A C A D E M I A A N D C L I N I C

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

• 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 multi-center 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.

Ann Intern Med. 1993;119:47-54.

From the Medical College of Pennsylvania, Philadelphia, Penn­sylvania. For current author addresses, see end of text.

" . . . there is already plenty of evidence to show that we are in danger of losing our clinical heritage and of pinning too much faith in figures thrown up by machines. Medicine must suffer if this tendency is not checked." (Paul Wood. January 1950 [1])

W e live in times of sophisticated and expensive diag­nostic technology. Computed tomography, magnetic resonance imaging, ultrasonography, and nuclear medi­cine have enormously expanded our ability to define anatomic and physiologic abnormalities but at the price of an ever-increasing cost of health care. The use of these tools may have also rendered our trainees over­confident in technology and, as a result, may have weakened their physical diagnostic skills. If such a weakness actually exists, it would contrast sharply with recent surveys showing that internists in practice con­sider physical examination one of the most valuable skills acquired during internal medicine training (2, 3). It would also lead physicians to rely too greatly on diag­nostic technologies that are unnecessary, expensive, and potentially dangerous.

Cardiac auscultation, long the symbol of all bedside diagnostic skills, provides the best example of the effect that modern technology and current training practices may have had on physical diagnosis. Recent reports have reiterated the effectiveness and importance of car­diac auscultation (4, 5). Nevertheless, echocardiography and color Doppler imaging studies may offer accurate and objective information when compared with the fee­ble signals perceived through a stethoscope. The use of these expensive technologies is also encouraged by their greater financial compensation in contrast to that for physical examinations, however skillfully per­formed. In addition, the American Board of Internal Medicine does not explicitly assess auscultatory profi­ciency of internists as part of the certification examina­tion. Thus, internal medicine trainees' interest and pro­ficiency in cardiac auscultation may be waning. Physicians with many years of practice and certifying boards now express concern with the physical exami­nation skills of trainees. Yet, only a few published stud­ies have tried to support or refute these concerns. A recent study indicated that internal medicine trainees may have difficulty establishing a correct diagnosis only on the basis of the cardiovascular physical examination (6). This study, however, was limited to only one med­ical center, only one level of training, and only three preprogrammed simulations. To overcome these limita­tions, we designed a study that could determine whether cardiac auscultation is still viewed as important

© 1993 American College of Physicians 47

Table 1. Number of Participants in the Proficiency Test Distributed by Program and Year of Training

Year of Training GUH HUH HUP MCP TUH TJU Total*

Number (%)

Internal medicine trainees First year Second year Third year Total

Cardiology fellows Medical students

4 (4.6) 5 (5.7) 6 (14.6)

15 (8.0)

14 (28.6)

13 (14.8) 9 (15.5) 6 (14.6)

28 (14.9)

16 (18.2) 6 (10.3) 8 (19.5)

30 (16.0)

26 (29.5) 16 (27.6) 9 (22.0)

51 (27.3) 6 (37.5)

35 (71.4)

13 (14.8) 12 (20.7) 5 (12.2)

30 (16.0) 3 (18.7)

16 (18.2) 10 (17.2) 7(17.1)

33 (17.6) 7 (43.8)

88 (100) 58 (100) 41 (100)

187 (100) 16 (100) 49 (100)

* Because of rounding, percentages do not total 100. GUH = Georgetown University Hospital; HUH = Hahnemann University Hospital; HUP = Hospital of the University of Pennsylvania; MCP = The Medical College of Pennsylvania; TUH = Temple University Hospital; TJU = Thomas Jefferson University Hospital.

for the practicing physician and that could evaluate the proficiency and teaching of cardiac auscultatory skills.

Methods

Survey of Program Directors

A one-page questionnaire, accompanied by a letter from two of the investigators, was mailed to the directors of all 659 U.S. accredited internal medicine residency and cardiology fellow­ship programs. Directors' addresses were gathered from the "green book" directory of approved residencies and fellow­ships (Directory of Graduate Medical Education Programs. American Medical Association, Chicago, 1990). Data were col­lected by mailed questionnaire between August and December 1990. All nonrespondents were sent a second copy of the survey 1 month after the initial letter.

