I wondered why Zeljko wrote this question. He replied, "A few days ago I read "Can 3M save the stethoscope?" at http://ow.ly/baKxT.

My answer to that question is that 3M (Littmann) can't save the stethoscope. Only the medical profession can save the stethoscope. My mission is to save the stethoscope and auscultation for the next generation of doctors.

Zeljko, would you like to add anything?

Liliana Grajales The traditional stethoscope should go away. Wireless electronic stethoscopes should be on every doctor’s and nurse’s pocket. The technology has been there for at least 10 years now. The interface is now more readily available than ever before. Why couldn’t the doctor/nurse use her laptop or phone to better hear and analyze the heart and breathing sounds?
I understand that medical schools do not want doctors to depend on electronic stethoscopes for those emergency cases when/where the technology is not available. That is fine, doctors could be taught to use the basic stethoscope in the classroom, but they will be missing a lot of information if there is a persistence to avoid the use of electronics and smart computers that can listen and evaluate sounds better than a doctor can. Relying on doctor’s hearing adds large variability to the diagnosis. This variability will probably get worse as new generations of iPod users become doctors.

yes in our country like India still it is required a lot. It is also psychological effect that the doctor has checked with stethoscope. If doctor diagnoses without that then patient feels that doctor does not know to diagnose.

henri flechner Each time you see a doctor only physics counts

Michael McCarthy, MBA, BS, RRT-NPS A stethescope is not indicated for an arm laceration but as a respiratory therapist I need to know if the sounds are bilateral or if there are crackles or wheezes. I don't need an electronic stethescope but I use a top-of-the-line cardiology stethescope. Electronic stethescopes are great for people with hearing impairments.

Zeljko Roncevic Cardiac auscultation is skill difficult to master. The art of listening to the heart is in danger of being dismissed in the presence of technology-which is expensive and does not necessarily involve the physician in thinking but only reading a report. Many doctors carry a stethoscope around their neck just as a symbol of the profession but they do not know how to properly use it. Stethoscope is only an instrument and auscultation is the art. Quality of auscultation findings is influenced by: the knowledge, experience and sense for music and rhythm. You can read about it in my article: "Music from the heart -- in a praise of auscultation" published in Ciculation 2007
http://circ.ahajournals.org/cgi/reprint/116/14/F79.pdf

The question is raised, because I'm interested in public opinion is the stethoscope still important or not. I think it is time to launch a movement "save the stethoscope".

Zeljko Roncevic I must cite Martin B Van Der Weyden from Australia: "With today’s fast-paced and frequently disengaged delivery of health care, it is ironic that our beloved stethoscope, the instrument designed to separate the physician and the patient, but which now connects them, is under threat. The “technophiles” in our midst are promoting the hand-held ultrasound device as state-of-the-art medicine. And all in the name of science!

Enough is enough!

Will it come to a “save the stethoscope” movement to protect the art of medicine from misdirected technology?" Save the stethoscope. Med J Aust 2006; 184 (5): 201.

Zeljko Roncevic Medicine moves from doctor's ears to the doctor's eyes.
Maybe it's good but should we forget the ears and the art of listening?

henri flechner The art of listening and mastering expertise.
Auscultation is key and every time you use an interface you are loosing something.
Have some statistical measurements been done.
Gage capability is important.

Zeljko Roncevic I have to say that I use acoustic stethoscopes, electronic stethoscopes with their software, musical software like Sony Sound Forge, various headphones, good speakers with subwoofer ( because heart sounds are of low frequency). In every patient I use acoustic stethoscope first and after that the electronic one.

Dr Gyan Khare Auscultation is a direct conection with the patient. Even though the electronic devices are precise, its the psychological connection which a medical practitioner gets using stethoscope and it can't be perceived using an electronic device. Should other devices be used in conjunction with stethoscope, yes! definitely, if the practitioner feels the need.

henri flechner belief that relying on electronic measurements especially on this field might not be appropriate.
We cannot consider a patient like an IP adress and checking hos status.
If we take an other example (cars) please check what we are doing to switch off the front seat passenger with a switch we do activate...humanly.

I think stethoscope is a good assistant to physicians, especially for those physicians in resource-limited areas and developing countries. The problem is for those areas, the physicians usually don't have a chance to get professional training on auscultation. Can future stethoscope be more intelligent that not only hear the sound from heart/lung but also understand sound to provide decision support to our physicians?

Liliana Grajales I believe auscultation brings value to the diagnosis, so I interpret the question not if auscultation is valuable, it is for me. However, I maintain that it could be improved by using electronic devices (stethoscope) that digitize the sound signals and allow further evaluation of recorded heart and breath sounds. Here is a list of the benefits of such device:
(1) Overcome high environmental noise caused by air conditioning systems, refrigerators, cars and other equipment near the doctor’s office.
(2) Overcome variability in doctor’s hearing ability and decreased hearing with age
(3) Sound data could be recorded and kept on the patients records as he/she ages
(4) Sound data could be digitized and evaluated. It is easy to develop software that could compare a patient recorded sound with characteristic and uncharacteristic heart and breath sounds
(5) Digitized sound data could be analyzed for heart rate variability during breath hold, deep breathing or other test that could help assess the variability and its adaptability to breathing patterns, improving patient’s heart and lungs condition evaluation
(6) The electronics in an electronic stethoscope is far simpler than the one implemented in a $20 dollar cell phone. If developed slightly further and complemented with simple data analysis software it could provide valuable data to the doctor and help him/her evaluate conditions and correlations not yet considered in today’s doctor’s office.
(7) As in any new technology, its use and applicability will become more evident as new generations of doctors understand and accept its benefits. Patients are becoming more accepting of technology, and overtime they will question the use of traditional tools and will demand the use of devices that would improve their diagnosis. They will also demand improvements in the psychological connection with their doctors, such as having one on one conversations with their doctor about their health, preventing care, and if ill, to better understand their condition (this includes rural patients who are becoming more knowledgeable through TV and cell phone)

I think stethoscope is still an important tool for a physician. Instead of just replacing it with technology that reproduces the sound in a speaker or a headphone, if we can let the physician still directly hear the sounds but augment it by being able to record it for future references and automated pathology detection, it would help us take care of the patient better.

