Which specialties ABSOLUTELY do not require the use of a stethescope?

[prominence]

I can think of pathology, radiology, and psychiatry off the top. Any other specialties?

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[DrMom]

PM&R, I assume

 

[Koji Kabuto]

Ophthalmology!!!!!

😱 😡 😱 Oh!! Those darned C-C fistulas!!!! 😡 😀 😱 😡

 

[Cassidy61]

ORTHO!!! Mine is collecting dust at home!!

 

[Bobblehead]

The psych residents at our institution while on the inpatient service still need to perform a perfunctory physical exam as part of the admission. However once they're in the clinics they go stethoscope free.

Ortho doesn't carry stethoscopes? That explains a lot.. 😉

 

[oldandtired]

The stethoscope is extremely overrated!

Everyone gets an echo and chest x-ray these days anyways. Soon doctors will be carrying around little hand held ultrasound machines.

 

[ckent]

Originally posted by oldandtired
The stethoscope is extremely overrated!

Everyone gets an echo and chest x-ray these days anyways. Soon doctors will be carrying around little hand held ultrasound machines.

Yeah, they are doing this study at Thomas Jefferson I think. All of the residents are given brief instructions on how to use a bedside ultrasound, and they are comparing that to stethescope usage in the inpatient setting. Stethescopes are kind of silly if you think about it. I'm certain that people of the future will look back on us using these rubber tubes and laugh at our incompetence. Not only that, but they are notoriously inaccurate in most people's hands except in the most extreme cases. It's really tough to tell the difference between a systolic and diastolic murmur, even with all the tricks they teach you (feeling the pulse, looking at the tele tracing, etc).

 

[Andrew_Doan]

Originally posted by Koji Kabuto
Ophthalmology!!!!!

😱 😡 😱 Oh!! Those darned C-C fistulas!!!! 😡 😀 😱 😡

Hey... I use one for my pre-operative H&Ps, so even ophthalmologists use a stethoscope sometimes! 🙂

 

[drvlad2004]

Originally posted by DrMom
PM&R, I assume

Yes and No. You will need your stethoscope during first year of PM&R. First year is usually inpatient PM&R (including SCI and TBI), which you will have to handle some IM related issues (UGH!) with patients on the floor. You definitely need the stethoscope during cardiopulmonary rehab. Other than that, you can toss that stethoscope in the garbage, because it will be as valuable as Britney Spears using a microphone during her live shows😀 . The reflex hammer will be a more useful tool.

Personally, I am looking forward to the day when I can toss that stethoscope into the wastebasket. I can't stand having that thing draped over my neck when I rotated throughout my third year. I agree that steths are inaccurate at detecting abnormalities in most cases.

 

[roja]

Originally posted by ckent
Yeah, they are doing this study at Thomas Jefferson I think. All of the residents are given brief instructions on how to use a bedside ultrasound, and they are comparing that to stethescope usage in the inpatient setting. Stethescopes are kind of silly if you think about it. I'm certain that people of the future will look back on us using these rubber tubes and laugh at our incompetence. Not only that, but they are notoriously inaccurate in most people's hands except in the most extreme cases. It's really tough to tell the difference between a systolic and diastolic murmur, even with all the tricks they teach you (feeling the pulse, looking at the tele tracing, etc).

I use my stethascope alot in the ER. Check tube placement.... murmurs? S1? whats that? 🙂

 

[ckent]

Originally posted by roja
I use my stethascope alot in the ER. Check tube placement.... murmurs? S1? whats that? 🙂

Actually, I don't think that using your stethescope for that purpose is not very useful as well. At my school, they use this CO2 monitor and check a chest x-ray in addition to "listening" for breath sounds bilaterally. I think that specificity of "hearing" breath sounds bilaterally indicating proper tube placement is probably pretty poor, as most of physical diagnosis done by "experts" has proven to be in study after study.

 

[roja]

Originally posted by ckent
Actually, I don't think that using your stethescope for that purpose is not very useful as well. At my school, they use this CO2 monitor and check a chest x-ray in addition to "listening" for breath sounds bilaterally. I think that specificity of "hearing" breath sounds bilaterally indicating proper tube placement is probably pretty poor, as most of physical diagnosis done by "experts" has proven to be in study after study.

