Cardiac Auscultation and Teaching Rounds:How Can Cardiac Auscultation Be Resuscitated?

Henry Schneiderman, MD

This issue of the Green Journal contains a report bySalvatore Mangione (1) on the lack of clinicalskills among physicians-in-training. Mangione

has become the chronicler of this problem; his 1993 paper(2) was greeted with much notice and little correctiveaction. Over the years Mangione has extended documen-tation of defective bedside methods and interpretativeabilities to other specialties (3). Now he shows that Cana-dian and British trainees are also poor at bedside auscul-tation, contrary to a widely held assumption that the Brit-ish are more skilled (4).

Among the subgroups studied by Mangione, none hadeven minimal competence in recognizing murmurs suchas mitral regurgitation that are encountered every day ingeneral internal medicine practice. Differences amonggroups are not nearly as impressive as the poor showingby all. Surprisingly, unsupervised study of auscultatoryaudiotapes, which intuitively seems helpful for ausculta-tory knowledge, did not raise scores.

End-stage failure of physical examination skills has ar-rived. Notwithstanding curmudgeons who assert that ithas always been this bad and physicians who ask “Whatharm?,” the joy of medicine suffers (5). So does relation-ship-building with patients, who experience our role ashealer more fully when we place hands and stethoscopeson their bodies for real diagnostic help, not merely asritual. Incapable physical examiners cannot make ratio-nal and cost-effective application of technology—and letus acknowledge with pleasure and gratitude how pro-foundly technology enhances medicine. Among the cre-ative responses to the crisis in cardiac auscultation (6) isthe suggestion by Tavel (7) to employ an extant, minia-ture higher-technology system to show graphically whatwe hear, to provide a feedback loop for growth and as ateaching tool. We need not treat such a device as trainingwheels, to be discarded. Rather, it can be incorporatedinto clinical bedside practice, just as stethoscope, oph-thalmoscope, and sphygmomanometer were when famil-iarity, education, and lower cost brought each into therepertoire of every generalist.

THE CURRENT SITUATION

The intern lurches from bed to bed on a bad admittingnight, listening briefly by rote, comprehending little tonothing, copying the plausible “grade 2/6 SEM” from theequally undependable physical examination of the assis-tant resident, gaping in terror that he will err and harm apatient before the echocardiogram comes, like the cav-alry, to the rescue. What is wrong with this picture is notits veracity, but the lack of a generalist attending physi-cian, or a fellow or attending physician in cardiology, whowill go over the findings. That is what we need to bringhousestaff out of the disorientation in which theyfounder. It is a vicious circle: distrusting physical findingsbecause they are “unreliable”—perhaps citing literatureon imperfect reproducibility as though this justified ni-hilism— ensuring that medical students are indoctri-nated with the same, and in a worst-case scenario belittledif they actually take time to listen repeatedly. All are de-void of a repertoire of bedside subroutines that might becalled upon to test and refine any initial impression. I basethese comments on my observations conducting physicaldiagnosis rounds for many years in my own universityhospital, teaching community hospitals, and teachingnursing home, as well as in many places around the coun-try where I have been the visiting professor known as “thephysical diagnosis guy.”

A PRACTICAL MEASURE

There are lucid expositions of the physical diagnosisproblem (5,6,8). However, some recent paeans to auscul-tation have been so idiosyncratic, so minutia oriented,and so time and effort intensive (9), that no skeptic, letalone any cynic, will pay heed. Other efforts are ongoing,both in cardiac auscultation and other parts of physicalexamination (10). Until these are rewarded not only bygrateful patients, but also by housestaff, Appointmentsand Promotions Committees, and those allocating as-signments, duties, and money, they will resemble othershoestring efforts. Unfortunately, these programs maynot outlast the inevitable discouragement and fatigue oftheir proponents.

