The stethoscope and the art of listening

Symbols and rituals are alive and well in clinical practice in Australia: Perspectives from a longitudinal qualitative professional identity study

PURPOSE

Many factors impact an individual's professional identity on their journey to becoming a doctor, including their experiences, the learning environment, role models, and symbols and rituals. Rituals and symbols associated with the medical profession have historically included wearing a white coat (now rare) and the stethoscope. This study explored two medical students' perspectives of symbolic identifiers in a six-year longitudinal study in Australia (2012-2017).

METHODOLOGY

A 2012 qualitative cross-sectional qualitative professional identity study in an Australian five-year undergraduate medical programme was extended to a longitudinal study with annual interviews. A conversation about the symbolism of the stethoscope and other identifiers began in Year 1 and concluded when the students were junior doctors.

FINDINGS

Symbols and rituals remain part of the 'becoming' and 'being' a doctor. In the context of Australian hospitals, the stethoscope appears to no longer be exclusively associated with the medical profession, with 'professional attire' distinguishing medical students and doctors from other team members (uniform). The study identified lanyard colour and design as a symbol and language as a ritual.

CONCLUSIONS

Although symbols and rituals may change over time and across cultural contexts, some forms of treasured material possessions and rituals will persist in medical practice.[Box: see text].

A wearable nanoscale heart sound sensor based on P(VDF-TrFE)/ZnO/GR and its application in cardiac disease detection

This paper describes a method for preparing flexible composite piezoelectric nanofilms of P(VDF-TrFE)/ZnO/graphene using a high-voltage electrospinning method. Composition and β-phase content of the piezoelectric composite films were analyzed using X-ray diffraction. The morphology of the composite film fibers was observed through scanning electron microscopy. Finally, the P(VDF-TrFE)/ZnO/graphene composite film was encapsulated in a sandwich-structure heart sound sensor, and a visual heart sound acquisition and classification system was designed using LabVIEW. A heart sound classification model was trained based on a fine K-nearest neighbor classification algorithm to predict whether the collected heart sounds are normal or abnormal. The heart sound detection system designed in this paper can collect heart sound signals in real time and predict whether the heart sounds are normal or abnormal, providing a new solution for the diagnosis of heart diseases.

Tablet-Based Wearable Patch Sensor Design for Continuous Cardiovascular System Monitoring in Postoperative Settings

Meticulous monitoring for cardiovascular systems is important for postoperative patients in postanesthesia or the intensive care unit. The continuous auscultation of heart and lung sounds can provide a valuable information for patient safety. Although numerous research projects have proposed the design of continuous cardiopulmonary monitoring devices, they primarily focused on the auscultation of heart and lung sounds and mostly served as screening tools. However, there is a lack of devices that could continuously display and monitor the derived cardiopulmonary parameters. This study presents a novel approach to address this need by proposing a bedside monitoring system that utilizes a lightweight and wearable patch sensor for continuous cardiovascular system monitoring. The heart and lung sounds were collected using a chest stethoscope and microphones, and a developed adaptive noise cancellation algorithm was implemented to remove the background noise corrupted with those sounds. Additionally, a short-distance ECG signal was acquired using electrodes and a high precision analog front end. A high-speed processing microcontroller was used to allow real-time data acquisition, processing, and display. A dedicated tablet-based software was developed to display the acquired signal waveforms and the processed cardiovascular parameters. A significant contribution of this work is the seamless integration of continuous auscultation and ECG signal acquisition, thereby enabling the real-time monitoring of cardiovascular parameters. The wearability and lightweight design of the system were achieved through the use of rigid-flex PCBs, which ensured patient comfort and ease of use. The system provides a high-quality signal acquisition and real-time monitoring of the cardiovascular parameters, thus proving its potential as a health monitoring tool.

Validity of Lung Ultrasound: Is an Image Worth More Than a Thousand Sounds?

