Monday, 17 September 2018

About the bicentenary of the stethoscope

Xavier Bayona

If there is a universal symbol of the health profession, besides the white coat, we certainly find it in the stethoscope. Laennec, in 1816 at the Necker Hospital in Paris, began his first studies in auscultation by means of an instrument he gave the name of stethoscope, derived from the words στηθος (chest) and σκοπεω (examine). Until that moment the auscultation was performed with direct listening placing the ear on the chest (already performed by Hippocrates). This direct listening had its practical limitations both in the transmission of sounds and for issues of modesty related to the gender of the patient if she was a woman (the doctors were mostly men) or for hygiene.

But technology has moved ahead and at this time clinical ultrasound, also called the "new phonendoscope", is now available to all healthcare groups. The ultrasound has improved its resolution and has decreased in size, becoming more portable and its price has also dropped. In this sense, some media such as the National Post recently wondered if the stethoscope is in its final stages following a congress held in Canada. Diagnostic ultrasound or sonography, popularly known as ultrasound, has had a very rapid evolution thanks to its innocuousness, facilitating the possibility of repeatedly performing echographic scans to the same patient, without risks, without expensive preparations and at a relatively low cost.

The news is good: improvements in ultrasound technology and its generalization allow improvements in the accuracy of diagnoses. But as in everything, when technology is more achievable, new difficulties appear. In the first place; a few years ago the debate began on the competences regarding which specialists can be adequately accredited and for what use. It has already been demonstrated that, for example, the "focal ultrasound" for systems, focused on clinical problems (and not conventional exploration), it improves treatments by improving the diagnosis (in precision and time of performance). The use of ultrasound in emergencies and urgent situations encompasses numerous new fields oriented in the use of ultrasound by the same specialist who treat critically ill patients both in in-hospital settings (such as in emergency or intensive care rooms) and in pre-hospital settings. In non-critical patients, the use of clinical ultrasound in primary care has also demonstrated added value by improving diagnosis, avoiding referrals and in short, bringing the resolution closer to the citizen's bedside.

The concern of professionals specialized in diagnostic imaging, or other specialties that use ultrasound as the usual diagnostic mechanism, is logical: how should the generalization of the examination be made to specialists from other settings with all the necessary guarantees? Fortunately, the different scientific societies involved in the process and the administrations have been working for a few years now to build the framework that guarantees the suitability for the implementation of the exploration outside the diagnostic services for the image and the ultrasound rooms.

Thanks to all these efforts, progress in ultrasound extends both in and out the hospitals and imaging diagnostic services. The use of ultrasound extends to almost all specialties and especially to primary care doctors and ultrasound commonly exists in many community health centres. Primary care health professionals need the means to support them in their work in order to provide the best assistance to the patient and ensure their diagnosis. Ultrasound is a technique that can help and support this clinical decision process.

Looking ahead to the near future, what will become of the stethoscope? My vision is that for several years it will continue to coexist with the extension of ultrasound in more generalist profiles. But in a few decades, most likely when ultrasound is taught in university medical studies, the "phonendoscope" will end up being a means of residual exploration.

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