The questionnaire's first section collected background infor­mation about the directors and their programs. The directors were asked to answer items concerning their age and type of subspecialty, the characteristics of their programs (number of trainees and university affiliation), and whether their residen­cies or fellowships offered any "structured" teaching of car­diac auscultation in their programs. Although clinical skills such as cardiac auscultation should be primarily acquired at the bedside (through experience with patients and direct su­pervision by attending physicians and more senior trainees), we believe that this traditional form of teaching might have become lost in our age of rounds conducted in halls and conference rooms. Thus we deliberately asked the directors to comment only on the presence of "structured" teaching in their training programs and to exclude "bedside teaching" during ward rounds. Lectures, seminars, and audiovisual teaching modalities (such as audiotapes) were included in our definition of "structured teaching." Program directors were also asked to indicate their field of interest and practice and, on this basis, were classified as either "invasive" (if their subspecialty was cardiology, pulmonary medicine, critical care, or gastroenterology) or "noninvasive" (if their subspe­cialty was endocrinology, rheumatology, infectious diseases, allergy and immunology, geriatrics, nephrology, hematology/ oncology, or general internal medicine). Program directors who were cardiologists were similarly asked to classify themselves as "invasive," "noninvasive," or both depending on the type of cardiology they practiced.

The questionnaire's second section asked for the directors' opinions regarding three statements: A) "Cardiac auscultation is an extremely important tool for any practicing physician"; B) "More time should be devoted to the teaching of cardiac auscultation during internal medicine (or cardiology) training"; C) "The recognition of the following cardiac events is ex­tremely important and therefore should be mastered by any practicing physician." The third statement contained a list of 11 cardiac events: 1) S3 gallop, 2) S4 gallop, 3) early-systolic click of aortic ejection, 4) mid-systolic click of mitral valve prolapse, 5) opening snap of mitral stenosis, 6) pericardial friction rub, 7) systolic murmur of mitral regurgitation, 8) sys­tolic murmur of aortic stenosis, 9) diastolic rumble of mitral

stenosis, 10) diastolic murmur of aortic regurgitation, and 11) continuous murmur of patent ductus arteriosus. The directors expressed their opinion about all three statements, including the 11 events, by choosing along a six-step scale in which 1 indicated strong agreement. For clarity, all the directors' scores were recoded into a six-step scale in which 1 = strongly disagree and 6 = strongly agree.

Statistical Analysis

We decided to carry out most of the analyses of the two program types separately because medicine and cardiology re­spondents were sometimes from the same program. Analysis consisted of chi-square tests to relate dichotomous and nomi­nal variables, Mann-Whitney U and Kruskal-Wallis rank tests to compare two groups or more than two groups on the several scale measures, and Spearman rank correlations to correlate scales and other numeric variables. For a few analyses, the comparison of cardiology and medicine programs was critical. The analyses were by chi-square and Mann-Whitney U tests, even though the data were a mix of repeated measures and nonrepeated measures, because some of the respondents were from the same institution. Nonrepeated measures methods were used because of the essentially independent functioning of such programs and the absence of any good alternative method of analysis. To compare the directors' attitudes toward the cardiac murmurs and cardiac extra-sounds of our list, we created a mean importance rating for each set of sounds and for each respondent. Thus we created a "murmur mean" for the five murmurs and a "sound mean" for the six extra-sounds. Analysis of these two means was carried out by paired r-test and ANOVA.

Auscultatory Proficiency among Physicians-in-Training

We assessed the auscultatory skills of 203 trainees. Partici­pants comprised 187 internal medicine residents and 16 cardi­ology fellows. In addition, we included in our assessment 49 third-year medical students who provided a comparison for the performance of physicians-in-training (Table 1). Of the 203 trainees, 188 were from eight university-affiliated programs in the Philadelphia area that offered no structured teaching of cardiac auscultation. These eight internal medicine and cardi­ology programs were based at the Medical College of Pennsyl­vania, the Hospital of the University of Pennsylvania, Temple University Hospital, Hahnemann University Hospital, and Thomas Jefferson University Hospital. Also included in our evaluation were 14 students and 15 internal medicine residents from Georgetown University in Washington, DC. This program was selected because in our survey we found it to be one of the few that devotes many hours to teaching cardiac ausculta­tion.

