Small Steps in Impacting Clinical Auscultation of Medical Students

The Evolving Stethoscope: Insights Derived from Studying Phonocardiography in Trainees

Phonocardiography (PCG) is used as an adjunct to teach cardiac auscultation and is now a function of PCG-capable stethoscopes (PCS). To evaluate the efficacy of PCG and PCS, the authors investigated the impact of providing PCG data and PCSs on how frequently murmurs, rubs, and gallops (MRGs) were correctly identified by third-year medical students. Following their internal medicine rotation, third-year medical students from the Georgetown University School of Medicine completed a standardized auscultation assessment. Sound files of 10 different MRGs with a corresponding clinical vignette and physical exam location were provided with and without PCG (with interchangeable question stems) as 10 paired questions (20 total questions). Some (32) students also received a PCS to use during their rotation. Discrimination/difficulty indexes, comparative chi-squared, and McNemar test p-values were calculated. The addition of phonocardiograms to audio data was associated with more frequent identification of mitral stenosis, S4, and cardiac friction rub, but less frequent identification of ventricular septal defect, S3, and tricuspid regurgitation. Students with a PCS had a higher frequency of identifying a cardiac friction rub. PCG may improve the identification of low-frequency, usually diastolic, heart sounds but appears to worsen or have little effect on the identification of higher-frequency, often systolic, heart sounds. As digital and phonocardiography-capable stethoscopes become more prevalent, insights regarding their strengths and weaknesses may be incorporated into medical school curricula, bedside rounds (to enhance teaching and diagnosis), and telemedicine/tele-auscultation efforts.

Recognizing cardiac murmurs in childhood: a survey of physicians' approaches and knowledge levels

OBJECTIVE

This study aimed to assess physicians' approach to cardiac murmurs and their level of knowledge about this sign, which is a crucial finding in childhood cardiac anomalies.

METHODS

The study intended to include all family physicians in the Adıyaman province of Turkey, but ultimately 150 out of 210 physicians participated and was completed with a percentage response rate of 71%. Participants were asked about their approach to cardiac murmurs, answered knowledge questions, and completed a questionnaire on demographic characteristics. Subsequently, eight heart sounds were played, and participants were asked to identify the nature of each sound.

RESULTS

Family medicine specialists (all scores were p < 0.001) and physicians who completed a pediatric internship lasting over a month (knowledge score p = 0.012, behavioral score p = 0.021, recording score p = 0.01) demonstrated significantly higher knowledge, approach, and recording scores. Age and years in the profession showed a negative correlation with recording scores.

CONCLUSIONS

The study highlights the significant impact of various factors such as gender, specialization, internship duration, experience, and theoretical knowledge on the ability to recognize and approach cardiac murmurs. These findings underscore the importance of incorporating these factors into medical education and development programs, especially those aimed at improving cardiac examination skills.

A randomized, controlled trial of an innovative, multimedia instructional program for acquiring auditory skill in identifying pediatric heart murmurs

Objective

To create a brief, acceptable, innovative method for self-paced learning to enhance recognition of pediatric heart murmurs by medical students, and to demonstrate this method's effectiveness in a randomized, controlled trial.

Materials and methods

A curriculum of six 10-min online learning modules was designed to enable deliberate practice of pediatric cardiac auscultation, using recordings of patients' heart murmurs. Principles of andragogy and multimedia learning were applied to optimize acquisition of this skill. A pretest and posttest, given 4 weeks apart, were created using additional recordings and administered to 87 3rd-year medical students during their pediatric clerkship. They were randomized to have access to the modules after the pretest or after the posttest, and asked to use at least the first 2 of the modules.

Results

47 subjects comprised the Intervention group, and 40 subjects the Control group. On our primary outcome, distinguishing innocent from pathological with at least moderate confidence, the posttest scores were significantly higher for the Intervention group (60.5%) than for the Control group (20.0%). For our secondary outcomes, the 2 groups also differed significantly in the ability to distinguish innocent from pathological murmurs, and in identifying the actual diagnosis. On all 3 outcomes, those Intervention group subjects who accessed 4-6 modules scored higher than those who accessed 0-3 modules, who in turn scored higher than the Control group.

Summary

Applying current principles of adult learning, we have created a teaching program for medical students to learn to recognize common pediatric murmurs. Its effectiveness was demonstrated in a randomized, controlled trial. The program results in a meaningful gain in this skill from 1 h of self-paced training with high acceptance to learners.

