Dr. Sanders focuses on hearing and its importance to medicine and the art of diagnosis in Chapter 7, and in particular, its importance for studying cardiovascular and respiratory illnesses. What did you see in this chapter that was surprising? Please reflect on the chapter, what you found interesting,
how it related to your case study, and comment on at least one other student's comments. (whoever posts first, please make a 2nd shorter post responding to a classmates ideas)
Post before Saturday, May 7th.
In this chapter, Dr Sanders talked about her favorite topic, the physical examination, again. This time, she discussed the importance of listening in diagnosing heart disease. It turned out that some major heart diseases can be diagnosed by listening. In one study mentioned by Dr Sanders, the accuracy of five cardiologists in diagnosing heart diseases was compared with the echocardiogram. While the echocardiogram was correct 95 to 100 percent of the time, the cardiologists were right between 70 and 90 percent of the time. The cardiac examination can be pretty good when done properly. Aortic stenosis, the topic of our case study, can be diagnosed by listening. It is surprising that such a useful skill is not being taught well in medical school and in residency. It is more surprising to find out that doctors are often sent out with inadequate training and sometimes no training at all to perform procedures. I know that doctors nowadays take recertification examinations periodically. Instead of assessing the doctors’ book knowledge, emphasis should be placed on assessing the basic skills such as physical examinations.
ReplyDeleteI think the refresher classes given by the American College of Physicians were a great idea. It is essential for rising physicians to have maximum hands-on practice, not just extensive factual knowledge from books. The heartbeat exercise Dr. Sanders went through at one class relates directly to our circulatory case study. Our patient, like the mannequin patient in the class, had a serious heart problem. It is essential for doctors to be able to understand, and even diagnose, a patient’s problem based on the sounds they hear through their stethoscopes. In chapter seven, Sanders stresses the importance and power of hearing, especially in a physical exam. Both our patient, who had left ventricular failure, and the fake patient from the book, who had pericarditis (inflammation of the sac around the heart) had irregular heartbeat sounds. The pericarditis caused a scratchy sound, a result of the pericardium rubbing against the muscle of the heart. Our patient’s ventricular failure could likely have caused a displaced apex heartbeat, a gallop rhythm (additional heartbeats), and fluid sounds in both lungs. Detecting abnormal “lub-dups” is a very old, but still extremely useful, efficient and quick way to identify heart conditions. I agree with Aaron when he said he was surprised that doctors are practicing with insufficient training. I agree that it is important for doctors to have as much hands-on experience as possible, especially when it comes to vital skills such as listening to a heartbeat.
ReplyDeleteI was surprised by the discussion of teaching physical examination techniques. It was alarming that doctors now no longer go through physical exam testing because there aren't many more experienced doctors who are comfortable even in their own physical examination practices. I agree with Annaick that the class to test the heartbeats of the mannequin conducted by the American College of Physicians and the work of Eric Holmboe are excellent measures to improve the physical examination, that could actually prevent Sanders' idea that the physical examination is becoming a lost art. It is surprising that only recently has the physical examination test been reincorporated into a medical student's required curriculum. In this chapter, the practice of using a stethoscope and of listening for abnormalities in the circulatory and respiratory tracts was demonstrated through different patients' cases. My case study, on stenosis, ties into the examination of Susan Sukhoo. Susan experienced "wheezeling" and was diagnosed with asthma, yet the asthma medications weren't improving her condition. Holmboe listened to Susan's heart, and described abnormal murmurs that he could here better when Susan lay on her side so that the mitral valve of the heart was closer to the chest surface. By using his sense of hearing, Holmboe diagnosed mitral stenosis - a disease in which the left ventricle shrinks down to the point that blood cannot easily flow out of the heart and to the body. From my case study research, this diagnosis seemed very probable, especially once Sanders mentioned Susan's past with rheumatic fever and lungs filled with fluid.
