Jan 8, 2016

The Stethoscope as Synecdoche

by Jim Loewen

Sociologist James W. Loewen is the author of Lies My Teacher Told Me.

In the first Sunday Washington Post of the new year, Lenny Bernstein (not related to the conductor/composer) has a front-page article, "After 200 Years, Time to Check the Pulse of a Medical Icon." He begins: “The stethoscope is having a crossroads moment. Perhaps more than at any time in its two-century history, this ubiquitous tool of the medical profession is at the center of debate over how medicine should be practiced.”

"Great!" I think. Long ago — I don't know where — I read about how the stethoscope was not an example of the progress of Western medicine, but of its regress. The author noted that a stethoscope does not clarify or amplify the sounds of the lungs breathing, the heart beating, or of whatever body part is being examined. On the contrary, asking the patient to take his/her clothing off that part and then putting one's ear flatly against it is clearer than any traditional stethoscope. My dad was an M.D. I had a stethoscope handy. I tried it, compared to my naked ear. My ear was much clearer and louder.

The stethoscope was not invented to be clear or loud. On the contrary, René Laennec, a French physician, was "reluctant" to place his ear on a patient's chest because she was young, female, and buxom. Back then (1816), few female doctors existed, so this discomfort was probably widespread on the part of physicians — and patients too. I suspect some doctors were also squeamish about placing their ear directly onto men's chests, abdomens, and worse.

A stethoscope helps a doctor look and feel more professional, with professional tools. It works worse, but the physician can feel better about himself[1] while using it. It reminds me of groundskeepers at the University of Vermont in the mid-'70s who used gas-powered blowers to get the leaves off sidewalks in the fall. Back then at least, blowers were heavy and inefficient. Using them took longer than vigorous sweeping with a push broom would have. But pushing a broom has no status. Operating machinery does. Similarly, the stethoscope has become a badge of office for physicians, to the point where they leave them around their necks or looped out of white coat pockets even when they are unlikely to need them.

Sociologically, the stethoscope allows the physician to distance from the patient, actually as well as figuratively. As Richard Selzer, the surgeon and renowned author of Mortal Lessons put it, "The entire medical world continues to pay homage to Laennec for his gift of space interpersonal."[2] Stethoscopes also let doctors put a literal up/down dimension onto their patients, even patients who happen to be eminent artists, jurists, or executives. We have all had the experience of doctors calling us by our first names while we are to call them "Doctor _____" in return. The stethoscope is part of this process — sort of a synecdoche.

Laennec felt the need to remove the sexual aspects of his patients and to professionalize listening. In "Behavior in Pubic Places: The Sociology of the Vaginal Exam," sociologist James Henslin and obstetrical nurse Mae Biggs describe how male doctors prompt transitions within their patients "from person to pelvic" when doing pelvic examinations.[3] Again, the motivations were to remove the sexual aspects and professionalize examining — laudatory goals probably desired on both ends of the speculum. The entire American uphill "delivery" system blossomed, peaked, and withered during the twentieth century. It similarly professionalized a natural process, childbirth, complete with stirrups, forceps, and anesthesia.

The stethoscope symbolizes the continuing trend in Western medicine to treat the illness, not the patient. As synecdoche. it stands for all the ways we now do this. Similarly, the forceps and anesthesia for childbirth convert the baby into a medical problem; the entire twentieth century delivery protocal rested on an analogy between foetus and huge stomach tumor.

This practice has had success. Antibiotics do wipe out infections, even without taking a history or listening to an organ. Putting a stethoscope onto a chest objectifies that chest in a way that putting an ear on it does not. Doctors already take courses on how to gain distance from patients to get over their deaths and move on. Patient death is hard on doctors. Who am I to say they should get closer to their patients?

At the same time, Western medicine mislaid some things along the way. We may not all get fifteen minutes of fame, but fifteen minutes is all most of us get of a doctor's time, no matter what is wrong with us. On top of that, we usually see a different doctor each time, at the massive bureaucracy or hospital to which we go. The impersonality of it all — the social distance — causes failures of care as well as successes. Intangibles like trust and even humor facilitate the flow of information in both directions that leads to successful treatment. The placebo effect — better known as the body's ability to heal itself — also depends on a human-to-human bond.

It turns out that Lenny Bernstein's article in the Post missed the role of stethoscopes in inaugurating and symbolizing this process of distancing. Today, medicine has moved so far away from the person-to-person interaction of Laennec's time, in 1816, or even that of my childhood in 1950, that the stethoscope can now be viewed as a positive thing. Rather than separating the doctor from the patient, Bernstein says the stethoscope "narrows the physical distance" [my italics] and "compels human touch." In the context of medical practice today, surely he's right. Recently I saw my physician because my big toe was tender and inflamed. He never got within six feet of it or me.[4] When my wife broke her pelvis and two ribs, her doctors examined only her x-rays and MRI images, not her. As a result, they misdiagnosed her at first.[5]

Now stethoscopes are going higher-tech, letting doctors distance themselves still farther. Portable ultrasound imaging from devices no bigger than cellphones are on the way. Perhaps the next step: a stethoscope app for our cellphones that sends our sounds to the doctor's office. Just as we no longer go to the library to read a journal article, we'll no longer go to the doctor's office to be examined.

Elazer Edelman points out in the New England Journal of Medicine, "a stethoscope exam is an opportunity to create a bond between doctor and patient." Bernstein closes his essay with a quote from Edelman: "You can't trust someone who won't touch you."

[1]I think this discussion is probably gendered, so I'll leave it "himself."

[2]Richard Selzer, The Exact Location of the Soul (NY: St. Martin's Picador, 2001), 153.

[3]James Henslin and Mae Biggs, "Behavior in Pubic Places: The Sociology of the Vaginal Exam," in Henslin, ed., Down to Earth Sociology (NY: Simon & Schuster Free Press, 2007), 229-41.

[4]Luckily, my toe cleared up.

[5]Luckily, she got better.