Ep 151 Stethoscope: Lub dub

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The patient's age and sex did not permit me to resort to the kind of examination I have just described, i.e., direct application of the ear to the chest.

I recalled a well-known acoustic phenomenon.

If you place your ear against one end of a wood beam, the scratch of a pin at the other end is distinctly audible.

It occurred to me that this physical property might serve a useful purpose in the case I was dealing with.

I then tightly rolled a sheet of paper, one end of which I placed over the precordium and my ear to the other.

I was surprised and elated to be able to hear the beating of her heart with far greater clearness than I ever had with direct application of my ear.

I immediately saw that this might become an indispensable method for studying not only the beating of the heart, but all movements able of producing sound in the chest cavity.

I was so excited for this episode, Erin.

Me too.

Me too.

I have listened to more heart sounds, I think, than I ever have in lung sounds.

We were just listening to them and it, it has created a weird sense of anxiety for me.

Do you remember that Radiolab episode about the person who could hear their own heartbeat?

And then, yeah.

Yeah.

I think that that's, I think that might be what's going on.

And I don't know why that is.

I don't have an answer to that.

Yeah.

I don't know.

Anyway,

but that quote, that paragraph was from, of course, Laneck, whom you'll hear a lot more about later in the episode, who basically invented the stethoscope.

Yep, spoiler.

Sure did.

Yeah.

And

hi, I'm Erin Welsh.

And I'm Aaron Alman Updike.

And this is this podcast, Will Kill You.

Today we're talking all about the stethoscope.

All about it.

Yeah.

You know, we

put this down in like our, let's do this as a topic.

Put it on the list.

And then when it came time to do it, we were like, wait,

what are we?

What are we, what is the goal here?

I still don't quite know what my goal is.

So hopefully some, we'll get something out of it.

You know, I'm really excited because I was like, okay, for me, it's clear cut, right?

Like, who invented the stethoscope?

How did it change things?

Blah, blah, blah.

All that usual stuff.

I feel like that's the story I'm really excited about because like I know very little pieces of it, but the like, what the stethoscope has become, I think is so interesting to then think back to when we didn't have them and like what it was like then.

I'm really excited about it.

Totally.

Well, and of course, I am excited because like, I, I want to hear these sounds, even though they give me anxiety or like some, some weird creeping sense of unease.

I want to understand how you can tell the difference because I feel like there's When someone listens to your your body and they're like, what are they listening to?

Right.

That's what I'm going to to talk about.

I'm really excited about it.

It should be fun.

Like, I figured that's the question I want to answer: when you go to your doctor and they stick this metal thing on your chest, like, why?

What are they, what are they doing, and what are they actually hearing?

Yeah, yeah, I'm really excited about this episode.

I feel like we're, I mean, we always say this, but I like sometimes feeling surprised by the things that we learn.

Like, there are some topics where we're like, we know more of the outline of the story, yeah,

and this is brand new.

But what's not brand new is that we start every episode with quarantining time.

What are we drinking this week?

We're drinking music to my ears because it's kind of like there's some musical murmurs and wheezes.

Yeah.

Yeah.

And music to my ears is a tasty little concoction.

You know, we're, we're bringing out the mezcal for this one.

It's been a while.

And maybe some campari in there, a little bitterness, some blood orange juice, a little tart acidic, and then some agave syrup just to help round it out, sweeten it up, make it delicious and tasty.

I love it.

We'll post the full recipe for that quarantini as well as our non-alcoholic placebarita on our website, thispodcastwillkilly.com and on our social media channels.

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Wow.

Okay.

Before we go too off the rails, should we get into the content?

All right.

I think we should.

I think we really should.

Let's take a quick break and then begin.

What the heck is a stethoscope?

I feel like everyone knows what a stethoscope looks like, but I'm going to describe it anyway, just in case.

A stethoscope is a metal piece at one end, and this metal piece usually has two different sides.

One of the sides is more open and curvy, and it's called the bell side.

It usually has just like a rubber ring around it.

And then the other side is more funnel-shaped and it's covered with this thin, usually plastic diaphragm.

And then this metal piece is connected to tubing that then splits into a Y shape and then is connected to ear pieces that we stick in our ears.

And at its core, a stethoscope is just a tool to help amplify sound.

And we use it to amplify the sounds in your chest for the most part.

And Erin, I know you're going to talk about like how it came to be and how it's changed because because it didn't always used to look like this.

And later we'll talk about like, does anyone still use the stethoscope and what are they using instead?

And what's going to replace the stethoscope?

But for this part, what I wanted to kind of focus on is like, what

are people listening to and listening for when they're using a stethoscope?

It's funny.

I feel like I take it a little bit for granted that like we get a decent amount of training in how to use the stethoscope in med school.

And so, it's like, oh, of course, you're listening to heart and lungs.

Everyone knows that.

But it's kind of been fun to go back and be like, oh, what

for someone who has never put their ears to a stethoscope?

Like, what, what are you hearing and what are you listening for?

Right.

So, the two main things that we're listening to are your lungs and your heart.

To a lesser degree, you can also use a stethoscope to listen to bowel sounds if you stick it on the abdomen.

But, like, I don't, I'm just personally not a huge fan of bowel sounds

can you can you say more

bowel sounds are like present or not present or like hyperactive or not hyperactive so they're just like not that

interesting when you think about like the different pathologies like you can't get that specific with a stethoscope on a belly Okay.

In any case, we're mostly using a stethoscope to listen to what's going on in the chest cavity.

And so I want to focus first on the lungs and then on the heart.

And we'll talk about what is a quote-unquote normal sound and what are the abnormal sounds that we're listening for to try and diagnose if something is amiss.

And to do this, we will use some recorded lung sounds and heart sounds.

So, thank you so much to the open source databases that exist for us to get this, and they will all be linked in our sources as well.

All right, so the first thing is lung sounds.

The sound that you hear when you are listening to a lung is literally the sound of air moving through the lung tubes, right?

Through your bronchi and through your bronchioles.

The name for these lung sounds is vesicular breath sounds.

That's the like technical term for it.

Okay.

And you hear these vesicular sounds mostly on inspiration.

So when you take a breath in, and then the first part of expiration, and then they kind of fade out after that.

so i'll play a quick clip for you to be able to listen

so that click click clicking that you hear is actually the heartbeat and we'll talk more about the heart in a second and that kind of does predominate in that particular clip but what you hear in the background is that very gentle very even whooshing, right?

It's like

rhythmic.

Wave sounds.

Wave sounds.

That is lung sounds.

Those are vesicular breath sounds, nice, healthy inspiration, expiration.

The deeper that you breathe in, the longer that you'll hear it.

What's always amusing is when you ask people to take a deep breath, they'll usually go

for a really long time and then

for a really long time.

And like half of that expiration, you're not hearing anything.