Wendell Thoene I agree with Liliana and her points are all very salient. She is right about hearing loss over time as when I was younger I could hear and go for four heart sounds but not anymore. The stethoscope is a wonderful diagnostic tool that enables physicians to hear unusual heart valve clinical issues, along with lung problems, and the "woosh-woosh" of actual blood flow. All of which is lost with respect to automated BP devices. We've come from the wooden tube stethoscopes of a little over a hundred years ago to the modern stethoscope, and now its time to improve on what we've been used to using with a bit of up to date electronic embellishment.

henri flechner I am afraid we are loosing common sense
Doctors have their role and their requirements
Not respecting doctors advice might be not appropriate
Just imagine an increase in Magnetic Field for any reasons.
All electronic equipment will be out of use....

Neda Al-Saadi Liliana makes strong points about subjectivity in cardiac auscultation. However, for a trained and experienced physician, a stethoscope is the first tool in assessment. Newer technology has enhanced capability for both sensitivity and recording and tracking information. It needs to be incorporated.

However, medical care is both diagnostic and treatment oriented. For the relationship between doctor and patient, human contact is important as is nuancing care to meet the needs of the individual. To the trained ear, analog information can provide details that the digital may miss. In addition, for patients with asthma, COPD, pneumonia and other difficulties with pulmonary function, the stethoscope is the first step in respiratory care.

Odd Viking Höglund Of course stethoscopes are still important; they are a must, also for veterinarians. I personally would never go back to a traditional stethoscope; I have become dependent on my electronic stethoscope.
Several strong statements and arguments are brought forward but I wonder if there is some confusion. Using an electronic stethoscope is great, it makes it easier to do a first assessment: is this patient normal on auscultation or not? And yes, we do need to continue to use all our senses in assessments of patients. And experience matters, especially in assessment of low grade murmurs.

However, step two, recording and analysis of the heart sounds does take some time and (obviously) has to be properly performed. The file can be e-mailed to an expert in the field, which is all very fine but in our field the tradition is instead that the cardiologist makes those recordings and the analysis. Often other examinations of the heart need to be done anyway (so the cardiologist could and should make them all anyway). A number of years ago it was foreseen that recordings of heart sound would be e-mailed to specialists, in the same manner as we sent ECGs, but we have not seen that happened in our field.

I believe the second step is too time-consuming in a busy general practice – I spent over a decade in private practice. In a teaching setting those devices are great, I even say fantastic. With the aid of electronic stethoscopes students can hear what the teacher hears and the sounds can be further discussed and analyzed with phonocardiography. So the teaching aspect also offers business opportunities. Here is some research where those techniques are used in the veterinary field, studies performed at our university (not involving me, but instead my better half); links to two PhD theses:
http://pub.epsilon.slu.se/8164/
http://pub.epsilon.slu.se/1462/

We will continue to use the stethoscope, and I would guess the electronic devices will become more and more popular. But I can’t see storage of recordings and or digital signal analysis becoming routine in general practice in the near future.

What is the best and most practical electronic stethoscope currently on the market, for use in primary care and developing world settings (assuming a laptop is available)?

henri flechner Answer for all of us :Nice to have your point of view.
Any medical electronic instrument cannot substitute to any doctor for "human touch and expertise".
Never have never will
Wes should never forget neglecting human touch.
Regards
Henri

henri flechner Best Stethoscopes are is relative and depends from one user to the other. If there is a choice to be made please refer to 3M Littmann Cardiology III Stethoscope
Regards
Henri

Chagai Dubrawsky Reference: Dubrawsky C.:Sudden cardiac death in the young.Calling for new tools.
Cardiology,2008; 109 (2);143.author reply 144.
Please read the letter.This says it all.I did invented the tool.

Odd Viking Höglund The stethoscope by Meditron came out on top last time the cardiology group did a comparison / evaluation. In our institution it is the only electronic stethoscope we use (and I have personally never used any other electronic stethoscope).

henri flechner The market will be saturated pretty soon while Doctors are very hard to find.
We are reaching an unbalanced situation where equipment is there and Doctors are barely available.

henri flechner The shortfall is predicted for U.S. doctors, which now totals about 954,000 while 150,000 doctors are needed in the next 15 years.
Who will be the future users?

John Strupat So many possibilities for this particular device that could help with consistent diagnosis in the hands of the non-expert. Consider the development of the humble ECG. Perhaps unfair to compare to human mastery of the stethoscope since no clinician (that I am aware of) can detect the electric signals from the heart without equipment? GP use of the early ECG machines gradually shifted from sending the paper printouts to a specialist, to electronic connection by modem to today's real time automatic computer analysis on site.
The electronic stethoscope can bypass 50 years of ECG device history with creative design and clinicians open to improvement (change).

The Stetho is a basic instrument for any medical professional, who is using to determine the heart or lung sounds. It will never go away or obsolete. I am importing a large some of every year and export to third world countries, also market here in USA.
How some one can depend on electronic Stetho, when 99% of the DR. even don't like to have or use Electronic Scale in their medical facility because it never give you correct weight in compere to mechanical one. May be it will get common in next century.

Neda Al-Saadi No one is saying that electronic stethoscopes do not have a place in cardiovascular care. They do. It is just that it should not be the first line of evaluation, and that an ECG is a more detailed diagnostic tool.

Zeljko Roncevic Stethoscope is always the first line in evaluation, after history and inspection. ECG is second line sometimes of little importance like in Congenital Heart Disease and often in valvular diseases where stethoscope is better.

Chagai Dubrawsky Let the public be aware : A new Medicine is now on the horizon.It is named:
Molecular Medicine.This new medicine is replacing the existing :Genomic Medicine-
Personnelied-Privatized medicine(References available)
Why is the change?
A)Genomic Medicine. Too much technology,too much computerers.No human touch.
B)Unaffordable;
As they used to say: What do you like about the New B.M.W. that you bought? So
much technology!.What you don't like about the new B.M.W. that you bought? Too
much technology.