The evaluation of auscultatory proficiency was arranged as a 1-hour patient-management conference, incorporated in the teaching schedules of the various programs. The first half of the conference tested the proficiency of trainees and the sec­ond half reviewed the various cardiac sounds and murmurs used in the test. The evaluation instrument consisted of 12 cardiac events directly recorded from patients and selected

48 1 July 1993 • Annals of Internal Medicine • Volume 119 • Number 1

from a pool of 250 sounds found on commercially available audiotapes. Each event was digitized into a microcomputer (Macintosh SE30, Apple Computer Inc.; Cupertino, Califor­nia), its waveform analyzed (MacRecorder, Farallon Comput­ing; Berkeley, California), and 12 events finally chosen on the basis of the purity of their sounds and good reproduction of findings typical of the corresponding disease process. These 12 events included all those events that the program directors had been asked to evaluate for clinical importance, and, addition­ally, the systolic and diastolic murmurs of aortic stenosis and insufficiency. Each selected event was recorded on a Hi-Fi Cassette Deck (CR W85, Fisher Corporation; Chatsworth, Cal­ifornia) and played back for 1.5 minutes to the trainees using stethophones (P.N.30-002 Humettrics Corporation; Chicago, Il­linois) and a Hi-Fi audiocassette player (Marantz PMD430; Chatsworth, California). Participants were told the chest area of recording of each event and had the opportunity to listen again as needed. After listening, they answered a multiple-choice questionnaire regarding all auscultatory findings. They checked in a forced-response format whether a particular find­ing was present or absent and then selected characteristics that best described the finding. Answers were graded using as a reference the phono-cardiographic tracing of the corresponding cardiac event. Scores were expressed as the percentage of respondents for year of training who correctly identified each of the sounds tested. Whenever respondents selected not only the correct finding but also findings acoustically similar and yet absent (for example, they checked an opening snap or a fourth heart sound together with the correct finding of an S3 gallop), an "adjusted" score was calculated, which considered this type of answer to be invalid.

Participants also completed a one-page attitude question­naire. This questionnaire was designed to gather information on the trainees' self-motivated learning of cardiac auscultation, their confidence with their own cardiac auscultatory skills, their opinions of the clinical importance of cardiac ausculta­tion, and the need to devote more time to its teaching during medical training.

Statistical Analysis

Two major questions were addressed. At each level of train­ing (from medical school to cardiology fellowship) does the trainees' proficiency with cardiac auscultation improve? To what degree do trainees improve their proficiency during 3 years of medicine residency? Each question was analyzed by a trend-analysis chi-square across the three categories of interest (students, medical residents, and cardiology fellows) and across the 3 years of medical residency. In addition, chi-square tests were used to compare medical students to medical resi­dents, medical residents to cardiology fellows, and first-year medical residents to third-year medical residents. Trainees' attitudes toward cardiac auscultation were analyzed by the Student Mest and chi-square test.

Results

The Survey

Of the 659 programs surveyed, 531 (80.6%) returned the questionnaire. The response rate was not statisti­cally different among different areas of the country. Of 659 respondents, 498 (75.6%) were program directors and were included in our final analysis. The remaining 33 respondents were excluded because they either iden­tified themselves as nondirectors or failed to provide this information.