ReplyDeleteChapter 7 put much more focus on the technique's doctors use in the physical exam. I found it surprising how little doctors really know, especially with regards to the heart exam. Dr. Sanders makes an interesting point at the end of the chapter by having teachers grade patient-doctor encounters. In the end, it's obvious that very few doctors actually know how to perform a physical exam, and cannot point out red flags for other doctors despite having years of training. I cannot imagine the amount of time these doctors have spent in an attempt to learn medicine, and yet they have an obvious ignorance in the physical exam. Dr. Sanders uses herself as an example of many doctor's lack of education in the physical: her examination of Susan Sukhoo was a complete debacle until Dr. Eric Holmboe pointed out a heart murmur Sanders missed while examining Susan's heart. While Holmboe was able to notice a relatively obscure murmur that the famous doctor Laennec once noticed, I think Sanders has done an excellent job in pointing out a huge problem with medical education. Namely, the physical exam.
ReplyDeleteI agree with Annaick's opinion that refresher classes given by the American College of Physicians is a good idea. However, the majority of this chapter makes me doubt that these classes are "refreshers." In fact, I would bet that many of these doctors do not have a full understanding of the physical at all. Plenty of doctors can diagnose a patient, but Dr. Sanders wishes that doctors could do it more efficiently with the use of the physical. Like Aaron, I'm shocked that doctors are sometimes sent out of medical school and residency with almost no training in some procedures. It makes me wonder what kind of training doctors receive in medical school. Obviously, doctors memorize a plethora of diseases, but I believe the more important skill is how to recognize the diseases when they appear outside the textbook. That skill seems to be not taught, but learned through experience. I think medical school should focus less on the raw knowledge of medicine and start thinking of solutions to give medical students the experience they need. Sanders mentioned that some programs are being instituted at Yale from day one, and this gives me a little comfort that doctors are trying to improve on their weaknesses. At the end of the chapter, Dr. Sanders uses the example of Dr. Shin Ru Lin as a means of conveying the lack in knowledge of the physical. Once again, another doctor missed a simple diagnosis (Aortic coarctation) through lack of experience in taking a patient's physical exam. If Dr. Sanders goal was to make her readers worry about where medical education is going, she has succeeded in provoking those feelings in me.
Chapter 7 of EPTAS was about the heart exam, which involves listening to a patient's heart, and ways in which medical schools are trying to teach students the skills of physical exams. I found it surprising that medical schools and licensing boards have only recently decided to explicitly teach and test physical exam skill such as the heart exam. These skills seem so important to diagnosing many common conditions that all doctors should definitely have to be proficient in them. I agree with Annaick and Brittany that the refresher courses on the heart exam are a good idea, and I also agree with Dryden that the fact that these so-called refresher courses even exist at all says something disturbing about the state of medical schools. There should probably be more explicit instruction for doctors on how to recognize diseases in real-life patients, not just from textbook descriptions.
ReplyDeleteMy group's case study, on pneumonia, does not tie in directly to the chapter because pneumonia is a respiratory disease. However, physical exam tests that use listening are the first and easiest way to diagnose pneumonia, as abnormal sounds like crackling and rumbling indicate the disease's presence. It is clearly important for doctors to be able to listen carefully to lung sounds and interpret what they hear so that they can diagnose pneumonia, a very common illness. As in many heart conditions, there are non-physical tests--chest x-rays-- that can be used to confirm a diagnosis, but it seems like pneumonia is relatively easy to diagnose based on a physical exam and the patient's symptoms alone.
Throughout the book, Dr. Sanders has been emphasizing both the importance of the physical exam as well as the essential lack of an expertly executed physical exam. In this chapter, Sanders begins with a description of a "refresher course" that was being administered to doctors, where they listened to sounds the heart made and tried to diagnose based on that. As many have said, the course are a good idea because they enable doctors to fine-tune their diagnostic skills by practicing the physical exam. Then again, one would hope that these courses would be redundant, and that every doctor, when they use a stethoscope to listen to your heart beat, knows what he or she is doing to the extent that they would be able to diagnose a strange noise.
ReplyDeleteMy case study, like Abby's, is on pneumonia, which isn't explicitly discussed in this chapter. That being said, listening is a key part in diagnosing pneumonia. For example, a doctor can thump on a patient's chest; a hollow sound is normal, a denser sound is an indicator of fluid in the lungs. The more practice doctors get with diagnosing things from a physical exam, and from hearing and listening to the body, the more efficient these diagnoses will become.