Zeljko Roncevic Summary

IS THERE A FUTURE FOR CARDIAC AUSCULTATION IN CHILDREN?
Ž. Rončević

In 1816, René Théophile Hyacinthe Laennec (1781-1826) invented the stethoscope which became a symbol of the medical profession. After centuries of fame in which the stethoscope was very important in diagnosis of heart diseases, technological revolution gradually reduces the importance of auscultation. Cardiac auscultation, especially cardiac auscultation in children is a skill difficult to master. The quality of findings of the cardiacauscultation is influenced by previous knowledge,
experience and even musical talent. All researches so far indicate insufficient auscultation competences of medical students, internal medicine and paediatrics residents, family medicine doctors, and even specialist. There are two ways to improve auscultation diagnostics of heart murmurs and sounds in children. One being better education of paediatrics residents and continuous education of paediatricians (along with the use of modern digital technologies), and the second being the usage of computer programmes specialized for diagnosing heart murmurs and sounds. Acoustic stethoscopes will be used for a long time but will gradually be repressed by modern electronic stethoscopes. Therefore, cardiac auscultation in children is a skill which will not become obsolete, but rather its continual usage will only be further secured by support from the available digital technology.
Descriptors: CARDIAC AUSCULTATION, ACOUSTIC STETHOSCOPE, ELECTRONIC STETHOSCOPE, COMPUTER DIAGNOSTICS
Paediatr Croat 2009; 53 (Supl 1): 27-29

henri flechner We are not old timers.
Stethoscope is the first instrument to be used.
Paradigm: screw driver is still used
Screw driver was invented in Germany in the late fifteenth century.

We are all using it.
Let's go back to basics

It is not the importance of stethoscope but the importance of training to the Physicians. When they are well trained, they can master the stethoscope well and discover the problem with the patient even without the electronic one. Nevertheless, if they are poorly trained, even with the help of electric stethoscope, they could not identify the problem of his patient. The fancy machine does not guarantee mistake free. In most of developing countries, the electric one is not popular, hence, physicians still rely heavily on the stethoscope.

henri flechner To Teeming Tsao:
a)I never observed really such an event I am Lucky?
b) Physicians are what they are
c)Duality between Physician and Patient is very crucial This is the main POINT

John Strupat @Zeljko, am I correct that "auscultation" is medical-speak for "listening"?

Electronic sensors with modern digital signal processors are capable of matching the finest human ears and brain combined. Now think about the possibilities to have several pickups around the chest all taking samples at the same time?
That would still be a Stethoscope for the 21st century.

Always nice to look backwards in history, however we are posting comments in the Medical Devices Group!

Are you asking if the "stethoscope" in it's most basic, low cost form is still important?
Definitely YES if one has the extensive training and skill OR no funds for something more modern.

henri flechner John please listen if you can.
There is no contradiction at all.
What is the benefit of putting several pick ups.
I want to learn from it.
Thanks
Henri

Zeljko Roncevic John you are correct auscultation is medical speak for "listening". I think about stethoscope in any form. Doctors like electronic stethoscope only if it is similar to classic stethoscope and if they can bring it always with them.

I personally like to research heart sounds and murmurs in any possible way. I used FFT, DFT (even Goertzel algorithm) together with engineers and I now can explain to me and to my students much better what I hear. I even recognized some unique kind of well known murmur with spectral analysis what is impossible to recognize by auscultation alone ( I'll publish it soon). What I want to say I like to hear patient heart sounds as an ancient music. Heart sounds for me are sounds of Universe something like Om in mantras. Every of us has heart sounds of his or her mother in veins (mother's heart sounds heard in uterus and during breastfeeding).

John Strupat Henri, in the same way that you hear heart valve sounds differently with a conventional acoustic stethoscope as you move around the chest wall. An electronic package with several sensors would detect and analyze these sounds from several positions all at the same time.

Why hear, when can you see.
Ultrasound the stethoscope of the 21st century...
Standard of practice in emergency medicine, critical care & anesthesiology.

Zeljko Roncevic If someone wants to make a medical device the best advice is: doctors must be included from the beginning because the device will be used by them for the benefit of patients.You can be satisfied with your device, but it is useless if doctors do not accept it. In the example of electronic stethoscope it must be good looking, ergonomic, with good acoustic properties and with high quality sound recordings.

henri flechner Who is the end user: Doctor
Customer first
Company second
If company does not follow customer, no business; no profit, Chapter11

Jim Osborne- FACHE Dear Zeljko,

I have audited and discussed this issue with many MD thought leaders both in theoretical as well as practical and experiential terms. Scripps for example has a very pro-active posture toward the digital pocket wireless integrated sonography unit becoming the overall replacement diagnostic tool for all but listening to the chest at the beside and in the clinic.

Hypothetically these units are poised to also defer a considerable number of otherwise unnecessary imaging procedures and subsequent additional dosage exposure. It is being proposed by Scripps and others that the MD and Nurse of the future will be armed with a fully integrated tablet and wireless pocket sonography unit as basic clinical armamentarium along with stethoscope for aforementioned chest listening only.

At my firm, we are clinical equipment planners and we consider this to be a possible major game changer. We would very much appreciate all knowledgeable feedback on this.

Sincerely/ Jim Osborne

JIM OSBORNE
BA/MHA, LEED, ACHE
DIRECTOR OF BUSINESS DEVELOPMENT
GENESIS PLANNING LLC
Technology Planning for Healthcare & Science
H O U S T O N l D A L L A S l L A K E C O M O l A B U D H A B I
1111 Louisiana, Floor 26 l Houston. Texas 77002
713.418.3802 Tel l 713.852.3780 Fax l 517.414.1583 Cell
josborne@genesis-planning.com
genesis-planning.com

Only non practitioners could advocate the exclusive use of electronic stethoscopes and the demise of the manual ones. Auscultation is part science, part art and it must be mastered and maintained with practice. As a former nurse and a current medical device designer I see the value both electronic and manual stethoscopes bring to patient care. Plus most of the world is nowhere near electronic stethoscopes yet.We should try to help practitioner get back to sensing their patient and relying less on monitors, not the opposite in the developed world. So many mistakes stem from never actually looking, talking, smelling the patient.So yes, we should save the stethoscope, by all means!

