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Breath Sounds pp 317-319 | Cite as

Epilogue

  • Mark L. Everard
  • Kostas N. Priftis
  • Leontios J. Hadjileontiadis
Chapter

Abstract

It is argued that the coming two decades will see a fundamental revolution in ‘medicine’ and health that will completely transform the field and how health care is viewed [1, 2]. In a world in which many predict that health care and ‘wellness’ will be transformed by the power of the smartphones, computerisation and the ever more rapid advances in sequencing technologies, what is the future of the humble, low-tech conventional stethoscope? In considering this question, it should be remembered that the revolution in European health care that was taking place around the late eighteenth and early nineteenth centuries was just as dramatic as that that is apparently underway in the first half of the twenty-first century. Laennec was a key player in this revolution in which the physician evolved from a professional operating largely on beliefs based on pseudo-‘philosophical’ ideas with no scientific basis to one that has a belief in trying to apply sound scientific insights (the sensible physician knowing that much of what he believes is scientifically sound may prove to be false as knowledge progress over time). Laennec’s insights, largely derived from his expertise in morbid anatomy, generated new knowledge and help embed the notion that, in order to develop effective therapy, we needed to try and understand the disease process based on scientific rigor rather than abstract speculation. He was one of the pioneers of that era who developed the concept that all contemporary ‘knowledge’ needs to be challenged and revised where it is found wanting.

It is argued that the coming two decades will see a fundamental revolution in ‘medicine’ and health that will completely transform the field and how health care is viewed [1, 2]. In a world in which many predict that health care and ‘wellness’ will be transformed by the power of the smartphones, computerisation and the ever more rapid advances in sequencing technologies, what is the future of the humble, low-tech conventional stethoscope? In considering this question, it should be remembered that the revolution in European health care that was taking place around the late eighteenth and early nineteenth centuries was just as dramatic as that that is apparently underway in the first half of the twenty-first century. Laennec was a key player in this revolution in which the physician evolved from a professional operating largely on beliefs based on pseudo-‘philosophical’ ideas with no scientific basis to one that has a belief in trying to apply sound scientific insights (the sensible physician knowing that much of what he believes is scientifically sound may prove to be false as knowledge progress over time). Laennec’s insights, largely derived from his expertise in morbid anatomy, generated new knowledge and help embed the notion that, in order to develop effective therapy, we needed to try and understand the disease process based on scientific rigor rather than abstract speculation. He was one of the pioneers of that era who developed the concept that all contemporary ‘knowledge’ needs to be challenged and revised where it is found wanting.

In developing the stethoscope, he launched the concept that information regarding the nature of an individual’s ill health may be inferred from interpretation of data generated with tools that augmented the clinicians’ five senses. In the respiratory field, it was the first of a number of technologies that have been developed in the intervening two centuries that includes X-rays, bronchoscopy, spirometry, CT scanning and PET scanning. With effort, the radiation exposure from a CT scan can be reduced to less than that of an AP+ lateral chest X-ray (Murray C, personal communication) providing infinitely greater information with no additional radiation, yet there is no expectation of the immediate demise of the CXR. It remains by far the most widely used adjunct to clinical assessment, and despite predictions of its imminent demise that have been repeated over the decades, sales of stethoscopes continue to rise [3]. Much of the rise in sales of conventional stethoscopes is occurring in developing countries, while sales of electronic stethoscopes for bedside and telehealth use continue to grow in developed countries [3, 4]. In the veterinary world, a very large pharmaceutical company has recently made a considerable invested in a ‘stethoscope’ and automated analysis system that would directly inform farmers when to consider treating cattle being monitored, indicating that such systems will continue given the economic impact they may have [5].

The symbolic power of the stethoscope should not be underestimated even in this high-tech era. In a recent study in which members of the public were shown photographs of a man in which one or more items associated with doctors, such as the stethoscopes, otoscope, theatre scrubs and tendon hammer, the individual in the photographs containing a stethoscope scored consistently higher as appearing to manifest each of the following attributes—honest, trustworthy, genuine, ethical and moral [6]. This boost in the effectiveness of consultations in itself would justify the small investment in a stethoscope.

