Simulator Training for Recognition of Murmurs: Give a Kid a Hammer?

Abstract

In their recent article in CHEST (February 2011), Fraser et al1Fraser K Wright B Girard L et al.Simulation training improves diagnostic performance on a real patient with similar clinical findings.Chest. 2011; 139: 376-381Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar demonstrated that students who have just listened to a mitral regurgitation on a high-cost, high-fidelity patient manikin simulator (“Harvey”) can recognize mitral regurgitation in a real patient more accurately than can students who heard other abnormal heart sounds on Harvey during training. We wish to issue a cautionary note. The evidence presented does not constitute an endorsement of simulator training, except as compared with no training. If, as we suspect, the students had little or no exposure to murmurs prior to the study (in their 8 h with standardized [healthy] patients and 2 days on the ward), then we might expect the students who heard the simulated mitral regurgitation would diagnose mitral regurgitation the next time they heard any murmur and, consequently, do better than students in the comparison groups who heard some other abnormality. Consistent with this interpretation, students who heard aortic regurgitation did not do significantly better than students who heard no murmur. The authors also describe a pilot study in which students who had practiced on aortic stenosis did worse on a case of mitral regurgitation than students who had heard no abnormalities. We also disagree with the authors' claim that we are lacking well-designed studies demonstrating that simulator training can improve performance on real patients.1Fraser K Wright B Girard L et al.Simulation training improves diagnostic performance on a real patient with similar clinical findings.Chest. 2011; 139: 376-381Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Going back nearly four decades, Aberg et al2Aberg H Johansson R Michaëlsson M Phonocardiosimulator as an aid in teaching auscultation of the heart.Br J Med Educ. 1974; 8: 262-266Crossref PubMed Scopus (5) Google Scholar showed comparable diagnostic skill (on real patients with mitral stenosis and aortic stenosis) following 2 h of patient-based clinical teaching vs 1 h of training with an electronic heart-sound generator. A more recent study found a marginal gain in students' recognition of clinical findings but no difference in their diagnostic accuracy or clinical skill (as tested on real patients) using Harvey-based training in comparison with training using an audio compact disc.3de Giovanni D Roberts T Norman G Relative effectiveness of high-versus low-fidelity simulation in learning heart sounds.Med Educ. 2009; 43: 661-668Crossref PubMed Scopus (82) Google Scholar In summary, although this study shows that a high-fidelity simulator can enhance recognition of a murmur, it also shows that the skill apparently does not generalize. More important, it does not address whether the same learning could result from much less costly approaches. Simulator Training for Recognition of Murmurs: ResponseCHESTVol. 139Issue 5PreviewWe would like to thank Drs Norman and Cook for their comments on our recent article in CHEST (February 2011).1 We agree with several of their points, including the fact that training in one clinical skill (recognition of aortic stenosis) does not generalize (to improved performance at recognizing mitral regurgitation), as we stated in the “Limitations” section of our study. This finding is another demonstration of the phenomenon of content specificity, rather than a reflection on our study.2 We also concur with their cautionary note that using high-fidelity simulators is not the only way to create a virtual learning experience to improve clinical skills. Full-Text PDF