To hear a patient’s heart, doctors used to just put an ear up to a patient’s chest and listen. Then, in 1816, things changed.

Lore has it that 35-year-old Paris physician Rene Laennec was caring for a young woman who was apparently plump, with a bad heart and large breasts. Dr. George Davis, an obstetrician at East Tennessee State University who collects vintage stethoscopes, says the young Dr. Laennec didn’t feel comfortable pressing his ear to the woman’s bosom.

“So he took 24 sheets of paper and rolled them into a long tube and put that up against her chest, listened to the other end and found that not only could he hear the heart sounds very, very well, but it was actually better than what he could hear with his ear,” Davis says.

Or, it could have been poor 19th century hygiene — lice and the smell of unwashed bodies — that kept Laennec from getting too close to his patient.

Either way, he went home and crafted a wooden cylinder with a hole down the middle, and that became the first stethoscope.

It took a while for the art of listening to the body through a tube to catch on. But the new tool fit into an evolving idea that doctors needed a more focused approached to diagnosis, “that you should distinguish tuberculosis from a lung abscess — and not just call it all consumption,” says Dr. Steven Peitzman, a professor at Drexel University College of Medicine.

He says doctors used to get praise if they had the ‘ear’ to hear and interpret the subtle body sounds that travel through a stethoscope’s rubber tubing; the stethoscope is the iconic symbol of a physician.

Vidya Viswanathan, a first-year student at the University of Pennsylvania’s Perelman School of Medicine, is still getting used to hers.

Some doctors say clinicians can now get much more information from newer technology than they can get from a stethoscope. Clinging to the old tool isn’t necessary, they say. Kimberly Paynter/WHYY hide caption

toggle caption Kimberly Paynter/WHYY

“You don’t realize until you are wearing it and trying to use it, how pokey it is in your ears,” she says. “I’m almost embarrassed to wear it because it implies I have knowledge I don’t have yet.”

Medical schools teach the art of listening.

“I am astounded at the things I’ll find with my stethoscope,” says Allison Rhodes, a third-year student at the Perelman School of Medicine. “I had a patient that had pneumonia, and it was really wonderful to be able to listen to her and say, ‘This is what I think it is.’ And then, later, see on the chest X-ray that that was exactly what it was.”

But some argue that the stethoscope is becoming less useful in this digital age. Dr. Bret Nelson, an emergency medicine physician at Mount Sinai Hospital in New York, says clinicians now get a lot more information from newer technology.

An ultrasound, for example, turns sound waves into moving images of blood pumping and heart valves clicking open and shut; those visual cues are easier to interpret than muffled murmurs, and may produce a more accurate diagnosis, Nelson says.

He admits the stethoscope is an icon but doesn’t buy the argument that if you lose the stethoscope, you lose the tradition of “healing touch.”

“Pulling an ultrasound machine out of my pocket, or wheeling the cart over next to the patient [and] talking through with them exactly what I’m looking for and how I’m looking for it — the fact that they can see the same image on the screen that I’m seeing strengthens that bond more than anything in the last 50 years,” Nelson says.

Nelson is 42 years old and graduated from medical school 16 years ago. He teaches medical students, and says it’s helpful to show new learners what “lies beneath.” At Mount Sinai, when medical students are taught to examine a heart, they learn how to use the stethoscope and an ultrasound machine on the same day.

“They know how to feel it, they know how to listen to it, and they know how to look at it,” Nelson says.

Still, obstetrician George Davis wants to keep the stethoscope around for a while. High-tech machines and imaging scans are great backup resources, he says, but his stethoscope helps him figure out which patients actually need additional testing.

“How much do those ultrasound machines cost?” Davis asks. “I can get a good stethoscope for less than $20. We are not going to sit there and do an echocardiogram on every patient who walks through the door.”

Davis worries that a whole generation of doctors is learning to rely too much on technology; he wants to hold on to first-line tools that are safe, effective and cheaper.

