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- Hector I. Michelena, MD⁎ ()
- ↵⁎Mayo Clinic, Cardiovascular Diseases, 200 First Street SW, Rochester, Minnesota 55905
I have read with great interest the insightful editor's page of the September issue of iJACC (1) which states that physicians will be imagers, with imaging becoming a mainstay of physical examination, diminishing the need for relying on stethoscopes. “Only seeing will be believing!” and thus, the traditional models of teaching will change subsequent to this cultural change.
I cannot help but respectfully disagree with this vision of imaging technology possibly being the bridge of interaction between 2 human beings, one of whom is exposing his/her body and mind with all their imperfections, miseries, fears, and hopes to another who must use all his/her senses in an orchestrated manner to conceptualize illness and deliver personalized care. I picture an environment in which the cardiovascular examination of a patient is worthless unless the “pre-condition” of a bedside hand-held echocardiogram has been previously obtained. The concept is much more worrisome in light of the existing corporative “push” of technology use by for-profit-driven entities. Furthermore, how does this imaging future apply to less-fortunate nations and patients who do depend on their physician's auscultatory and physical exam competence for their well-being? And what will happen to the time spent face-to-face with the patient when we can do without the time spent in auscultation?
I certainly envision a new cardiovascular physician well versed in all imaging technologies, cost-effectively applied in the quest for the safest and most effective treatment plan of a patient, but I also envision this technology making physical examination teaching much more effective: i.e, what better way to teach a medical student, at the bedside, to hear a Austin-Flint murmur or the presence and timing of a mitral opening snap, then to see (on bedside ultrasound) the aortic regurgitation jet impinging on the anterior leaflet of the mitral valve and the pliable, mobile appearance of the mitral diastolic opening, respectively? Recently, a colleague sent me a patient for a transesophageal evaluation of suspected significant mitral regurgitation after a nonrevealing transthoracic echocardiogram. I listened to the patient and agreed to do it only to find a very eccentric, commissural jet of significant mitral regurgitation which would have gone undetected if my colleague did not know how to hear a holosystolic blowing murmur suggestive of it. Yes, it was advanced technology leading to the diagnosis, but it was careful auscultatory art leading to appropriate use of technology. Auscultation technology has also evolved (2) and promises to remain a critical part of the armamentarium used in physician-patient interaction, both for the detection of disease and for the sake of the interaction itself.
As physicians treating patients and teaching students, we cannot watch disease only, we have to smell it, touch it and especially, hear its music.
- American College of Cardiology Foundation