Stanford, CA - Third-year medical students, residents, faculty members, and private practitioners may all have similar skills when it comes to performing cardiac exams, a new study published in the March 27, 2006 issue of the Archives of Internal Medicine suggests [1]. Using a new multimedia interactive tool to test cardiac exam skills, Dr Jasminka M Vukanovic-Criley (Stanford University School of Medicine, CA) and colleagues found that only cardiology fellows scored significantly higher than the other groups tested; among the mostly internal- and family-medicine residents and physicians, competence scores do not appear to improve over time.

All I ever learned about the heart exam I learned in the second year of medical school.

"I jokingly say, 'All I ever learned about the heart exam I learned in the second year of medical school,' " Criley told heartwire. "Scores did not get better after that, despite years of training, even in practicing physicians."

For their study, Criley et al used a test for assessing cardiac-exam skills that uses audiovisual recordings from actual patients to evaluate knowledge of cardiac physiology, auditory skills, visual skills, and the integration of all three. In total, 860 participants took the test: 318 medical students, 289 internal- and family-medicine residents, 85 cardiology fellows, and 131 physicians (of whom 62 were faculty members and 69 were private practitioners). The remaining 37 participants were nurses or other physicians or did not identify their level/area of training.

Criley and colleagues report that the scores of third-year medical students were higher than those of second-year students but were similar to those of internal-medicine residents, family-medicine residents, full-time faculty, volunteer clinical faculty, and private practitioners. The only group to score significantly higher was the cardiology fellows, who scored better (p<0.001) in all four areas tested.

Of note, practicing physicians, including faculty, demonstrated a high sensitivity and low specificity for detecting systolic murmurs, suggesting that they may not be using the carotid pulse to establish the timing of murmurs in the cardiac cycle.

"With our test, we were able to tease out not only what questions were missed but also how examinees used or failed to use visual clues when listening and how they integrated visual and auditory findings," Criley commented.

The finding underscores what Criley told heartwire would be her primary advice to practitioners performing cardiac examinations. "Look as well as listen," she suggests. "Use the carotid pulse to establish systole, to determine whether the murmur you hear is systolic or diastolic. Students commonly believe that diastolic murmurs are too subtle to hear, so if they hear a murmur, they reason it must be systolic. If it is a loud murmur, it must be holosystolic. This 'systolic bias' in listening was also found in the physicians we tested."

Criley and colleagues say their findings should have an impact not only on medical students but also on faculty and other practicing physicians who may need to upgrade their skills, particularly if they are responsible for training the next generation of physicians. Criley suggests that the same technology used for their multimedia test can be used to teach and to enforce teaching standards.

"The lack of teaching materials is a problem in many schools and training programs; [this is] exacerbated by teachers who are too busy to teach and who may themselves need further training in cardiac examination," she said. "The burden of teaching cardiac examination has fallen largely on primary-care practitioners, since cardiologists are teaching less and less."

Inadequate training in cardiac-examination skills only makes a physician's job harder later on, she points out.

" 'Train hard, fight easy,' said Russian Field Marshall Alexander Suvorov. If you train with audio-only recordings in medical school, you may never learn to integrate sight and sound while examining a patient," Criley observes.

She credits her father-in-law, senior author Dr John Michael Criley (UCLA School of Medicine, Torrance and Los Angeles, CA), for instilling in her an appreciation of cardiac exams. He has been teaching cardiac-exam skills for 45 years and pioneered many of the early studies into the physiological origins of heart sounds and murmurs during the 1960s, she said. "He is very passionate about it and he transmitted this passion to the rest of the family, including me."

In a related editorial [3], Dr David L Simel (Duke University, Durham, NC) observes that despite technological advances in medicine, physicians still need to appreciate the importance of the cardiac exam.

"Our obsessive dependence on diagnostic technology that generates data with alluring precision may ultimately create a real erosion of our physical diagnosis skills," 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."

Although technological advances likely have a role, they require thorough evaluation. In the meantime, he adds, "Every physician would benefit from rediscovering the fun and intellectual honesty that comes with putting his or her own physical-examination performance to the test. When was the last time you asked a colleague to confirm a physical finding? Ultimately, we may adopt new technology to improve auscultation. But whether or not we adopt new technology for meaningful improvement, practice and repetition will always be required."