A recent report at the American College of Cardiology annual meeting concluded that handheld ultrasound was superior to a group of trained cardiologists in the determination of cardiac pathology and function (J. Am. Coll. Cardiol. 2013;61:E1442).
This sort of information immediately raised my hackles. I am all for technological advances, but this proclamation struck close to my heart. I have progressed from cardiac catheterization using "red glass" accommodation for fluoroscopy to high-intensity multiplane angiography. I have even participated in the development of biventricular pacemakers for the treatment of heart failure and defibrillation. But the suggestion that a cardiologist can be replaced by a toy activated my Luddite receptors.
For those of you who are unaware of who or what a Luddite is, I refer you to England in the year 1811, when Edward (Ned) Ludd protested the replacement of hand-loom workers with a mechanized knitting process that threw thousands of English weavers out of work. He started a protest movement by Luddites that led to attacks on weaving mills and ultimately the hanging of some of his followers as terrorists in 1817. At about that time, in 1816, Rene Laennec developed the stethoscope by using a "quire" of paper rolled into a cylinder to listen to an obese young lady’s heart rather than his naked ear placed on her chest, which was the practice at that time.
From that paper tube has evolved the stethoscope as we know it today. Occasionally it is used to listen to the heart and lungs of patients, but it is seen mostly as a professional "necktie" in TV dramas. The fact that cardiologists and the stethoscope were to be replaced by the handheld ultrasound just as the loom weavers were replaced by the knitting machine led me to respond to the challenge.
I believe that the author, Dr. Manish Mehta of Oregon Health and Science University, Portland, spoke to an important issue. I would agree that many cardiologists are more comfortable using an echocardiogram than a stethoscope. The value of auscultation skills can be judged by the fact that cardiology board examinations do not include testing of auscultation skills but provide numerous questions on the interpretation of echocardiograms. Of course, there are the economic benefits of performing an echocardiogram compared with auscultation, which does not come up on my charge sheet.
I would grant that a handheld ultrasound can identify whether a pericardial effusion is present, a physical diagnostic challenge that I have frequently failed, particularly in thick-chested individuals. But give me a thin, young guy and I’ll get it every time. But does the presence of a leaking or stenotic valve or an enlarged heart, both easily identified by the handheld ultrasound, indicate heart failure? Give me an S3 gallop or distended neck veins and I can make the diagnosis of heart failure without a B-type natriuretic peptide level. The problem is that no one – well, very few of us – teaches how to examine the heart.
There is also the importance of the physician actually touching the patient as part of the examination. Not only examining the heart; but how about the abdomen? If we followed the path led by the BS echo, we could take the nurse’s recorded chief complaint and send the patient directly to radiology for a CT or an MRI. The fact that this is what the patient really wants does not escape this skeptic. But is this what medicine is really about? Much has been written about physician-patient interaction, but has it come to doctors being only a triage to the radiology department?
I am not going to break up the nearest echo machine with my stethoscope and end up on the hospital director’s "scaffolds" like the 18th century Luddites did. Echocardiography clearly provides a wonderful view of the heart and its valves, and can guide us to the surgical correction of valvular and muscular defects. Some technology, such as Doppler imaging, actually does provide information about physiologic phenomena including myocardial function and ischemia. But if the cardiologists lose in a contest with handheld ultrasound, it is because we have lost our bedside skills as a result of our overreliance on technology and have been blinded to its limitations.
Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.