Introduction: There is debate as to whether lung-ultrasound (LUS) can replace lung-auscultation (LA) in the assessment of respiratory diseases. Methodology: The diagnostic validity, safety, and reliability of LA and LUS were analyzed in patients admitted in a pulmonary ward due to decompensated obstructive airway diseases, decompensated interstitial diseases, and pulmonary infections, in a prospective study. Standard formulas were used to calculate the diagnostic sensitivity, specificity, and accuracy. The interobserver agreement with respect to the LA and LUS findings was evaluated based on the Kappa coefficient (ᴋ). Results: A total of 115 patients were studied. LUS was more sensitive than the LA in evaluating pulmonary infections (93.59% vs. 77.02%; p = 0.001) and more specifically in the case of decompensated obstructive airway diseases (95.6% vs. 19.10%; p = 0.001). The diagnostic accuracy of LUS was also greater in the case of pulmonary infections (75.65% vs. 60.90%; p = 0.02). The sensitivity and specificity of the combination of LA and LUS was 95.95%, 50% in pulmonary infections, 76.19%, 100% in case of decompensated obstructive airway diseases, and (100%, 88.54%) in case of interstitial diseases. (ᴋ) was 0.71 for an A-pattern, 0.73 for pathological B-lines, 0.94 for condensations, 0.89 for pleural-effusion, 0.63 for wheezes, 0.38 for rhonchi, 0.68 for fine crackles, 0.18 for coarse crackles, and 0.29 for a normal LA. Conclusions: There is a greater interobserver agreement in the interpretation of LUS-findings compared to that of LA-noises, their combined use improves diagnostic performance in all diseases examined.

An Introduction to Point-of-Care Ultrasound: Laennec to Lichtenstein

Point-of-care ultrasonography (POCUS) is rapidly evolving as a noninvasive adjunct to physical examination among various specialties. POCUS increases the sensitivity of conventional physical examination by providing the answers to simple clinical questions at the bedside. As such, it can reduce fragmentation of care and expedite management. In addition, using bedside ultrasound as the first-line investigation may eliminate unnecessary radiation and contrast exposure. The advent of highly portable and affordable ultrasound devices has made the use of POCUS more practical and user-friendly, making it the stethoscope of the 21st century. This review will provide an overview of the rationale for integrating POCUS into nephrology practice. We also discuss the current scope of POCUS practice and state of training.

Is the dental profession ready for person-centred care?

Introduction In the last decades, health professions have progressively moved towards person-centredness. Dentistry, however, lags behind the other health professions and remains deeply anchored in a biomedical vision.Aims Our objective was thus to better understand how dentists perceived person-centred care (PCC) and identify the challenges they may face in implementing it.Methods We conducted qualitative descriptive research in the province of Quebec, Canada; it was based on in-depth interviews with 11 general dental practitioners working in private clinics.Results Thematic analyses reveal that dentists had little interest in understanding the life and stories of their patients. Furthermore, their openness to share decision-making was limited to procedures that they considered of relatively low value and less for procedures they considered of higher value, such as indirect restorations.Discussion We argue that dentists' reluctance to understanding and shared decision-making is rooted in the old-established identity of dentistry as an art. Dentists indeed considered the dental craft as sacred - an art form with unbreakable axioms that defined quality of care.Conclusion It is time for the dental profession to reflect on its ideological foundations and reconsider its identity. This reflection is crucial to respond to the needs of a changing society that is losing its confidence in the profession.

The Birth, Death, and Renaissance (?) of Dissection: A Critique of Anatomy Teaching With-or Without-the Human Body

A riveting debate regarding the fate of dissection, the classical method of anatomy, is sweeping through medical academia, as imaging tools gain a greater foothold in anatomy teaching programs. This Perspective does not aim to grapple with the question of "how should anatomy be taught" but rather to explain why the transformation of anatomical education is taking place by situating these developments in the broader philosophical context of modern medicine, offered by Michel Foucault's The Birth of the Clinic: An Archaeology of Medical Perception. Emphasizing the body's crucial role in the epistemological change in medical practice in the early 19th century, Foucault coined the term "medical gaze" to denote the doctor's observation of the patient's body in search of signs of disease. Within this new systematic perception of disease, which brought about the anatomo-clinical method, the clinical gaze thus embraced the study of the body via dissection. The author contends that the introduction of medical imaging into the diagnostic process has resulted in a shift in the focus of the clinical gaze from the body to its medical image and that this process is mirrored in anatomy by its discarding of the cadaver. Given the fundamental differences between the phenomenology of the body and its medical image, the author suggests that when using medical images in medical schools and teaching hospitals, one teaches, at the very least, a new kind of anatomy. Foucault's analysis of the painting The Treachery of Images by Réne Magritte lends some support to the ideas presented here.