So what shall we do? I propose something that does notcost one cent and requires little or no retraining. It can beaccomplished by anyone who has a chance to teach, evenif the student is as junior as a second-year medical stu-dent. Simply devote at least one teaching round in amonth on-service to cardiac auscultation. This has to be

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done at the bedside with minimal antecedent case presen-tation (“Let’s see somebody who has a heart finding, evenan innocent systolic ejection murmur. Give me a two-sentence bullet presentation of the case, and then tell mewhat impressions and questions you have about the heartsounds and murmurs”).

This exercise requires a small group, four trainees orfewer, so that the ambient noise stays low and a circusatmosphere is avoided. If this means having to do twoseparate shorter sessions so that everyone gets a chance, itis well worth the effort. If people start to speak, howeversoftly, a stern warning not to talk while anybody is listen-ing with the stethoscope is mandatory, and can be soft-ened by saying, “We all know it is hard enough, let’s stackthe deck in our own favor.” The patient must be notifiedand willing. It helps to have the unit clerk and the nurseaware, so that the patient is not called away.

EVERYTHING IS IN THE DETAILS

The door has to be closed, the television off, and theroommate silent. Learners need to be told to use the wait-ing time productively while others are listening. One cantell them to make and write down every observation thatthey 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 thateach learner write an answer on paper, for his or her eyesonly, to commit to a finding.

We often specify where and what we will address: forexample, “Please listen only at the left upper sternal bor-der with the diaphragm.” This focuses discussion, andone can also see how many housestaff place the dia-phragm far lateral to the anatomic landmark. That erroroffers a chance for gentle correction in real-time: “Youwill hear more if you move medially,” and also rewardsothers who have been paying attention with an elemen-tary but much-needed “pearl.”

To address all audible sounds worsens the confusion ofthose who feel most shaky in the exercise. Invariably ahouse officer— often the most conscientious—will men-tion the carotid or something else outside the explicittopic. This requires firm gentle refusal; otherwise it is afree-for-all, and the small, central, usable lesson will notbe successfully communicated.

Sometimes when a finding is subtle, I hold the head ofmy stethoscope in place while removing the earpieces,and say, “Let’s minimize variability of instrument andlocale.” This also makes housestaff and students feel ac-cepted and valued. On other occasions, especially withthe bell and a low-pitched sound, one can ask the patient,“Please tell my young colleagues if they press muchharder than I did, or much more softly.”

After we leave the room, I ask each student, in ascend-

ing order of seniority, to state what was heard. I explainthat there will be disagreement and that this is a safe placeto be corrected without prejudice or humiliation. I alwaysdraw a small graphic of my own findings. I like to avowthat somebody else may have heard something I missed:my organs of Corti are older than those of trainees. Wetalk about the pathophysiology of the finding. For thosewho missed or mislabeled a finding, I suggest returning tothe patient later, alone and at leisure, and listening again.

If I am having a good day, I e-mail the chief residentlater in the day a citation on the particular issue covered,often using my bibliography as a source (11) or a PubMedsearch.

GENERALIZABILITY

Housestaff are intensely grateful for these sessions. Suchcardiac auscultation rounds do not in any sense require amaster teacher, nor a cardiologist. Acknowledgment ofthe teacher’s limitations and desire to grow reduces learn-ers’ embarrassment. Frequently recurring productivetopics have been the following:

● Is the murmur tricuspid regurgitation or mitral regur-gitation? I usually focus on locale of maximal intensityas the most valuable feature. Discussion and demon-stration of inspiratory augmentation, often added as ahelp, is not pathognomonic; likewise augmentationwith abdominal pressure. I like to do the two maneu-vers together, release suddenly and let the patient ex-hale at that point. If the murmur intensifies sharply atthat point, I favor mitral over tricuspid origin.

● Is a third heart sound present? Showing the need tokeep the bell touching lightly and the value of left lat-eral decubitus position is important. So is a reminderthat the presence of an S3 in an adult above age 40, whois not in overt congestive heart failure and free of mitralregurgitation, is strongly correlated with a low ejectionfraction of 35% or less.

