Saturday, June 17, 2006

The Plastic Stethoscope

Remember this scene from the 1967 movie, The Graduate when Benjamin is learning what he REALLY needs to know about life?

Mr. McGuire: I want to say one word to you. Just one word.
Yes, sir.
Mr. McGuire: Are you listening?
Yes, I am.
Mr. McGuire:

There may be more truth in this line that I realized since first seeing this movie.

When we were young eager medical students with our open-eyed wonder at the incredible intricacies and complexities of medicine, the physical exam opened an incredibly interesting and cost-effective way to actually diagnose ailments with the touch of your finger, sounds reaching your ear, or discovering the characteristic sweet infectious smell of pseudomonas aeruginosa colonizing an open wound. Each of us were given the almost magical opportunity at making important diagnostic revelations with only our senses. Perhaps most important to me, a budding young cardiologist-to-be, was the revelation that when I placed my first Sprague-Rappoport stethoscope to my ears, I could actually hear those subtle heart sounds that I had been taught. No cheap substitute stethoscope would do - it just didn't have the acoustic characteristics to bring the subtle heart tones to my ears like that bright, shiny, heavy, testimonial- to- careful- engineering could bring. It was like the difference between HD radio of today and the old AM stations of earlier times. No comparison.

Last Thursday (6/15/06) in the Wall Street Journal, there were two articles juxtaposed on the same page: "Hospital Intiative to Cut Errors Finds About 122,300 Lives Saved" and "Ambulances Find Overwhelmed ERs 'At Breaking Point'." One article extolled the phenominal gains of the new initiatives in heath care delivery to minimize errors juxtaposed to the crisis confronting guys on the front lines of Emergency Medicine - the medical safety net that often can't meet the demand imposed upon it due to overcrowding in our Emergency Rooms.

And then I've realized that every bed in our hospital has converted to private rooms. Why? Certainly its nice to offer such nice confines to our patients, but the push to reduce 'errors' has necessitated the conversion to limit the spread of infection from one patient to the next, we're told. In fact, patients with a so much as a positive nasal swab for methicillin-resistant staphlococcus aureus (MRSA) but no sign of clinical infection are placed in a private room and labeled for "contact isolation." Any person having contact with this patient must remove their hospital coat, don a plastic "gown" over their clothes, wear plastic gloves and mask, and surrender their $150 stethoscope for a plastic tube attached to a thin plastic wafer that stays in the patient's room. Let me be clear: the engineering properties of this plastic auditory apparatus serves no useful clinical purpose rather than the placebo effect for the patient that someone really is listening to a their lung sounds.

"Here we are, seeing fewer patients, but with fewer errors. Perfection wins out over the real need."
The report from Harvard that I noted in the Wall Street Journal claimed that in 18 short months we've saved "122,300 lives" through this hospital error-reducing initiative. Amazing. Earlier we were told in a much-quoted study from the "Institute of Medicine (IOM)" that reduction of medical errors would save between "44,000 to 98,000 errors" annually (average 71,000). And miraculously, in 18 months we've actually saved more lives than previously expected! Are we really? I just haven't clinically seen that many people cooling it from this many medical errors. Another review of hospital deaths by physician reviewers, felt the IOM's report greatly exagerated their findings. And yet here we are, seeing fewer patients, but with fewer "errors." Perfection wins out over the real need.

While in the Navy, I took the Combat Casualty Care Course (or "C4" as we called it). We learned about the medical term of triage - do the most good for the most people. Look at what looms before us: the baby boom generation coupled with the advances of medical care, technology, and improvements in therapies that have increased life expectancy like never before. Bird flu might be around the corner. Terrorist activities have strained the medical community before. Third world countries see teams of people die from HIV. Yet here we are, reaching "error perfection" in a sea of humanity who needs our help. And I can't even use the most cost-effective technology that exists: a fine acoustically-tuned stethoscope.

Medicine needs a reality check. The fact that the early stages of a hospital initiative that already fixed more errors than really existed in the first place seems little more than political (or perhaps professional) grand-standing to me. Perfection might be reasonable goal to strive for with noble intentions, but could we be causing the greatest medical error of all: sacrificing care to the many with huge expense (how much do all those plastics we wear and place to our ears cost in terms of missed diagnoses and missed admissions?) so that we can get paid by Medicare for reaching perfection in the few?

As I put on my 7th plastic gown, gloves, and facemask while shuffling from room to room on rounds and reached for the tubing with plastic wafer attached, I wondered...


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