“Shouldn’t we be using what is low-tech and practical?” he asks.

Nelson counters that point-of-care imaging is becoming less expensive every day. Twenty years ago, he says, an ultrasound machine was as big as a refrigerator and cost $400,000. Today, a handheld, portable device plugs into a computer tablet and costs less than $10,000.

Many care providers in the community may even have an ultrasound in their pocket one day soon, he says. Who would have foreseen that today we have, “a slide rule, a calculator, a flashlight, a phone, a computer terminal and 36 video games,” all on one device — our smartphone.

This story is part of NPR’s reporting partnership with WHYY’s health show The Pulse and Kaiser Health News.

With the opioid epidemic reaching into every corner of the U.S., more people are talking about addiction as a chronic disease rather than a moral failing.

For researcher A. Thomas McLellan, who has spent his entire career studying substance abuse, the shift is a welcome one, though it has come frustratingly late.

McLellan is co-founder of the Treatment Research Institute in Philadelphia and former deputy director of the White House Office of National Drug Control Policy. His work has focused on understanding addiction as a disease and improving the ways it is treated, a mission that took a personal turn midway through his career when he lost a son to overdose.

NPR’s Audie Cornish spoke with McLellan about how addiction is viewed and how that view has shaped the treatment system we have today. He also has suggestions on how to make it better.

Here are interview highlights, edited for length and clarity.

On why addiction has traditionally been seen as a criminal justice issue, not a health issue

Think about it. If you didn’t have brain science, which has just really emerged in the last two or three decades, all you had to look at was the behavior of addicted people. They are not pleasant people when they are in full addiction. They steal, they lie, they swear they’re going to do something and they don’t. It’s quite easy to think of this as it has been thought of for literally hundreds of years: as a character disorder, as poor upbringing as a problem of parenting. And that’s how we approached it. It’s not coincidence that the Justice Department has played such a pivotal role. The emerging science shows this is a brain disease. It’s got the same genetic transmutability as a lot of chronic illnesses. And the organ that it affects is the brain, and within the brain it is motivation, inhibition, cognition, all those things that produce the aberrant, unpleasant behaviors that are associated with addiction.

On whether the drug treatment system is prepared to address the current opioid crisis

So there are two ways you have to think of it. First, there’s the traditional addiction treatment system. It was purposely set up to be separate from all of health care and that’s the way it’s been for four decades. They’ve been doing heroic things, but they’ve been underfunded, undertrained and they have been unable to provide the most contemporary kinds of treatment and monitoring. So then you turn to the rest of health care, mainstream health care. What we found is that less than 10 percent of American medical schools have a course in addiction. Ditto nursing, ditto pharmacy schools. So, contemporary physicians are not equipped to do it. Yet it’s those same kind of services, medications, behavioral therapies, monitoring and management, they now do routinely for diabetes, hypertension, chronic pain.

On the idea that addiction has to be treated over the long haul, the way diabetes and other chronic diseases are

It’s a tough sell on two sides. No. 1, it’s a tough sell for people who suffer from addiction. It’s tough to hear, “I’m sorry, we don’t have a cure. You can’t get detoxed, go away for 30 days, get your head straight and not be affected.” Same is true for diabetes. There is no place that I know of that gives you 30 days of insulin treatment and a hearty handshake and sends you off to a church basement. It just won’t work, so that’s tough.

It’s been tough for medicine, too. These are doctors who have never learned about addiction in school. Why in the world, if they’re already busy trying to treat other chronic illnesses, why should they take this on? And here is actually the best answer. You may say that expanding insurance options, providing more and better care for addicts is a waste of money, or it’s a gift to someone who doesn’t deserve it. The real gift is for the rest of health care, because it is impossible to manage most chronic illnesses without some attention to substance use disorders. They’ve been willfully ignored by medicine for decades and it’s costing them roughly $200 billion a year in wasted or inappropriate medical care.

