Regular Rate and Rhythm, with No Murmurs, Rubs, or Gallops
Source: Mangione S, Nieman L. JAMA 1997;278(9):717-722.
In this study of the cardiac physical examination skills of medical trainees, 453 residents and 88 medical students listened to tapes containing extra heart sounds (S4, S3, opening snap, pericardial friction rub, midsystolic click, early systolic click) and murmurs (mitral regurgitation, aortic stenosis, aortic stenosis/aortic insufficiency, mitral stenosis, patent ductus arteriosus). As a group, the trainees performed uniformly poorly, identifying on average only about 2.5 out of 12 sounds correctly. There were no important differences between internal medicine residents, family practice residents and medical students. A small group of cardiologists given the same examination correctly identified 80-90% of the sounds.
COMMENT BY GORDON D. RUBENFELD, MD
Where I interned, there was a senior cardiologist who had heard it all. I called him for help after 20 futile minutes examining a patient sent for evaluation of congestive heart failure. Our senior auscultor took out the cheapest looking stethoscope I’d ever seen, moved the patient through a graceful series of maneuvers (never exposing more than a few square inches of skin), smiled, and then, while holding the diaphragm in place, he handed me the earpiece. There it was, plain as day: an S3 and a very soft, late peaking systolic murmur inching up the carotids. Incredulous, I looked at his stethoscope, then mine, then back to his paltry dime store model. Anticipating my question, he delivered his line: "Son, it’s not the ears, it’s what’s between them."
This study by Mangione and Nieman suggests that "what’s between the ears" of our trainees isn’t very skilled. This study, and others like it that critically evaluate clinicians’ physical diagnosis skills, raise three important questions. 1) Were the clinicians of decades past better at physical diagnosis than we are today? 2) Is the physical examination still valuable in this era of CT scans and echocardiograms? 3) How should we teach the physical examination more effectively?
It is possible that the average clinician today is no worse an auscultor than his or her colleagues of decades past. Several factors conspire against the modern examiner. Widespread use of antibiotics in developed nations has largely eliminated rheumatic disease. Early recognition and surgical treatment of valvular heart disease reduces the number of chronically severe and acoustically easy cases. A general increase in body mass and emphysema in the population can make heart tones distant. Finally, it should be remembered that our forebears could diagnostically opine at great length without fear of a confirmatory test short of a post-mortem. Today, the echocardiogram is readily available to point out what we should have heard but missed.
Even if previous generations of physicians outpaced our skills in physical examination, this begs the question of the use of the physical examination. Only recently have we begun to apply the standards used to evaluate diagnostic tests to the physical examination (Simel DL, Rennie D. JAMA 1997;277(7):572-574). As data become available to guide the rational use of the physical examination, we may learn that certain time-worn techniques (the angled flashlight on the neck to judge venous pulsations, for example) are just a waste of time. We should be wary of claims that the physical examination must be cost-effective because it is performed without technology. Such seat-of-the-pants analyses are based on an implicit comparison to the $500 we know a cardiologist bills for an echocardiogram. Once the machine is paid for, a quick diagnostic peek by a salaried clinician need not be that expensive.
Once we have identified the useful, accurate, and reliable pieces of the physical examination, we still must identify effective means to teach them. Evidently, current techniques are failing. With managed care competence, interdisciplinary skills, public health awareness, and total quality management principles all vying for space in our residents’ curriculum and brains, how do we find time to teach cardiac auscultation? Teaching the physical examination proceeds along the same path as teaching central venous catheterization, cardiopulmonary resuscitation, or withdrawing life support. There must be supervised repetition on a wide variety of cases in a setting that stresses the importance of the skill and encourages quality improvement through constructive feedback and reflection. This may be enhanced through the use of multimedia techniques including simulators and audio tapes.
The physical examination, even if critical study reveals that it is a useless diagnostic tool, will never be entirely replaced. While moving his flimsy stethoscope over the chest with his right hand, my cardiology mentor’s left hand was a constant reassuring presence on the patients’ shoulder and his eyes never left theirs. Try that in a CT scanner.
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