But that's a bit of an aside.

I always feel like stressed because I'm like, am I doing this fast enough?

Am I breathing deeply enough?

Are they going to miss something?

Because I'm like,

and then they're like, I'll breathe in.

And then they're like, okay, breathe out, breathe in.

And I'm like, that's too fast.

I do that.

It's because we're only, you only hear that first part of expiration.

So the expiration is less important, except when there's pathology.

So we'll get there.

But the first thing that you might notice if you're listening for lung sounds is if you don't hear them at all.

Because Because if you don't hear lung sounds when you put your stethoscope over someone's lungs, then that means that something is going on, right?

You should hear air moving in and out.

If you don't, it might mean that there's a blockage.

So that could mean a mass.

It could mean so much fluid that there's just like a chunk that you're not moving air.

It could mean that a lung has been collapsed.

So there is literally no lung there for you to hear.

Or it could mean that you have such massive obstruction, even from something like asthma, that there's just not air moving in and out enough that you can hear it with a stethoscope.

And so this would be like on one side, you would hear breath sounds because someone would have to still be breathing.

And on the other side, you would hear no breath sounds.

And that would indicate pathology.

Potentially, yeah.

Okay.

Yeah.

So that's just breath sounds present, breath sounds absent.

Then there are a couple of different abnormal lung sounds that we will focus on.

And neither of these these are specific in and of themselves to any like one particular diagnosis.

None of the exam that you get with a stethoscope is like an absolute clincher necessarily.

They're all part of like an overall exam and findings that are going to help you try and figure out what's going on.

And the types of lung sounds have a lot of different names in like older literature and newer literature and across the globe, but I'm going to use the names that the American Thoracic Society tends to use.

And so that is wheezes and ronchi.

And ronchi are just lower-pitched wheezes.

And then crackles.

And with crackles, you have both fine crackles and coarse crackles.

Now, this is not all of the things that you would hear, but this is the majority of the abnormal or also called adventitious breath sounds that you would hear.

So let me play a clip for you of crackles.

Did you hear that?

They're kind of, I feel like crackles is a really good word in all honesty because they sound crackly, like you're mixing up a piece of paper or something like that.

There's other descriptions that I really love.

There's a description for fine crackles specifically that they sound kind of like if you join Velcro together and then separate it.

That's another way to describe the fine crackles.

And that clip that I played is a little more coarse crackles than fine crackles.

What's causing these crackles?

Fine crackles happen when you have inspiration that's opening these really small airways that have been collapsed.

And that kind of collapse can happen for a number of different reasons.

So you might have crackles, fine crackles or coarse crackles, in something like pneumonia.

You might have crackles with something like heart failure because you have fluid in the lungs.

Or you might have coarse crackles with something like chronic obstructive pulmonary disease or COPD or bronchitis.

There's a lot of different types of pathology that can cause crackles.

Then there are wheezes.

Wheezes are one of my favorite sounds in the lung, even though they're not like no one wants to be wheezy.

It's not good.

But let me play you this clip.

Why are they your favorite?

I think that they're my favorite because

a lot of the times with wheezing,

you can really diagnose something with wheezes and then treat it.

a little bit more specifically.

So with wheezes, we're usually thinking about asthma or COPD.

Are those the only things in the world that can cause wheezes?

Definitely not.

If you have like a foreign body ingestion, you might have a focal wheeze.

And the wheeze is happening because there's air that's trying to squeeze through a really small, constricted tube.

So, let me play the clip so you can hear that.

That sounded really horrible.

That makes me feel like I can't breathe.

Yeah.

So, in that clip, there's more inspiratory than expiratory wheezes.

You can get both.

It's not a good sound.

You definitely know that, like, there is something very much wrong going on here.

But a lot of times with wheezing, it's something that we can then say, oh, based on the other things that I know about this person who's coming in here and this lung exam, I know what the next treatment is going to be.

Does that make sense?

I think that's why I like wheezes.

It's not like they're good.

So if there are more inspiratory wheezing than expiratory, then what does that indicate?

That there's probably like a very detailed

answer to that question that I don't specifically have.

You can hear both inspiratory and expiratory wheezing, but classically something like asthma is described as expiratory wheezes, but you can certainly get both inspiratory and expiratory wheezing in something like asthma, COPD, et cetera.

Okay.

So that's like the main types of lung sounds that you might hear.

There's nuances there.

There's other types of sounds that you might hear too.

But these all just give the listener a bit of an idea about what is going on in the lung and then maybe what to do about it.

I have some questions.

Okay.

Okay.

So when you're listening to, first of all, where are you listening to the lungs?

What is the best place to put that little end of the stethoscope?

Yeah, it's not about one place.

It's about listening in multiple places and comparing them.

So people are always going to listen minimum in like four different areas because the two lungs and the top and the bottom.

But then there's also places that can stay kind of hidden.

And so sometimes you have to listen around like towards the front side to get like the right middle lobe.

And really, the more places that you listen across the back, the more information that you're going to gather.

But it's really about comparing one side to the other and comparing the top to the bottom to listen to the whole lung.

Okay.

And it's not just, so it's a really good question of where do you listen?

Because it's not just the sounds that you're hearing.

It's also where you're hearing the sounds.

Are you hearing crackles everywhere or do you only hear them in one specific spot?

Are you hearing wheezing everywhere or just in one particular spot?

And so that information is also really important as part of this whole exam.

Okay.

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When it comes to something like crackles and wheezing and stuff like that, you know, like you said, the location of the, you know, the origin of that or how pervasive it is or whatever, that's important.

But what about the degree?

Like if you're hearing fine crackles versus coarse crackles, what does that tell you?

If any, or is it just like a descriptive

Yeah, so it might give you ideas about what the underlying pathology is.

If it's more coarse versus more fine, you think of slightly different pathology.

And if it's like roncus, like those low-pitched wheezes versus those high-pitched wheezes, it's going to clue people into different types of disease that's going on, if that makes sense.

Okay.

There's like too many different lung diseases to get into like all those specifics.

Well, and then that kind of brings me to another question, which is like, we use the stethoscope.

It's a tool.

How often is it the last?

line?

Like, how often is it the diagnostic tool rather than like, oh, I some wheezing.

Oh, I hear some crackles.

We better get you an x-ray to see just how bad it is or whatever.

Yeah, it so depends on the situation that you're in, right?

If somebody is in an emergency room and they look super sick, no one's going to end with a stethoscope, right?

You're going to be getting imaging.

You're going to be doing more things.

And you might be treating something even if you think that your lung exam sounded totally normal, right?

It all just depends on the situation.

There There are definitely situations that this stethoscope might be the last part of your diagnosis.

For example, a kid who has a known history of asthma who comes in having trouble breathing, you put a stethoscope on their chest and they're wheezing, then you'd say, okay, let's treat this as an asthma exacerbation.