I found the segment on Dr. Sanders’ missed diagnosis of mitral stenosis interesting. First of all, it relates to our case study in that in both mitral stenosis and aortic stenosis the flow of blood from the lungs into the heart is obstructed. Therefore the symptoms and heart sounds of Sanders’ story are very similar to our case. Also, I enjoyed reading about a firsthand experience of dealing with the difficulties of listening to the heart and making a diagnosis based off of sound. It definitely drove home the point that doing such a thing takes a lot of refined skill and it made me appreciate how tricky it is to really quantify sound and come up with an accurate diagnosis – the concept of connecting a disease with a symptom in your mind also was reinforced with this example.
ReplyDeleteI agree with Virginia’s view that the refresher course given to test students on their examination skills is a good idea. I’m obviously no expert, but common sense seems to say that practice makes perfect and since practicing on legitimately sick patients could produce potentially fatal results, the refresher course concept makes a lot of sense.
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ReplyDeleteI agree with the others that the "refresher courses" are a useful tool for doctors. However, the whole concept of needing to relearn how to do a physical exam seems so backwards to me. On a personal level, I associate going to the doctor with getting a physical exam, because that's generally how a normal pediatric appointment works. So the idea that a doctor can be actively practicing medicine without knowing how to do a physical exam is really disheartening for me.
ReplyDeleteHowever I did find the description of actually listening to the heart interesting, like Natalie. I never before quite appreciated how carefully doctors have to listen to be able to perceive the small variations that could lead to very different diagnoses. Susan Sukhoo's case really demonstrated that idea.
My case study is on scuba diving and decompression illness, so it's not directly related to this chapter. But like with heart problems, the idea of closely paying attention to signals from the body is important in diagnosing decompression illness. Often the symptoms get misattributed to overexertion or something else and the patient can suffer long-term consequences, just like if a heart problem is misdiagnosed there can be disastrous effects.
In chapter 7, Dr. Sanders describes the aspects of the physical exam related to hearing, specifically the field of the cardiac exam. She discusses how sounds can be used to correctly identify most diseases of the heart, as long as physicians are trained well. I was surprised by how many doctors she said didn't know how to complete the examination successfully though. Once again this simple knowledge deficit results in huge deficits both from a monetary standpoint (as more expensive tests are ordered) and from a health standpoint. I too agree with Annaick that the refresher classes taught with mannequins are actually a very useful establishment. It is only natural that doctors would need to brush up on skills (or be taught those that they never learned), and the classes give them opportunities to evaluate their own knowledge. My case study focuses on on decompression sickness, which occurs when divers resurface from areas of high pressure too quickly, and bubbles of gas form in their blood. The case study reaffirmed Dr. Sanders' statements about how fragile the heart is. Even the smallest disruptions can cause huge ramifications throughout the body. As Natalie pointed out, listening to a heart is a difficult process that requires careful procedure. Our case study, while not directly addressing this issue, ultimately demonstrates the same point.
ReplyDeleteAgain emphasizing the importance of the physical examination, in chapter 7 Lisa Sanders discusses sounds associated with medical diagnoses. I found this chapter very interesting and perhaps less expected as the other chapters because previously, I had never really thought that sound and medicine really had anything to do with each other. After reading this chapter, I realized that our sense of sound does provide a great and sometimes vital source of information for doctors. I didn’t know that sound alone could be used to detect critical medical problems, such as emphysema that Laennec found in one of his patients. After thinking about sound throughout this chapter, I came to the conclusion that sounds made in a human’s body is indeed important because one of the most audible organs of our body is the heart, the part of us that keeps us alive. Listening for sounds can often be a good way to detect problems with the body because there are few sounds made within the body, but if abnormalities in these sounds are detected, we can conclude for sure that something is wrong. However, I don’t think we can completely rely on our sense of hearing when it comes to diagnosing a patient. Oftentimes, doctors don’t know what to look for and overlook minute details... details that may be central in the end. As in Susan’s case with mitral stenosis, the speaker doesn’t detect the strange, harsh, unnatural sound in her heart because it was super quiet and was likely to go unnoticed if not identified or suggested earlier. Therefore, I as of now conclude that the physical exam must be made up of several different types of tests because utilizing each of our senses could lead to new discoveries and would ensure more accurate diagnoses. While hearing is an important factor in being a doctor, it is all the parts of the exam as a whole that ensures an effective, low-failure-rate detective process.