Presence of Auscultatory Teaching

Only 27.1% of internal medicine programs offered structured auscultatory training compared with 37.1% of

Table 2. Teaching Modalities of Cardiac Auscultation Used by the 89 Internal Medicine and 63 Cardiology Programs Providing Structured Auscultatory Training to Their House Staff

Teaching Methods* Internal Medicine Cardiology

nln (%)

Lecture Seminar Audiotapes Others

Number of hourst

64/89 (71.9) 18/89 (20.2) 43/89 (48.3) 29/89 (32.6) 28.4 ± 50

40/63 (63.5) 20/63 (31.7) 31/63 (49.2) 25/63 (39.7) 25.7 ± 31.3

* Because some programs used more than one teaching modality, percentages do not total 100.

t Expressed as mean ± SD of the cumulative number of hours ded­icated to structured teaching of cardiac auscultation across the entire internal medicine or cardiology training.

cardiology programs (P = 0.02). Consistent with this difference, cardiology programs assigned a higher im­portance to such teaching (P = 0.02). Different educa­tional methods and varying numbers of hours were used by these programs (Table 2). Programs in internal med­icine and cardiology did not differ significantly in regard to the type of intervention used.

Program variables such as number of trainees, area of the country, university affiliation, and presence of a cardiology fellowship within the institution were all re­lated to the presence of structured teaching in cardiac auscultation for cardiology programs, internal medicine programs, or both (Table 3). University affiliation had a strong negative association with teaching of auscultation in cardiology programs (P < 0.001) and a weak negative association in internal medicine programs (P = 0.07). Internal medicine programs with teaching of ausculta­tion were also significantly smaller in size and averaged fewer trainees than programs with no teaching of aus­cultation (P = 0.04). This was not true of cardiology programs (P > 0.2). The area of the country was asso­ciated with the presence or absence of auscultatory teaching for internal medicine but not for cardiology programs (P = 0.04 and P > 0.2, respectively). Finally, a weak negative association was found between the teaching of cardiac auscultation among internal medi­cine programs and the presence of a cardiology fellow­ship in the same institution (P = 0.09). On the basis of these characteristics, internal medicine programs with­out any structured teaching of cardiac auscultation were more likely to be large in size, university affiliated, and located in the northeast.

Directors' Opinions Regarding Cardiac Auscultation

Both internal medicine and cardiology program direc­tors assigned great clinical importance to cardiac aus­cultation, although cardiologists felt more strongly about it (mean ± SD: 5.30 ± 0.77 and 5.46 ± 0.72, respectively; P = 0.02 on a 1 to 6 scale). All directors felt that more time should be dedicated to the teaching of cardiac auscultation during training (4.87 ± 1.03 and 4.84 ± 1.20 for internal medicine and cardiology direc­tors, respectively; P > 0.2).

Several variables concerning both the respondents

1 July 1993 • Annals of Internal Medicine • Volume 119 • Number 1 49

Table 3. Predictors of the Presence or Absence of Structured Teaching of Cardiac Auscultation, According to Type of Program*

Program Characteristics Medicine Programs P Value Cardiology Programs P Value

With Without

P Value

With Without Teaching Teaching Teaching Teaching

Number 89 239 63 107 Number of trainees-!", n 42.7 ± 27.9 50.5 ± 31.0 0.04 11.1 ± 10.4 10.6 ± 6.6 >0.2 Area of the country, n(%)

Northeast 25 (28) 108 (45) 0.04 24 (38) 54 (50) >0.2 South 21 (24) 39 (16) 13 (21) 21 (20) Midwest 25 (28) 57 (24) 14 (22) 22 (21) West 18 (20) 35 (15) 12 (19) 10(9)

University affiliation, n(%) Present 30 (34) 107 (45) 0.07 30 (48) 81 (76) <0.001 Absent 59 (66) 132 (55) 33 (52) 26 (24)

Cardiology fellowship, n(%) Available 36 (40) 122 (51) 0.09 Unavailable 53 (60) 117(49)

* Data are expressed as percentage of total. t Values are expressed as mean ± SD.