In an intubation, I would never use one single thing to check tube placement. I use a capnometer (the CO2 monitor), the presence of condensation on the tube and bilateral breath sounds. If you only use a capnometer and condensation (and not your stethescope) you can still end up with a Right main stem intubation and a 'normal (or postive)' change in color and condensation.

I also use my stethescope when placing an NG tube. You need to hear the 'whoosh' of air to know that it is placed well.

hhmmmmm, lets see... also wheezing in asthmatics...

Lack of breath sounds on one side in someone in a trauma would make me seriously think about needle decompression in someone in respiratory distress.


So, yeah, there are definately reasons to have a stethescope in the ED.

 

[Galaxian]

You don't think a stethoscope is useful? You should hang out with a yoda-master cardiologist sometimes. Those guys hear a murmur on so many people you'd think they're inventing them. Of course, anything you find on exam with a stethoscope will have to be confirmed...murmur gets an echo, crackles gets a cxr, wheezes, well that one pretty much speaks for itself, but I personally think that if someone's wheezing then you can tell just by talking with them.

 

[oldandtired]

"You should hang out with a yoda-master cardiologist sometimes. Those guys hear a murmur on so many people you'd think they're inventing them"

Like you said, murmur= ec$$$ho. Cardiologists are the greediest bastards around.

 

[ERMudPhud]

Originally posted by Galaxian
You don't think a stethoscope is useful? You should hang out with a yoda-master cardiologist sometimes. Those guys hear a murmur on so many people you'd think they're inventing them. Of course, anything you find on exam with a stethoscope will have to be confirmed...murmur gets an echo, crackles gets a cxr, wheezes, well that one pretty much speaks for itself, but I personally think that if someone's wheezing then you can tell just by talking with them.

As an intern I spent a month on the service of a master cardiologist (so much so that his Littman master cardiologist was gold plated) I noticed that before the echo his progress notes commented on one or at most two murmurs. After the echo his physical exams were much more detailed.

I think the one time that a stethoscope might really matter would be when you don't have time to get an imaging study. The ER would seem to be a perfect example. What do I use my scope for.

1. loaner to the surgical subspecialists when they have to do an admission H&P

2. Tube placement? Capnography or direct visualization is the gold standard and I rarely pull back a right main tube without looking at an xray first.

3. Murmurs? unfortunately two of the murmurs that might make an acute difference, mitral stenosis in CHF ( a wicked combination) and aortic insufficiency in a type A dissection are incredibly hard to hear

4. Wheezing? I do use it to see how asthmatics are progressing but you could probably get as good an idea from looking at them, talking to them and measuring serial peak flows.

5. Bowel sounds? come on, I can't think of a single senario in which bowel sounds would make a difference and the patient doesn't end up getting imaged some how.

6. NGT placement? My nurses usually do that.

7. It allows me to look and act like the doctor my patients expect me to be but it probably changes my management of a patient less than once a month

 

[Andrew_Doan]

Originally posted by Ophtho_MudPhud
Hey... I use one for my pre-operative H&Ps, so even ophthalmologists use a stethoscope sometimes! 🙂

I forgot another use in ophthalmology... to listen for a carotid-cavernous sinus fistula of the orbit. These you can listen for! 🙂

However, the patient will also be proptotic, may have limited ocular motility, increased intraocular pressure, and dilated & tortuous periorbital vessels. At times, these signs may be subtle and a bruit heard in the orbit may help with the diagnosis.

Of course, this diagnosis would be followed up with an orbital echo or CT of the orbit.

 

[beyond all hope]

Situation #1: Pt with fever and cough. To chest X-ray or not? Answer: Auscultation is 99% sensitive for detecting patients that will have an infiltrate in the setting of fever and a cough, therefore needing antibiotics.
Stethoscope obliviates the need for CXR in these patients with clear lungs.

Situation #2: AMI. If they have a new murmur, you must consider MR, VSD or dissection, which changes management entirely.

Situation #3: Fever, new heart murmur. Grab your echo, baby, cause you're ruling out IE.