I propose a global design competition -- to attract the best artist designers everywhere -- to repurpose redesign this Icon of medicine -- the stethoscope -- Altius Fortius Maximus....

Zeljko Roncevic Dear Brunaud,

I'm pediatric cardiologist and I use echocardiography a lot.

Before every echo I auscultate patient with stethoscope. Additonal informations are always good. Innocent Still's murmur in a child can be recognized with stethoscope and auscultation. Price of auscultation in USA (I suppose is 50 $). If you refer patient to cardiologist for ultrasound price is 1000$ and cardiologist will see healthy heart with left ventricle false tendons. What about cost/benefit? More than 100 hundreds years ago they wrote (many times) that x-ray is stethoscope of twenty century.

Zeljko Roncevic Exuse me one hundred years.

John Strupat Katrin, your proposal is really the only way to answer the original question, but the end result may not be same as the historical stethoscope.

I would add 2 consideration to the design competition:

- the actual market includes other health professionals that outnumber doctors by 10x or more. I'm thinking of nurses and respiratory therapists here in North America.

- the historical stethoscope is a spot testing device. A modern design could monitor heart and breath sounds over long periods, for example during exercise and everyday activities.

Now we just need some sponsors and I will take part myself.
Let the contest begin!

Zeljko Roncevic I'll be happy if this dicussion will bring something new and useful.

Perhaps if physicians and other healthcare providers practiced the art of "listening" with the stethoscope they would also practice the art of "listening" to their patient. Technology can't overcome the fact that communication is a key factor in diagnosis and keeping health care costs in check.

Zeljko Roncevic Dear Elisabeth,
you are quite right.

John Strupat Elizabeth, technology does not have to interfere with communication with the patient and does not have to drive up health care cost.
What I see as the primary goal for a new approach here is to improve consistency.

If I am a 22 yr old male med student with full range hearing, I will "hear" almost everything from an acoustic stethoscope and be trained to analyze and make a diagnosis.
Yet 25 years later, I now have vast experience with the stethoscope but can no longer "hear" what I did before. So, do I now make a different diagnosis because I missed details?
What if I also have a head cold that day?

A great medical device design will solve this and make for better health care as well.

Michael McCarthy, MBA, BS, RRT-NPS 25 years later this physician will have tools the young physician could only dream of. For example perhaps he'll know the patient has pulmonary edema based on low sodium, oxygenation, dependent edema, WOB and secretions. He may not need a stethescope as the younger guy needed. I think someone is trying to sell electronic stethescopes and I'm not ready to buy. Not by a long shot.

I am a seasoned Cardiology Physician Assistant and I certain that the Stethoscope will not go away. This would be like a physical exam going away. It is a tool used in an initial objective evaluation. It is usually not an definitive diagnosis. In an area of runaway healthcare cost it is difficult to accept that auscultation will go the way of the dodo. Auscultation of the heart is a skill that is mastered by cardiovascular professionals. As a trained cardiovascular medicine provider I would not require an electronic device. If there is an abnormality, I would suggest an Echocardiogram.

John Strupat Good points Michael. My bad. My intent was to compare the effect of the physical attributes of a 22 year old with a 47 year old regarding their ability to "listen" to the same patient.

I was also speculating a little on future possibilities (since this is a Medical Devices group).
Nothing to sell to you with advanced capabilities beyond the acoustic stethoscope.

Instead of some suggestions on what might be valuable in the future I do wonder why so many comments seem to say that it's not possible to make a better "stethoscope" than the old standard?
Really, 'not possible' or just 'I can't imagine it'?

henri flechner It might be time to summarize the topic stethoscopes topic
a)What has been achieved
b)What are the key player ors stake holders
c)What key action can be done (ie worskhop)
We have to designate a leader
For me this person should be Zeljko
If he agrees then we can proceed and go from there.
We have too many cookers in this group and need a structured approach
Your comments are welcome but the group has started 10 days ago.
Enough valuable inputs have been made to get the substance out of it.

I do not want to give the hot potato to Zeljko but he can mitigate all the aspects
Regards
Henri

It may not be as useful as it use to be in earlier days. But it will always be a part of doctors. Whether it is in form of electronic stethoscopes.

Zeljko Roncevic And now is time to talk about hand - held ultrasound (Vscan) device and stethoscope. Will Vscan replace stethoscope?

John Lennon said "Tomorrow never knows".

Will all GP doctors or even nurses have V scan in there pocket instead of stethoscope? They hesitate to buy electronic stethoscope of 350$ don't mention Vscan (6000 $).

Who will educate them, how long when and where? Who will control quality of there ultrasound reports after they examine patient with Vscan? What about board certificates and eventual legal problems?

Today V scan is used in intensive care units. Is it stethoscope of 21st century we'll see in the future. In 2016 will be 200 years of stethoscope and I'm sure stehoscope will be alive 4 years from now and many more years after thet. As I wrote before: modern medicine moves from doctor's ears to the doctor's eyes.
Maybe it's good but should we forget the ears and the art of listening not only of their hearts but also to listen what they say? Auscultation is part of regular doctor's examination of patients and it will be not easy get it out.
" For the near future at least, stethoscopes should continue to hang there, waiting to be used by those who know auscultation, while echocardiograms (hand-held or standard) should be performed and interpreted by those who know echocardiography" - D a n i e l M S h i n d l e r B U S I N E S S B R I E F I N G : U S C A R D I O L O G Y 2 0 0 4

Zeljko Roncevic Hearing loss is a common disorder associated with aging (presbycusis). The loss associated with presbycusis is usually greater for high-pitched sounds. Heart sounds and murmurs are in low frequency range (20 to 700 Hz) so it's not so big problem as we think.

