Out With the Old...Wait, Not in Health Care

There has got to be a moral in there somewhere.

VCRs revolutionized our TV viewing experience.   We could record television shows to not only watch programs at our own convenience, but we could also fast forward through commercials!  We could watch the movies we wanted, when we wanted to, in the comfort of our own homes.  Video rental outlets popped up everywhere, from boutique neighborhood stores to wildly successful chains like Blockbuster.    

Alas, technology moves along.  DVRs came along in the 1990's, especially TiVo.  Suddenly those VCRs seemed old-fashioned.  As broadband has become more common, streaming services are now threatening to render DVRs obsolete as well.  Blockbuster is gone, while Netflix has been nimble enough to remake itself primarily as a streaming service.  

VCRs are a classic example of how technology (usually) moves on.  Except in health care.

Like stethoscopes.  Digital advocate Dr. Eric Topol recently tweeted: "The stethoscope's 200th birthday should be its funeral."  Jagat Narula, a dean at the Icahn School of Medicine at Mt. Sinai, flatly says, "The stethoscope is dead.  The time for the stethoscope is gone."  

That's all well and good, but -- to paraphrase Mark Twain -- reports of its death are greatly exaggerated.

The well-known story is that the stethoscope was invented by René Laënnec to avoid having to listen to a female patient's chest by putting his ear to her chest, as he thought that technique improper.  Laënnec's crude tube was gradually improved upon over the years.  Stethoscopes became a de facto symbol of being a physician, along with white coats (which have their own baggage).   Google "physician" and almost all the resulting images show physicians with stethoscopes.  

It's not like stethoscopes do all that good a job, or, perhaps, that physicians use them all that well.  A 2014 study found that participants only detected all tested sounds 69% of the time.  As the authors diplomatically concluded, "a clear opportunity for improving basic auscultations skills in our health care professionals continues to exist."   

Similarly, a 1997 study found that: "Both internal medicine and family practice trainees had a disturbingly low identification rate for 12 important and commonly encountered cardiac events," while a 2006 study found that stethoscope skills did not improve after the third year of medical school and "...may decline after years in practice."  Whoops.

Oh, and stethoscopes also help carry germs.

And it's not like there aren't alternatives.  As one might expect in the 21st century, there are electronic/digital stethoscopes.  These allow for amplification of body sounds, and even for the transmission and recording of those sounds.   Their output can be converted into graphic representation and compared, either historically for the same patient or to established parameters.  

There are also handheld ultrasounds that provide another strong alternative.  Ultrasound has been a diagnostic tool for decades, but handheld units only became available in the late 1990's.  The question of whether they would make stethoscopes obsolete was soon being asked, and there is plenty of research supporting the assertion that they are as good or better than stethoscopes.   

And now, of course, there are smartphone apps for stethoscopes.  Apple was claiming 3 million doctors had downloaded its $0.99 stethoscope app as long ago as 2010, with Android versions also available.  HealthBud, a new device that uses smartphones, has research to back up its claim that it is at least as good as stethoscopes, and is seeking FDA approval.  Its developer claims, "This device is much less expensive to produce and offers a safer alternative to both traditional and disposable models without sacrificing sound quality." 

And yet stethoscopes hang in there.  

We might like to think that physicians continue to use traditional stethoscopes because they are simply being thrifty, since electronic stethoscopes and handheld ultrasounds are much more expensive, but that seems a reach.  They've certainly not been reluctant to adapt other types of newer, more expensive technology -- at least, not as long as they can charge more for it.  

It is a conundrum that has bedeviled economists: why in health care does new technology almost always increase costs, unlike most other industries?  E.g., DVRs were much better than VCRs, but quickly became comparably priced.  Professor Kentaro Toyama cites what he calls technology's Law of Amplification: "Technology’s primary effect is to amplify, not necessarily to improve upon, underlying human inclinations."

And in health care, those underlying inclinations don't drive towards greater value.

When it comes to stethoscopes, it's not about the money.  Many physicians believe that the stethoscope helps foster the patient-physician relationship.  In a recent article in The Atlantic, Andrew Bomback admitted that, "Indeed, for many doctors (myself included), the stethoscope exam has become more ceremony than utility."  He cites the case of a colleague who borrowed a stethoscope -- even though it was only a low-end model -- before examining a patient, explaining, "Patients expect you to have one of these things."

Physician/engineer Elazer Edelman argues that a stethoscope exam can help to create a bond between patients and physicians.  He worries that technology may be fraying the "tether" between doctors and patients. Still, if the relationship depends on which device a physician uses to listen to our chest, that relationship is in bigger trouble than we think.

The stethoscope illustrates that health care can be anything but rational.  Their use -- like those white coats -- persists because both patients and physicians expect them to be used.  It is a form of status worship.  Honestly, it's not dissimilar to talismans that more primitive cultures expect from their medicine men, their shamans, their witch doctors.  

Given what we know about the power of placebos, we may not be as different from those primitive societies as we like to think.  

So, R.I.P. VCRs, and thanks for the memories.  As for stethoscopes, and for health care more generally, though, maybe the moral is that we should focus less on status symbols and more on what is best for patients.