Auscultation Skills Research Articles

Using a multimedia tool to improve cardiac auscultation knowledge and skills.

Today's medical school graduates have significant deficits in physical examination skills. Medical educators have been searching for methods to effectively teach and maintain these skills in students. The objective of this study was to determine if an auscultation curriculum centered on a portable multimedia CD-ROM was effective in producing and maintaining significant gains in cardiac auscultatory skills. Controlled cohort study. All 168 third-year medical students at 1 medical school in an academic medical center. Students were tested before and after exposure to 1 or more elements of the auscultation curriculum: teaching on ward/clinic rotations, CD-ROM comprehensive cases with follow-up seminars, and a CD-ROM 20-case miniseries. The primary outcome measures were student performance on a 10-item test of auscultation skill (listening and identifying heart sound characteristics) and a 30-item test of auscultation knowledge (factual questions about auscultation). A subset of students was tested for attenuation effects 9 or 12 months after the intervention. Compared with the control group (1 month clinical rotation alone), students who were also exposed to the CD-ROM 20-case miniseries had significant improvements in auscultation skills scores (P < .05), but not knowledge. Additional months of clerkship, comprehensive CD-ROM cases, and follow-up seminars increased auscultation knowledge beyond the miniseries alone (P < .05), but did not further improve auscultation skills. Students' auscultation knowledge diminished one year after the intervention, but auscultation skills did not. In addition to the standard curriculum of ward and conference teaching, portable multimedia tools may help improve quality of physical examination skills.

Using a Multimedia Tool to Improve Cardiac Auscultation Knowledge and Skills

Using a Multimedia Tool to Improve Cardiac Auscultation Knowledge and Skills

Auscultatory Skills Declining Among Medical Residents

Diagnostic technology has brought tremendous advances in the care and treatment of cardiac patients, but have valuable and less costly bedside

Cardiac auscultatory skills of physicians-in-training: a comparison of three English-speaking countries

PURPOSE: Cardiac auscultation is suffering from a declining interest caused by competing diagnostic technology and, possibly, inadequate teaching and testing of physicians-in-training. Because access to technology, traditional teaching practices, and methods of trainees’ assessment vary among different countries, we speculated that trainees’ proficiency in auscultation might also vary. SUBJECTS AND METHODS: We tested the cardiac auscultatory skills of 314 internal medicine residents (189 from the United States, 89 from Canada, and 36 from England) from 14 programs. All participants were asked to listen by stethophones to 12 prerecorded cardiac events and to answer a multiple-choice questionnaire. They also completed a survey concerning attitudes toward cardiac auscultation and auscultatory teaching received during training. RESULTS: Mean (± SD) identification scores for the 12 cardiac events ranged from 0% to 58% for American trainees (mean 22% ± 12%), 0% to 58% for Canadians (mean 26% ± 13%), and 0% to 42% for British trainees (mean 20% ± 12%). Canadians’ cumulative scores were slightly but significantly greater than those of American ( P = 0.02) and British house officers ( P = 0.05). British house officers improved the most during the 3 years of training ( P <0.05). Canadian and British trainees had received more auscultatory teaching during medical school and residency; they had also used audiotapes more frequently (all P <0.001) CONCLUSIONS: Auscultatory proficiency was poor in all three countries. Although there were slight differences among countries, the most striking finding was the consistent inaccuracy of all trainees. This suggests that variables other than teaching and testing affect proficiency.

Clinical auscultation skills in pediatric residents.

The aim of this study is to determine the level of clinical auscultation skills in pediatric residents at Duke University Medical Center. Forty-seven residents from pediatrics and joint medicine/pediatrics training programs at Duke University Medical Center were enrolled in this study. They were asked to examine the cardiovascular patient simulator, Harvey, and report their findings. Five common conditions seen in the pediatric population were presented: ventricular septal defect, atrial septal defect, pulmonary valve stenosis, combined aortic valve stenosis and insufficiency, and innocent systolic ejection murmur. The responses were scored by the number of features and diagnoses accurately reported. Five pediatric cardiologists and cardiologists in training were also asked to participate in a manner similar to the trainees. The mean score of features identified for the resident group was 11.4 +/- 2.6 of a possible 19. The diagnostic accuracy was 33%. There was no significant difference between residents by year of training or by type of residency program, although there was a trend toward improved performance with more training. The difference in performance between the pediatric cardiology group and the residents group was striking. The condition that was most frequently misdiagnosed was the innocent systolic ejection murmur. The clinical auscultation skills of pediatric residents in this study were suboptimal. There was a trend toward improvement as training progressed, although not statistically significant. These skills are likely to improve further with increased exposure to patients with cardiovascular disease especially in the ambulatory care setting.