John Strupat Confining the discussion to only devices that could be involved in auscultation, would there be value in a medical device that would help identify chest sounds and their sources?

I'm thinking about when and where an expert is not available. Must have a very high rate of successful identification and yet be relatively low cost.

Is there agreement that investigating this topic could have merit?
Is there any down side to the use of such a device?

henri flechner The human values are
hearing
the taste
touch
smell
view
Any other human priority might add some values
We should never forget those till those 5 attributes are there in another virtual world

Jin Lee To the comment of Dr.(Sir) Wei Wu--
Precisely for that purpose, the Digital Stethoscope is developed. In rural area, each situation is demanding medical center facility but out of reach.
Digital Stethoscope can initially cover a lot of it.
Sometimes, beyond their own field of medicine- like, cardiologist can hear pneumonia suffering child's breathing sound with improved knowledge.

Doctors who practice in advanced countries would strongly object on my comment however, think about less developed country - remote area where another 100km is to go for nearest ultra sound device.

New- electronic stethoscope can hear, look as in graph, record, send information to other doctor etc. etc.

Zeljko Roncevic Thanks all for your comments and contribution.

henri flechner In 1816, French physician Rene Laennec began using a short hollow tube to listen to the heart and lungs of his patients. Initially this monaural tube was probably just a piece of paper rolled into a cylinder, but Laennec found that it greatly improved his listening abilities.
Laennec authored a book in 1819 titled "De l'Ascultation Mediate" in which he described his findings.
In general, the stethoscope is a relatively "low-tech" way for us to listen to heart, lung, vascular and intestinal sounds of our patients, but it is a visual symbol of the practice.
KEY INTERACTION :Using the stethoscope is a way for the doctor, nurse or physician's assistant to keep close to the patient.
Some of our modern non-invasive imaging techniques, however, may increase that distance. "Separation can alter the enduring tasks of physicians: listening to our patients."
Well, it seems that many physicians rely less and less on the stethoscope today,
It is following the "modern area"
CONCLUSION: even though modern electronics will help let's not forget the GOAL
LISTEN

Dr Gyan Khare True!! Let's not forget the goal---LISTEN-- It is not only the care but the psychological bondage that stethoscope provides between the attending physician and the patient.

Jerry Robinson Jin...

I think you are exactly right. I think it is ALSO just the "top" - most obvious application that needs to be addressed

It's not just remote areas, either. There are TOO MANY places were "cost of medicine" prohibits people from getting trained medical care. They are left with the choices of "no medical care" or something at a great distance or great cost.

Next generation mHealth applications will address this.

henri flechner Mindmap and Medical Devices
a)Mindmap is a a graphical method of taking notes. Their visual basis helps one to distinguish words or ideas
b)Medical devices Diagnosis, prevention, monitoring, treatment or alleviation of disease.
Diagnosis, monitoring, treatment, alleviation of or compensation for an injury or handicap.
Investigation, replacement or modification of the anatomy or of a physiological process
Control of conception
c) Please look at the following adress
http://www.himss.org/content/files/mindmap.htm
Please do comment as usual.
This subject might be out of scope it might help
Thanks
Henri

Zeljko Roncevic After all this comments I'm happy that I can conclude: the stethoscope (acoustic or electronic) is still important.

henri flechner Incident yesterday:
1)went to a village no internet
2)visit somebody with obvious heart disease due to smoking and drinking
3)Arteries partially or completely altered
4)localisation of patient difficult
Outcome:
1)Even in so called "developed countries" only a doctor can come and visit
2)This family will be obliged to move to a"big city"
Question: is there any way to avoid this move with serious psychological impact?
Thanks
Regards
Henri

Jerry Robinson Zelijko...

It think much of the Doctor Patient relationship is a type of Theatre.... It is CRITICALLY necessary for the Doctor - to perform in an objective fashion and also for the Doctor's own mental well being..

It's critical for the Patient! In a situation of stress, there are elements of props that are necessary - as well as useful.

You are right - and for reasons beyond information gathering of patient info...

henri flechner A Theater is "just a representation" no more no less.
When you deal with illness and doctor you do not go for pleasure.
It is a will for obvious reasons.

Information is passive.
Patients and Doctors are human beings

Jerry Robinson I think you have to look beyond that Henri...

Doctor's and Patients play a role in their relationship with each other... Roles are what allow each party to be "somewhat interchangeable" with other members of the group - and to allow each party to maintain their own "professional" perspective.

I certainly don't relate the "pleasure" part to the roles.. Objectivity and professionalism come more to mind.

All parties are humans - but the roles are different for Patients and Doctors. it is part of what keeps each party sane...

Clive Smith As a stethoscope designer, I have found this discussion very interesting. I have many comments on so many of the thoughts presented thus far. In the interests of short postings and a "conversation" rather than a "lecture", I will try and post multiple short comments, rather than one long essay.

Let me just relate an experience I had at the American Heart Association (AHA) conference a couple of years ago. The V-Scan had just been released and our Thinklabs booth was near the GE V-Scan booth. Eric Topol had declared that stethoscope "dead by 2016" and I decided that the quicker we test Topol's argument, the better. Life is short and even thought I've poured years into stethoscope design, if doctors are going to dump the stethoscope, I need to find that out sooner rather than later and face reality as I find it. So I tried to steer as many cardiologists to GE's booth as possible so I could get feedback. (The GE manager thought I was nuts.)

Result: I could not get one cardiologist to agree that the stethoscope is dead. When one did agree, I said to him, "So we'd better fold our tent and do something else" to which he replied, "Not so fast. Two weeks ago I heard something with a stethoscope that I missed on the echo". One more note - GE has not had an easy time selling the V-Scan. We can discuss the reasons in another posting.

