Cardiac examination involves many of the senses, as physicians look at and touch the patient and listen to the heart sounds of the patient while considering the individual's history and symptoms, according to background information in the first article. The process is highly effective when performed correctly, but skills appear to be in decline, with one recent study finding serious errors in two-thirds of patients examined. New, high-tech devices, including multimedia CD-ROMs, electronic heart sound simulators and mannequins have been developed to aid in teaching, but none of these can replace contact with and repeated practice on patients, the authors write.
Jasminka M. Vukanovic-Criley, M.D., Stanford University School of Medicine, California, and colleagues used a 50-question, computer-based multimedia test to evaluate the cardiac examination skills of 860 participants. Of those, 318 were medical students, 289 were resident physicians, 85 were cardiology fellows, 131 were physicians (including faculty members and private practitioners) and 37 were others (including nurses, researchers and administrators). Participants took the test at one of 16 sites in the United States and Venezuela between July 2000 and January 2004.
Average competency scores of third- and fourth-year medical students were significantly higher than those of first- and second-year medical students. However, there was no difference in average score between third- and fourth-year medical students, resident physicians and practicing physicians, including faculty. Cardiology fellows performed significantly better than all other groups.
"Cardiac examination skills do not improve after MS3 (the third year of medical school) and may decline after years in practice, which has important implications for medical decision making, patient safety, cost-effective care and continuing medical education," the authors conclude. "Improvement in cardiac examination competency will require training in simultaneous audio and visual examination in faculty and trainees."
(Arch Intern Med. 2006; 166: 610-616. Available pre-embargo to media at www.jamamedia.org.)
Editor's Note: This study was supported by grants from the National Heart, Lung, and Blood Institute, Bethesda, Md.
More Experienced Physicians May Be More Accurate at Detecting Third Heart Sound
In a related study, based on cardiac examination of actual patients, physicians with more clinical experience were more likely to accurately detect a third heart sound, according to a second article in the March 27 issue of Archives of Internal Medicine.
The third heart sound can be heard in early diastole (a phase of the heart's pumping cycle), according to background information in the article. This specific heart sound could indicate problems in the function of the heart's left ventricle and may increase risk of adverse effects in patients undergoing noncardiac surgery and also in those with heart failure or acute myocardial infarction (heart attack). "Identification of this valuable physical finding requires relatively little time, and it is accessible to any physician with a stethoscope," the authors write. "However, studies have demonstrated very poor interobserver agreement among physicians and have suggested that trainees may not receive adequate instruction in auscultation," or listening for the sound.
Gregory Marcus, M.D., and colleagues at the University of California, San Francisco, performed a study of 100 patients (65 men and 35 women) undergoing a diagnostic test known as cardiac catheterization. The patients were examined by four physicians--one attending cardiologist, one cardiology fellow, one internal medicine resident and one internal medicine intern. The patients also underwent other tests, including one known as phonocardiographic analysis, which provided a 10-second recording of each patients' heartbeat that was analyzed by computer for a third heart sound.
Phonocardiography detected third heart sounds in 21 (23 percent) of the 90 patients whose readings were valid. The researchers assessed how well the physician examiners did compared with phonocardiography and found that cardiology fellows and attending cardiologists displayed a fair amount of agreement with the computer-analyzed results. Interns and residents, however, did not display any significant agreement with phonocardiography. The more experienced the physician, the higher the association between hearing the third heart sound and other clinical markers of ventricular dysfunction in patients, including the results of tests known as left ventricular ejection fraction and recording of left ventricular end-diastolic pressure. Phonocardiography, however, remained superior to all physicians' examinations.
"The clear improvement in auscultatory accuracy by the fellows compared with the residents and interns may be due in part to the emphasis on the cardiac physical examination and regular bedside teaching by senior cardiologists provided to the cardiology fellows," the authors write. "It is also possible that individuals with greater interest in or skill at clinical auscultation may pursue cardiology specialty training." All physicians can improve their skills through continued interest and mentorship from an experienced practitioner, they conclude.
(Arch Intern Med. 2006; 166: 617-622. Available pre-embargo to media at www.jamamedia.org.)
Editor's Note: This study was supported by an unrestricted educational grant from Inovise Medical Inc. (Dr. Micheals) and internal research funds from the Division of Cardiology, University of California, San Francisco.
Editorial: Practice Remains Important to Cardiac Examination
No matter how technology improves, physicians will still need skill and practice to perform cardiac physical examination, writes David L. Simel, M.D., M.H.S., of Durham Veterans Affairs Medical Center and Duke University, Durham, N.C., in an accompanying editorial.
"Our obsessive dependence on diagnostic technology that generates data with alluring precision may ultimately create real erosion of our physical diagnosis skills," Dr. Simel writes. "We can prevent this degradation only if we remember that improved performance requires the time to practice skills repetitively under the guidance of great mentors who reinforce and ensure correct techniques."
(Arch Intern Med. 2006; 166: 603-604. Available pre-embargo to media at www.jamamedia.org.)
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