Pulmonary Auscultatory Skills During Training in Internal Medicine and Family Practice

We conducted a multicenter, cross-sectional assessment of pulmonary auscultatory skills among medical students and housestaff. Our study included 194 medical students, 18 pulmonary fellows, and 656 generalists-in-training from 17 internal medicine and 23 family practice programs in the Mid- Atlantic area of the United States. All participants listened to 10 pulmonary events recorded directly from patients, and answered by completing a multiple choice questionnaire. Proficiency scores were expressed as the percentage of respondents per year and type of training who correctly identified each event. In addition, we calculated a series of cumulative scores for sound recognition, disease identification, and basic knowledge of lung auscultation. Trainees' cumulative scores ranged from 0 to 85 for both internal medicine and family practice residents (median = 40). On average, internal medicine and family practice trainees recognized less than half of all respiratory events, with little improvement per year of training, and were not significantly better than medical students in their scores. Pulmonary fellows had the highest diagnostic and knowledge scores of all groups. These data indicate that there is very little difference in auscultatory proficiency between internal medicine and family practice trainees, and suggest the need for revisiting these time-honored skills during residency training.

Cardiac Auscultation Skills of Physicians in Training

To the Editor. —Using a standardized patient assessment, we confirmed the disturbing findings in the article by Drs Mangione and Nieman 1 concerning the cardiac examination and substantiate their fears regarding other basic physical diagnostic skills. Nearly 1500 students from 8 New York City medical schools are assessed annually at The Morchand Center for Clinical Competence at the Mount Sinai School of Medicine, and examination results commonly show weaknesses in this area. For the class of 1997, for example, in a standardized patient with shortness of breath, chest pain, and possible aortic dissection, only 4% of 1026 examinees evaluated blood pressures in both upper extremities, 50% auscultated the lungs, and 10% percussed the posterior lung fields. In another standardized patient with signs and symptoms of new-onset diabetes mellitus, only 10% of students checked gross visual acuity, and 28% assessed position sense. Another standardized patient presented with the classic signs and symptoms of acute

Cardiac Auscultation Skills of Physicians in Training

To the Editor. —I concur with Drs Mangione and Nieman 1 that cardiac auscultation is a valuable clinical skill that merits added structured teaching for medical students and residents. While their method represents an improvement over the multiplechoice testing that is common to medical school and licensing examinations, identification of digitized cardiac sounds and murmurs is not a sufficient measure of clinical competency for physicians in training. Furthermore, the authors' statements regarding generalist physicians and health care utilization are not supported by the data presented. In an earlier publication, 2 the authors cited a 1959 study by Butterworth and Reppert 3 and concluded that physicians in training today are less skilled in cardiac auscultation than their predecessors. However, comparison of the data is hampered because the assessment of Butterworth and Reppert was a matching exercise and included a different type and number of cardiac events. Pressing their point regarding the present erosion of

Cardiac Auscultation Skills of Physicians in Training

Cardiac Auscultation Skills of Physicians in Training

Cardiac auscultation skills of physicians in training

To the Editor. —I concur with Drs Mangione and Nieman 1 that cardiac auscultation is a valuable clinical skill that merits added structured teaching for medical students and residents. While their method represents an improvement over the multiplechoice testing that is common to medical school and licensing examinations, identification of digitized cardiac sounds and murmurs is not a sufficient measure of clinical competency for physicians in training. Furthermore, the authors' statements regarding generalist physicians and health care utilization are not supported by the data presented. In an earlier publication, 2 the authors cited a 1959 study by Butterworth and Reppert 3 and concluded that physicians in training today are less skilled in cardiac auscultation than their predecessors. However, comparison of the data is hampered because the assessment of Butterworth and Reppert was a matching exercise and included a different type and number of cardiac events. Pressing their point regarding the present erosion of

