Auscult the Skin, Not the Sweater

I applaud Dr Henry Schneiderman for his remarks in a recent “What’s Your Diagnosis?” column regarding the proper way to perform auscultation and percussion of the chest (CONSULTANT, October 2008, page 874). I am a family practitioner, and I examine my patients on their bare skin. It is a shame that I have had to remind my own primary care physician, my cardiologist, and my pulmonologist to listen to my heart and lungs through my skin-as we were all taught to do in medical school-rather than through my clothes. It is a breath of fresh air to have someone address this issue.

--Robert Schiavone, MD
Louisville

I am grateful to Dr Schiavone for his note, and I share his outlook. The application of the stethoscope to the skin of the body surface rather than to clothing avoids both the creation of artifactual sound and the filtering/obscuring of diagnostically valuable sound that is generated within the body. This is so elemental, and so universally agreed-upon by those who have studied the science behind our clinical practice, that it is a counterpart of what attorneys call Black Letter Law, ie, something we expect every practitioner to know perfectly and to act on consistently, without need of reminding to make it part of thought and action. I know by heart all the reasons why auscultation through clothing commonly occurs anyway-a false sense of modesty, the press of time, consistent depiction in the media of auscultation through clothing (along with universal backward display of chest radiographs on view boxes), use of physical examination as ritual and not for diagnosis-and I find them utterly unconvincing. When we indulge in ausculting the sweater, we lose the very diagnostic help we sought, introduce artifact, and give a subliminal message either that the patient is so repellent that we can’t abide the sight and touch of his or her body, or that we are practitioners of tele-diagnosis who abhor the normal familiarity of the human body.

--Henry Schneiderman, MD
Vice President for Medical Services and Physician-in-Chief
Hebrew Health Care, West Hartford, Conn
Professor of Medicine (Geriatrics) and Associate Professor of Pathology
University of Connecticut Health Center, Farmington