Conclusion: Humankind are toolmakers. The stethoscope is one tool. So is the ultrasound. Tools become obsolete, but less often than expected. We add things to our arsenal of technology, but expansion of the toolset is more common than extinction of a given tool. Ultrasound will no doubt expand and medicine no longer relies on those "golden ears" cardiologists to figure out valve disease. But the stethoscope is alive and well. The question - do doctors still know how to use them and should they?

henri flechner If the knowledge is vanishing then retraining is possible.
Should be part of Mandatory re qualification of Medical staff.
No Option.
We cannot afford to loose BASICS.

Zeljko Roncevic Clive, thanks for your comment,
it's nice to see an opinion of electronic stethoscope designer.

Your question at the end of comment is good. Many doctors, especially the new generation don't know to use stethoscope properly but they like to be good in auscultation.

So the most important thing is to change the way of learning auscultation at University and during residency. Except patients it will be good to use more e-learning, multi medial presentations, the new generation of cell phones like iPhone, discussions with students and physicians.

Zeljko Roncevic Everything what I wrote applies to nurses and other medical professionals too.

Jin Lee Thank you Dr. Roncevic for this interesting discussion.
As one of Electronic Stethoscope distributor, I'd like to watch how medical world with advanced stethoscope goes on.

Zeljko Roncevic I focused this discussion on cardiac auscultation, but now I have to say that stethoscope is even more important for pulmonary auscultation. In this kind of auscultation stethoscope was not suppressed by x-ray or ultrasound.
Next week (October 18-20) I'll be invited speaker at 1st Balkan Pediatric Pulmonary symposium in Sophia, Bulgaria. I'll present there " Two hundred years of stethoscope".

Jin Lee Dr. Roncevic, the stethoscope on pulmonary is equally or more important then cardiac auscultation.
My son who is an asthmatic. He is 9 now but a couple of years ago he developed a very strong asthmatic symptoms and later on in the midnight, his breath sound became horrible to tolerate. At 3 am., I checked with my Digital Stethoscope and compared the sound and the graph in my computer with reference data. It strikingly matched as Pneumonia. I ran to the emergency room in near by hospital and doctor also confirmed the disease with the digital stethoscope I brought along. We administer medication together with enough dose of Ventolin nabul.
He is basically a healthy boy and Dr. released him after 3 hours to treat at home with medicine.
He became fine in less than 5 days.
I understand that early diagnose of pneumonia is critical rather than waiting to show on chest X-ray after 48 hours. Digital stethoscope can detect somewhere between 12 ~ 24 hours upon outbreak of the symptoms.

I am sure the sensitivity of Digital Stethoscope significantly help pulmonary doctor a various different subtle sound for correct diagnoses.

As long as there are still healthcare providers that feel comfortable with it and prefer using it, the stethoscope remains important. Whether or not newer electric models are more efficient or smaller or more sensitive etc, health care providers are the ones who decide what they will use, not us!

John Strupat @ Daniel - my view is that the medical device industry should always offer choices to the healthcare industry. Providers are somewhat free to choose unless widespread testing shows a clear advantage of any new technology such that it then becomes "recommended".

Providers are then still free to choose but may have to defend their choice in court should a negative situation arise.

No one here has pointed out specifically why a sophisticated electronic stethoscope could not be designed to substitute for a young, skilled listener with an acoustic stethoscope. However, it is clear that some do not want that to happen.

Seems like a fertile area for innovation?

I agree with all the arguments. I will add another one: The human side of an auscultation. If everything will become electronic and digital we will not need to touch a patient. Touching is described as : Eliciting or capable of eliciting sympathy or tenderness (to our patients. DY).

John Strupat I can't imagine that it is possible in the near future to create an electronic stethoscope that could be used without touching the patient. Acoustic energy still needs to reach the electronic sensors in the same way that it is picked up and transferred to human ears in a traditional stethoscope.
A sophisticated electronic device would only change who could touch the patient and possibly obtain the same end result as an expert practitioner. A worthy goal if it helps more patients, right?

Jerry Robinson Traditional acoustic versus electronic...

Electronic would not exclude human contact or the human element.

I don't see that one approach would exclude the other, either. It could well be that each has advantages... after all, electronic systems need power and are not as reliable as an acoustic system...

Jin Lee Oh- one must not mistaken that electronics or digital devices can eliminate affection and human touch- NO!
Digital Stethoscope simply enhances the sensitivity to catch subtle sounds that doctor did not able to hear before. And show it as a graph form and record it or send it to remote place for further evaluation. Most of digital Stethoscope runs by 3v. (2 x 1.5v) battery we can get nearly every street corner stores. My clock on the wall, wrist watch, handy phone, tablet, sphygmomanometer etc. runs by battery and never cause any reliability problem.

Clive Smith Again, for the sake of full disclosure, I design electronic stethoscopes, so you're free to consider my comments self-serving. Or you could consider them to offer the insight of many years of communication with physicians about the subject of auscultation, many of whom are in the most esteemed medical institutions in the world:

1. Electronic vs. Acoustic vis a vis examining the patient - Electronic stethoscopes still involve placing the instrument on the patient, so there's no loss of contact with the patient. It's a lot more personal than sending the patient for an echo.

2. Sound Quality - Everything we use has amplification. We want loud and clear sound when we listen to music, attend concerts, watch TV. That many physicians are satisfied examining patients with an instrument that produces pathological sounds below the threshold of human hearing is utterly absurd. It flies in the face of science to think that there's something sacred about virtually inaudible acoustic stethoscopes. They are relics that should be banned from medical practice.

3. Reliability - The pen and paper is more reliable than the electronic medical record, the computer or the iPad. The bicycle is more reliable than the car. Should we require that physicians live next to the hospital when on call and never use electronic devices for communication and record-keeping? Can electronic stethoscopes break down? Yes. Do they break down? Yes. As a designer and manufacturer, I'm her to tell you that they're imperfect, since electronics is more complex than a hollow tube. Here's my counter-argument - An electronic stethoscope does sometimes break down, but an acoustic stethoscope is unfit for medical use new out of the box, given that there is a better option in the electronic stethoscope.