Cardiac Auscultation Skills of Physicians in Training

Cardiac Auscultation Skills of Physicians in Training

Cardiac Auscultation Skills of Physicians in Training

To the Editor. —We agree with Drs Mangione and Nieman1that the burden of teaching and testing these essential skills rests today primarily with medical schools and that repetition through simulation is a logical remedy. The 30-year experience of our 11-center consortium for medical education, including Harvey, the cardiology patient simulator, and the UMedic multimedia computer system (MCS; University of Miami, Miami, Fla) should lend credibility to our plan to remedy the problem. The teaching effectiveness of Harvey, a full-size mannequin that realistically simulates all the bedside findings of 27 cardiac conditions, has been documented in a National Heart, Lung, and Blood Institute—supported study2involving 208 senior medical students at 5 institutions. Those trained with Harvey scored significantly higher on posttests involving actual patients (P

Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency

Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency

Cardiac Auscultatory Skills of Internal Medicine and Family Practice Trainees

Medical educators have had a growing sense that proficiency in physical diagnostic skills is waning, but few data have examined the question critically. To compare the cardiac auscultatory proficiency of medical students and physicians in training. A multicenter cross-sectional assessment of students and house staff. A total of 8 internal medicine and 23 family practice programs of the mid-Atlantic area. A total of 453 physicians in training and 88 medical students. All participants listened to 12 cardiac events directly recorded from patients, which they identified by completing a multiple-choice questionnaire. scores were expressed as the percentage of participants, for year and type of training, who correctly identified each event. Cumulative scores were expressed as the total number of events correctly recognized. An adjusted score was calculated whenever participants selected not only the correct finding but also findings that are acoustically similar and yet absent. Trainees' cumulative scores ranged between 0 and 7 for both internal medicine and family practice residents (median, 2.5 and 2.0, respectively). Internal medicine residents had the highest cumulative adjusted scores for the 6 extra sounds and for all 12 cardiac events tested (P=.01 and .02, respectively). On average, internal medicine and family practice residents recognized 20% of all cardiac events; the number of correct identifications improved little with year of training and was not significantly higher than the number identified by medical students. Both internal medicine and family practice trainees had a disturbingly low identification rate for 12 important and commonly encountered cardiac events. This study suggests a need to improve the teaching and assessment of cardiac auscultation during generalists' training, particularly with the advent of managed care and its search for more cost-effective uses of technology.

Recognizing normal heart murmurs: a logic-based mnemonic.

A logic-based mnemonic for the auscultory diagnosis of nonpathologic murmurs, which I developed for teaching medical students and house staff, is presented with the hope of improving the auscultatory skills of primary care pediatric practitioners. The objective is positive identification of nonpathologic murmurs rather than diagnosis by exclusion. The auscultatory features of these murmurs are largely determined by their causative mechanisms. The logic, therefore, is based on an understanding of these mechanisms so that the listener will know why these murmurs have their characteristic sound features and specifically what to listen for. The logic can also be used in explaining nonpathologic murmurs to parents. The mnemonic device should reduce the need for rote memorization. Heart murmurs are present in most pediatric patients, and almost all are nonpathologic. Yet, the most common reason for referral to many pediatric cardiologists is for the evaluation of a heart murmur, two thirds of which are deemed normal.1,2 I believe that improving the accuracy of auscultation by primary care practitioners and improving their confidence in recognizing normal murmurs will decrease referrals to pediatric cardiologists, without underreferral of patients with heart disease. This outcome would be of significant psychologic and economic benefit to patients and their families. In referring to nonpathologic murmurs, the commonly used terms are innocent, functional, and normal. I prefer the latter. Perhaps, because “normal” is a less technical, more familiar word to parents, to me it seems easier for them to understand and accept the benign nature of these murmurs with this terminology. The formulation of the logic begins with a consideration of causative mechanisms. A heart murmur is a continuous series of sounds, with a variable number of different sound wave frequencies present at each instant. The wave frequency content of a murmur determines, to a large extent, …