The Effectiveness of Different Teaching Modalities for the Detection of Heart Murmurs in Undergraduate Medical Education: A Review

One of the many physical exam skills introduced to medical students during their pre-clerkship education is cardiac auscultation, one purpose of which is to teach the detection and identification of heart murmurs. Cardiac auscultation with a stethoscope has been the standard method of teaching. Another method, point-of-care ultrasound (POCUS), has been recently introduced as another modality by which students learn to detect and identify murmurs. The emerging popularity of POCUS in undergraduate medical curricula has led many institutions to include it in their curricula; however, doing so is challenging. Not only is cost a major factor, but reorganizing curricula to allow sufficient time for POCUS training has proven to be difficult. Additionally, the presence of notable gaps in the literature regarding the efficacy of POCUS for teaching the detection and identification of heart murmur has increased scrutiny of its value. Studies that assessed teaching cardiac auscultation to medical students in their pre-clinical years via stethoscope have used different teaching methods. However, evaluation of these studies identified numerous limitations, one being little long-term retention of cardiac auscultation knowledge. Furthermore, several barriers to integration of POCUS in undergraduate medical education were identified. The purpose of this review is to synthesize the literature comparing the effectiveness of these different tools of a cardiac exam for detection of heart murmurs in undergraduate medical education and identify gaps in literature requiring future exploration.

Utilization of Simulation to Teach Cardiac Auscultation: A Systematic Review

This systematic review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, evaluates the effectiveness of simulation-based education in teaching cardiac auscultation. A team of researchers conducted a comprehensive, systematic search of the PubMed database from 2010 to 2021, focusing on cardiac auscultation, education, proficiency, and students. After rigorous filtering, a total of 14 articles, primarily involving medical students and residents, met the inclusion criteria. The articles were categorized based on their focus areas: diagnostic accuracy, knowledge acquisition, competency, and learner satisfaction. Findings suggest that the majority of the studies (86% or 12 out of 14) reported positive outcomes of using simulation for teaching cardiac auscultation, demonstrating improvements in the identified focus areas across diverse contexts. The review underscores the need for future research to further standardize simulation teaching practices, aiming to reduce costs, improve usability, and possibly incorporate multiple simulation approaches in a universal educational process. This approach could enhance outcomes across varied fields and learning styles.

The Effectiveness of Training on Auscultation of Heart with a Simulator of Cardiology in Medical Students

Abstract The purpose of this study was to determine whether the training module with a simulator of cardiology improves auscultation skills in medical students. Methods. Medical students of the third year after completing the module of the cardiovascular system of the discipline “Propaedeutics of internal diseases, passed a two-hour or four-hour training module in clinical auscultation with retesting immediately after the intervention and in the fourth year. The control group consisted of fourth-year medical students who had no intervention. Results. The diagnostic accuracy in two-hour training was 45.9% vs 35.3% in four-hour training p <.001. The use of a cardio simulator significantly increased the accurate detection of mitral regurgitation immediately after training on a simulator (more than 73%) p <.001. The next academic year, regression was observed in the diagnostic accuracy of mitral insufficiency in the intervention group after six months of observation by 4%. The auscultation skills of students at the bedside of real patients did not increase after training on a simulator: the accuracy of diagnosis of the auscultatory picture of the defect was equally low in the intervention group and the control group (35.0% vs 30.8%, p = 0.651). Conclusions. Two-hour training was more effective than four-hour training. After training on cardiac auscultation using a patient’s cardiological simulator, the accuracy rate was low in a situation close to the clinical conditions and a clinic on a real patient.

Do basic auscultation skills need to be resuscitated? A new strategy for improving competency among nursing students

BACKGROUND

Auscultation of heart and lung sounds is a foundational competency for Registered Nurses (RNs). Precise and timely assessments are important for the early detection and recognition of the deteriorating patient. Studies have shown that improved teaching methods that incorporate emerging technologies and address different learning styles are needed to improve competency in auscultation.

METHOD

Undergraduate nursing students (n = 127) were randomized into treatment and control groups. The control group received the usual preparation in auscultation learning strategies. The treatment group received the usual training plus three auscultation learning sessions that were each 2 h in length (cardiac, pulmonary and mixed sounds).

RESULTS

The virtual auscultation teaching strategy had a significant impact on undergraduate nursing student's competency in recognizing heart murmurs. The treatment group also had increased scores compared to the control group increased scores in distinguishing normal versus abnormal heart and lung sounds, identification of crackles and diminished breath sounds.

CONCLUSION

Virtual auscultation as a teaching strategy was shown to have a positive impact on undergraduate student nurse competence in accurately identifying heart and lung sounds.