ReplyDeleteThis chapter was closely related to my case study, myocardial infarction. Myocardial infarction most often manifests as a heart attack. I am now curious to see if myocardial infarction can be detected early on by listening for strange heart noises.
I agree with Annaick that the “refresher class” is a great idea for all doctors because after specializing these doctors understandably forget a lot of information that they learn in medical school. I also agree with Natalie that it does require an abundance of skill and experience to be able to use these sounds and come up with an accurate diagnosis. While we do get a little scared when we read about doctors not knowing everything, we must understand that so much time, work, and experience must go into being a great doctor.
In this chapter, Sanders analyzes the importance of the heart exam, its uses, and, more importantly, its misuses. Patty Donnally exhibited all the traditional symptoms of aortic coarctation, a condition in which the aorta develops abnormally, limiting blood flow to the kidneys. Had Dr. Lin or Dr. Asch performed a simply physical exam test comparing upper body blood pressure and lower body blood pressure, the patient’s case could have been solved much more easily. Quite clearly, Sanders believes mistakes, tendencies, or acts of carelessness like those shown by Dr. Lin and Dr. Asch are a direct result of poor teaching practices. One of Sanders’ main purposes of writing this chapter (and, by extension, this book) is to outline the flaws in how medicine is taught or practiced. Although it is useful to recognize that many physicians do not carry out physical examinations (especially the heart exam) correctly, the only way to correct this issue is to, quite simply, train doctors better. This is essentially the main idea trying to be conveyed throughout the many pages of this chapter (book). There may not have to be an underlying cause as to why not every physician can perform every physical test perfectly and at the right time. I also believe this issue is one that doesn’t require over-analysis. Like Abby, I, too, am baffled as to why many medical schools are only just realizing the value of physical exam skills. I commend the efforts of Dr. Eric Holmboe to create programs to improve the physical exam training particularly in residency programs. However, as this chapter revisits, the success of a physical examination is largely determined by the relationship between the patient and the physician. Dr. Holmboe is irritated by the fact that many physicians are trying to listen to the heartbeats of patients who are fully clothed. “The physical exam just becomes a much more useful tool when you use it correctly.”
ReplyDeleteMy case study involves a man who is afflicted by high altitude pulmonary edema. Using a stethoscope, a physician will typically hear crackling sounds coming from the lungs of a patient who has this condition. Although not examining heartbeats, physicians must still possess skill in using stethoscopes and listening to sounds.
I thought it was interesting that medical school graduates would need to relearn the heart exam. I guess it makes sense--people do often forget the basics of a subject once they have moved on to something more complicated. Also, of course, machines are becoming more reliable as humans are becoming less so. Yet, it is still crucial for doctors to be able to hear and identify the sounds that the heart and other organs are making to be able to get another step closer to a diagnosis. In the case of Susan Sukhoo, we saw what happens when a doctor misses an important sound, along with the diagnosis which the doctor could have made from it. All that Dr. Sanders knew about Susan's case was that she was wheezing, so she tried treating her for asthma. Sanders could hear the wheezing, but she missed the extra murmur in her heartbeat. Her next mistake was continuing to assume that Susan had asthma even though her symptoms were clearly getting worse. Luckily the problem was found before it was too late, but this is only one of many cases in which the doctor either isn't careful enough in their examination or doesn't know how to be. I agree with Sarah that this is not a very encouraging thought to have.
ReplyDeleteI'm not really sure how this relates to my case study. I have a case of a diver who has the bends, which is when nitrogen can't get out of the blood fast enough to keep up with the dropping pressure. While this could somehow connect with the overall theme of flaws in the physical exam, I'm not sure what it has to do with hearing in particular.
I agree with Sarah that it is crucial for doctors to learn physical examination. As in the case of Susan Sukhoo, a physical finding may shed light on the diagnosis. In addition, a physical finding may to direct workup like blood test and imaging. The presence of an abnormal heart sound might prompt to obtain an echocardiogram.