And so then you'd treat it and then see if they get better by listening to their lungs again.

So there are situations where it's still something that you very much use

and would not then need to do further imaging, or even like further imaging might not tell you all that much.

But as we'll talk more about like throughout this episode, there are a lot of

things about the stethoscope that are limitations, I guess, of the stethoscope.

And so there are a lot of new modalities that are much better for making diagnosis compared to the stethoscope.

Right.

Because there are presumably a lot of lung pathologies that you wouldn't be able to hear through a stethoscope, but you would be able to see on a

imaging.

Yep.

Lung and heart, especially.

And heart.

Yeah.

Okay.

So then that's sort of another question.

And this, this applies to both.

This is just like stethoscope broadly.

Yeah.

How subjective is it?

Like, obviously, you can take these classes, like in med school, you're trained, okay, this is a wheeze, this is a crackle, this is fine crackle, coarse crackle, a lot of the heart stuff that we haven't touched on yet, and then be tested on that.

But

how subjective is it?

Yeah, that's, I think, one of the biggest, the biggest questions.

There's huge inter-user variability in stethoscopes.

That's one of the biggest downsides of them.

What one person hears and what another person hears, they might describe totally differently, they might hear things totally differently.

And especially when it comes to a lung exam, the lungs change over time.

And so, what one person hears at one moment, another person might never be able to hear again because that sound might disappear or move or something like that.

So there is definitely a lot of variability.

There was a paper that I read that was like lamenting how medical students are just no longer trained in the stethoscope.

And I was like, come on, like, I think I read it.

It was a little much.

Yeah.

Well, it's like all of these papers seemed so dramatic.

They were so dramatic.

They were already holding like a funeral for the stethoscope.

And I'm like, I've never seen a doctor without one, even if they don't use them.

Like, come on now.

I do.

I think that it's, it's such an interesting medicine has this tendency.

This is sorry.

This is, I wasn't going to riff like this until way later in the episode, but

riff away.

I love it.

Medicine has this tendency to like really dramatize new technologies as being like the end of the practice of medicine.

And I think that

the stethoscope has absolutely gotten caught up in that, right?

Where it's like, well, if students can't use the stethoscope, then where has medicine gone?

When it's like,

sorry, ultrasound is great, you know?

Right.

But at the same time, like, I can say, and this is just like me as an individual and of one, I use my stethoscope very frequently, almost every day, as a primary care provider, especially one who sees kids.

And so I don't think that we are at this day and age in 2024 at the point where anyone's throwing their stethoscope out the window.

And I do think that it still has clinical uses.

And sure, maybe someday it won't and we'll be able to replace it.

And that's okay.

But for right now, it definitely still has its place.

And it also isn't the only thing and it's not perfect for sure.

Yeah.

I mean, medicine has such a short memory where it's like, I know, we think that somehow we are here and this is how we've always been here.

Well, and that's why I'm so, I'm so excited, Aaron, to hear about like when this came, because I know know there was like controversy when the stethoscope came to be.

And I just, I love, I'm excited for it.

But on to the heart.

We still have

another organ to discuss.

I feel like the heart is what probably people think about and focus on the most when you think of the stethoscope.

I don't know.

Maybe it's a toss-up, heart and lungs.

But the heart is a big thing that you're also listening to and probably what gets even more focus in med school training in terms of the specifics of what you're trying to listen for and the diagnosis that you're trying to make when it comes to heart sounds.

Because with a stethoscope, with a well-trained ear, as they say, and a stethoscope, you really can make diagnoses of the heart function a little bit better than you can with the lungs.

At least that's my interpretation as a not.

perfect provider.

I don't know, whatever.

So what is someone listening to when they're sticking a stethoscope on your heart, on the front side of your chest?

The first thing, of course, is the heart sounds that you would expect to hear.

And that is lub-dub, lub-dub.

Let's take a listen to a normal heart, shall we?

Lub-dub, lub-dub.

Yeah, right?

Pretty much what I expected.

Right.

Do you know what those sounds are?

Your heart.

Technically right, Erin.

100% right, Erin.

Oh, that was quite funny.

So, yes, it is your heart.

The first lub, that first sound, also called S1,

is the beginning of what's called systole.

And that is when your heart is contracted.

So that sound that you hear, lub, is actually the the sound of your valves, specifically the valves that are, that go between the top half and the bottom half of your heart.

So your mitral and tricuspid valves, snapping shut.

That is the sound.

It's the snapping shut of those two valves.

That's that first sound that you're hearing.

And then the second sound that you hear, dub, is the beginning of diastole.

And that is when your heart is relaxing.

It's filling back up.

And the sound that you're hearing is the pulmonic and the aortic valves closing so the valves that block off your heart from shunting the blood to your lungs and the rest of your body right so those are the two sounds that we expect to hear s1 s2 it's the closing of the first two valves and then the closing of the second two valves

and there's a lot

Like that sounds just like, wow, there's so much pathology that you can hear

in between those two sounds.

If those two sounds are split in certain ways,

and if like one sound is stronger or quieter, where you're hearing one sound as stronger than the other.

So there is like quite a lot of pathology that you can actually distinguish within heart sounds.

The biggest thing, like the most obvious thing that we're looking for in terms of like pathologic heart sounds are murmurs.

So if the sound that you hear, lub dub, are actually just the closing of valves, those are kind of discrete sounds, right?

Lub, dub, lub, dub.

Murmurs are when those sounds get blurred a little bit and they get blurred because of turbulent flow.

And so what a murmur sound tells you is that something is going on with the valves, which one, depends on the murmur and depends on where on the chest you hear it.

But it means that there's something going on with the valves so that the flow of blood across those valves is no longer a nice linear flow like it should be, and it's turbulent.

And so it causes whooshing type of sounds that you can hear.

Let me play a couple examples of like the most classic kind of murmurs because I think it'll give you a really good sense of how different it is from just a lub dub lub dub.

whoa

right

you hear how different that sounds yeah it's not yeah

yeah

So that one is a murmur called aortic stenosis.

So your aorta, of course, is what connects the left ventricle, the left side of your heart to the rest of your whole body.

And that valve is supposed to close at S2.

It's supposed to be open during systole when your heart is contracted and blood is supposed to be able to flow to your whole body.

But what can happen sometimes is that valve gets stenotic or hard.

And so then it doesn't open all the way.

So it's more narrow.

And when that happens, when the blood tries to go across that valve, it gets forced think of like forcing like sticking your finger on your hose or something and the water that's previously just flowing quietly is like whoosh right yeah so you hear this very specific kind of murmur that's like

where it gets louder and then quieter it's called a crescendo de crescendo i'm telling you murmurs are like that's a whole language musical yeah yeah and so if you hear that especially at specific places then that can tell you that murmur, that specific murmur means that someone has aortic stenosis.

