The stethoscope as metaphor
“Those who advise that all stethoscopes should be ‘scrapped’ may be influenced by the fact that they do not know how to use their own.”
From Pulmonary Tuberculosis, 1921, by Sir James Kingston Fowler (1852–1934) of the Brompton Hospital, England
The commentary by Clark et al in this issue1 is a timely reminder of an important problem in modern medicine: the demise of the bedside. My only divergence from the authors is in their conclusion, since my Mediterranean pessimism leads me to believe that theirs is just a gallant attempt at rearguard action for a battle that, unfortunately, has long been lost.
More than half a century ago, Paul Wood warned us against the “danger of losing our clinical heritage and pinning too much faith in figures thrown out by machines,” thundering that “medicine must suffer if this tendency is not checked.”2 Well, that tendency was not checked, and medicine (and our wallets) have indeed suffered.
Still, technology is not the enemy. The misuse of technology is the problem.
Like Dr. Clark and his colleagues, I’ve seen many cases in which technology unguided by bedside skills took physicians down a path where tests begot tests and where, at the end, there was usually a surgeon, and often a lawyer. Sometimes even an undertaker. The deaths of Jonathan Larson (writer-composer of the musical Rent) and of his namesake, actor Jonathan (John) Ritter—who both succumbed to undiagnosed aortic dissection—make me wonder whether their pulses were ever checked.
Editorials have lamented the “hyposkillia” of our times,3 and the usual suspects have been already rounded up: our overreliance on tests, our ever-increasing fascination with the machine (what Erich Fromm called the necrophilia of our times),4 the loss of bedside teaching, and lastly, the lure of compensation. But one important player has so far gone unnoticed, despite being probably the major offender. In fact, it may even be responsible for the other disturbing trend in modern medicine: the loss of empathy.5
I’m referring to the disappearance of the humanities in both the undergraduate and the graduate curriculum. This is actually new. If we look, for example, at the great bedside diagnosticians of the past, we find that they were passionately interested in everything human. Most, if not all, were indeed humanists—lovers of the arts and literature, travelers and historians, poets and painters, curious of any field that could enrich the human spirit. Charcot, who single-handedly invented neurology, was not only a superb scientist, but also a talented artist who drew and painted (skills he considered fundamental for bedside observation) plus a bona-fide Beethoven fanatic who spent Thursday evenings on music, strictly forbidding any medical talk. Laënnec himself was a poet and musician who modeled his stethoscope after the flutes he made. And Charles Bell (of Bell palsy, phenomenon, and law) was a well-respected painter who soldiered with Wellington and left us incredible sketches of the Waterloo wounded and maimed. Even Osler, the pinnacle of 19th century humanistic medicine, believed so strongly in the value of a liberal education as to provide students with a list of 10 books (ranging from Plutarch and Montaigne to Marcus Aurelius and Shakespeare) to read for half an hour before going to sleep. Addressing the Classical Association just before his death, he lamented the “grievous damage” that had been done by regarding the humanities and science in any other light than complementary, while in reality they are “twin berries on one stem.”6