Situation #4: Syncope with a systolic ejection murmur. You better start treating aortic stenosis before it gets worse.

Situation #5: OD patient with psychosis, tachycardia and dilated pupils. Is it anticholinergic or sympathomimetic? Listen for bowel sounds.

Situation #6: Asthmatic with wheezes, and suddenly the wheezes stop but the patient is still tachypniec/tachycardic. Silent chest. Mg, Terbutaline and get the intubation kit.

Situation #7: Trauma patient with SOB with unilateral decreased breath sounds. Get your 14 gauge needle, cause they're ain't enough time for an X-ray

Situation #8: My personal favorite. Teenage patient in no distress with normal vital signs, no med hx and no drug use is convinced they're having a heart attack/stroke/pneumonia/whatever. You listen to the heart and lungs, note a normal pulse, no murmurs and normal lungs sounds. You reassure the patient they will be okay (and check a Upreg and Utox). Send them home. No x-rays or blood tests needed.

The list goes on an on. Echo is very cool but the stethoscope still has a long list of important uses. It's fast, free, noninvasive, cheap to use, gives you important clinical data and patients really like it when you listen to their heart and lungs. (placebo, baby)

A lot of people think you listen to the heart to catching new murmurs on physical exams, that no one ever heard before. Rarely. It is an essential part of the physical exam.

 

[triathlete411]

I heard a story, don't know if it's true, about an anesthesiology resident doing his EM rotation, where his use, or lack thereof, of his stethoscope cost him his job.

The attending physician asked him to check tube placement on a newly intubated trauma patient. The resident listened and declared breath sounds bilaterally. However, the attending had removed the patient from the ventilator so hearing breath sounds would have been impossible. The resident was fired on the spot.

 

[Galaxian]

This whole thread is really asking one question...considering the rapid advancement of imaging and laboratory medicine, and the current medicolegal situation, is the physical exam becoming a lost art?

 

[Eyesore]

Originally posted by Koji Kabuto
Ophthalmology!!!!!

😱 😡 😱 Oh!! Those darned C-C fistulas!!!! 😡 😀 😱 😡

Originally posted by Ophtho_MudPhud
Hey... I use one for my pre-operative H&Ps, so even ophthalmologists use a stethoscope sometimes!

Originally posted by Ophtho_MudPhud
I forgot another use in ophthalmology... to listen for a carotid-cavernous sinus fistula of the orbit. These you can listen for!

However, the patient will also be proptotic, may have limited ocular motility, increased intraocular pressure, and dilated & tortuous periorbital vessels. At times, these signs may be subtle and a bruit heard in the orbit may help with the diagnosis.

Of course, this diagnosis would be followed up with an orbital echo or CT of the orbit.

I do believe that was what Koji Kabuto was saying Ophtho_MudPhud. It seemed like Koji was joking that ophthalmologists don't use it, then he said oops I suppose there is a use in ophthalmology. Just my 2 cents.

 

[beyond all hope]

I would say unequivocably no.

Yes, there are certain tests that have supplanted the PE. Especially in non-clinical fields such as internal medicine. In the clinical specialities, such as surgery, EM or neurology, there are simply no tests that can replace the physical exam.

In EM it's a simple matter of getting the most amount of information in the shortest period of time. Case in point: pt came to me a few nights ago complaining of chest pain. When I looked at him, I noted a plethoric face, trembling hands and EtOH on breath. I noticed that he vomited liquid with a small amount of blood. Thus the differential of CP/ROMI was pretty much sidelined towards UGIB/pancreatitis/EtOH withdrawl. Still, I threw an EKG and CXR at him, but I was aiming towards EtOH gastritis/pancreatitis and the labs confirmed it.

The physical exam has becoming a screening exam for most clinicians, with confirmatory results from labs/images. The PE tells you where to go. You echo anyone if you hear a murmur, you CT the belly if you feel tenderness, you US the leg if you see swelling, etc.

The days of physicians making complex diagnoses by PE alone is almost gone. Still, many simple diagnoses can be made by only history and physical. Asthma, CHF, pnemonia, gastroenteritis, to name a few. Besides, why rely on your PE alone when you can have a confirmatory test.