Without needing any additional imaging, you can say, well, you have an aortic stenosis.

Okay.

If you hear that murmur.

Yeah.

But now,

there's lots of other kinds of murmurs.

And depending on where and when you hear them and what they sound like,

that can tell you, is this murmur because someone's mitral valve isn't working correctly?

Is it because someone's tricuspid valve, so on the right side of their heart, is that the one that's not working?

Is the murmur in systole, so when the heart is contracted, or is it in diastole, when those ventricles are trying to fill back up, right?

There's a lot of different things that you can get from when that murmur is and what it sounds like.

Interesting.

I know.

So there is definitely a lot of pathology that you can't hear with a stethoscope.

Even that example that I gave of aortic stenosis,

if it's really severe, you actually don't hear it at all because now it's just like such a tiny valve that you just can't, you can't even hear the flow across that valve.

Okay.

And there is varying degrees.

For example, let me play a great, this is a great classic med school murmur

that happens with what's called mitral regurgitation.

So when the valve on the left side of your heart is a little floppy, then sometimes you get backflow of blood during when your blood is supposed to be squeezing out to your aorta.

So if you listen to this,

whoa.

So that one sounded different, right, than the previous murmur?

Yes.

So that one also had a fun little what's called an extra heart sound that you can get when you have other kinds of heart pathology like if your heart is very dilated then you might get these like extra instead of lub dub it's like lub dub dub lub bubbub kind of a thing

so you might hear that murmur in someone if that pathology is severe if you maybe have a crappy stethoscope or don't know what you're listening for or if it's just not that severe you have like a little bit of regurgitation then yeah, you might not hear that with a stethoscope.

There are other modalities, like ultrasound, gonna keep saying it,

where you would be able to see the blood flow because you're actually seeing the blood rather than just hearing the blood flow.

So, that's like the main and most obvious kinds of things that you'd be listening for in a heart.

And really, it all comes down to trying to get a picture of how the valves are working and how the heart is squeezing a little bit of information about how it's squeezing

and you can get all of that information just by listening for these murmurs and listening at different places on your chest so you asked when we were talking about the lungs where you listen there's four main places that people listen to listen to the heart and those are named after the four valves so aortic pulmonic tricuspid and mitral all physicians take money

that's me we remember it.

It took me a second.

I was like, whoa.

Okay.

Sorry.

That's how we remembered it in med school.

But so, depending on like what type of murmur you hear and where you hear it, it can give you clues as to what that pathology might be.

And then there are degrees of like, is it a really loud one or is it a really soft one?

Does it start out loud and then get softer?

Like there's so much

that like people who are really, really good at murmurs would be like, the joke is like, if a cardiologist can just like touch their stethoscope to someone's chest, they'll hear a murmur that a med student would have to like listen really closely with like the best possible stethoscope to hear it.

There's like all these jokes about it.

But that's a really good joke.

Isn't it?

I'm just hilarious.

I told it really well.

But that's like how you rate the degree.

Like, is it a one out of six, a three out of six, blah, blah, blah.

That's like there is like a scale.

Yeah, there's a scale out of six on how loud a murmur is.

Okay.

Interesting.

And then, like, presumably, I mean, this is getting into like other things, not stethoscope, but like, presumably, then that is, do we do surgery?

Do like, what are the steps that you take?

Totally, totally.

What are the next steps?

It all depends on what that murmur is.

How long has it been there?

Because there are lots of totally benign murmurs, especially in childhood.

These tend to be often described as musical murmurs.

The ones that we listened to were all very pathologic murmurs, but there are lots of different flavors of murmur.

And some of them, if someone hears, would definitely require follow-up and some of them probably wouldn't.

Okay.

It all just depends on like how old is the person?

Is it the first time you're ever hearing it?

Et cetera, et cetera.

Right.

So.

That's what we do with the stethoscope.

We'll talk a lot more about like how far we've come, but that's like when someone sticks a stethoscope on your chest, that's what they're trying to figure out is, does it just sound like lub dub and like

or does it sound weird?

Yeah.

There you go.

Aaron?

How'd this guy come up with it?

How did we do anything before it?

Oh, those are great questions.

And I can't wait to tell you what I can of the answers to them right after this break.

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We've kind of talked about this already, Aaron, but truly, is there anything that symbolizes doctor more than the stethoscope?

I mean, the little, what do you call it?

The snake.

Seducious or whatever?

Yeah, no.

No, it's the stethoscope.

Like, okay, I thought maybe the white coat could also count as short as a gender.

But then, like, you could see a picture of someone in a white coat and think, oh, maybe they're a scientist who works in a lab.

Yeah, it's a little more generalized.

Yeah.

But the stethoscope, that's the thing that acts as the visual cue for doctor.

Yeah.

It's included in every single doctor Halloween costume, any like kids' doctor play set, any toy figurine of a doctor.

If you Google image search just the word doctor, which I did, nearly every single picture features a person in a white coat with a stethoscope.

I will note that the first picture that did not include a physician with a stethoscope was McDreamy from Gray's Anatomy.

I can't remember the character's real name.

Was it Jared?

It does start with a G, I think.

Nope.

McDreamy.

Anyway.

McDreamy.

McDreamy is the gray-haired guy, right?

I don't think, I don't know if it started out gray.

Oh.

I never finished the show.

I stopped when one of the characters turned into a ghost.

And yeah.

I remember that.

You had an LVAD, too, right?

Anyways.

Aaron, it was like

15 years ago.

But studies have shown that doctors with stethoscopes are perceived as more trustworthy than those without, which I think is fascinating.

The stethoscope is such an establishment.

It is such an integral part of practicing medicine, even if it's not used, that it seems impossible to imagine a time when it didn't exist or a future without the minute.

Although, as we'll discuss, that does seem to be the future that some people are envisioning.

It's more controversial than I bargained for.

I did not expect to see articles with headlines like, bring back the stethoscope, save this, you know, relic of medicine.

medicine and I'm like really like it's hilarious to me how much drama there can be in medicine sometimes about things like that right I was like we just talked we just mentioned Gray's anatomy of course there's drama in medicine

but as it turns out the stethoscope is actually a lot younger than I expected it to be.

And its development marked the beginning of a huge transition in medicine and in the relationship between patient and doctor.

So let me take you back to the second half of the 1700s.

Medicine during this period of time was still very much under the spell of Hippocrates and the humoral theory of disease, where illnesses, of course, were thought to be caused by an imbalance in the body's humors, blah, blah, blah.

Human anatomy was still in its early stages since dissections had long been seen as sacrilegious and only recently were people beginning to develop like an atlas of the entire human body.

And as a result, this belief persisted that most illnesses were not localized, but systemic, owing to this humoral imbalance.

And I'm talking the origin was systemic, not the effects were systemic.

