Stethoscopes contribution to diagnostic errors

Robert Bell rmsbell200 at YAHOO.COM
Fri Mar 27 23:30:00 UTC 2015

What is real hearing loss? Hearing loss that leads to diagnostic errors being made?
I would have thought that minimal hearing loss could lead to diagnostic error. Am I wrong?
Rob B
      From: Albert Wu <awu at>
 Sent: Friday, March 27, 2015 9:46 AM
 Subject: Re: [IMPROVEDX] Stethoscopes contribution to diagnostic errors

The proportion of practitioner with real hearing loss should be small

The challenge might be what comprises ³sufficient² experience


Albert W. Wu, MD, MPH, FACP
Professor and Director
Center for Health Services & Outcomes Research
Johns Hopkins Bloomberg School of Public Health
624 N Broadway Room 653
Baltimore MD 21205
(410) 955-6567 / fax (410) 955-0470
Mobile (410) 978-1539

On 3/27/15, 10:28 AM, "Robert Bell"
<0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG> wrote:

>Dear Prof Krishnan,
>The point I am making is should a stethoscope be used by someone with
>hearing loss and/or lack of experience, if we wish to reduce errors in
>And do we have the data to make an evidence based decision on this?
>Rob B
>Sent from my iPad
>On Mar 26, 2015, at 11:12 AM, Krishnanramanmenon
><krishnanramanmenon at GMAIL.COM> 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
>> 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
>>> Rob B
>>> Moderator: David Meyers, Board Member, Society to Improve Diagnosis in
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