What Residency Looks Like LXXI: Mediated Knowledge

Doctor: "I'd like a second opinion on your self-diagnosis--so a random guy from the waiting room is googling your symptoms."

Sometimes residency looks like a comic strip about the rejection of medical expertise--on both sides of the physician-patient relationship!--that your father clipped and mailed to you. It's stuck to the whiteboard in the workroom for the "Junior Hospitalist" service, which is a team of one attending and three to four residents, who act as "pre-ttendings." As "pretend attendings," we see patients and make clinical decisions mostly on our own. It's a good chance to practice semi-independently before we become real attendings.

We're also learning about using point of care ultrasound (aka POCUS) to look for pneumonia, fluid around the lungs, heart function, fluid in the abdomen, and veins for IVs. Some people argue that POCUS is the future of the physical exam, that physicians either won't use stethoscopes, or will use them even less than they already do. I've been thinking a lot about this, as I am slowly making my way through Jacqueline Duffin's dissertation/first book, To See with a Better Eye, a biography of Rene Theophile Laennec (1781-1826), the inventor of the stethoscope. He called it "le cylindre" (the cylinder), because at first it was a tube of rolled up papers, and then it was a hollow column of wood that he turned on his flute lathe. Even though "stethoscope" means "to see inside the chest," that instrument is used to hear sounds coming from inside, whereas POCUS uses sound waves to "see" inside the body. Actually, we don't "see" directly, as with an endoscope; instead, we see artefacts from the sound waves traveling through air and bouncing off more or less solid anatomical structures. It's mediated sight, just as Laennec described listening with a stethoscope as mediated auscultation--direct auscultation involved the doctor putting his ear directly against the patient's body. Now there's a physical exam skill they don't teach anymore.

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