Right, right.

And so things like heart disease, liver disease, illnesses associated with the lungs, they weren't really conceptualized the way that we think of them today.

Diseases of the heart were known, but symptoms indicative of heart disease weren't really considered, if that makes sense.

So like someone has a symptom of something and you think, oh, that symptom is in their heart, but it's a systemic disease.

I see.

Like it's their entire body's humors that are in balance, not the anatomy of their heart is actually not functioning the way that it should.

It's like their heart isn't working because the rest of their body is off balance.

Yes.

Okay.

Yeah.

And part of what perpetuated this was that in the late 18th and into the 19th centuries, physicians were limited in what they could observe in a patient beyond what the patient themselves could tell them, which is important, as we know, and it sort of, I think, has over time, we've now, the pendulum has swung in the other direction to some degree, but it doesn't always capture all of the elements, right?

Like someone can feel completely not sick whatsoever, and there could be something that shows up on their, on whatever imaging or shows up even in the stethoscope, like with a stethoscope.

And if you remember from our fever episode, watches with secondhands weren't developed until the 1690s, which only then allowed physicians to accurately measure pulse rate.

And the mercury thermometer, invented in 1714, wasn't regularly employed by physicians until the early to mid 1800s.

And the incorporation of these tools into medicine, especially for diagnostic purposes, was part of this larger trend in the scientific search for truth with a capital T, like objective truths that could be measured and standardized so that their meanings remained constant across individuals, across space, and across time.

In medicine, it seemed to be driven in part by a mistrust by the physician of the patient's account of things.

The physician's like, well, I can't trust what you're telling me.

I got to see it for myself.

I got to hear it for myself.

I got to smell it for myself, whatever it is.

Not necessarily necessarily malicious, but a recognition that people's accounts can vary, sensations can feel differently to different people, and that there could be a disconnect between the way someone feels and what they're experiencing.

Like fever, for instance, where you might feel freezing cold, but actually your temperature is burning up.

Low-grade fever.

One of these tools or methods to make objective measures in medicine was developed in 1761 by a physician from Vienna named Leopold Ahrenbrueger.

Essentially, percussion entailed tapping a person's body with their fingers and then listening to the sounds produced, which were supposed to tell you the, quote, vitality of the internal organs, especially the heart and lungs.

So you would like, thunk, yeah.

And he wasn't the first to listen to the internal goings on of the organs, but he was among the first to write about it systematically and apply it to specific diagnoses.

So like maybe a dull thunk meant that the lungs were full of fluid or a hollow echo meant the spleen was doing just fine.

I don't really know the guidelines.

I'm making, I made all of that up, but neither did the physicians who came across his treatise, which apparently included only the vaguest of descriptions.

Gotta love that.

Yeah, right.

He's like, let me tell you about this method.

It's really great.

And you just tap your fingers on that person's body and then listen.

Yeah.

And then what you hear will tell you everything about what the person has.

The end.

And so this

sort of lack of description probably had something to do with his method of percussion not catching on the way that he had hoped.

But it was also because what he was proposing was very much outside of the norm for medicine at the time.

Because for one thing, this method of percussion required physicians to think of the body body and disease in anatomical terms, which was still very much a new concept.

Anatomy took a backseat in most explanations of the day of how disease began and how it developed.

And secondly, to successfully employ the percussion technique, physicians really had to get in there, like up close and personal.

They had to touch their patients and then they would have to bring their head close to their chest or whatever part of their body to get a good listen.

And this was something that would, you know, called into question the physician's dignity, since manual labor was considered beneath the physician at the time.

They were intellectuals, not common laborers.

They used their minds, not their hands.

I find that so interesting and not at all a part that you learn about medicine.

Yeah.

Yeah.

Well, and it's also, okay, let me read you a quote that I think even brings a little bit more color into this picture.

Quote, in particular, the physical intimacy required by percussion threatened to undermine the professional standing of the physician, even to place him in a class with the surgeon over whom he affirmed both medical and social superiority.

End quote.

Wow.

So it's like surgeon for a surgeon?

Yeah.

They run deep.

Yeah, they do.

Wow.

So I think it was, it was really interesting.

Like the divide was so stark and the hierarchy was so well established where a physician was a thinking man.

He was, I mean, and I say man because

pretty much.

Yep, what I mean.

And

yeah, so it was like, no, they make diagnoses with their books, with their minds, with the way that they take in all of the data.

They don't cut.

They don't touch.

That's just fascinating to me.

Oh, Aaron, this profession.

I know, I know.

And so Aaron Brueger's percussion had a lot working against it, and it largely faded into obscurity.

But it did catch on in a handful of doctors who passed it down to their trainees.

One of these trainees went by the name of Renee Theophili Hyacinth Laneck.

I'm just going to say Laneck from this point forward.

Laneck was born in France on February 17th, 1781.

When he was just five, his mother died from tuberculosis and his father sent him to live with a great uncle.

His childhood and youth was filled with playing the flute, reciting and composing poetry, learning Latin and Greek, and going to the countryside for fresh air when his asthma acted up.

And I just need to, okay, I found this paper from like the 1920s that was celebrating the life of Laneck.

Like no one was higher in this person's esteem than Laneck was.

It was the most praise.

Okay, let me just get to it.

Quote: Okay.

From this land of salt sea breeze, gray rocks and downs, and druidical forests of mystery came the calm and prodigious intellect of one comparable only to Hippocrates in his vast store of medical lore and almost superhuman accomplishments.

End quote.

Okay, I mean,

I mean, he did a lot, but like, I know.

I mean, he also was the first to, besides the stethoscope, he did other things too.

I think he did Linux

cirrhosis.

He described that for the first time.

I think he had a lot of.

There's rules named after him and stuff.

Yeah.

And he, he identified melanoma as not.

as being a cancer and separate from he like a lot of people thought at the time that it was tuberculosis like the black granules that came to the surface and he was like no this is not that

anyway but when he was when laneck was 14 and a half he started as a student in the school of medicine of the hotel dieu at nantes and quote soon after he was appointed military surgeon of the third class at a salary of something like nothing a year end quote

which

First of all, a few things to unpack.

I love the description of something like nothing.

And then

soon after, he was 14 when he enrolled.

If you just imagine like a 15-year-old.

How soon are we talking?

Couple years, five years, one year?

I would think he was probably within a few years.

Oh my God.

Yeah.

So

in this stint, he did a bit of surgeoning with the troops.

And then when that was over, he continued his medical education in Paris, which of course is where he invented the incredible device for which he still receives just untold praise from like the author of that article.

The story goes that as he was on his way to the hospital one morning in September 1816, he saw some children playing with a wooden beam and a pin.

One kid held the end of the piece of wood to his ear while his friend scratched the other end with a pin, sending little signals.

Okay, did this actually happen?

