an advantage, but rather just a level playing field. Hell, a woman taking the MCAT or Step 1 (I don't remember which) was allowed extra breaks because she was preggo.

 

[jhc]

I think this is going to be a non-issue.

Like others have said, finding subtle murmurs is hard for everyone! Don't sweat it, it gets a little easier over 4 years of med school, though I think for many this is a skill which takes longer than this to fully realize. However, if you need it, no one is going to prevent you from using an electronic scope in clinical practice.

They ARE banned from Step II CS and possibly OSCE exams. You probably could get an ADA exemption, but why? These are fake patients... if they have a "murmur" they will make it obvious to you so long as you ascultate appropriately. I've never heard of anyone getting docked because they failed to pick up a I-II/VI murmur on a standardized exam.

Get a standard Cards III or similar. If by the middle of your third year you really feel that you are missing things that other students are clearly hearing, consider an electronic stethoscope. Just use a regular one for exams, and don't stress about that part of it.

 

[Chemguync]

Low frequency/soft/"subtle" murmurs are just fabrications that attendings make up to get a kick out of the eager med student who says "oh ya! I heard it! Neat!"

Either that or I've had the volume up way too high for too long

And furthermore, the retina only exists in artist's renditions.

 

[BigRedBeta]

As others have said, you just don't have the experience to knwo what you're listening for. That will come when you're an M3. The biggest thing you can do when you start clerkships is listen to everyone that walks through the door. At the beginning you'll just be able to make that normal/abnormal distinction, and then later, you'll be able to say things like "the patient has fine end-expiratory crackles, worse on the right than the left, with prolonged expiratory phase". Or "the patient has a grade II/VI crescendo-decrescendo systolic murmur"...seriously, it's all about practice.

I say this as someone who has a very similar set of ear problems and has undergone both a fascial graft tympanoplasty and a cartilage graft typanoplasty on the same ear in the last three years. I know I have about a 25-30 dB hearing deficit on the left that's even more apparent at the extremes of frequencies.

And even with that problem, I've done just fine using the Cardio III.

 

[smq123]

Low frequency/soft/"subtle" murmurs are just fabrications that attendings make up to get a kick out of the eager med student who says "oh ya! I heard it! Neat!"

Either that or I've had the volume up way too high for too long

And furthermore, the retina only exists in artist's renditions.

It's like the Emperor's clothing, isn't it? You assume that only "stupid people" can't hear these murmurs, so you pretend that YOU hear them too so that others don't think that you're stupid as well.

The worst is auscultating someone after the cards consult has seen him/her. The cardiologist lays their stethoscope on the chest, listens for, oh, 3 seconds, and says, "Yep, textbook example of mitral regurg."

And then YOU listen 10 seconds later, and you're like...uh...maybe my "textbook" fixed itself? 😕

 

[Sean2tall]

I can vouch they are definitely forbidden on Step 2 CS (Just took it Thurs). They go so far as to "check" all stethoscopes that they are approved and have no electronic or other enhancements. Even a penlight that's attached is forbidden.

As others have said, this is not because it will give you an unfair advantage of ability to hear the fake findings. You could probably have the ear pieces out of your ears and still get credit. I think the reason is that those stethoscopes allow you to record sounds and play back etc., which theoretically you could be using like an mp3 player to sneak in study notes or something.