Why Auscultate?

This blog has been very observational and analytical. And maybe a little sarcastic, big surprise. So let me just put a little sincerity on the record: I love this work. Seriously.

It just feels important. The day-to-day tasks, all the mundane details, they really matter. When I take a history, I actually care about getting every fact right. When I listen to a lung, I actually listen for crackles, like really listen. Hard. When someone has a heart murmur (and there are lots), I actually do those maneuvers like having them bear down, or lie in lateral decubitus.

I have to tread carefully here: I’m not saying I don’t do my job at home. I do listen to the heart and lungs on all my U.S. patients. And if one of my CHF patients in the U.S. has massive wet crackles at the bases, I’ll pick that up. But do we really base our treatment decisions on it? Rarely. Let’s say I’m trying to decide whether I should change the lasix dose. If the crackles sound the same, but the chart says he put out 4 liters of urine, which one are you going to trust?

When I do a heart exam, my opinion about whether it’s a late-peaking murmur radiating to the carotids don’t mean diddly. We’re gonna get an echo to find out if there’s stenosis. And all treatment decisions will be based on that. The heart exam is irrelevant.

Here in Uganda, the physical exam matters. Here, my physical exam is the final word. And I’ve discovered that when my physical exam is the final word, I actually care about doing it right.

Let’s be clear: I’m not saying that in the U.S. there’s no need for smart people to make diagnostic and therapeutic decisions. There’s plenty of brain work available. It’s just the physical exam that’s useless. And for a good reason: technology is better.

But patients want to be examined when they get seen by a doctor. So what’s the result? Doctors waste a lot of time doing physical exams that won’t really affect their treatment decisions. They’re disengaged from their work. Lower job satisfaction.

Me on the other hand? Here in Uganda? Every moment that I’m with a patient I’m engaged. Because I’m actually paying close attention to every lung I auscultate and every abdomen I palpate.

Is there grey area here? Obviously. There are plenty of examples in the U.S. of times when the physical exam does matter. And of course, when you’re unsure, you always go back to the patient.

But my “job satisfaction” here in Uganda has been strikingly high, and I think one reason is the real importance of ordinary tasks like the physical exam.

The other reason is lakes with islands in them.