A doctor without a stethoscope? Inventiveness helps Caroline Ward to overcome her hearing problem, but what about her image?

When I was told at the age of 17 years that I was hard of hearing, my first thought was, "will I still be able to do medicine?" I had wanted to be a doctor for as long as I could remember, so being told I had an impairment that could hinder this in any way was really upsetting. Luckily, my hearing loss is not too severe, so there have been few problems to overcome, but a skill that is pretty essential in medicine is auscultation, and this is slightly dependent on the ability to hear.

"Cookie bite hearing"

My pattern of hearing loss is affectionately called "cookie bite hearing" as my audiogram looks like someone has taken a huge bite out of it. This means that I have only slightly depleted hearing at either end of the scale, but the middle frequencies have gone AWOL. I have different patterns of hearing loss in each ear, making it more difficult for my brain to process whatever sounds are picked up. This is compounded by the fact that the audible frequencies are those of background noise, while the more useful frequencies, like speech, are the ones where I have the greatest loss. Consequently, I can manage one to one conversations but social situations like pubs are often virtually impossible. I cannot lipread, but by combining what I hear with what I decipher from the patterns made by the speaker's mouth and a bit of imagination, I can usually work out most of what is being said.

With these tricks, it looked like I could minimise most of the audiological problems I would encounter. My hearing loss has never been a major issue so when I applied to medical school it never occurred to me to mention it. In October 1995 I arrived at Bristol University, ready to launch myself into my medical career, complete with a beautiful stethoscope that had been an 18th birthday present.

The author's audiogram showing "Cookie bite hearing"

A hearing aid instead of a stethoscope

Our first clinical attachment began in the first week of the first year. We were only talking to patients, not examining them, so it wasn't until we were using stethoscopes in anatomy that I noticed that I was finding it harder than everyone else to auscultate. I thought that it was something that I had to get used to, like everyone else, but I soon realised my hearing loss meant that I really could not hear well enough with a stethoscope.

That Easter it was decided that the best way to correct my hearing was a hearing aid. I asked the audiologist about the stethoscope, but he had no solutions. Meanwhile, I had to get used to being able to hear in my right ear.

When I returned to university, I decided that I should let the medical school know about my hearing. I went to see the preclinical dean, and we had a chat that boiled down to the fact that they were not going to make a big thing of this if I wasn't, but if I needed any help then they were there. It was great that they were so supportive, but it also did not make me feel any different.

All medics need stethoscopes...

Our first hospital attachment began in the second term that year. I had by then grown accustomed to my hearing aid, but I had not done anything about the stethoscope. On my first day, I went to see an ENT consultant. He was interested in the problem as, surprisingly, he had not encountered it before, but he had no solution. A web search and questions to an ENT website came up with nothing, so the only possibility was to adapt the stethoscope myself.

I spent most of my spare time on that attachment in the medical physics department. On the wards, I had to remove my hearing aid to put the earpiece of my stethoscope in its place, but I could not hear much. It is also not particularly confidence inspiring for the patients to see me remove a hearing aid in order to listen to their chests. For this reason, we decided to try to couple the earpiece of the stethoscope to my hearing aid. We failed miserably. I have a vent in the aid, so holding the earpiece next to the aid made it whistle, because of feedback on the circuit. It was also surprisingly difficult to hold the earpiece in place, even after experimenting with various materials. After six weeks in the hospital, I returned to lectures, no nearer to being able to use my stethoscope. The next year, I was intercalating so I could sit in my lab all day, not worrying about hearing anything except lectures.

...but some need special ones

During this year, I saw an advert for a hearing technology exhibition. I found the man who was running the exhibition and put my problem to him. He told me about electronic stethoscopes that amplify the sound picked up by the diaphragm of the stethoscope. He gave me a phone number of a company that markets them, but the number was unobtainable. Now that I knew such things existed, however, I could spend a day of my summer holiday trawling around the Harley Street area in London and eventually located one with a powerful amplifier in a medical supplies shop. I tried it out in the ear without a hearing aid, and it appeared to work very well. During my next hospital attachment, I could hear anything that there was to hear and my only problem - just like anyone else's - was identification.

I switched that summer to a new, more local, audiologist; he decided not to replace the aid in my right ear and gave me a new aid in the left ear. Suddenly my hearing was far more "three dimensional" as I was hearing on both sides. This new hearing regime, however, put my auscultatory ability right back to square one. Now I was unable to put stethoscope earpieces in either ear, so my wonderful electronic stethoscope was useless. The last thing I wanted to do was remove the aids and be juggling a bulky electronic stethoscope, two expensive hearing aids, and possibly also a patient's arm and blood pressure apparatus.

A loopy solution

The solution was reached during a discussion with my audiologist, where the subject of telecoils was brought up. We realised that I could use a telecoil as a receiver for my stethoscope by using the electronic part, minus the tube and earpieces, and incorporating it into a personal loop system. These systems are widely used by people with hearing aids and consist of a microphone into which people talk, which is wired up to an amplifier and then connected to a neck loop--a loop of wire that fits around the neck and transmits the signal to the telecoil in the hearing aid. I phoned several manufacturers of hearing instruments, asking about their personal loop systems, but they were expensive and too large to be carried in the pocket of a white coat.

I then remembered the presence of a plug socket in the casing of the stethoscope, which is an output for connecting it to a monitor. I went to a friend called Ed who is a whiz with electronics and enrolled his help; we decided to use this socket to connect a wire to the amplifier and put a loop of wire at the other end, which would act like a neck loop. He found me a wire with a plug that would fit the socket and made a coil of wire that was small enough to fit over my ear, rather than a large neck loop. This was connected to the long wire via a variable resistor. Initially, I could not hear very much with this, but during an appointment with the audiologist the next day we discovered how to adjust the sensitivity of the telecoil. Without the stethoscope, we did not know how high to set it, so we arbitrarily set it at half of the maximum.

Much later that night, I was playing with my newly sensitised hearing aid and the stethoscope, adjusting the variable resistor by small amounts, when I suddenly hit a point where I could hear my heartbeat really clearly. It was incredibly frustrating as the hour was far too unsociable to be able to phone Ed and tell him that it was working. The only problem with it was the large amount of electrical noise from the telecoil, which obscured sounds from the stethoscope and also made using the telecoil really annoying. When I returned to the audiologist for my final check up, we reset the telecoil to be slightly less powerful, eliminating most of the noise but balancing this with the sensitivity necessary for auscultation with the stethoscope loop system.

The first time I had the chance to use my new stethoscope was in my attachment with the charity Care of the Elderly. This was great as it provided me with a full range of heart murmurs, breathing sounds, and patients with very loud and very soft heartbeats, so I was really able to play around with my new improved toy. It was now getting more strange looks than ever from both patients and medical staff, but the improvement was astonishing. It seems that all of the original problems have been solved. Most importantly, I am now able to auscultate without having to remove my hearing aids.

But what about "the look"?

The stethoscope is very light and compact, compared with its original form. I can wind up the wire and coil and put them in a small plastic box in my pocket, which is only 83631.5cm in size and weighs nothing. So I now have a simple, neat little system which took very little time to make and consists of bits that Ed had lying around at home and in the electronics lab: two pieces of wire, one variable resistor, and a plug, at a total cost of less than a pound. It is still possible to connect the normal tubing and earpieces to the electronic part, so two people can listen to the same thing at the same time (I'm really looking forward to using that trick in paediatrics). This leaves me with just one problem: how will I look like a doctor without a stethoscope slung around my neck?