Dr René Laennec couldn’t have guessed that his invention would one day become the third hand of every doctor in this world.
The stethoscope is used to listen to the various sounds produced in our body. It includes heart beats, abnormal heart sounds like murmurs and clicks, breath sounds, bowel sounds etc. Our Medicine Professor, Dr Bhaskaran Chalil used to say that it is not the brand or make of the stethoscope that matters. According to him, the real stuff is the area lying between the two earpieces that matters the most. Hope you got the idea!
A stethoscope placed stylishly around the neck of any person makes him a doctor in the eyes of the patient. That look is something which you have to experience in order to understand. It is difficult to explain in simple words.
A doctor uses the stethoscope for auscultation while examining. The patient on the other hand wants to be examined with the stethoscope even if he has a lump or injury on the hand!
Apart from listening to the lung and heart sounds, it is also used to listen to arterial and venous blood flow. Along with the sphygmomanometer, it is used to record the blood pressure.
A complete medical examination warrants the use of stethoscope. But, in a busy Out Patient Department of a government hospital, is it really necessary to use the stethoscope even if the patient came for an ailment for which it’s use is not at all required?
I have written about a usual scene at the Out Patient Department in our Primary Health Centre. Taking the history and examining the patient alone can take five minutes, prescribing the medicines can take another minute for a normal consultation. But, in rural India where majority of the community depends on such PHCs for the minor ailments, the consultation process takes place in just one to two minutes. That includes taking the history of the patient, examining the patient and then writing the prescription.
In order to understand this more clearly, just consider the following situation :
- A patient walks in to the consulting room with the Out Patient card in his hands.
- The doctor greets the patient, offers him a seat and asks for the Out Patient card.
- The doctor enquires about the reason for the patient’s visit.
- The doctor writes down the out patient number, name, age, sex and the probable diagnosis in a separate register on his desk.
- Then he asks for the history of the ailment. For example, if the patient has a fever, the questions will be like – how long has it been since the fever started, how does the fever vary during different times of a day, whether it is associated with any chills or rigour, any other associated symptoms, family history of fever and so on..
- The doctor briefly examines the patient, records his temperature (if needed), and auscultates him with the stethoscope.
- The doctor may send for blood or other investigations if he feels necessary.
- Otherwise, he simply writes down the medicines in the Out Patient card and directs the patient to the pharmacy.
All these steps happens in just two minutes. An average of 150 patients are seen by a single doctor in a PHC every day. If you are interested in doing the math related to the number of patients and the time taken to finish off the OPD, do read this article.
Can you guess the most important of these steps as far as the patient is concerned?
It is “using the stethoscope” for examination. The other steps mentioned above are meaningless for the patient.
I have once worked in a PHC, where the doctor used to place the diaphragm of the stethoscope on the patients forehead to examine the reason for the patient’s headache! Don’t think that I’m exaggerating. It’s a true incident which I’ve seen myself. And guess what! That same doctor was the most successful general practitioner in that area.
“Aren’t you going to check me with those?” asked a patient pointing to the stethoscope during my first year of service at the place where I work now.
The patient had a minor cold and complained of fever two days ago. I had asked the staff nurse to record this patient’s temperature. The staff nurse had written the temperature on the out patient card as 98.6 degree Fahrenheit. I had written down just a nasal decongestants for the patient and asked him to review if there was any other symptoms. But, the patient wanted me to use the stethoscope to find out whether he had fever or not. He was not ready to leave his seat and I finally decided to auscultate his chest to please the patient. That was a wise decision to make considering the extra time being wasted by explaining the concept of medical examination to that patient.
From that day onwards, I auscultate the patient’s chest if they want to be examined with the “tubes”. I haven’t followed the paths of the general practitioner whom I mentioned earlier. In such cases, I simply reveal to the patient that the stethoscope has only limited uses.
Over the years, using a stethoscope in every patient has become more or less like a habit for me. This routine has also helped me to detect cardiac murmurs in previously undiagnosed young children. So, now whenever I do the brief examination, I automatically use the stethoscope. There is no more thinking about the logic of using it while examining.
This article was based on my clinical experiences in a state like Kerala, where the literacy rate is said to be so high compared to the other states in India. I wonder, how the patients feels about the doctor’s examination in other parts of the world.
Image Credit – Medisave UK