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Academia and the Profession |

The Teaching and Practice of Cardiac Auscultation during Internal Medicine and Cardiology Training: A Nationwide Survey

Salvatore Mangione, MD; Linda Z. Nieman, PhD; Edward Gracely, PhD; and Donald Kaye, MD
[+] Article and Author Information

From the Medical College of Pennsylvania, Philadelphia, Pennsylvania. Requests for Reprints: Salvatore Mangione, MD, Department of Medicine, The Medical College of Pennsylvania, 3300 Henry Avenue, Philadelphia, PA 19129.


Copyright 2004 by the American College of Physicians


Ann Intern Med. 1993;119(1):47-54. doi:10.7326/0003-4819-119-1-199307010-00009
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Objectives: To assess the time and importance given to cardiac auscultation during internal medicine and cardiology training and to evaluate the auscultatory proficiency of medical students and physicians-in-training.

Study Design: A nationwide survey of internal medicine and cardiology program directors and a multicenter cross-sectional assessment of students' and housestaff's auscultatory proficiency.

Setting: All accredited U.S. internal medicine and cardiology programs and nine university-affiliated internal medicine and cardiology programs.

Participants: Four hundred ninety-eight (75.6%) of all 659 directors surveyed; 203 physicians-in-training and 49 third-year medical students.

Interventions: Directors completed a 23-item questionnaire, and students and trainees were tested on 12 prerecorded cardiac events.

Main Outcome Measures: The teaching and proficiency of cardiac auscultation at all levels of training.

Results: Directors attributed great importance to cardiac auscultation and thought that more time should be spent teaching it. However, only 27.1% of internal medicine and 37.1% of cardiology programs offered any structured teaching of auscultation (P = 0.02). Programs without teaching were more likely to be large, university affiliated, and located in the northeast. The trainees' accuracy ranged from 0 to 56.2% for cardiology fellows (median, 21.9%) and from 2% to 36.8% for medical residents (median, 19.3%). Residents improved little with year of training and were never better than third-year medical students.

Conclusions: A low emphasis on cardiac auscultation appears to have affected the proficiency of medical trainees. Our study raises concern about the future of this time-honored art and, possibly, other bedside diagnostic skills.

Figures

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Figure 1.
Clinical importance scores for 11 cardiac sounds and murmurs.

Scores attributed by program directors in internal medicine and cardiology are reported as means on a six-step scale, with 6 = extremely important. MR denotes mitral regurgitation; AS, aortic stenosis; AI, aortic insufficiency; MS, mitral stenosis rumble; PDA, patent ductus arteriosus; RUB, pericardial rub; S4, S4 gallop; S3, S3 gallop; OS, opening snap of mitral stenosis; MSCLK, mid-systolic click; and ESCLK, early systolic click. The diagonal line indicates identity between internal medicine and cardiology directors' opinion. Significance is reported for difference of opinion between the two groups of directors.

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Figure 2.
Accuracy in identifying six cardiac murmurs and six extra-sounds according to type of training.P

Cardiology fellows are represented in black, medical students in white, and medical residents in the striped pattern. MR, mitral regurgitation; AS, aortic stenosis; AS/AI, aortic stenosis and insufficiency; AI, aortic insufficiency; OS/MS, opening snap and mitral stenosis, rumble; PDA, patent ductus arteriosus; RUB, pericardial rub; S4, S4 gallop; S3, S3 gallop; OS, opening snap of mitral stenosis; MSCLK, mid-systolic click; and ESCLK, early systolic click. Accuracy is reported as percentage of correct answers. Adjusted scores were calculated whenever the respondents selected not only the correct finding but also findings acoustically similar and yet absent. The adjusted score considered these type of answers to be invalid. Significance is reported for improvement across the three types of training (* all < 0.02).

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Figure 3.
Accuracy rates, according to year of internal medicine training.P

Third-year medical residents are indicated in black and first-year medical residents, in white. MR, mitral regurgitation; AS, aortic stenosis; AS/AI, aortic stenosis and insufficiency; AI, aortic insufficiency; OS/MS, opening snap and mitral stenosis rumble; PDA, patent ductus arteriosus; RUB, pericardial rub; S4, S4 gallop; S3, S3 gallop; OS, opening snap of mitral stenosis; MSCLK, mid-systolic click; and ESCLK, early systolic click. Accuracy is reported as percentage of correct answers. Adjusted scores were calculated whenever the respondents selected not only the correct finding but also findings acoustically similar and yet absent. The adjusted score considered these type of answers to be invalid. Significance is reported for improvement across the internal medicine training (* all < 0.04).

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