Stethoscopes contribution to diagnostic errors

Xavier Prida dr.xavier.prida at GMAIL.COM
Fri Mar 27 15:49:15 UTC 2015

As we have moved this conversation back to the original arts of medicine -
history taking, methods and accuracy of physical exam tools- interesting
elucidation of the use of visual arts and artists to develop "chunking" of
data in a *NY Times* article- *Learning to See Data *by *Benedict
Carey* in *Sunday
Review*, March 27 2015. Applications are myriad - at the bedside, at the
interface of technology and procedures, but perhaps with an admixture of
Type I and Type II thinking.

On Thu, Mar 26, 2015 at 2:12 PM, Krishnanramanmenon <
krishnanramanmenon at> wrote:

> Dear prof. Follanshbee,
> I agree with you wholeheartedly that no modern instrument can ever replace
> clinical skills.
> As an older generation medical student and a teacher of general medicine
> of several years' standing, I can still make out a murmur and make a decent
> cardiac diagnosis even without the help of an echo machine. That is also
> important in a setting where resources have to be carefully utilised.
> Naturally the echo machine has its role, but it should never be permitted
> to 'hijack' our thought processes, as you have rightly pointed out.
> Just today,  I  demonstrated to a batch of first clinical year medical
> students the sequence of the cardiac clinical examination-  and was
> delighted to see their eyes light up when they each recognized in turn the
> murmurs of mitral regurgitation, aortic stenosis and a difficult aortic
> regurgitation all in the same patient. I have done this exercise on several
> generations over the years. Seeing the sparkle in these eyes has always
> given me immense satisfaction- to guide them towards getting a good
> history, to show them how to get the signs right, to get them fascinated by
> the great canvas of clinical medicine, mesmerized by the intellectual
> challenge of 'cracking a case', these are what every teacher aspires. The
> methods of Sherlock Holmes are simple, unsophisticated and very rewarding!
> Some of these young students became renowned cardiologists: but they still
> acknowledge they were helped by the good clinical medicine they were
> taught  in their formative years.
> Every day I see mistakes made when the rules of clinical examination are
> not followed: long standing upper respiratory disease missed in a patient
> with 'asthma'. Recently I saw a PET scan ordered for someone with
> ankylosing spondylitis, but plain radiographs had not been taken!
> One of my professors used to tell us that a good history and 'physical'
> would give us a diagnosis 98% of the time, and in a few of the others
> arriving at a diagnosis may prove difficult in spite of all the
> sophisticated tests available!
> I would like to add to this that a large number of unnecessary, expensive
> and often invasive   investigations could be avoided if only more
> clinicians followed the rule of of 'good history then a careful and
> detailed clinical examination'.
> Let us hope that the instruments we have will remain our  good servants
> and not become harsh masters.
> Prof. R. Krishnan
> Formerly president of the Association of Physicians of India, Kerala
> chapter
> Calicut-India
> email: krishnanramanmenon at
> Sent from my iPad
> On Mar 26, 2015, at 6:37 PM, "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
> >
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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
> >
> >
> >
> >
> >
> >
> > Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
> Medicine
> >
> > To unsubscribe from the IMPROVEDX list, click the following link:<br> <a
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> </a>
> > </p>
> >
> >
> >
> >
> >
> >
> > Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
> Medicine
> >
> > To unsubscribe from the IMPROVEDX list, click the following link:<br>
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> </a>
> > </p>
> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
> Medicine
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> </a>
> </p>

Xavier E. Prida MD FACC FSCAI
Assistant Professor of Medicine
USF Morsani College of Medicine
Department of Cardiovascular Sciences

Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

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