I probably not.

I doubt it.

I highly doubt it.

I don't think he ever wrote about it personally.

I think it only shows up in people who wrote about Lenak.

How funny.

Yeah.

That fateful day, he remembered seeing those children.

Like, come on.

But maybe it did happen.

Maybe.

And he, I think, you know, if it did happen, the incident would have probably been soon forgotten.

If not, he had a particular patient.

And like you heard about in the first-hand account, he couldn't use his usual method of percussion or direct auscultation where he like put his ear directly on this person's chest because

his patient was a young woman with suspected heart failure, which we didn't mention this at the top, but we included audio of a clip of someone who has heart failure.

Yeah.

In that firsthand account.

Those crackles.

The crackles.

The smart sounds.

And so, yeah, he was like, well, I don't want to get up close and personal.

This is really uncomfortable.

And so then he, the firsthand account, he rolled up that piece of paper and was like, whoa,

I can, this is amazing.

This is, this has potential not only for this particular patient and this particular situation, but so many things.

Like he immediately saw potential.

And over the next few years, Laneck put this new tool to work and he called it the stethoscope, meaning I look into the chest.

He played around with different designs and materials, starting with a piece of paper tightly tightly rolled, like he described.

And then he would like glue the ends to try to create more of a, I don't know, capture the sound because it would come out.

And I don't know how anything about like audio engineering works, which is, you know.

Yeah, that was the thing I thought about looking into.

And then I was like, physics and me don't get along.

So I didn't.

And then he tried different materials.

He tried ivory.

He tried gold beater's skin, which I looked it up.

It's made from an animal's intestine.

So like, yep.

Then he tried various woods and ultimately he landed on soft woods with an opening at the end.

So, Erin, you described this modern stethoscope.

Yeah.

If you saw, if you just like saw in a random museum or antique store or something, one of Laneck's early stethoscopes, you would not recognize it as a stethoscope.

You'd be like, what is this like?

long pin.

It's like a wooden cylinder.

I would because I've seen pictures of them, but like if you haven't seen pictures of them, you would not, you would think it was like just a stick thing.

Yeah.

It looks like a stick.

Maybe there's like a flaring out at the end.

Maybe.

Yeah.

Maybe.

Which is funny because I think that like now our image of the stethoscope is of the modern stethoscope, which is not that, that old.

And so it's, it's just funny.

It's like, anyway.

Yeah.

But so in 1819, Laneck presented his stethoscope to the world with the publication of his two volume on media auscultation, available for the low price of 13 francs or 16 if you wanted a stethoscope included with it.

He made a bunch of them, which is a complete stroke of genius, right?

That is really funny.

I love it.

He's like, here's the book and here's the thing.

Yeah.

He's like, you don't have to wonder what this is like.

You don't have to wonder what these noises I'm describing.

See for yourself, hear for yourself.

Love it.

Yeah.

His book and the stethoscope took off in popularity, probably in part because the device was included with it, or you could buy it, but also because his descriptions of various chest sounds in association with certain diseases were so detailed and precise.

Yeah.

Like, let me read you a quote.

Oh, I love it.

Quote, when the patient coughed or spoke, and still more during respiration, there was heard a tinkling like that of a small bell which has just stopped ringing or of a gnat buzzing within a porcelain vase.

Right.

Like you really understand

what you're hearing or what you're supposed to be hearing or what he was hearing.

Yes.

What a way with words.

Like, I don't think I would be as

creative or articulate.

And you heard me, Aaron, and I was like, you know, it's like, whoosh.

And then he goes, woo-woosh.

Now, now put that in writing.

And there you go.

And so in these volumes, he created new terminology entirely, like stethoscope, but also rails, frematis, cracked pot sound, metallic tinkling, egophany, bronchophony,

cavernous breathing, puerile breathing, veiled puff, and brute.

Yeah.

Yeah.

Some of those words we still use.

It's kind of amazing.

I mean, like, okay, maybe I am back to thinking thinking that he's like hypocrites level.

But with this tool and his book, Laneck revolutionized medicine.

The stethoscope has been called the first major diagnostic tool of modern medicine.

Before the stethoscope, there was virtually no way to observe what was going on inside the body.

except for autopsy, which of course happened after death, or surgery, which at the time almost always led to death.

With this device, Laneck was able to say, these sounds are linked to this disease or this illness, and then he could confirm the location and pathology in autopsy later on, something that again was in its early stages, like the concept of localized disorders.

His book flew off the shelves as the stethoscope picked up speed, leading to more refined descriptions, applications outside of lung and heart sounds, like in obstetrics and orthopedics.

And then people started to make variations in the design of the device that allowed for better listening.

So Linek, who was only 35 years old when he invented the stethoscope, would only live to see some of this excitement.

Because of course, having a diagnostic tool doesn't necessarily help prevent or treat or cure disease.

Linek had never been the image of perfect health, even as a kid.

But as the 1820s rolled around, his asthma, his insomnia, and his chest pain got worse.

In 1826, he had a sense that things were coming to an end.

He had a fever, productive cough, shortness of breath, and he'd been a doctor long enough to know the signs of tuberculosis when he saw them.

But he had for years denied that he had the disease.

A lot of people in his family had gotten sick and died of tuberculosis.

And so maybe it was sort of a matter of just like, I don't, this can't, this can't happen to me.

How can this happen to me?

And so finally, in the summer of 1826, while in the countryside, he had his physician nephew listen to his chest using the tool of his own invention, what he called, quote unquote, the best part of my legacy.

And the diagnosis, I don't know, I don't know why I feel so sad.

I feel this is more emotional than I expected.

I know.

I can feel tears.

The diagnosis was, I'm laughing, but I really do feel sad.

The diagnosis was tuberculosis.

And he died later that summer at the age of 45.

Wow.

Yeah.

But as we all know, the stethoscope didn't die with him at all.

There was some resistance.

Erin, you kind of alluded to that earlier.

Like some patients were afraid of this new instrument.

Some physicians felt like the physical labor aspect of it gave off too much of a surgeon vibe.

But most of the energy was focused on better incorporating the tool into medicine.

Like, how can we use this?

How can we maximize the use of this tool?

And so the rest of the 19th century was filled with improvements on Linux simple design.

In the 1850s, Dr.

George Philip Comens developed the first two-ear stethoscope.

Smaller stethoscopes were introduced so you could carry them more easily.

People worked on flexible stethoscopes.

And in the early 1900s, physicians realized that they could pick up sounds better better if they stretched a diaphragm over the mouth of that little open cup at the end of the stethoscope.

As the century came to a close, it seemed like the stethoscope was here to say a permanent fixture in medicine.

But is there such a thing?

Finally, question.

Yeah.

I mean, if there is, the stethoscope is probably the closest thing to it, but its future seems uncertain.

