William Cayley: Out with the old (and practical) and in with the new (and techie)?

bill_cayley_2Out with the old and in with the new? Improvements in the quality and portability of electronic diagnostic equipment have led to increasing discussion of late over the possible demise of the stethoscope. News outlets for the general public and for medical professionals have noted the growing debate over whether portable and handheld ultrasound, as well as other electronic diagnostic devices, should replace the traditional tool and icon of the physician: the stethoscope.

I tend to be a bit of a skeptic about the alleged wonders of the latest and greatest technology, and admittedly have a bent towards sticking with what is proven to work. So, to further investigate the potential merits of the stethoscope and its competitors, I had a brief (and admittedly limited) look for quality studies addressing the question. (Interestingly, the majority of controlled trials relating to stethoscopes have more to do with studying them as transmitters of nosocomial infection, not as diagnostic tools—but that discussion is for another day).

Searching Pub Med, I was only able to locate six trials from the past 10 years evaluating conventional stethoscopes against either an electronic or digital stethoscope. Three studies promoted the superiority of electronic auscultation, but the other three essentially found no difference—and none of the six evaluated the relative diagnostic performance of a conventional stethoscope versus a handheld ultrasound device.

Just because we can build something fancier, or higher tech, or that does a “better” job does not mean it is truly “better”—especially if it is more costly. I currently practice in a rural area in the US (in a rather low tech clinic), but have also had short term experience in Africa, and in both settings I think the stethoscope is invaluable. It is a simple tool that, if used appropriately, can be very valuable.

Sure, we can build tech devices (even handheld) that are easier to use and which may be more precise, but several questions remain:

1. What do you do when your electronic tool breaks, or the batteries are dead?

2. Is increased precision truly helpful? (ie, does “more precise” really mean better diagnosis or care?)

3. Are we moving from “old fashioned” and simple to “high tech” just because it is there?

4. Most importantly, is the increased cost of the high tech option offset by meaningfully superior performance?

Appropriate and judicious use of technology is entirely appropriate in advancing medical care, but across the board adoption of “new tech” that does not make a clinically meaningful difference to our patients is not.

We need to change the focus of medical innovation away from high tech toys, to low tech and cost effective ways to serve those who have no medical care.

William E Cayley Jr practices at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare beyond the following: I am the author of the https://lessismoreebm.wordpress.com/ website (“Indexing evidence based, ‘less medical’ patient care”), and an earlier version of these comments was shared on the HIFA.org email forum (http://www.hifa2015.org/hifa2015-forum/).”