And don't forget there are many examples where a clinician will trust their own judgement DESPITE images/labs to the contrary. Small fractures, early pneumonias, all of these may be missed on x-ray but often we treat on symptoms and PE alone.

 

[dbiddy808]

You are a medicine intern that does not carry a stethoscope? That is scary! I hope you are joking.

 

[Koji Kabuto]

quote:
--------------------------------------------------------------------------------
Originally posted by Koji Kabuto
Ophthalmology!!!!!

Oh!! Those darned C-C fistulas!!!!
--------------------------------------------------------------------------------





quote:
--------------------------------------------------------------------------------
Originally posted by Ophtho_MudPhud
Hey... I use one for my pre-operative H&Ps, so even ophthalmologists use a stethoscope sometimes!
--------------------------------------------------------------------------------





quote:
--------------------------------------------------------------------------------
Originally posted by Ophtho_MudPhud
I forgot another use in ophthalmology... to listen for a carotid-cavernous sinus fistula of the orbit. These you can listen for!

However, the patient will also be proptotic, may have limited ocular motility, increased intraocular pressure, and dilated & tortuous periorbital vessels. At times, these signs may be subtle and a bruit heard in the orbit may help with the diagnosis.

Of course, this diagnosis would be followed up with an orbital echo or CT of the orbit.
--------------------------------------------------------------------------------

Originally posted by Eyesore
I do believe that was what Koji Kabuto was saying Ophtho_MudPhud. It seemed like Koji was joking that ophthalmologists don't use it, then he said oops I suppose there is a use in ophthalmology. Just my 2 cents.

Yes! That was what I was intending. I just can't believe someone came in my defense. Not that it needed any defending in the first place. But thanks for setting the record straight.

 

[cbc]

I cant see how steths are not useful in all outpatient cases, when you cant get an echo on everyone who walks through the door, and ie complains of general pain in the thoracic area.

 

[DD214_DOC]

I imagine whatever specialty does autopsies (forensic path?) wouldn't need a steth.

 

[robinhudster]

"The attending physician asked him to check tube placement on a newly intubated trauma patient. The resident listened and declared breath sounds bilaterally. However, the attending had removed the patient from the ventilator so hearing breath sounds would have been impossible. The resident was fired on the spot."

That sounds fishy. What if the patient was breathing spontaneously??? Firing someone "on the spot" for that sounds very suspicious.

 

[ERMudPhud]

Originally posted by Beyond all hope

Situation #1: Pt with fever and cough. To chest X-ray or not? Answer: Auscultation is 99% sensitive for detecting patients that will have an infiltrate in the setting of fever and a cough, therefore needing antibiotics.
Stethoscope obliviates the need for CXR in these patients with clear lungs.

Just curious, Reference?

Situation #2: AMI. If they have a new murmur, you must consider MR, VSD or dissection, which changes management entirely.

Gold standard now for most MI's is angio when available and I don't think new MR or VSD necessarily changes that. See my previous post about dissection

Situation #3: Fever, new heart murmur. Grab your echo, baby, cause you're ruling out IE.

Endocarditis is usually diagnosed after the blood cultures and after the echo. How many volume depleted, septic, tachycardic patients do you think will at least have a flow murmur?

Situation #4: Syncope with a systolic ejection murmur. You better start treating aortic stenosis before it gets worse.

Even in critical AS the valve doesn't close before your eyes. You will get an echo long before the patient goes to the OR. I agree that finding this murmur in syncope does change things but most elderly syncope patients get an echo even if we don't think they have an AS murmur ( Although it is systolic, is it usually referred to as an "ejection" murmur?)

Situation #5: OD patient with psychosis, tachycardia and dilated pupils. Is it anticholinergic or sympathomimetic? Listen for bowel sounds.

Who cares they are treated the same unless your going for a trial of physostigmine. Have you ever actually heard/really listened for bowel sounds on a screaming, psychotic, thrashing, restrained meth freak/jimsom weed ingestion

Situation #6: Asthmatic with wheezes, and suddenly the wheezes stop but the patient is still tachypniec/tachycardic. Silent chest. Mg, Terbutaline and get the intubation kit.

