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Cardiac auscultation and teaching rounds: how can cardiac auscultation be resuscitated?

2001; Elsevier BV; Volume: 110; Issue: 3 Linguagem: Inglês

10.1016/s0002-9343(00)00736-1

1555-7162

Henry Schneiderman,

Nursing Diagnosis and Documentation

This issue of the Green Journal contains a report by Salvatore Mangione (1Mangione S. Cardiac auscultatory skills of physicians-in-training: a comparison of three English-speaking countries. Am J Med. 2001;110:210–216.Google Scholar) on the lack of clinical skills among physicians-in-training. Mangione has become the chronicler of this problem; his 1993 paper (2Mangione S. Nieman L.Z. Gracely E. Kaye D. The teaching and practice of cardiac auscultation during internal medicine and cardiology training. A nationwide survey.Ann Intern Med. 1993; 119: 47-54Crossref PubMed Scopus (207) Google Scholar) was greeted with much notice and little corrective action. Over the years Mangione has extended documentation of defective bedside methods and interpretative abilities to other specialties (3Mangione S. Burdick W.P. Peitzman S.J. Physical diagnosis skills of physicians in training a focused assessment.Acad Emerg Med. 1995; 2: 622-629Crossref PubMed Scopus (38) Google Scholar). Now he shows that Canadian and British trainees are also poor at bedside auscultation, contrary to a widely held assumption that the British are more skilled (4Gilston A. Clinical examination of the respiratory system. J R Soc Med. 2000;93:158. LetterGoogle Scholar). Among the subgroups studied by Mangione, none had even minimal competence in recognizing murmurs such as mitral regurgitation that are encountered every day in general internal medicine practice. Differences among groups are not nearly as impressive as the poor showing by all. Surprisingly, unsupervised study of auscultatory audiotapes, which intuitively seems helpful for auscultatory knowledge, did not raise scores. End-stage failure of physical examination skills has arrived. Notwithstanding curmudgeons who assert that it has always been this bad and physicians who ask "What harm?," the joy of medicine suffers (5Craige E. Should auscultation be rehabilitated?.N Engl J Med. 1988; 318: 1611-1613Crossref PubMed Scopus (63) Google Scholar). So does relationship-building with patients, who experience our role as healer more fully when we place hands and stethoscopes on their bodies for real diagnostic help, not merely as ritual. Incapable physical examiners cannot make rational and cost-effective application of technology—and let us acknowledge with pleasure and gratitude how profoundly technology enhances medicine. Among the creative responses to the crisis in cardiac auscultation (6Tavel M.E. Cardiac auscultation a glorious past—but does it have a future?.Circulation. 1996; 93: 1250-1253Crossref PubMed Scopus (114) Google Scholar) is the suggestion by Tavel (7Tavel M.E. Brown D.D. Shander D. Enhanced auscultation with a new graphic display system.Arch Intern Med. 1994; 154: 893-898Crossref PubMed Google Scholar) to employ an extant, miniature higher-technology system to show graphically what we hear, to provide a feedback loop for growth and as a teaching tool. We need not treat such a device as training wheels, to be discarded. Rather, it can be incorporated into clinical bedside practice, just as stethoscope, ophthalmoscope, and sphygmomanometer were when familiarity, education, and lower cost brought each into the repertoire of every generalist. The intern lurches from bed to bed on a bad admitting night, listening briefly by rote, comprehending little to nothing, copying the plausible "grade 2/6 SEM" from the equally undependable physical examination of the assistant resident, gaping in terror that he will err and harm a patient before the echocardiogram comes, like the cavalry, to the rescue. What is wrong with this picture is not its veracity, but the lack of a generalist attending physician, or a fellow or attending physician in cardiology, who will go over the findings. That is what we need to bring housestaff out of the disorientation in which they founder. It is a vicious circle: distrusting physical findings because they are "unreliable"—perhaps citing literature on imperfect reproducibility as though this justified nihilism—ensuring that medical students are indoctrinated with the same, and in a worst-case scenario belittled if they actually take time to listen repeatedly. All are devoid of a repertoire of bedside subroutines that might be called upon to test and refine any initial impression. I base these comments on my observations conducting physical diagnosis rounds for many years in my own university hospital, teaching community hospitals, and teaching nursing home, as well as in many places around the country where I have been the visiting professor known as "the physical diagnosis guy." There are lucid expositions of the physical diagnosis problem (5Craige E. Should auscultation be rehabilitated?.N Engl J Med. 1988; 318: 1611-1613Crossref PubMed Scopus (63) Google Scholar, 6Tavel M.E. Cardiac auscultation a glorious past—but does it have a future?.Circulation. 