(age, year of internal medicine certification, and "inva­siveness" of their subspecialty) and their programs (uni­versity affiliation, availability of "structured" ausculta­tory teaching during training, and area of the country) were related to the time and importance assigned to cardiac auscultation by the various directors. There was a weak but significant correlation between the directors' year of internal medicine certification and the impor­tance they assigned to auscultation (r = -0 .13 , P -0.02) and the perceived need for more time to teach it (r — -0.16, P = 0.01). The director's age also corre­lated with perceived importance of auscultation (r = 0.083, P = 0.07 for internal medicine and r = 0.013, P - 0.04 for cardiology) and perceived need for more teaching of auscultation (r = 0.133, P = 0.01 for inter­nal medicine and r = 0.16, P = 0.02 for cardiology). Thus older directors with more years of certification appeared to be more favorably inclined toward teaching cardiac auscultation. For internal medicine programs, invasive subspecialists assigned greater importance to cardiac auscultation (5.49 ± 0.64 on a 1 to 6 scale) than did noninvasive subspecialists (5.25 ± 0.79; P = 0.01). Invasive subspecialists also felt more strongly about the need for more time to teach cardiac auscultation (5.09 ± 1.07 and 4.81 ± 1.02, respectively; P = 0.01). For cardiologists, university affiliation was associated with lower perceived importance and need for more teaching of cardiac auscultation (P < 0.001 and 0.04, respectively). No such pattern emerged for medicine programs (Ps > 0.2). Not surprisingly, programs that taught cardiac auscultation assigned more importance to cardiac auscultation and wanted more time for it than did nonteaching programs. This was true of both cardi­ology and medicine programs (all four Ps < 0.02). Fi­nally, cardiology directors of different areas of the country differed significantly regarding the perceived need for more time dedicated to the teaching of auscul­tation (P = 0.04). The northeastern region stood out as the area wanting the least additional time. This was not true for internal medicine programs.

The directors' opinions regarding the statement "the recognition of the following cardiac events is extremely

important and therefore should be mastered by any practicing physician" are shown in Figure 1. Although all listed events were thought to be clinically relevant, both cardiology and internal medicine program directors assigned significantly more importance, on the average, to the murmurs than to the extra-sounds (P < 0.001 by paired Mest for both groups of directors). Nevertheless, the S3 gallop and the pericardial friction rub were

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.

50 1 July 1993 • Annals of Internal Medicine • Volume 119 • Number 1

Figure 2. Accuracy in identifying six cardiac murmurs and six extra-sounds according to type of training. 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 P < 0.02).

ranked as high as the murmurs, whereas the patent ductus arteriosus murmur was ranked as low as the extra-sounds. An ANOVA combining cardiology and internal medicine directors showed also a greater im­portance given to murmurs (P < 0.001) and overall more positive ratings by cardiologists (P < 0.001) and no interaction (P > 0.2). The absence of an interaction indicates that the relatively greater importance assigned to murmurs was consistent in magnitude between car­diology and internal medicine directors. There was also a small but consistent tendency of the cardiology direc­tors to perceive each event as clinically more important than did their internal medicine colleagues. This differ­ence was significant for all cardiac events with the ex­ception of the S4 and the pericardial rub.

The Proficiency Test

Change in Proficiency with Training

Our results indicate substantial improvement during training for only a few specific auscultatory findings (Figure 2). The simple ability to detect the finding even when erroneously identifying other acoustically similar but absent sounds ("nonadjusted" scores) increased from students to cardiology fellows only for the mur­murs of aortic stenosis and insufficiency, the opening snap/diastolic rumble of mitral stenosis, the pericardial friction rub, and the S4 gallop (all Ps < 0.02 by trend analysis). For "adjusted" scores (identifying the finding correctly and without other errors), only the recognition of the murmur of aortic stenosis and insufficiency, the murmur of patent ductus arteriosus, and the pericardial friction rub improved significantly from students to car­diology fellows (all Ps < 0.02).

Medical residents were never statistically more accu­

rate than medical students on either the "adjusted" or "nonadjusted" scores. However, cardiology fellows were statistically more accurate than medical residents on 7 of the 12 events tested, with the exceptions being the early systolic click, the opening snap, the opening snap/diastolic rumble of mitral stenosis, the patent duc­tus arteriosus, and the aortic insufficiency murmurs ("nonadjusted" scores). "Adjusted" accuracy scores for the various events ranged from 0 to 56.2% for car­diology fellows (median, 21.9%) and from 2% to 36.8% for medical residents (median, 19.3%).

