Stethoscopes contribution to diagnostic errors

Follansbee, William follansbeewp at UPMC.EDU
Thu Mar 26 13:07:43 UTC 2015

As a cardiologist, I would like to offer a slightly different perspective on this topic. The most important part of the stethoscope is not the ear pieces. The greatest limiting factor in its effective utilization is not hearing loss. Rather the most important part of the instrument is what is between the ear pieces. You don't need keen senses to use the instrument effectively, you need a keen mind. To be good at auscultation, you must have a strong understanding of physiology and pathophysiology, in order to make astute observations. Wenkebach described Mobitz I heart block, with a pretty accurate description of its mechanism, before EKGs were invented. He did it at the bedside by looking at the relationship of the A waves and the V waves in the jugular venous pulse. The vast majority of patients will tell us their diagnosis if we just ask astute questions, listen carefully to the answers, and observe critically and analytically at the bedside.

Those who advocate for use of pocket ultrasound devices or other imaging instrumentation to replace the stethoscope underestimate the down side of that approach. When we start taking care of patients by images, which is already happening to an extraordinary degree, we sacrifice the knowledge of physiology and pathophysiology, and with it a crucial component of critical thinking.  Having been an attending cardiologist in a university hospital for 35 years, I would suggest that our trainees of today have extraordinarily limited understanding of basic physiology. Most quite  literally don't know what a mid-systolic murmur is, so it will be impossible for them to accurately diagnose it. That, of course, is on all of us as educators.

Is this still important today? I would suggest that it is, ironically perhaps more so now than ever.  Because when you start taking care of patients by images without being able to critically assess that information at the bedside in the context of knowledge of pathophysiology and in the context of the patient's presentation, it leads to bad decisions. It leads to errors in diagnosis, it leads to suboptimal diagnostic plans and often gross over utilization of testing, and perhaps most importantly it leads to serious errors in treatment. Imaging tests all have significant if not substantial error rates. Even when the findings are accurate, the significance of a given finding on an echo varies markedly depending on the context that is found at the bedside. I commonly see what I believe to be suboptimal decisions in patient management because people react to an imaging test, without thinking critically about the information in the context of pathophysiology. 

We should not be testing people's hearing, we should be testing their knowledge, and go back to the basics where the foundation of good decision making exists.


William P. Follansbee, M.D., FACC, FACP, FASNC
The Master Clinician Professor of Cardiovascular Medicine
Director, The UPMC Clinical Center for Medical Decision Making
Suite A429 UPMC Presbyterian
200 Lothrop Street
Pittsburgh, PA 15213
Phone: 412-647-3437
Fax: 412-647-3873
Email: follansbeewp at

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-----Original Message-----
From: robert bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG] 
Sent: Wednesday, March 25, 2015 10:10 PM
Subject: [IMPROVEDX] Stethoscopes contribution to diagnostic errors

Should physicians/HCPs be checked before being able/allowed to use a  stethoscope?  Should they be cleared for hearing loss before being allowed to use a stethoscope?  This would seem to be so very important with so much high frequency hearing loss in young people.

I have the idea that many errors in diagnosis are associated with stethoscope decisions.

It would seem that there are tremendous differences between a First Year Medical student with or without hearing loss, a fourth year medical student, with or without hearing loss, a 2nd year resident, with or without hearing loss, a practicing physician with or with our hearing loss, and a cardiologist of 30 years experience, with or without hearing loss. 

Should we not address the basics before we move further ahead in trying to reduce diagnostic errors?

Do we know what the error rates are in various groups of HCPs who use stethoscopes?

Rob B

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