1996; 93: 1250-1253Crossref PubMed Scopus (114) Google Scholar, 8Weitz H.H. Mangione S. In defense of the stethoscope and the bedside.Am J Med. 2000; 108: 669-671Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar). However, some recent paeans to auscultation have been so idiosyncratic, so minutia oriented, and so time and effort intensive (9Woywodt A. Hofer M. Pilz B. et al.Cardiopulmonary auscultation duo for strings—opus 99.Arch Intern Med. 1999; 159: 2477-2479Crossref PubMed Scopus (8) Google Scholar), that no skeptic, let alone any cynic, will pay heed. Other efforts are ongoing, both in cardiac auscultation and other parts of physical examination (10Mangione S. O'Brien M.K. Peitzman S.J. Small-group teaching of chest auscultation to third-year medical students.Acad Med. 1997; 72: S121-S123Crossref PubMed Scopus (11) Google Scholar). Until these are rewarded not only by grateful patients, but also by housestaff, Appointments and Promotions Committees, and those allocating assignments, duties, and money, they will resemble other shoestring efforts. Unfortunately, these programs may not outlast the inevitable discouragement and fatigue of their proponents. So what shall we do? I propose something that does not cost one cent and requires little or no retraining. It can be accomplished by anyone who has a chance to teach, even if the student is as junior as a second-year medical student. Simply devote at least one teaching round in a month on-service to cardiac auscultation. This has to be done at the bedside with minimal antecedent case presentation ("Let's see somebody who has a heart finding, even an innocent systolic ejection murmur. Give me a two-sentence bullet presentation of the case, and then tell me what impressions and questions you have about the heart sounds and murmurs"). This exercise requires a small group, four trainees or fewer, so that the ambient noise stays low and a circus atmosphere is avoided. If this means having to do two separate shorter sessions so that everyone gets a chance, it is well worth the effort. If people start to speak, however softly, a stern warning not to talk while anybody is listening with the stethoscope is mandatory, and can be softened by saying, "We all know it is hard enough, let's stack the deck in our own favor." The patient must be notified and willing. It helps to have the unit clerk and the nurse aware, so that the patient is not called away. The door has to be closed, the television off, and the roommate silent. Learners need to be told to use the waiting time productively while others are listening. One can tell them to make and write down every observation that they can about the patient, the environs, and the exercise. I prefer to ask a focused auscultation question, such as, "Is S2 split, and if so, is P2 louder than A2?" I insist that each learner write an answer on paper, for his or her eyes only, to commit to a finding. We often specify where and what we will address: for example, "Please listen only at the left upper sternal border with the diaphragm." This focuses discussion, and one can also see how many housestaff place the diaphragm far lateral to the anatomic landmark. That error offers a chance for gentle correction in real-time: "You will hear more if you move medially," and also rewards others who have been paying attention with an elementary but much-needed "pearl." To address all audible sounds worsens the confusion of those who feel most shaky in the exercise. Invariably a house officer—often the most conscientious—will mention the carotid or something else outside the explicit topic. This requires firm gentle refusal; otherwise it is a free-for-all, and the small, central, usable lesson will not be successfully communicated. Sometimes when a finding is subtle, I hold the head of my stethoscope in place while removing the earpieces, and say, "Let's minimize variability of instrument and locale." This also makes housestaff and students feel accepted and valued. On other occasions, especially with the bell and a low-pitched sound, one can ask the patient, "Please tell my young colleagues if they press much harder than I did, or much more softly." After we leave the room, I ask each student, in ascending order of seniority, to state what was heard. I explain that there will be disagreement and that this is a safe place to be corrected without prejudice or humiliation. I always draw a small graphic of my own findings. I like to avow that somebody else may have heard something I missed: my organs of Corti are older than those of trainees. We talk about the pathophysiology of the finding. For those who missed or mislabeled a finding, I suggest returning to the patient later, alone and at leisure, and listening again. If I am having a good day, I e-mail the chief resident later in the day a citation on the particular issue covered, often using my bibliography as a source (11Schneiderman H. Peixoto A.J. Bedside Diagnosis. 