Look at the references on Mg and asthma first. Second, the evaluation of asthmatics is based on multiple factors and serial peak flows with oxymetry are the best measures of who is getting better and who is getting worse

Situation #7: Trauma patient with SOB with unilateral decreased breath sounds. Get your 14 gauge needle, cause they're ain't enough time for an X-ray

Actually, they better be worse than just short of breath and they need more than a needle. I've lost track of the number of needle decompressions that didn't even succeed in creating a pneumothorax

Situation #8: My personal favorite. Teenage patient in no distress with normal vital signs, no med hx and no drug use is convinced they're having a heart attack/stroke/pneumonia/whatever. You listen to the heart and lungs, note a normal pulse, no murmurs and normal lungs sounds. You reassure the patient they will be okay (and check a Upreg and Utox). Send them home. No x-rays or blood tests needed.

Agreed but skip the Utox

The list goes on an on. Echo is very cool but the stethoscope still has a long list of important uses. It's fast, free, noninvasive, cheap to use, gives you important clinical data and patients really like it when you listen to their heart and lungs. (placebo, baby)


Agreed

 

[ERMudPhud]

Originally posted by beyond all hope
In EM it's a simple matter of getting the most amount of information in the shortest period of time. Case in point: pt came to me a few nights ago complaining of chest pain. When I looked at him, I noted a plethoric face, trembling hands and EtOH on breath. I noticed that he vomited liquid with a small amount of blood. Thus the differential of CP/ROMI was pretty much sidelined towards UGIB/pancreatitis/EtOH withdrawl. Still, I threw an EKG and CXR at him, but I was aiming towards EtOH gastritis/pancreatitis and the labs confirmed it.
.

I agree the H&P is still important, especially in EM. However, even in this case example I don't think you stethoscope played much of a role. As for neurology. I think I do a quite good and thorough neuro exam. Unfortunately, when I call neuro they invariably say admit him to medicine, get an MRI and/or EEG in the AM and then I'll see him. So much for the neuro exam. I do use the neuro exam for spinal cord complaints and I believe it is invaluable in deciding who gets an MRI in the middle of the night for their abcess/bleed/met/ cord compression of whatever sort. Unfortunately many of my surgeons now request CT's and or U/S's in the middle of the night before seeing the patient. The only ones left doing H&P's before the confirmatory studies are the EM and primary care doc's. After the CT/MRI/US/Echo confirm the diagnosis the specialist probably could (and often does) get away with little if any H&P. Some of my surgeon have been known to first meet their prospective appy patients in the OR after the CT shows the diagnosis.

 

[ortho2003]

don't knock ortho on stethoscope use...I use mine almost every day.

It is great for checking reflexes...

 

[jawurheemd]

I use my stethoscope for patient reassurance. There a mystic quality behind it in many patients' eyes. Just the fact that I listened to their body gives them the feeling that I did something, and they feel better. The healing powers of the stethoscope.

 

[ak1978]

Originally posted by ckent
Yeah, they are doing this study at Thomas Jefferson I think. All of the residents are given brief instructions on how to use a bedside ultrasound, and they are comparing that to stethescope usage in the inpatient setting. Stethescopes are kind of silly if you think about it. I'm certain that people of the future will look back on us using these rubber tubes and laugh at our incompetence. Not only that, but they are notoriously inaccurate in most people's hands except in the most extreme cases. It's really tough to tell the difference between a systolic and diastolic murmur, even with all the tricks they teach you (feeling the pulse, looking at the tele tracing, etc).

🙁 Sir William Osler would probably turn in his grave (well, ok, he was cremated) if he were to read some of these posts...
Studies have shown that IM residents are no better at auscultation than 3rd year medical students, and that proficiency doesn't increase with additional years of training.
I think the decline of physical exam skills (in part due to lack of bedside teaching and in part to nihilistic thinking by younger physicians) is sad and efforts should be made to revive them. In England, part of the qualifying exam for the MRCP requires examination of real patients. Just because we practice modern medicine doesn't mean we have to forget our roots.