Those in the medical world who have met me at medical conferences or corresponded with me, know that I come to the marketing of electronic stethoscopes as an engineer, not a salesman. I don't market our product, I simply explain it and leave the decision to the practitioner. We engineers are trained to deal in truth and fact. In that light, the opinions above, while seemingly self-serving, are based in my convictions as an engineer who looks at what many doctors still use to examine patients, and I am appalled that they consider this to be "listening to the patient." I'm open to discuss the clinical value of auscultation vis a vis echo. This is a legitimate discussion for which physicians are far better qualified. But if you're going to examine a patient, given the value of your time, use a stethoscope suited to the 21st century.

Zeljko Roncevic Clive, can you write here your opinion about clinical value of auscultation vis a vis echo?

Zeljko Roncevic Because I love a stethoscope despite numerous, sometimes overvalued threats to its survival, may say that the stethoscope has a pretty secure future in respiratory medicine and pediatric cardiac auscultation in developed and undeveloped countries. In undeveloped countries stethoscope will be used for a long, long time. Dr. Eric Topol has announced the death of a stethoscope, but it seems that the stethoscope is still useful and vital and no one knows when will die, but certainly not soon.

Jim Osborne- FACHE Dear Dr. Roncevic,

I have been auditing yours and other clinical narratives regarding the diagnostic patient centered model of care delivery and the ensuing PPACA, ACO and Meaningful Use initiatives before us. In addition, as I believe you are aware, my area of expertise is in the area of medical equipment and healthcare technology.

With all of this being said, I believe that you and your colleagues have zeroed in on the fact that a tactile and coneniently mobile hybrid of stethoscope and sonography is needed that offers a large enough screen resolution and is very readily capable of simply and intuitively uploading to any system EMR/ EHR at the touch of a clinician's data entry.

I invite you and all of your colleagues to comment on this as I believe that we may be in need of some new and progressive product development. Please review and advise.

Besat Regards/ Jim Osborne- Genesis Planning LLC

Zeljko Roncevic Dear Jim,
now I'll write for the first time that the hybrid of electronic stethoscope and sonography with microphone in ultrasound probe will be probably the best solution for the future. Something like Nescafe 2 in 1. To do that we need a good cooperation between just for instance GE and Thinklabs with help of maybe Genesis Planning (and eventually me).

Kenneth Bassett Hello, finding this discussion for the first time, and coming from an Engineering stand point. I don't mind either electronic or acoustic stethoscopes from my perspective, as long as they are integrated into a good data control system. Someone using a stethoscope on a patient adds discrete, subjective data based on the operators experience and ears, and a computerized electronic stethoscope adds quantitative, continuous data. If you have a good information system you can correlate the two and take what pieces of data you feel are valuable to the system, and control the quality of care given to the patient.

I see the value of an acoustic stethoscope for attributes of portability and simplicity of design (I'm thinking of something like a compass), so the technology will still be long lasting because of these factors, and innovation will take place when other attributes are needed, as Jim Osborne said. So you lose the power of the technology of a compass when you want more information (how far am I from point B?, where am I right now?) so you innovate to use a GPS, which also has portability and is continually improving. Likewise you need more depth in your observation of a patient (what is their condition right now?, how will they be in 15 minutes, an hour?), while still maintaining the defining attributes of an acoustic stethoscope. That is when innovation will happen and how it will be driven.

Zeljko Roncevic In the case of auscultation continual monitoring is not necessary because information you can get are not changing fast. I narrated about the problem of the stethoscope and auscultation (as Jim said) a lot so hope that this is my last narration here. It's not enough recognized that there is a big difference of cardiac auscultation value between pediatric and adult auscultation. I wrote it in my comment about "The death of the stethoscope" and I'll repeat it here: "In pediatric patients, even in USA, the stethoscope is indispensable screening tool, especially in congenital valvular disease. How you will know in an asymptomatic baby with valvular pumonal stenosis and pressure gradient of 70 mm Hg that there is stenosis at all without stethoscope, or in another baby with valvular aortic stenosis with the same gradient. Do you think that in USA they do echo to all babies? So it is clear that without stethoscope we can't choose children for echo and if we don't know that they have congenital valvular stenosis we shall not suggest prevention of bacterial endocarditis. There is no difference in pediatric patients between USA and 3rd world countries of the stethoscope value as a screening tool." After this explenation I'm open for possibilities of technological improves of the stethoscope and possible combinations with portable ultrasound equipment.

Jin Lee Advanced Digital Stethoscope these days comes with very sophisticated reference data base software together with analytic phono-cardiogram.

Zeljko Roncevic The most important thing for electronic stethoscope except good acoustic properties is possibility to make recordings of excellent quality accomplished with software for good gaphic presentation of sound (phono and spectrogram).

Jin Lee Oh - JABES Digi-Steth has a sample sound and graphics data base of cardio and pulmonary abnormalities to reference with. If one mentioned 3M, I must say to look at that. Digital Stethoscope's remote possibility is also noteworthy for Telemedicine.
One can hear heart sound of patient in Africa thru Skype in New York in real time. It is also possible between Space Station and Ground Station checking astronauts heart beat who is in the space.

Zeljko Roncevic I have to say that I use a few types of electronic stethoscopes and I'm not in conflict of interest but I will not write here what is my personal choice.

I'm curious to understand how much time (I suppose few minutes) the physician spends in listening to perform a good auscultation. Both for pediatric and adult. Thanks.

Kenneth Bassett A graphic presentation of the sound is good. Are means and variances calculated? It seems like some statistical analysis would be a very powerful tool, especially in conjunction with a good information system including doctor/patient interactions and treatment/patient interactions.

Zeljko Roncevic Yuri "good auscultation" lasts 5-10 minutes what depends of does physician use and some maneuvers. In children's auscultation it depends is child is quiet or not. If doctor record cardiac sounds there is need for additional 10 -15 minutes for analyzing graphical presentations with PC after transfering sound record from electronic stethoscope.

John Strupat Some speculation on my part that a more valuable real-time electronic stethoscope would not require post analysis. The important issues would be identified on the spot during the auscultation.