ReplyDeleteWe’ve seen in most chapters the importance of the physical exam and performing it effectively and this chapter we see it in relation to sound and hearing. I never really thought about listening being a key diagnostic tool, for some reason it just never really registered with me what doctors are doing when they listen to their stethoscopes. In general, humans do not use their sense of hearing to gain information as much as other animals do but it is very important and sometimes overlooked. I agree with what a lot of people are saying about the importance of a refresher course to ensure that doctors can accurately and effectively use the information they can gain by listening. My, Virginia’s and Jlor’s case study is on pneumonia. In our case study description, it talks about how the doctor came to the diagnosis of pneumonia for out patient. When the doctor listened to our patient’s lungs while he breathed and tapped on the chest, it sounded muffled and filled with fluid. The normal way it should sound is hallow, with nothing making breathing difficult. Pneumonia can also be found in an x-ray but the more sure a doctor can be in an initial examination, the better.
ReplyDeleteIt's funny that this chapter is focused primarily on the physical exam. I think it's cool that Dr. Sanders takes it so seriously. I like that she takes the practical and "easier" route when talking about examinations. Like I have said in previous blog posts, I agree with Dr. Sanders that the physical exam is the most important of all diagnostic tests. I think that hearing is also very important. In ALL doctor shows it shows the distressed patient wheezing and then the doctor taking out the stethoscope and diagnosing the patient within 5 seconds. This is extremely cool. This chapter related to our case study because the pericarditis caused a scratchy sound, a result of the pericardium rubbing against the muscle of the heart in the patient in the chapter as well. Our patient also had left ventricular failure and it was cool to see how other patients reacted to this. I tried looking it up on WebMD, but that didn't really help me out very much because there were like 100 symptoms that go along with it. In addition, I also think it's helpful and necessary for doctors to re-learn the heart exam. It's very important for doctors to be up to date with the new techniques and even the old ones that they have forgotten. I agree with basically everyone that it is important to have as much hands-on examination time and practice as possible because without it, it would be impossible to learn more things about patients and for medicine to expand and grow.
ReplyDeleteDr. Sander's story about how so many doctors are taught less and less on the subject of the physical examination utterly terrifies me. How can I trust any doctor now in helping me get a diagnosis if the actual skills of doctors are highly erratic at best? Also, she mentions the aorta and other parts of the heart, like the atriums and ventricles. I feel accomplished knowing what those are! Also, when Dr. Sanders first tried using the stethoscope on herself and hearing the steady intake of air in her lungs, I was reminded of our case study in which a 10-year-old boy suffers from pneumonia and cannot breathe properly. And I agree with Leah that Dr. Sander's determination in wanting to preserve the physical examination is really surprising. Her ongoing arguments for the physical exam are extremely consistent and I praise her for that.
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ReplyDeleteThis chapter stessed the importance of doctors being able to identify different problems occuring in the heart based on listening to the pulse. Sanders talks about a case where a patient named Susan Sukhoo has mitral stenosis, but was only thought to have asthma because the additional heart murmur was not initially noted by her doctor. This example once again highlighted the importance of the physical examination, a point that Dr. Sanders proves time and time again throughout the book. Though amazing technologies such as the echocardiogram are available and can help in discovering problems in the heart, it is still chiefly important for doctors to be well trained and skilled at identifying heart problems by listening to the rythm of the pulse. I agree with Annaick and others that the courses being offered at the American College of Physicians aimed at refreshing the skills needed to perform heart exams could be very beneficial and help many to be competent in this area that Dr. Sanders has shown to be very key in diagnosing patients.
ReplyDeleteMy case study is of a man who suffers from High Altitude Pulminary Edema, where the lungs are filled with fluid as a result of the lack of oxygen in the body at high altitudes. As Kevin mentioned earlier, one of the symptoms of HAPE is a scratchy noise upon inhaling, once again showing the importance of paying attention to details and noises heard while examining a patient because it could ultimately help diagnose them.
Dr. Sanders again stressed the importance of the physical exam in chapter 7, specifically focusing on the physical exam in the context of diagnosing major heart diseases. To highlight this point, Sanders brought up a study in which five cardiologists were compared to an echocardiogram - the cardiologists had an accuracy of 70-90% in diagnosing heart diseases while the echocardiogram had an accuracy of 95-100%. So, it is clear that the cardiac exam could very well be reliable and effective. Sanders also mentioned the case of Susan Sukhoo to additionally stress the importance of physical exams. Sukhoo was believed to simply have asthma - but, upon listening to her heart, she was diagnosed with a heart murmur; the physical exam clearly brought to attention a much more serious problem of Sukhoo's. I agree with Raizel that a physical exam is certainly crucial, but is a difficult process and requires very careful examination (so, working on bettering the physical exam would be vey beneficial). My case study is on aortic stenosis, which can be found through a physical exam (a common symptom of stenosis is that the heart makes detectable sounds due to the restricted pathway for the blood to be pumped through). I agree with Aaron that doctors should really focus on being completely comfortable with the physical exam, and that teaching how to perform a physical exam carefully should definitely be a priority of medical schools'.