 

[Tenesma]

physical examination is truly losing out - why rely on stethoscopes when one day we will all have portable ultrasound machines that will be way more accurate???

 

[The White Coat Investor]

I am very interested in decreasing the amount of labs and X-rays I order by improving my physical exam skills. I too would like the reference for the pneumonia study mentioned above.

Unfortunately, there are two things that keep me from doing this.
1) The standard of care now usually dictates that we get studies. If most of my colleagues would get a study when presented with this patient, I need to do so too, both medicolegally, and one could argue, ethically.
2) I find myself getting burned. Example, trauma patient with a non-tender pelvis but some left upper quadrant pain. So I get an abdominal CT, and the read includes a pelvic fracture. That looks bad.
3) In a lot of circumstances, the labs/X-rays are just a helluva lot better at making the diagnosis. Example, pancreatitis. Yes there are clinical clues, but are any of those half as sensitive and specific as a lipase level?

Oh, and as far as the anticholinergic/sympathomimetic situation, whatever happened to checking the skin for diaphoresis. I think I would trust that over bowel sounds.

 

[dobonedoc]

I can't wait to list mine on Ebay at the end of my internship! Of course, like Ortho2003, I'll then need to find a new tool for DTRs.

 

[Finally M3]

I just sold my oto/ophthalomoscope. Good thing I bought mine used on eBay anyways....

 

[Tenesma]

sorry desperado - hate to be pedantic, but the diagnosis of pancreatitis is still a clinical diagnosis and not a laboratory/radiologic diagnosis - yet..... ;D

 

[RADRULES]

Really, who needs a steth anymore? It is a relic of a prior time in medicine. Keep ordering those rad studies! PE protocols for everyone with shortness of breath and CT thorax, abd, pelvis for "abdominal pain." I will thank all of you when I am pimpin' in my new Benz! In fact, thanks in advance!

DISCLAIMER: The above was a joke and not intended to demean any particular field of medicine or the memory of Sir William Osler.

Out.

 

[Daniel vD]

Originally posted by JKDMed
I imagine whatever specialty does autopsies (forensic path?) wouldn't need a steth.

Bowel sounds continue for some time after death, right?

Though by the time an autopsy is performed, I guess they've ceased as well...

 

[The White Coat Investor]

Originally posted by Tenesma
sorry desperado - hate to be pedantic, but the diagnosis of pancreatitis is still a clinical diagnosis and not a laboratory/radiologic diagnosis - yet..... ;D

"Diagnosis should be made on the basis of imaging procedures and function tests."

J Hepatobiliary Pancreat Surg. 2002;9(4):413-22.

"The main points of recommendation in these guidelines are: (1) measuring lipase for the diagnosis of acute pancreatitis (recommendation grade, A)..... (3) Enhanced computed tomography (CT) should be used for assessment of degree of pancreatic necrosis and inflammation (RG, B)."

Evidence-based clinical practice guidelines for acute pancreatitis: proposals
Journal of Hepato-Biliary-Pancreatic Surgery
Issue: Volume 9, Number 4
Date: October 2002
Pages: 413 - 422

Not sure what you're talking about Tenesma. When you really get down to it, everything's a clinical diagnosis anyway, right? I mean, somebody has to decide if the labs and studies mean anything and they have to correlate it with the H&P, but come on, in someone with acute abdominal pain and a normal lipase, and no pancreatic inflammation on CT, it is customary to go looking somewhere besides the pancreas.

 

[rehabmd]

PM&R- Although needed in residency during the inpatient blocks, it is really not needed during more than half of the rehab residency which comprises the outpatient blocks. I do outpatient adult and pediatric neuromusculoskeletal rehab and my exam consists of a standard neuro exam, musculoskeletal exam and/or denver developmental screening(which assesses motor, language and social skills in children by playing with them). I see alot of adult patients with musculoskeletal problems(low back pain, joint pain, tendinitis, fractures, lacerations) and children with cerebral palsy, spina bifida and orthopedic conditions. Rehab residency training also consists of 6-9 months of electromyography experience to assess nerve and muscle disorders. I also do botox injections and acupuncture. As an outpatient neuromuscular specialist, my use of a stethosope is minimal.