Multimedia presentation of lung sounds as a learning aid for medical students

New educational technologies might help to compensate for the decrease in time and emphasis dedicated to physical examination in medical training. This may, in particular, be applicable for improving the skills in auscultation of the chest. We investigated whether a multimedia presentation of acoustic and graphic characteristics of lung sounds could improve the learning of pulmonary auscultation by medical students, in comparison with conventional teaching methods. We studied 48 medical students without clinical experience, who had received conventional formal teaching on chest examination. Chest auscultation skills were evaluated using an inaccuracy score for the student's auscultation report on three patients, selected according to a standardized procedure. After a baseline evaluation, 27 students in groups of 5-10, participated in a multimedia seminar on lung sounds during which digitized lung sounds were played and the corresponding time-expanded waveform and frequency spectrum were commented on and displayed on a computer. The remaining 21 students received conventional bedside training, acting as control group. The following week, all the students underwent a second evaluation of chest auscultation skills. No differences in the inaccuracy score were observed between the two groups in the preliminary test. However, in the second postintervention assessment, the inaccuracy score of the students who had followed the seminar (11.2 +/- 1.3 points) was significantly lower than that of the controls (16.6 +/- 1.6 points). The answers to a feedback questionnaire confirmed that the great majority of the students found the association of the acoustic signals with their visual image to be useful for learning and understanding lung sounds.(ABSTRACT TRUNCATED AT 250 WORDS)

Enhanced Auscultation With a New Graphic Display System

To provide an objective method to support and teach auscultation, a new portable system (graphic display system) was evaluated for graphic display and printing of heart sounds. Ninety-one patients from three institutions, with a variety of heart sound abnormalities, were studied by two examiners. A graphic recording was made in each and compared with the auscultatory findings. The findings of the graphic system confirmed the auscultatory impressions of both examiners in 77 (85%) of the 91 cases. Brief sound transients, such as split second sounds and ejection sounds, third heart sounds, and prosthetic opening and closing sounds, were all regularly recorded with the graphic system, often allowing resolution when examiners were in disagreement. Graphic recordings commonly were at variance with examiners in detecting fourth sounds, possibly because of examiners' difficulty in distinguishing these from split first sounds as well as limitations of the graphic system itself. High-pitched murmurs of low intensity (< grade 2), as exemplified by those of aortic and mitral regurgitation, were occasionally missed by the graphic system, probably because of baseline interference by background noise. The graphic display system can often provide more information than can be obtained by standard auscultation alone, especially in the detection of low-frequency and multiple sounds, and in the accurate timing of intervals. It is often unable to detect soft high-frequency murmurs. Permanent records allow for more objective comparison of the auscultatory findings of various examiners at different times. This system provides an excellent means by which auscultation skills may be taught or enhanced, especially since its speed and portability allow immediate feedback for comparison with auditory perceptions.

Physical assessment by nurses: a study of nurses’ use of chest auscultation as an indicator of their assessment practices

A non-experimental survey was conducted to determine if the factors such as years of practice, how physical assessment skills were learnt and how often these skills were utilised, influenced nurses' reluctance to implement physical assessment. A sample of 150 registered nurses was surveyed. Analysis indicated that the majority of respondents has been taught to listen to chest sounds (auscultation) but did not implement this skill on a daily basis. Chi square analysis indicated that younger nurses with less years of experience were more keen to learn chest auscultation skills than nurses who were older and had more years of nursing experience.

Educating rural home health care nurses in respiratory assessment: an evaluation study.

AbstractBecause nurses in rural home health agencies function as monitoring agents for the health care team, their role has grown to include increased patient assessment responsibilities. The rural setting, however, can prevent nurses from receiving the kind of training that enables them to provide accurate assessment data to their teams. In Vermont, an educational program in respiratory assessment was built into the work load of 34 nurses in five rural home health agencies. Using a collaborative, individualized training plan, this study aimed to determine the number of interactions with a trained assessment educator that would bring nursing assessment skills to an optimal level. Learners' scores in inspection, palpation, and percussion increased significantly after 10 collaborative training visits, holding steady through a six‐month posttest. Significant change in auscultation skill occurred after 20 collaborative visits, but returned to preinstruction levels at the six‐month posttest. The study points to the potential of collaborative education for home health nurses, accommodating both the need for educational experience and the constraints against education within the dispersed rural health care system.