At least that's what we've been talking about based on some of these papers titled things like Throw the Stethoscope Away, a historical essay, and in defense of the stethoscope and the bedside.

I have some good ones too.

And although these papers are from the last couple of decades, the sentiment of behind this is a lot older, as is the downward trend in the stethoscope's use.

Why is that?

We've talked about this, like other diagnostic, more precise precise tools have come onto the scene that provide better and more accurate pictures of what might be going on.

Like the x-ray machine, which is quite old.

And when it was introduced and started to become widely used, it replaced the stethoscope as a major diagnostic tool of lung conditions or CT scans, MRIs, chest radiographs, ultrasounds, and so on.

With these instruments, we move closer and closer to objectivity in medicine in terms of measuring tools, not in terms of bias.

Medicine is not objective by any means.

Percussion was developed and the stethoscope invented so that physicians could better observe for themselves what was going on inside their patient, to not have to rely on their patient's testimony entirely to make a diagnosis and decide on a course of treatment.

But like we've talked about, the noises that people hear, the sounds that you hear in a stethoscope, they are open to interpretation, interpretation, to misdiagnosis, to simply not hearing them at all.

And several studies have confirmed that stethoscopes harbor lots of germs like MRSA, although I don't know if they are significant vectors for transmission or if that's been measured.

Oh, there is a paper that measures that.

And it doesn't carry C.

diff, which is nice.

Most of the papers.

That's great.

Yeah.

Yeah.

But teaching these sounds can be difficult in that regard.

You know, it's like in the ear of the beholder, I guess.

A squawk to one physician might sound like a bell clang or crackle to another.

The ideal diagnostic test in medicine is one that produces results that look the same to every physician, right?

Like, wouldn't we want them to be universally yes, no, binary almost?

We would.

We would.

I mean, that's the ideal.

Yeah.

Is is any diagnostic test capable of that at this point?

No, I doubt it.

But I mean, maybe, but I think we can get closer, you know, and I think that's, that's the whole thing behind it.

And this isn't to say, of course, that noting that squawk or bell clang or whatever isn't important, because that might be what gets you to order additional tests to find out what's going on.

And the stethoscope itself is, I think, an opportunity to keep medicine present in the room, like grounded in humanity and physical diagnosis and dependent in part on bedside skills.

And I want to hear your thoughts on all this, but first let me leave you with

this quote from a 1979 article that I really liked.

Quote, today the stethoscope is the old warrior of medicine.

Although it cannot compete with the array of elaborate and expensive technologies for which it paved the way, it clings tenaciously, resisting retirement.

Its staying power in modern times is based in part on its giving both physicians and patients a sense of continuity with the past.

Identified with dependable diagnosis, the familiar object evokes confidence.

Most important, it provides those physicians who still know how to use it with good, immediate, and low-cost information that can eliminate the need for complicated diagnostic tests.

End quote.

So, Erin, what do you think?

Is the art of auscultation something we should preserve?

Or is that sentiment just a reflection of the natural resistance to change and fear of the new?

Oof, I cannot wait to tell you Aaron's opinion corner about this

right after a quick break.

Erin, it's funny that you ended that section with a quote from a paper from 1979 because I actually, I'm guessing it's the same paper.

Let me see.

The one from by Riser from Scientific American.

Yes.

I love that paper.

Yes.

I also have a quote from that paper, but it's a totally different quote.

And it's like the opposite end of the coin.

And I think what it highlights is what you mentioned, which is like, why does the stethoscope represent what it has come to represent in this like push and pull of like new technology and physical exam and all these things.

So let me read you my quote from that same paper.

Yay.

Okay.

Quote, when the 19th century physician chose to make diagnosis less on patients' verbal accounts of their symptoms and more on the physical signs of illness that, in many cases, he alone detected, he was obliged to make up his own mind about illness.

As a medical era, the 20th century must be characterized as a time when physicians have come to rely less on themselves and more on specialists, technicians, and machines to collect and evaluate the evidence of disease.

End quote.

Erin, I almost included that quote.

It's just, it's such a good one because that really is what it feels like it comes down to, where there are people who say that the stethoscope is a mark, like the ability to use a stethoscope to make a diagnosis, to have that good ear, like that's the mark of a good physician.

And the fact that we are kind of doing away with it, or there are people who say we need to do away with it, like that is the problem with medicine and blah, blah, blah, right?

These new technologies are going to replace us as physicians.

Like that is, that is something that you hear and not just about the stethoscope.

That's like a fear of medicine.

Like what is the future of the physician

in the face of all of these new technologies?

I think that the stethoscope and the problems with the stethoscope and the new technologies that exist really get at the heart of that fear that exists in the practice of medicine.

My, okay, my, my, now for my opinion, Corner.

Yeah, yeah, I want to hear your opinion, Corner.

So, like I said, like, I, I use a stethoscope pretty frequently.

Do I use it every day?

Definitely not.

Do I use it on every patient?

Definitely not.

Do I always feel like I'm really confident in what I'm hearing?

Nope.

Definitely not.

I think that, in terms of the like future of medicine question, like the stethoscope is such a minor thing in that.

It's like

symbol, Aaron.

Yeah.

It's $100

or $150,

which when I was in med school was super expensive and for a lot of people is very cost prohibitive.

But like compared to an ultrasound, compared to an x-ray, like it's really a drop in the bucket.

Is it useful?

Sure.

It's still useful today.

Is it the end-all end-all-be-all?

No.

Should it be a substitute for these incredible technologies that are coming out?

Absolutely not.

And what I think is so interesting is that like, there doesn't have to be a reality where these new technologies threaten medicine as a practice, right?

If we use the stethoscope as an example, yes, there is wide user variability in the stethoscope and it's an imperfect tool and there's areas for improvement, but it has its place and so many other tools that we also use have inter-user variability, right?

Think about an x-ray.

Not every radiologist interprets an x-ray the same way.

And so, I think that what this lets us get at is one of the ways that the stethoscope itself and the practice of auscultation can actually and has begun to be improved upon in the same way that x-rays and radiology and things are being improved upon.

And that is data.

So with the advent of digital stethoscopes, you are able to not only augment the sounds that you're hearing by doing things like noise canceling, like reducing ambient noise, and then amplifying the sounds that you hear, which makes it easier for the user to hear the sounds.

It also allows for us to record sounds.

Recording tons and tons of sounds of normal and abnormal hearts and lungs allows for things like machine learning algorithms to compile all of this data.

And what's really cool is that you said, Erin, like what is a crackle to one person might sound like a squawk to another.

And that is true in that Someone might say one word or a different word or interpret something.

But if you look at waveforms, there are very distinct waveforms associated with these things that we call crackle, fine crackle, coarse crackle.