Improvement in Proficiency during Internal Medicine Training

Across the 3 years of medicine residency, the detec­tion of aortic stenosis and insufficiency, S3 gallop, and opening snap/diastolic rumble of mitral stenosis im­proved significantly (all Ps < 0.04 by trend analysis of the "nonadjusted" scores). However, only the identifi­cation of the S3 gallop and the opening snap/diastolic rumble of mitral stenosis remained significantly im­proved when the "adjusted" scores were analyzed (all Ps < 0.04) (Figure 3).

Overall, the 12 cardiac events tested were recognized correctly (and without any other mistakes) by fewer than one third of the residents. Six of the 12 events were identified only by 10% or fewer of the medicine trainees. When compared to internal medicine residents from other programs, trainees from Georgetown Uni­versity demonstrated a more accurate identification of the pericardial friction rub (66.7% versus 37.5%; P = 0.03) and a trend toward a more accurate identification of the mid-systolic click (40% versus 20.2%; P = 0.07).

1 July 1993 • Annals of Internal Medicine • Volume 119 • Number 1 51

Figure 3. Accuracy rates, accord­ing to year of internal medicine training. 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; Al, 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 P < 0.04).

Although these differences became nonsignificant when calculated for "adjusted" scores (due to the small sam­ple size from Georgetown), they do indicate that a greater emphasis on the teaching of cardiac auscultation can improve proficiency among trainees.

Trainees' Attitudes toward Cardiac Auscultation

Internal medicine residents and cardiology fellows did not differ significantly in the importance they assigned to cardiac auscultation (3.7 ± 0.7 and 3.7 ± 0.9, respec­tively, on a 1 to 4 scale, with 1 indicating "obsolete and useless" and 4 indicating "extremely important"). In­ternal medicine residents (93.5%) and cardiology fellows (88.2%) thought that more time should be dedicated to the teaching of cardiac auscultation during internal med­icine training; 92.9% of cardiology fellows thought that more time should be dedicated during cardiology train­ing. Consistent with their greater accuracy, 61.5% of the cardiology fellows had independently used cardiac audiotapes to improve their auscultatory skills, com­pared to 35.2% of the medical residents (P < 0.05). When asked to rate their own auscultatory skills, inter­nal medicine and cardiology trainees did not differ sig­nificantly (2.5 ± 0.7 and 2.7 ± 0.6, respectively; P > 0.2 on a 1 to 5 scale, with 1 indicating "poor" and 5 indicating "excellent").

Discussion

These two studies indicate that there is no structured teaching of cardiac auscultation in three fourths of American internal medicine programs and two thirds of cardiology programs. And yet both program directors and trainees stated that they value cardiac auscultation as a skill that "all practicing physicians should master." The lack of teaching appears to have adversely affected the clinical proficiency of physicians-in-training, who showed a discouraging inaccuracy in the detection of 12

selected cardiac findings, all rated as clinically impor­tant by the program directors. In our study, internal medicine residents improved little with each year of training and were never better than a group of third-year medical students. This finding confirms the obser­vation of St. Clair and colleagues (6) and suggests that a whole new generation of physicians is being trained with little emphasis on making a diagnosis by ausculta­tion only. Indeed, the trainees of our study were sub­stantially less accurate in their recognition of cardiac auscultatory events than were the trainees similarly tested by Buttenworth and Reppert in 1959 (7).

Our proficiency test was based on a series of re­corded heart sounds. Although the quality of these ed­ucational tools has substantially increased since the first commercially available sets (the "Gamble-Cabot Car­diac Diagnoses Records" first sold in 1928), it may be argued that the ability to recognize recorded sounds correlates poorly with auscultatory ability at the bed­side. We tried to overcome this possible limitation by reviewing the soundwaves of hundreds of sounds and selecting only those that best exemplified the corre­sponding cardiac events. We also used only stetho-phones and cassette decks of high fidelity to administer the proficiency test. We would have liked to validate our method by testing a large group of cardiology at­tending physicians but this was not possible. Three car­diology attending physicians, however, did take the test, and both their performance and their feedback to us confirmed the high quality of the sounds used. The validity of our method was also indicated by the greater accuracy shown by cardiology fellows when compared to internal medicine residents, suggesting that the per­formance of each trainee reflected the skills of the in­dividual and not the limitations of the test. As suggested by their more frequent use of cardiac audiotapes, it is likely that cardiologists might have had a greater self-motivated interest to learn independently and sharpen

52 1 July 1993 • Annals of Internal Medicine • Volume 119 • Number 1

their auscultatory skills during medical school and in­ternal medicine residency.

