[Ann Emerg Med. 2009;53:534-535.]
It happens to most of us sooner or later: you lose something that you didn't know mattered to you. For me it was a trusted tool of my trade; a friend who shared the grind of my training, the triumphs and embarrassments of my saves and screw-ups, and the public and the personal transformations that permit the passage into the professional self. It was my stethoscope. During a commonly busy, overinterrupted and mind-flooding night shift, somewhere between pulling on a dislocated and annoyingly powerful shoulder of a local bodybuilder and intubating through bloody vomit (when you just have to toss the thing aside or it will dangle and distract), I realized my Littman II was no longer around my neck. I don't know whether it “walked away” with someone or got tossed into a biohazard bin with the rest of the mess. Several days of retracing steps during my subsequent shifts were fruitless. I got by with a flimsy pink throwaway from the supply closet that got me laughs from the nurses and queasy glances from patients, and finally faced facts: Lassie was gone, and I needed a new sidekick.
At the end of June, when the physicians' CME allowance is due to expire, the publishers rake in the dough. The authoritative tomes arrive to their new owners crisp and heavy and become faithful doorstops and shelf decorations for years to come, rarely used because up-to-date clinical knowledge is only a few clicks away. Fully aware of my about-to-evaporate $300 surplus only redeemable at an online medical bookstore, I typed “stethoscope” and clicked search. And there it was, an oddly excessive (though “free” for me), yet functional and beautiful, gold-plated Littman II.
Medical students get enamored with techie medical tools, particularly super-amplified electronic stethoscopes sporting fancy lights and buttons. I tried a few in the past and was disappointed with their inability to survive the beating of my work for more than a week. I also found that patients were uncomfortable with professional tools that resemble a karaoke gizmo from Toys-R-Us. However, the patients always appreciate sentiments of quality: a crisp white coat, the graceful act of putting on glasses when reviewing their moles and paperwork (too bad for us contact wearers), or a slow, comforting tone of voice. Amidst the impersonal rush, obnoxious odors and neighbors, nonexistent privacy, and irksome noise, little things the physician does set the tone for what is otherwise an insult to injury. Amused at having talked myself into it and convinced the patients would love it, I ordered the shinier version of Lassie.
When I first used it on a patient, he murmured “hmm, that's nice” while putting extra effort into his breaths and sneaking satisfied glances onto his chest. I expected the patient's reaction but it was my own that made me pause. Seeing the shiny stethoscope but hearing the same old rhonchi made me think of the biblical story of the golden calf.
According to some interpretations of the Bible, after 40 days of Moses' absence, the Israelites felt lost without their leader and wished to create something that would lead them instead.1 Aaron, the brother of Moses, complied and melted the people's earrings to make the golden calf, which the Israelites promptly worshipped.2 Suddenly, I saw striking parallels between the ancient story and my professional world. In the beginning of the 20th century, the opinions and experience of legendary physicians like Osler, who singlehandedly authored The Principles and Practice of Medicine, were the source of authoritative medical guidance.3 But then the spirit of the scientific revolution deeply permeated the art of medicine, and the opinions of the few famous experts gave way to research findings as the source of clinical fact. The democracy of scientific publication empowered any practitioner to contribute to and modify “the art.” The mathematical analysis of scientific findings was so stimulating, intellectually satisfying, and logical, it had acquired an aura of the truth.
Without a doubt, the scientific method improved medicine greatly, uncovered lifesaving therapies, and put an end to many practices that were time honored but not beneficial. Yet these days it is too rare for science to be motivated only by the search for truth. Medical investigators are seeking financial support, professional recognition, satisfaction of academic requirements, or tenure; they need their studies to succeed. This means not only the dramatic positive results but also findings of nondifference so en vogue with the journals seeking to appear resilient to sponsor influence. While using my gold-plated stethoscope, I pondered the actual evidence under the shiny surface of evidence-based medicine, which young practitioners are taught more rigorously to worship than to understand and troubleshoot. Straw-man comparators and selective publication of positive trials, false criterion standards, pressures to publish and to please the sponsors, biased interpretation of unfavorable results, statistical finagling that can find significant differences whichever way you need them spun—evidence-based medicine is an enterprise based on theoretical purity and honor but full of and inevitably affected by human faults.4, 5 As a bedside applicant of “evidence,” I am responsible for ensuring that it helps my patients rather than harms them after it achieved ulterior motives. I will not blindly “kneel before the altar of the randomized controlled trial.”6
My golden stethoscope tells patients about the service I strive to provide. It also reminds me to think about the applicability of averaged and biased research to my complex and unique patients. I hope that makes a difference between golden and gold-plated practice.
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