The physiologic symphony in which point-of-care ultrasound (POCUS) is but one instrument
Perform an Internet query for "POCUS vs. stethoscope" and you will quickly realize that these two have been at odds for years now. Countless arguments have been made and studies carried out to delineate whether medicine is ready to do away with the stethoscope altogether. Recently on Twitter, assistant professor of medicine in nephrology at Duke University School of Medicine Dr. Matt Sparks (@Nephro_Sparks) incited a lively thread when he shared this: "I lost my stethoscope today, should I replace it?" ending the tweet with #OldSchool. Comments ran the gamut expressing everything from the fervent “Yes…the stethoscope is an essential part of our ritual with patients” from Dr. Ritu Thamann to appeals to dump the “wheeze detector” and adopt #POCUS. But should the stethoscope already be considered "old school", ready for retirement? Medicine has been practiced in some form since prehistoric times with Shamans and apothecaries serving as healers over 7000 years ago. The invention of the stethoscope happened just 200 years ago. If nothing else, replacing this tool that has long been an indelible symbol of our profession seems at least mathematically premature.
Feeling desperate for the perspective of a guru, I reached out to Dr. Robert Kaplan, an academic hospitalist at the Tibor Rubin VA (UC Irvine affiliate) in Long Beach, CA. Dr. Kaplan is well-known throughout the UC Irvine School of Medicine for his exquisite physical exam skills. His office wall is an altar to his love of teaching. It is covered with Golden Apple awards, mostly earned for his popular physical exam rounds done every Thursday afternoon with a group of eager medical students. Deeply passionate about the evolution of medicine, Kaplan majored in History of Science at Harvard College in the late 1970s. After completing medical school and internal medicine residency he intentionally chose the subspecialty with some of the strongest ties to medical history: infectious diseases. It's clear when he begins to talk about examining patients that he has devoted well over the required 10,000 hours to be considered an expert. He admits "most of it has been self taught by years of repetitive work on a particular part of the body. Devotion to practicing is what builds the most competence". It was this type of grit with the physical exam that made him an excellent person to answer my questions: what role should POCUS have in the physical exam? Does it truly make the stetho obsolete? Say it ain't so!
"One could argue that ultrasound could replace a detailed lung exam but you can't really hear wheezing or other airway sounds with an ultrasound". Uh-oh, here come the hecklers. He continues "and what about hearing a pericardial friction rub or bowel sounds", which simply aren't things that can be seen. As we talk more about the physical exam we come to the realization that a head-to-toe, inside and out physical investigation really involves all the senses. "Nothing beats walking into the room and seeing the cigarette pack in the shirt pocket or an alcohol withdrawal tremor so intense the entire bed shakes. Bruises, rashes, things inside the mouth, Roth spots on a fundoscopic exam”. Did he say fundoscopic exam? "My ophthalmoscope battery is broken so I haven't been doing as many retinal exams as I used to". He then proudly begins displaying the tools that he carries with him in his white coat pockets: A stethoscope, of course, but also two tuning forks (256 Hz and 512 Hz, the 128 Hz is reportedly too easy an exam), a reflex hammer, and scissors used mostly for removing dressings. I mean, how else would you see and smell a wound for yourself? As a musician, this made me think of the interplay of the senses during the physical exam. The smells, sights, sounds, and feel of the patient coming together, sometimes in harmony, sometimes in dissonance, to create a kind of physiologic symphony. Each sense contributing an equally critical layer to a complex composition.
I also spoke with several internal medicine residents about their thoughts on the matter. The majority expressed some sentiments similar to Dr. Kaplan's: "The most important part of my physical exam is when I walk in the room and just look at the patient. I immediately get a sense of whether the patient is sick or not sick and a general idea of their baseline", said Drew Sheldon, a current PGY-3 en route to pulmonary critical care fellowship. He is also one of the primary teachers of POCUS skills for the residents so I was eager to hear his opinion. Would he toss his stethoscope if he had to choose between it and POCUS? "Of course. Most of the time I don't even need my stethoscope to examine a patient". Perhaps there is a generational component to this debate.
As we reminisced about the times when doctors blocked off a half-day to see new patients Kaplan remembered "My dad was an internist before thyroid assays existed. He tested response to therapy for hypothyroidism with a machine that measured the arc and speed of the relaxation phase of the ankle jerk reflex. He was actually very happy when they got the blood test". Kaplan, himself, is not afraid of technological progress in medicine either. He owns a very expensive electronic stethoscope and loves using the associated smartphone app for recording and amplifying sounds to share with his learners.
Recognizing the heartbreak caused by my love of medicine traditions colliding with my passion for innovation, Kaplan left me with this: "Whether using your hands or a stethoscope or bedside ultrasound, this is still intimate time with the patient rather than sitting in a chair looking at a computer screen and typing. Any intimate time we spend with the patient creates continuity with the classic practice of medicine". It was as though he also carried a suturing kit in his white coat pocket and used it to sew the million pieces of my heart back together. Perhaps it is ok to marry the past with the present, stetho with POCUS (#STOCUS). Perhaps adding an instrument to the physical exam instead of replacing one will keep it rich, symphonic, and informative the way it was meant to be. And with that, I happily plant my flag right smack dab in the middle of the debate.
And last, but not least, when forced to choose just one, the guideline that Dr. Kaplan says no internist can live without is the IDSA Guidelines for the Management of MRSA Infections.