More recently, and the point of this article, a small ultrasound machine is being hailed as the new stethoscope.This is bolstered by recent medical literature bemoaning the loss of auscultation skills by the latest generation of doctors. Physician reliance on the stethoscope has indeed decreased.A 21st-century medical student is initially exposed to cardiac auscultation with inspiring lectures that often incorporate innovative electronic teaching techniques of heart sounds. This usually spurs their enthusiasm for the stethoscope. After all, it is the symbol of their chosen profession.This shortlived enthusiasm for auscultation is evident during their rotations in the clinical third and fourth years, where they examine real patients with a stethoscope. Unfortunately, soon afterwards, when time becomes precious during their internship and residency, they seem to come to the inevitable conclusion that the ultrasound machine is much more expeditious and accurate in establishing a cardiac diagnosis. Their interest in further learning the fine points and nuances of using a stethoscope wanes.This is especially true if there is no knowledgeable mentor available to teach them the fine art of honing their stillimmature auscultation skills.Auscultation role models are hard to find. It becomes more practical to order an ultrasound study than to spend time listening to the heart.

Over the last 30 years, cardiac ultrasound (usually referred to as echocardiography) has emerged as a powerful diagnostic tool for patients with heart disease. It has dramatically altered the diagnostic approach in children with congenital heart disease. Echocardiography has virtually replaced cardiac catheterization as the primary diagnostic tool in most of pediatric cardiology. In adult cardiology, echocardiography has emerged as a convenient and reliable first-line method of testing in most cardiac disorders. At the same time, the scientific literature on echocardiography has validated its extensive diagnostic capabilities.

Echocardiography provides extensive anatomic and functional information about the heart. It often clarifies stethoscopic, electrocardiographic, and X-ray findings. Both the stethoscope and the ultrasound exam of the heart provide physical evidence of abnormalities, but the ultrasound may be more informative at an earlier stage of a disease. For example, ultrasound can actually measure the strength of cardiac muscle in heart failure. The stethoscope will only provide such evidence late in the course of the disease when the heart actually begins to enlarge and fail. Ultrasound can help identify which coronary artery caused a heart attack. Readily available ultrasound may shorten the time it takes to make a diagnosis. It can identify causes of chest pain other than heart attacks, altering the treatment of patients dramatically and providing correct life-saving diagnosis in many cases.

Nevertheless, it is unwise to alter the customary sequence of evaluating a patient in most cases. After obtaining a history from a patient, a physical examination (including auscultation) should be performed. At that point, the stethoscope may reveal that a calcified valve has caused this patient to faint. Detailed ultrasound using the high-end equipment will still be required to decide whether to proceed with an operation to replace the valve. An out-of-sequence cursory or limited ultrasound examination performed during the initial evaluation may not reveal the true extent of the problem.

As ultrasound technology improves, the image resolution gets progressively better, but there is still a significant minority of patients that are difficult to image. In those people it is occasionally necessary to insert an ultrasound probe into the esophagus to image the heart without obstruction from ribs or from lung tissue. It is called transesophageal echocardiography (TEE).This is a semiinvasive procedure that is fairly safe, but does carry some degree of discomfort. It has revolutionized the medical treatment of some heart rhythm disorders and the surgical treatment of heart valve disorders and has become an indispensable tool in specialized heart centres.