The diagnostic accuracy of lung auscultation in adult patients with acute pulmonary pathologies: a meta-analysis

The stethoscope is used as first line diagnostic tool in assessment of patients with pulmonary symptoms. However, there is much debate about the diagnostic accuracy of this instrument. This meta-analysis aims to evaluate the diagnostic accuracy of lung auscultation for the most common respiratory pathologies. Studies concerning adult patients with respiratory symptoms are included. Main outcomes are pooled estimates of sensitivity and specificity with 95% confidence intervals, likelihood ratios (LRs), area under the curve (AUC) of lung auscultation for different pulmonary pathologies and breath sounds. A meta-regression analysis is performed to reduce observed heterogeneity. For 34 studies the overall pooled sensitivity for lung auscultation is 37% and specificity 89%. LRs and AUC of auscultation for congestive heart failure, pneumonia and obstructive lung diseases are low, LR− and specificity are acceptable. Abnormal breath sounds are highly specific for (hemato)pneumothorax in patients with trauma. Results are limited by significant heterogeneity. Lung auscultation has a low sensitivity in different clinical settings and patient populations, thereby hampering its clinical utility. When better diagnostic modalities are available, they should replace lung auscultation. Only in resource limited settings, with a high prevalence of disease and in experienced hands, lung auscultation has still a role.

A mathematical model of bowel sound generation

Humans have been interested in bowel sounds and wondered about their origins for millennia. To better understand the phenomenon, a mathematical model of bowel sound generation was developed based on a spring-mass-damping system. This is similar to vocal folds models for speech. The bowel sound model has four parameters that link to bowel activities: the individual wave component, pressure index, component quantity, and component interval time. All types of bowel sound documented previously can be modelled by combining different values for these parameters. Further, a 2500 ms bowel sound incorporating all the common types was simulated to present the model's accuracy.

Point-of-care ultrasound education to improve care of dialysis patients

Point-of-care ultrasound (POCUS) is rapidly emerging as a bedside diagnostic tool that can enhance physical diagnosis and facilitate clinical decision making. Although ultrasound is widely used by nephrologists for vascular access and kidney imaging, diagnostic POCUS skills in other anatomic areas are not part of routine nephrology training. In this narrative review, we will provide an overview of selected POCUS techniques, highlight potential uses of POCUS in routine nephrology practice, and describe a new curriculum implemented at Johns Hopkins University School of Medicine to teach diagnostic POCUS skills to nephrology fellows.

The decline of cardiac auscultation: 'the ball of the match point is poised on the net'

A brief review of the history of cardiac auscultation confirms its decline. The intervention of healthcare institutions may avoid loss of medical culture and increased costs by adequate training of medical staff.

When there is no doctor: reasons for the disappearance of primary care physicians in the US during the early 21st century

Primary care doctoring in the USA today (2007) bears little resemblance to what existed just 25 years ago. We focus on what is likely to unfold in the U.S. over the next several decades and suggest that by about 2025, primary care doctoring in the U.S. could be rare, possibly unrecognizable and even nonexistent. Seven reasons for the probable disappearance of primary care doctoring are identified. The most important reason is medicine's loss of state sponsorship: the U.S. state has shifted from a pluralistic orientation to a New Right approach. With less state protection medicine has become even more attractive for private interests. Six additional reasons include: (1) the epidemiologic transition (chronic diseases reduce doctors to a palliative role and monitoring of incurable conditions); (2) the overcrowded health care playing field (non-physician clinicians are supplanting primary care doctors); (3) the unintended consequences of clinical guidelines (the art of doctoring is reduced to formulaic tasks, easily codified and performed by non-physician clinicians); (4) the demise of the in-person examination (in-person examination is being replaced by impersonal testing); (5) primary care doctoring is becoming unattractive (physicians are dissatisfied, alienated and experiencing income declines. Applications by U.S. graduates to primary care programs continue to decline); (6) patients are not what they used to be (Internet access and Direct to Consumer advertising are changing the doctor-patient relationship). By 2025, many everyday illnesses in the U.S. will be managed via the Internet or by non-physician clinicians working out of retail clinics. Some medical problems will still require a physician's attention, but this will be provided by specialists rather than by primary care doctors (general practitioners).

How Laënnec invented the stethoscope

Although it is well known that Laënnec invented the stethoscope, the story of how he invented it is less well known. This article discusses the many theories behind the story as well as the impact of Laënnec's discovery on the practice of cardiology in the 21st century.