However, it is as a practical, valuable, adjunct to the clinical assessment that will see the stethoscope remaining the first medical device a medical student will invest in (other than their smartphone). The problem with any piece of technology is that when used effectively and appropriately, it can enhance our lives and effectiveness but if misused, because of lack of effective training and a failure to appreciate its strengths and weaknesses, its application may be deleterious. Most doctors, hopefully, understand that a ‘silent chest’ is of great concern in someone with a significant exacerbation of asthma; yet, few seem to appreciate that the lack of ‘added’ or adventitial sounds does not exclude significant pathology, as, for example, in those with a persistent bacterial bronchitis who typically have a clear chest but a wet cough when asked to cough. Similarly, most medical students appear to be taught that additional respiratory sounds are either crackles or wheeze. Hence, if an added sound is not clearly a crackle, then it must be a wheeze or a ‘transmitted sound’ (a curious term given that all sounds are transmitted from somewhere, but, in this context, the clinician is assuming, often erroneously, that it is apparently transmitted from the upper airways).

The preceding chapters highlight the ongoing challenges in trying to describe the sound reaching our ears via this apparently simple device and communicate this in a meaningful manner to another. The suggestion that automated analysis will help clear this confusion is yet to be confirmed despite decades of work.

Two hundred years ago, Laennec described five sounds that he repeatedly heard when listening to patients with pulmonary disease and through his obsessional attention to details developed an in-depth understanding of the likely implication. While not perfect, his work still stands as probably the most logical and least confusing approach to nomenclature being developed at a time when there were no other tools available. Since then, the development of a variety of imaging modalities and techniques for assessing ‘lung function’ has greatly enhanced our ability to characterise the nature of pulmonary disease, but none to date has replaced the need for a good history and careful examination. It remains to be seen whether the latest ‘medical revolution’ utilising the power of systems biology approaches to integrate data including that generated by the new ‘omnics’ technologies, such as phenomics, epigenetics and microbiome sequencing, will, eventually, replace the need for the central role of the doctor-patient discussion and examination, thus, eventually seeing the stethoscope relegated to the museum. In fact, medicine is moving back to the patient’s narration of his/her disease, a narration given by various types of gadgets and new communication means, even via “medical selfies”! Not only will these gadgets mean medical staff will need to touch patients less, they will also put a mass of data about a person’s body into his/her own hands. This clearly raises the question: “What does this do to the professional - does the doctor become a coach, a servant or an adviser - what will the new role be?” Doctor, eventually, must go back to the bedside; to be an interpreter of symptoms—so she/he can learn every possible aspect of what the patient is feeling and experiencing. From this perspective, there is no immediate prospect that the stethoscope will disappear during our professional lifetime!

References

  1. 1.
    Topol E (2015) The patient will see you now. Basic Books, New YorkGoogle Scholar
  2. 2.
    Price ND, Magis AT, Hood L et al (2017) A wellness study of 108 individuals using personal, dense, dynamic data clouds. Nat Biotechnol.  https://doi.org/10.1038/nbt.3870
  3. 3.
  4. 4.
  5. 5.
  6. 6.
    Jiwa M, Millett S, Meng X, Hewitt VM (2012) Impact of the presence of medical equipment in images on viewers' perceptions of the trustworthiness of an individual on-screen. J Med Internet Res 14(4):e100.  https://doi.org/10.2196/jmir.1986 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Mark L. Everard
    • 1
  • Kostas N. Priftis
    • 2
  • Leontios J. Hadjileontiadis
    • 3
  1. 1.Division of Child Health, University of Western AustraliaPerth Children’s HospitalPerthAustralia
  2. 2.Children’s Respiratory and Allergy Unit, Third Department of Paediatrics, “Attikon” HospitalNational and Kapodistrian University of AthensAthensGreece
  3. 3.Department of Electrical and Computer EngineeringAristotle University of ThessalonikiThessalonikiGreece

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