ReplyDeleteAs some others have already said, this chapter was again discussing the physical examination process, but with the new diagnostic tool of sound. Dr. Sanders focused on using this diagnostic tool to diagnose certain heart diseases. I found the story of Susan Sukhoo very interesting because it pointed out the significant importance of sound in figuring out a “case.” Despite Susan’s several visits to the doctor’s office, she was still thought to have just an odd case of asthma. Even though her diagnosis made her sickness sound under control, one night she woke up gasping for air and feeling as though her chest was squeezing tighter every time she moved. She was rushed to the hospital, and after a cardiac examination by Dr. Eric Holmboe, Susan was diagnosed with mitral stenosis. Dr. Holmboe was able to diagnose her because he listened very closely while he was listening to Susan’s heart. This particular example proves that the detail in a heart exam is essential in diagnosing a patient with heart problems. I found it interesting that sound could easily make or break a diagnosis.
ReplyDeleteI agree with Brisa that even though modern medicine has access to complex technologies, it is very important for doctors to master the art of physical examination. The many aspects of physical examination (such as observing, touching and listening) can be very helpful in finding a diagnosis; therefore it is a good idea for doctors to stay experienced in this area.
In this chapter Dr. Sanders further emphasizes the importance of a physical exam by exploring what she calls one of the fundamentals of the physical, the heart examination, and its relation to the concept of listening to sounds to determine a diagnosis. I found the refresher courses Sanders attends at the American College of Physicians semi surprising because I had never before associated sound with being that significant of a factor in a physical examination. The courses in general really highlight the difficulties of perfecting such an aspect of the physical examination as shown by the medical students’ process of defining sounds and their meaning. In the specific case of Susan Sukhoo, Dr. Holmboe’s success derives from his sense of hearing because by taking the time to listen to her heart he was able to diagnose her with mitral stenosis. This chapter relates to our case study on stenosis because listening is a factor by which this illness can be diagnosed. The blocked pathway of the blood makes irregular sounds that doctors can detect and use to diagnose a patient. I agree with what most have said about the refresher courses being a good idea, as they provide a way for doctors to practice such an important skill.
ReplyDeleteIn this chapter, Dr. Sanders talks (yet again) about the physical exam and the problems surrounding it. This time she discussed how a simple hearing test can be nearly as accurate as an echocardiogram (which uses sound itself to determine results) It struck me how accurate a simple analog test can be. The sad part, of course, was the fact that physicals are becoming less and less taught in medical school. The physical (as Dr. Sanders is always pointing out) is a very important part of a doctor's visit. Especially for a routine checkup, the physical can detect things that ordinarily wouldn't be caught until things have progressed to a dangerous level. It's also so much cheaper this way. I agree with Jlor when he says that he's frightened by this tendency to skip the learning of the physical in medical school. (or to discount it) Like he said, there is a lot of trust that must be shared between patient and doctor, and at the heart of that trust is the belief that the doctor knows what he or she is doing. We should definitely put a greater emphasis on teaching analog diagnostic tools.
ReplyDeleteAs for our case study, we have High Altitude Pulmonary Edema (HAPE). This is a condition that affects people when they are at extreme heights, in thin air. At these altitudes -- especially if the patient is on a mountain -- it is important for the doctor to be able to diagnose without access to really high tech tools. And indeed often HAPE is diagnosed and cured simply by reliance on physical observations and diagnostics.
The use of a physical exam in my opinion is undoubtedly important. the invaluable knowledge that a doctor gains from a simple touch cannot be counteracted by technology in any way. This chapter related to my circulatory case study largely by the way our patient with aortic stenosis had thier symptoms discovered while testing for a different condition. It was discovered by accident, and a physical exam would have discovered the bulge right away.
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