● Is there a right ventricular third heart sound? Here theissue focuses on the left lower sternal border ratherthan the apex. One demonstrates use of the right su-praclavicular fossa as an alternative acoustic windowwhen, as in so many of these patients, obstructive air-way disease has rendered heart tones inaudiblethroughout the precordium.

● Is there a systolic thrill? Here the analogy of feeling akitten’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 noharm in positioning the patient in left lateral decubitus.One shows the need to use interphalangeal or metacar-pophalangeal joints rather than fingertips, and thevalue of touching lightly for 45 seconds to focus on

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palpable cardiovascular vibration: “If you push harderand harder, you guarantee only that you obliterate allpalpable vibration. Just pretend you have all day.” Thistopic is particularly successful when used to settlewhether a systolic murmur at the right upper sternalborder represents aortic stenosis, aortic sclerosis, orhypertrophic cardiomyopathy, and when it settleswhether a confusing murmur heard widely over theprecordium reflects mitral regurgitation or aortic ste-nosis.

● Is the second heart sound split? If so, is it pathologic orphysiologic? This draws on findings that abound onany inpatient general medicine service and in any nurs-ing home. A lovely source of a paradoxically split sec-ond sound is a patient with a pacemaker: prematuredepolarization of the right ventricle mimics the acous-tic effect of left bundle branch block. The caveat is thatmany older persons have an inaudible pulmonic com-ponent of the second heart sound, even if one carefullyauscults all interspaces from first through fourth at theleft sternal border.

If on reading these methods you are tempted to say,“Baby stuff!”, please believe such issues and skills consti-tute an alphabet from which the words of cardiac diagno-sis are spelled. Today’s housestaff and students desper-ately need help in mastering these very items. Each at-tending physician needs to overcome any sense ofpersonal inadequacy as an examiner or lack of qualifica-tion as a teacher of this information. Despite all that hasbeen wrong for so long, it is still the case that most staffphysicians 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 yourown skills even more than the housestaff’s: the best way tolearn something cold is to teach it. The benefit to patients,to trainees, and to our own spirit is immense. Please feelfree to use my wording on the comments and queries, tomodify and improve it, or to replace it altogether.

REFERENCES1. Mangione S. Cardiac auscultatory skills of physicians-in-training: a

comparison of three English-speaking countries. Am J Med. 2001;110:210 –216.

2. Mangione S, Nieman LZ, Gracely E, Kaye D. The teaching andpractice of cardiac auscultation during internal medicine and car-diology training. A nationwide survey. Ann Intern Med. 1993;119:47–54.

3. Mangione S, Burdick WP, Peitzman SJ. Physical diagnosis skills ofphysicians in training: a focused assessment. Acad Emerg Med.1995;2:622– 629.

4. Gilston A. Clinical examination of the respiratory system. J R SocMed. 2000;93:158. Letter.

5. Craige E. Should auscultation be rehabilitated? N Engl J Med. 1988;318:1611–1613.

6. Tavel ME. Cardiac auscultation: a glorious past— but does it have afuture? Circulation. 1996;93:1250 –1253.

7. Tavel ME, Brown DD, Shander D. Enhanced auscultation with anew graphic display system. Arch Intern Med. 1994;154:893– 898.

8. Weitz HH, Mangione S. In defense of the stethoscope and the bed-side. Am J Med. 2000;108:669 – 671.

9. Woywodt A, Hofer M, Pilz B, et al. Cardiopulmonary auscultation:duo for strings— opus 99. Arch Intern Med. 1999;159:2477–2479.

10. Mangione S, O’Brien MK, Peitzman SJ. Small-group teaching ofchest auscultation to third-year medical students. Acad Med. 1997;72(suppl 1):S121–S123.

11. Schneiderman H, Peixoto AJ. Bedside Diagnosis: An Annotated Bib-liography of Literature on Physical Examination and Interviewing.3rd ed. Philadelphia: American College of Physicians; 1997.

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