The discrepancy between the great clinical impor­tance attributed to cardiac auscultation by program di­rectors and the little time actually devoted to its teach­ing reflects a declining academic interest in many forms of bedside diagnoses. Reports on auscultation have al­most disappeared from the medical literature, whereas technologically oriented publications have increased sharply. Attending physicians on ward rounds are now spending increasingly more time away from the bedside and in conference rooms and corridors. In one study, as little as 16% of attendings' time on ward rounds was spent at the bedside, and for one half of this time the patient's presence was not required for discussion (8). Calls for a return to the bedside have been raised not only by the academic community (9) but also by pa­tients, who expect to be examined and touched by their physicians and are appalled at being informed that "the physical exam is almost extinct in this country. We have so many better ways of knowing what's going on . . . that it really isn't necessary" (10). Rates of errors in physical examination have been encountered as fre­quently as 13.1% and 15.6% in residents and interns (11), with errors of omission occurring two to three times more frequently than errors of commission and serious errors leading to major changes in diagnosis and management occurring in almost two thirds of the pa­tients examined. These high rates of error and omission have been similarly noted in university-affiliated attend­ing physicians, directly correlating with an increased use of subspecialty consultation (12).

Our data indicate that bedside skills such as cardiac auscultation are taught today primarily by medical schools. Therefore, the deficiencies noted in the perfor­mance of physical examinations by students receiving their medical degree (13) may not be corrected during subsequent training. It may even be argued that the exposure of medical students to physicians-in-training (who may spend as much as 20% of their time teaching students and peers [14]) may lead to a situation in which "the blind are leading the blind." Because to­day's trainees will become tomorrow's practitioners and academic teachers, there may soon be a scarcity of teachers skilled in the art of auscultation who can trans­mit their enthusiasm and expertise to future generations of students and physicians.

Throughout this project we felt we had touched a very sensitive chord. Most trainees were very support­ive and cooperative, praised our work, and expressed their desire for a greater emphasis on physical diagnosis during training. Program directors frequently wrote comments to us, usually expressing encouragement for highlighting a time-honored skill in need of a revival. A few noted that cardiac auscultation is " . . . becoming a lost art ." One quipped, " . . . would you rather have an attending with a stethoscope or a fellow with a 2-D echo?"

The declining emphasis on physical diagnosis skills, if left unchecked, will probably lead to a greater reliance on expensive technology and a more rapid decline of proficiency in bedside skills. In this case, the stetho­scope of the future may well become " . . . a largely

decorative instrument insofar as its value in diagnosis [with its function mainly limited to provide comfort to] apprehensive patients with functional complaints [who] are often relieved as soon as they feel the chest piece on their pectoral muscles" (15). We disagree with this statement and believe that there are still many reasons to promote the teaching of bedside diagnostic skills such as cardiac auscultation. Among these are cost-effectiveness, the possibility of making inexpensive se­rial observations, the early detection of critical findings, the intelligent and well-guided selection of costly diag­nostic technology, and the therapeutic value of the physical contact between physician and patient. Even more important, in times when the "fun" seems to have been abandoned in the practice of medicine, cardiac auscultation and other bedside clinical skills can restore the satisfaction and intellectual pleasure of making a diagnosis using only our physical senses.

It has been recommended that formal courses on physical diagnosis should be organized by program di­rectors in internal medicine for the benefit of their house staffs (16). However, because of time constraints during training and the inevitable shift toward a more technologically oriented practice of medicine, it would be unrealistic to expect all graduating residents to mas­ter every physical diagnosis skill. A ranking by "clinical importance" is therefore necessary to encourage teaching (and possibly testing) of those skills that are indeed nec­essary for the practice of good-quality medicine. Resi­dency programs could then use this information to pro­mote proficiency in these selected skills. We are currently involved in further pursuing these research avenues.