On what has changed for people whose families are affected by addiction

The people that I know who have lost spouses, children, some of them are so ashamed that they wouldn’t even acknowledge it as a cause of death. And one thing I’ve found is that in health care, you don’t get the kind of health care that science dictates or that is even economically prudent. You get the health care that you negotiate and that is politically motivated. So for most of my life, there has been no groundswell demanding the kind of care that other illnesses have rightfully come to expect. In my life, the best thing that has ever happened and given people like me hope that your grandkids won’t have the same illness is the Affordable Care Act. It now mandates that the same kinds of care that are available for other illnesses of the body are also available for illnesses of the mind. We can do it. It’s economically sensible to do. We just haven’t had the political will.

The scale of the Zika virus outbreak in Venezuela is unclear. The government is reporting more than 5,000 cases with three related deaths. But independent Venezuelan physicians fear it could be as many as 400,000 infections. The outbreak is occurring in a country with a collapsing medical system, an economy in tatters and no funds to buy mosquito repellant, contraception or medicine.

Transcript

AUDIE CORNISH, HOST:

Next to Colombia in Venezuela, the poor state of the country’s medical system has health experts particularly worried about the rise of Zika. Colombian health officials say Venezuelans with Zika are crossing the border to seek treatment. Reporter John Otis is in the Venezuelan capital of Caracas. He joins us now. And first, John, what’s known about the extent of the spread of Zika in Venezuela right now?

JOHN OTIS, BYLINE: Well, it remains a big mystery, The Venezuelan Health Ministry said last month that there were about 4,000 cases of Zika, but there’s also been a big spike in fevers that have nothing to do with the usual culprits like dengue or malaria. And so that’s why there’s a lot of doctors here speculating that the numbers of Zika cases could be much, much higher. Some will even say there’s up to a few hundred-thousand cases. But again, this is speculation.

There’ve also been about 240 cases of Guillain-Barre. That’s a disease that can cause paralysis and might be linked to Zika. So far, the government’s reported no cases of microcephaly, but that could change because pregnant women who were infected with Zika when the virus first hit last year – they’re going to start having their babies later this spring.

CORNISH: You mentioned doctors, but what are Venezuelan officials saying to the public about this?

OTIS: That’s one of the big problems here. They’re just not saying much. This is a very secretive government. They often withhold data about everything – just normal things like inflation or agricultural production. They stopped publishing their weekly health bulletins back in 2008, and – while other countries – presidents in other countries often use the bully pulpit to educate people about Zika. President Nicolas Maduro here in Venezuela – he’ll often give speeches of up to five hours, but so far, he’s barely mentioned Zika.

CORNISH: You know, you talked about the problems here – obviously political upheaval in Venezuela, a bad economy. When it comes to the medical system’s kind of ability to handle something like this, what are the concerns?

OTIS: There are major, major concerns here, Audie. This country’s going through a severe economic crisis, and that’s left the health system in shambles. Oil is Venezuela’s main export. The prices have collapsed, and so the government now lacks petrodollars to import medicines and even basic products to help prevent Zika like mosquito repellent or Tylenol to take care of the fevers. There’s a major shortage of hospital beds, and you’ve also got brain drain because doctors who, because of the collapsing currency, are only earning a hundred bucks a month or so – a lot of them have left the country for better-paying jobs abroad.

CORNISH: What about the international community? What resources are people sending to help?

OTIS: Opposition lawmakers recently went up to Washington, and they asked the World Health Organization if they could provide emergency help to Venezuela. But for that to happen, for the World Health Organization operate, they need a formal request. And the Moduro government has refused to make that request because they just don’t want to recognize that Zika’s a problem here.

There was also a meeting of Latin American health ministers in Uruguay last month to discuss Zika, and Venezuela was the only country that showed up that failed to put forward a plan for combating Zika. So things look pretty grim here right now.

CORNISH: Journalist John Otis reporting to us from Caracas, Venezuela. Thank you so much, John.

OTIS: Thank you very much.

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