A great story begins with a compelling opening line. In 2012, the opening line in the story of a physician’s visit to a patient’s bedside is being rewritten much like it was rewritten in the mid-1800s with the development of the stethoscope. I’d like to thank my colleague Troy Jones for bringing this quote from the London Times, 1834 to my attention.
“That it will ever come into general use, notwithstanding its value, is extremely doubtful; because its beneficial application requires much time and gives a good bit of trouble both to the patient and the practitioner; because its hue and character are foreign and opposed to all our habits and associations” (London Times 1834)
Line 1: “A doctor walks into a room, the patient, ashen and frightened looks up from his bed with questions of mortality in his eyes. The doctor, stethoscope around his neck sits on the bedside and they talk of sounds from the heart. The doctor indicates that heart valve surgery is required …and they talk”.
Doctor: “I hear a murmur, sounds like your aortic valve is stenotic. That’s why you’re short of breath. You need an angiogram and then a heart valve replacement ” (thought bubble– I wonder how severe the aortic stenosis is-need to swing by the echo lab? I really should draw the valve for him, I better explain what a cath is? Wish I had a picture of a St. Jude valve, wonder if he’ll ask about TAVI)”.
Patient: OK, whatever you say. Can you talk to my family about this?
Thought bubble: “What is aortic stenosis? Surgery? Is that angiogram dangerous?”
Thought bubble: “That was easy”
Of course only the doctor has heard the sounds. What they mean can be vague and hard to convey to others. Even the best physician-patient dialogue may fail to convey why the loss of a second aortic value sound and a late peaking murmur means its time to fix that valve. Now to the near future…
The near future:
Line 1: “A doctor walks into a patient room, the patient, ashen and frightened looks up from his bed with questions of mortality in his eyes. The doctor, stethoscope around his neck, removes an iPAD from his pocket, sits on the bedside sits and shows the patient his echocardiogram, a teaching video, demonstrating an angiogram, and images of several types of heart valve prostheses… and they talk”
Doctor: “I hear a murmur, sounds like your aortic valve is stenotic, you probably need an angiogram and heart valve replacement. Here is your echocardiogram…see how the leaflets on the valve don’t open? This diagram shows a normal valve and here is one like yours, that’s called aortic stenosis. That small opening doesn’t allow enough blood to flow, which is why you are short of breath. We can either replace your valve with a metal valve (like this one-image on iPAD) or a porcine valve (like this one). First we need to do an angiogram. See this diagram? That’s how we do it. I suggest the metal valve because you are under 70 years of age…see this graph…it shows better long-term results with metal valves in younger patients.”
Patient: Can you send those pictures to my daughter?
Doctor: “Sure.” He emails the links for these files to the patient’s daughter. “And you may want to go online to see these patient support groups, like Mended Hearts where patients talk about recovering form surgery.”
Thought bubble: “That was easy”.
Patient: “Thanks doc.”
Thought bubble: “Finally a doctor I understand”
Since Rene Laënnec invented the stethoscope in 1816, this has been the cool tool for doctors (link Clin Med Res. 2006 September; 4(3): 230–235.). It allowed physicians to hear sounds from within, which only they could interpret. In this sense the stethoscope separates “us” from “them”…we know what it says and they (the patients) don’t. The stethoscope is also a tribal talisman. The wearing of a stethoscope, whether jauntily hung from the neck, draped over a shoulder or peaking from the pocket of a white coat, denotes “doctor” like few other objects (apologies to reflex hammers and tuning forks).
In the right hands, or more accurately, inserted into ears with the right central connections, a stethoscope remains useful. In 2012, a loud P2 still denotes pulmonary hypertension and a late-peaking, crescendo-decrescendo murmur with absent S2 still indicates critical aortic stenosis (and you can even listen to the lungs and abdomen!). A paradoxical benefit of the stethoscope, which my former fellow (pictured below, Dr. John Ryan, cardiologist) refers to as a guessing tube, is that it forces close contact between doctor and patient. This is paradoxical because Laennec’s goal in creating the stethoscope was not to promote proximity but to provide distance from the patient (allow auscultation while keeping his ear off the patient’s chest). Nonetheless, the relative proximity required for auscultation ensures we think about the patient’s appearance, sense their emotional state and spend time with them. However, there is room in the white coat for a stethoscope and an iPad.
If the stethoscope is a guessing tube (more a reflection on atrophied clinical skills than the limits of the tool) then an iPad is a peripheral brain. The ability to show patients their images and labs at the bedside (and these data are theirs) is revolutionary. Calling up explanatory diagrams, trial results, guidelines etc. allays the fears and answers questions for our ever more informed patients. Doing this at the bedside is efficient and allows a visit to be definitive…not a prelude to another visit.
Dr. Nancy Luo, an aspiring cardiologist and one of the leaders of the iPad initiative at the University of Chicago, has been on the forefront of implementing this technology. With and without an electronic health record there are benefits (and of course challenges). The devices can be wiped electronically if stolen, they need to be wiped physically to avoid infection etc….but still…in Dr. Luo’s hands they are an amazing tool that, like the stethoscope, couples the patient and physician more closely (Link: http://medmonthly.com/2012/10/you-imagine-doctors-connect-to-patients-in-an-mhealth-world/).
We will be starting an iPad program at Queen’s Medicine soon. It will be fun, it will be educational, it will be a partnership with KGH and the Department. The project will no doubt reveal weaknesses in our current processes, but that just propels us forward. I expect the program will promote scholarly activity; hopefully papers will be written. Perhaps we will shorten the time to discharge or speed order processing…whatever the outcome, we will learn. The message to our trainees at Queen’s and our patients is that we are moving forward. An iPad working group has been established and will meet in December. After a pilot program to ensure smooth implementation expect to see young doctors with Guessing Tubes and iPad on the wards.