Like if you can look at this on a computer screen instead of only relying on your ear to hear the differences, then you can actually pick up on things in a much more specific way by combining the digital stethoscope with imaging of that sound in terms of waveform, which is awesome.

It's so cool.

But there's so much more than just digital stethoscopes.

And if there is one single tool that may spell the downfall of the stethoscope,

It's another pretty old one that has gotten upgrades in recent decades, and that is the ultrasound.

So specifically, what is called point of care ultrasound.

And I'm not going to get into details of ultrasound because again, physics and me are not friends.

But everyone can probably picture an ultrasound machine if you've ever seen either in real life or in a movie, someone getting an ultrasound of their baby, right, of their fetus.

So ultrasound uses sound waves that bounce off of tissue and then are reflected back into a transducer and then interpreted as these magical black and white images.

And while we all might think of an ultrasound machine as this giant bulky thing that they wheel into the room and they squirt all this gel and it's a huge screen with all of these buttons,

Because of advances in technology, there are now ultrasounds that plug into your smartphone that are literally just the size of a transducer or even ones that are an entire ultrasound that's the size of a tablet or a small laptop.

They're really portable.

They're much less expensive.

And while a lot of these, at least today in 2024, don't have the resolution of the really big, fancy ultrasounds, They do a really amazing job, even in relatively inexperienced hands, say first-year medical students who are learning how to use ultrasound, at picking up pathology equal to or better than a stethoscope in very experienced hands.

And that includes in the heart and lungs, but also a lot of other places in the body too.

So I think that point of care ultrasound is one of the things that comes up time and time again as being the thing that's going to outseat or replace the stethoscope.

And it's true that this is kind of the big thing right now in medical schools that people are really being trained in.

And that's kind of like, it's the new stethoscope.

Is that a thing?

It's like, ooh, this is the thing we all need to get trained in.

And as we've talked about on this podcast before, one of the issues with incorporating anything new in medicine is the kind of time lag and turnover.

Yeah.

And when it comes to ultrasound, one of the challenges is that while a lot of medical schools have really accelerated this training, not all of the attendings have, which means that maybe it's your new trainees who know what they're doing and the people who are supposed to be training them who have no idea how to do it.

There's also issues with any new diagnostic tool, and especially the better diagnostic tools that we get, if in inexperienced hands, especially, can have things like false positives, right?

So you have this risk where you're going to see things that maybe you're not interpreting the correct way or you're overcalling things as being abnormal.

And really, it's not a big deal, if that makes sense.

Yeah.

So there's downsides to every new piece of technology.

There's ups and downs to every diagnostic and screening tool that we use in medicine, but they're all just a part of the story.

And I think that that's what's missed in all of these, you know, very heated, emotional papers about defending the stethoscope or saying, stop listening and look.

That's the ones that are defending the ultrasound as being the end-all be-all.

Like, why does it, why is it so binary?

Like, why can't it be that the stethoscope?

Right.

And it just seems like you're creating this.

It's like a, it's like an invented argument.

And so

it's like, who are you debating against?

Just a ghost who's like, throw away the stethoscope entirely and get rid of all of them.

Let's burn them all in a giant pile.

Like, right.

But then if we do that, and then we're relying on computers.

Now computers have replaced the physician.

Oh, but if we do that, then, and part of it is like there, there is a lot to learn.

So part of, I think, if I give them some grace, part of the like drive in some of these arguments is like, what should we be focusing on when we're teaching in medical school?

Sure.

Because there is so much.

So, like, how much do we need to focus on the stethoscope versus the ultrasound versus the whatever else?

And that's a valid question, you know, like how much do you focus?

But it also just like, I don't know, it feels like it misses the point.

It feels like it misses the point.

It is sort of this like existential fear of, yeah, are we going to no no longer be needed?

Right.

I think it does call into question what makes a good physician, which is like a whole separate episode that we could talk about.

That I also have a lot of opinions on.

Yeah.

I think it's

what seems really important to me about the stethoscope, someone who's not in medicine, who's completely outside, is that it's low cost relative to like an ultrasound.

Yep.

And it seems like that would be helpful in terms of a decision tree.

If someone doesn't have insurance or if they don't have good insurance, things like an ultrasound can be really expensive.

And so it's like, if you don't know that you need to get an ultrasound, it's like, is that part of the decision tree?

I don't know.

You know what I mean?

Yeah.

Well, and it gets so complicated too, because then that is, in all honesty, an argument for point of care ultrasound over things because you're able to diagnose better

in the clinic setting without having to send someone and bill for a separate,

but billing.

Oh my God, don't get me started.

So, you know, and this is America specific because that's what I know.

But yeah, it's, it's all really interesting.

And I think that they're at this point in 2024, the stethoscope still exists.

It still has a place.

It's still being taught.

Will it go away someday?

Maybe.

It doesn't mean the demise of physicians.

Yeah, but AI is, Aaron.

AI.

Soon it'll be AI.

AI might be.

Just kidding.

It's also not, Aaron.

Hot take.

I've got opinions.

Not worried about it.

Bring it on.

Anyways,

want to know more?

We've got sources.

We got so many sources.

So there's that paper that we both loved by Riser from 1979 in Scientific American titled The Medical Influence of the Stethoscope.

I loved it.

And there's a bunch more, but honestly, that one was like really, really great.

I have a lot of sources, unsurprisingly.

So the sounds that you heard, all of those recordings, the lung sounds came primarily from a database that came from a paper titled A Respiratory Sound Database for the Development of Automated Classification.

And I wrote down specifically which clips we ended up using.

So if anyone wants to find those clips, they also have like literally thousands more.

It's phenomenal.

There's another really great heart sound database that was an open access database for the evaluation of heart sound algorithms.

But the ones that we primarily used for this so that they could be specific to types of murmurs was the incredible database from University of Michigan School of Medicine.

We'll link to all of those.

And then I had a bunch of really fun papers.

Some of them were old, like the clinical methods, the history, physical, and laboratory examinations from way back in 1990.

And then a lot of those drama papers that we talked about, like a paper from 2021 titled, The Future is More Than a Digital Stethoscope.

Anyways, we'll post the full list of our sources from this episode and every single one of our episodes on our website, thispodcastwillkillYou.com.

Thank you to Blood Mobile for providing the music for this episode and all of our episodes.

Thank you to Tom Breifogel and Liana Squilachi for the incredible audio mixing.

Thank you to exactly right.

And thank you to you, listeners.

We hope that you had fun with this episode.

I sure did.

Yeah, I did too.

And what are your thoughts on the stethoscope?

Yeah.

Yay, nay.

Yay, nay.

Don't care.

Do you like it?

Wash it better?

What do you think?

Yeah.

And a special thank you, of course, as always, to our wonderful, generous patrons.

We appreciate your support so very much.

So much.

Thank you.

Thank you.

Thank you.

Well, until next time, wash your hands.

You filthy animals.

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