I do not know the terminology used here, but each "medical concern" is identified by a human as a pattern of sounds. This is exactly what the electronics could also do.

A similar idea is automatic analysis of electrocardiogram signals. The error rate compared with an expert cardiologist is very low. Such equipment is very mature technology now.

Zeljko Roncevic John, there are already a few models with real time graphic presentations, one of them is with blue tooth transfer. Computer aided auscultation is on market for a few years and I'm not sure that they are near perfect in auscultatory diagnosing. The main question is, what I'm doing for a few years in many ways : how to distinguish an innocent from pathological heart murmurs in children. It's important because if murmur is innocent there is no need for echo. Of course, if murmur is pathological echo is necessary. I can recognize by auscultation alone innocent so called Still's (musical) murmur with almost 100 % certainty . The point is how to help primary care physician to recognize this murmur much better then now.

John Strupat I was thinking of more of a medical diagnostic display rather than a more conventional graphical display of the data with perhaps an analysis like a spectrogram.

Surely if one can translate a spoken language to different language or print out spoken language in almost real-time, then the acoustic patterns from auscultation cannot be fundamentally more complicated?

If you can describe Still's murmur, for example, or have an audio file that most clinicians find agreement with, then a specialist in DSP can develop an expert system to do so as well.

Note that this is not likely to require extraordinary computer power either. Language translation can be done fairly well on a modern cell phone.

Wouldn't that end result be useful for patient care?

Zeljko Roncevic My PhD thesis is about Still's murmur : "Possibilities of Still's murmur recognition by spectral energy analysis of heart sound signals". With the help of my friend who is engineer I analyzed 40 recordings in wav format with FFT and Goertzel algorithm.
We measured acoustic properties of manually extracted Still's murmurs (they occur in middle systole). Spectrogram is very typical. I can't say everything I know because I'm in phase of publishing an article about this murmur. At this point discussion is too much expert oriented and boring for others so who is interested can contact me personally.

John Strupat A valuable end goal here would seem to be real time acoustic pattern recognition of this particular problem, among many other medical problems detected by a human expert with a stethoscope.

Would appear to have the most widespread value if the device simply indicated "Still's murmur" without the need for graphical displays of the waveforms and transforms.

The technical reasons for not being able to do this are not obvious?

Zeljko Roncevic Yes, the end goal is real time acoustic pattern recognition.

Zeljko Roncevic End at the end please read this two articles:
An argument for reviving the disappearing skill of cardiac auscultation.
http://www.ccjm.org/content/79/8/536.full.pdf+html
The stethoscope as metaphor.
http://www.ccjm.org/content/79/8/545.full.pdf+html

It is interesting to read your collective thoughts on both the science and art of auscultation. I worked for a number of years as a technical manager with the leading brand of acoustic stethoscope. I also worked on the development team that brought the first couple of digital electronic stethoscopes to the profession and did all of the European field work that determined doctors needs and preferences for those devices.

Some of the comments, and "wish lists" above look very much like the contents of my lab notebooks! Indeed, most of that wished for, already exists in current technologies, with the remainder easily attainable but which are currently not considered commercially viable.

The stethoscope, will in my opinion, remain as a primary diagnostic tool for the forseeable future. However, the methods by which its use is taught and the associated cognitive process will change beyond recognition in the not too distant future by the exploitation of the digital stethoscope to both capture and display heart and lung sounds.

Sophisticated medical algorithms utilised in digital devices may well extend the usage of the stethoscope to other areas, currently inaccessible to conventional acoustic auscultation.

Zeljko Roncevic Carl, thank you for a nice comment.
You are right, human body produces many sounds which have not been explored so far. The electronic stethoscope will be used in many situations to enable analysis of the various sounds . I also think that there is a need for analysis of the human voice (comparing recordings in health and disease, especially babies crying). In this case, a good microphone will only be required (and certainly a good sound processing).

Kevin Trice, MD, MBA Pulmonary Apps is a company that is trying to improve the traditional stethoscope. The stethoscope is a symbol of medicine, ~150 years old in design, and unbelievable subjective in its use. The risk of transmitting diseases from one patient to another, the poor quality sound it imparts (compared to digital, enhanced audio), and its need to keep the practitioner and patient <2 feet from each other, are all incredibly ridiculous inconveniences in 2014. I agree there is an art to auscultation, but how good can that art be if all the doctors and nurses interpret the sounds differently. Our wireless, disposable, DigiBreathe tabs are designed to provide real-time, audible and visual representation of lung and heart sounds.

Why have we we using only our hearing (which gets worse with age), and not using our eyes, other senses, and technology to dramatically improve the quality of the data we get. I don't think we should eliminate stethoscopes, just radically change their appearance, quality, and usefulness.

All comments are welcome (as are early adopters and some investors!)

Clive Smith Kevin,

Interesting invention. You might want to take a look at the new Thinklabs One Digital Stethoscope http://thinklabs.com

Zeljko Roncevic I started this discussion almost two years ago and it's nice to see that the stethoscopes are still interesting. What I can say after two years except: I'm happy that some people still trying to improve stethoscopes in any form. So Kevin and Clive thank you both for your commitment and enthusiasm. I really love the stethoscopes and auscultation as well as echo but I'm still surprised (from time to time) how interesting sounds human heart can produce.

Chagai Dubrawsky The issue of the value of a stethoscope in listening of its: heart,lungs, abdomen,should never be discounted.
With the recent developments in IP/IT, digital technology-computers, the medical community
forgot to listen to the patient,Consequently,when a patient is visiting his personal physician, he is talking to a computer.No good can come out, from a human interacting with a computer(Golem). Computer is lacking the sixth sense. It has only five senses. The whole, present
crisis in medicine is rooted in this issue.(1)
Case in point:ACA-Obamacare
* Eric Swain.From the Editor.How to Avoid the Looming Healthcare Crisis. MD+DI.Medical Device and Diagnostic Industry.Nov.1,2007.

www.mddionline.com/article/how-avoid-looming-healthcare-crisis