Stethoscopes contribution to diagnostic errors

Alan Morris Alan.Morris at IMAIL.ORG
Thu Mar 26 17:11:16 UTC 2015


Thank you, Dr. Follansbee - I agree.
I still teach residents and fellows how to distinguish a split S2 from an
opening snap,  and an S3 gallop.  Auscultation of the S2, and appreciation
of the intensities of its two components, is our only screening test for
pulmonary arterial hypertension.  I use a teaching system I constructed
about 25 years ago.  Trainees appreciate this exposure - it is new to
almost all of them.

With regard to applied physiology, none of the trainees know of the mean
circulatory filling pressure or what determines cardiac output
(intersection of the venous return and ventricular function curves).
Arthur Guyton is unknown to them.

Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Director of Research
Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603
Mobile Phone: 801-718-1283




On 3/26/15, 7:07 AM, "Follansbee, William" <follansbeewp at UPMC.EDU> wrote:

>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.
>
>Respectfully,
>
>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 upmc.edu
>
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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
>To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>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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