Presented in part at the 57th annual meeting of the American College of Chest Physicians, San Francisco, California, November 1991.

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

Current Author Addresses: Drs. Mangione, Nieman, Gracely, and Kaye: The Medical College of Pennsylvania, 3300 Henry Avenue, Phil­adelphia, PA 19129.

References

1. Wood P. Diseases of the Heart and Circulation. Philadelphia: Lip-pincott; 1950:viii.

2. Kern DC, Parrino TA, Korst DR. The lasting value of clinical skills. JAMA. 1985;254:70-6.

3. Mandel JH, Rich EC, Luxenberg MG, Spillane MT, Kern DC, Par­rino TA. Preparation for practice in internal medicine. A study of ten years of residency graduates. Arch Intern Med. 1988;148:853-6.

4. Lembo NJ, Dell'Italia LJ, Crawford MH, O'Rourke RA. Bedside diagnosis of systolic murmurs. N Engl J Med. 1988;318:1572-8.

5. Craige E. Should auscultation be rehabilitated? N Engl J Med. 1988;318:1611-2.

6. St. Clair EW, Oddone EZ, Waugh RA, Corey GR, Feussner JR. Assessing housestaff diagnostic skills using a cardiology patient simulator. Ann Intern Med. 1992;117:751-6.

7. Buttenworth JS, Reppert EH. Auscultatory acumen in the General medical population. JAMA. 1960;174:32-4.

8. Collins GF, Cassie JM, Daggett CJ. The role of the attending phy­sician in clinical training. J Med Educ. 1978;53:429-31.

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9. Linfors EW, Neelon FA. The case for bedside rounds. N Engl J Med. 1980;303:1230-3.

10. Kaufman M. Try a little tenderness. The Philadelphia Inquirer Sun­day Magazine. 1991. Oct 27;Sect. C:3.

11. Wray NP, Friedland JA. Detection and correction of house staff error in physical diagnosis. JAMA. 1983;249:1035-7.

12. Goetzl EJ, Cohen P, Downing E, Erat K, Jessiman AG. Quality of diagnostic examinations in a University Hospital outpatient clinic. Ann Intern Med. 1973;78:481-9.

13. Sox HC, Morgan WL, Neufeld VR, Sheldon GF, Tonesk X. Sub­group report on clinical skills. J Med Educ. 1984;59(11 pt 2): 139-47.

14. Brown RS. Staff attitudes toward teaching. J Med Educ. 1970;45: 156-8.

15. Rubin EH, Rubin M. Thoracic Diseases. Philadelphia: W.B. Saun­ders; 1961.

16. Hurst JW. Osier as visiting professor: house pupils plus six skills. Ann Intern Med. 1984;101:546-9.

Personal purity is the prophylaxis which we, as physicians, are especially bound to advocate. Continence may be a hard condition (to some harder than to others), but it Can be borne, and it is our duty to urge this lesson upon young and old who seek our advice in matters sexual. Certainly it is better, as St. Paul says, to marry than to burn, but if the former is not feasible there are other altars than those of Venus upon which a young man may light fires. He may practise at least two of the five means by which, as the physician Rondibilis counseled Panurge, carnal concupiscence may be cooled and quelled—hard work of body and hard work of mind. Idelness is the mother of lechery; and a young man will find that absorption in any pursuit will do much to cool passions which, though natural and proper, cannot in the exigencies of our civilization always obtain natural and proper gratification.

William Osier The Principles and Practice of Medicine New York, Appleton-Century, 1935

Submitted by: Stephen L. Green, MD Hampton Roads Medical Specialists P.C. Hampton, VA 23666

Submissions from readers are welcomed. If the quotation is published, the sender's name will be acknowledged. Please include a complete citation, as done for any reference.—The Editors

54 1 July 1993 • Annals of Internal Medicine • Volume 119 • Number 1