3rd ed. American College of Physicians, Philadelphia1997Google Scholar) or a PubMed search. Housestaff are intensely grateful for these sessions. Such cardiac auscultation rounds do not in any sense require a master teacher, nor a cardiologist. Acknowledgment of the teacher's limitations and desire to grow reduces learners' embarrassment. Frequently recurring productive topics have been the following: •Is the murmur tricuspid regurgitation or mitral regurgitation? I usually focus on locale of maximal intensity as the most valuable feature. Discussion and demonstration of inspiratory augmentation, often added as a help, is not pathognomonic; likewise augmentation with abdominal pressure. I like to do the two maneuvers together, release suddenly and let the patient exhale at that point. If the murmur intensifies sharply at that point, I favor mitral over tricuspid origin.•Is a third heart sound present? Showing the need to keep the bell touching lightly and the value of left lateral decubitus position is important. So is a reminder that the presence of an S3 in an adult above age 40, who is not in overt congestive heart failure and free of mitral regurgitation, is strongly correlated with a low ejection fraction of 35% or less.•Is there a right ventricular third heart sound? Here the issue focuses on the left lower sternal border rather than the apex. One demonstrates use of the right supraclavicular fossa as an alternative acoustic window when, as in so many of these patients, obstructive airway disease has rendered heart tones inaudible throughout the precordium.•Is there a systolic thrill? Here the analogy of feeling a kitten's purring, perhaps through a pillow, is useful. One can emphasize that to feel the apex for thrills, though not for apical impulse location, there is no harm in positioning the patient in left lateral decubitus. One shows the need to use interphalangeal or metacarpophalangeal joints rather than fingertips, and the value of touching lightly for 45 seconds to focus on palpable cardiovascular vibration: "If you push harder and harder, you guarantee only that you obliterate all palpable vibration. Just pretend you have all day." This topic is particularly successful when used to settle whether a systolic murmur at the right upper sternal border represents aortic stenosis, aortic sclerosis, or hypertrophic cardiomyopathy, and when it settles whether a confusing murmur heard widely over the precordium reflects mitral regurgitation or aortic stenosis.•Is the second heart sound split? If so, is it pathologic or physiologic? This draws on findings that abound on any inpatient general medicine service and in any nursing home. A lovely source of a paradoxically split second sound is a patient with a pacemaker: premature depolarization of the right ventricle mimics the acoustic effect of left bundle branch block. The caveat is that many older persons have an inaudible pulmonic component of the second heart sound, even if one carefully auscults all interspaces from first through fourth at the left sternal border. If on reading these methods you are tempted to say, "Baby stuff!", please believe such issues and skills constitute an alphabet from which the words of cardiac diagnosis are spelled. Today's housestaff and students desperately need help in mastering these very items. Each attending physician needs to overcome any sense of personal inadequacy as an examiner or lack of qualification as a teacher of this information. Despite all that has been wrong for so long, it is still the case that most staff physicians have auscultatory lessons to offer their juniors. We need multiple approaches to enhance clinical skills; this is but one of them. If you try it, you will grow your own skills even more than the housestaff's: the best way to learn something cold is to teach it. The benefit to patients, to trainees, and to our own spirit is immense. Please feel free to use my wording on the comments and queries, to modify and improve it, or to replace it altogether.