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* Division of Pediatric Cardiology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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Methods. The auscultation skills of all first-year (PGY1; n = 20) and second-year pediatric residents (PGY2; n = 20) were evaluated at the beginning and end of the academic year. Five patient recordings were presented: atrial septal defect, ventricular septal defect, pulmonary valve stenosis, bicuspid aortic valve with insufficiency, and innocent murmur. Residents were asked to classify the second heart sound, identify a systolic ejection click, describe the murmur, and provide a diagnosis. All PGY1 and most PGY2 (14 of 20) participated on the inpatient cardiology service for 1 month. PGY2 on the cardiology service also attended outpatient clinic. PGY1 did not attend outpatient clinic but were allotted 2 hours/week to use a self-directed cardiac auscultation computer teaching program.
Results. Resident auscultation skills on initial evaluation were dependent on training level (PGY1: 42 ± 15% correct; PGY2: 53 ± 13% correct), primarily as a result of better classification of second heart sound (PGY1: 45%; PGY2: 63%) and diagnosis of an innocent murmur (PGY1: 35%; PGY2: 65%). There was no difference in the ability to identify correctly a systolic ejection click (20% vs 23%) or to arrive at the correct diagnosis (35% vs 40%). At the end of the academic year, the PGY1 scores improved by 21%, primarily as a result of improved diagnostic accuracy of the innocent murmur (35% to 65%). PGY2 scores remained unchanged (53% vs 51%), regardless of participation in a cardiology rotation (cardiology rotation: 50%; no cardiology rotation: 51%). Combined, diagnostic accuracy was best for ventricular septal defect (55%) and innocent murmur (60%) and worst for atrial septal defect (18%) and pulmonary valve stenosis (15%). However, 40% identified the innocent murmur as pathologic and 21% of pathologic murmurs were diagnosed as innocent.
Conclusions. Pediatric resident auscultation skills were poor and did not improve after an outpatient cardiology rotation. Auscultation skills did improve after the use of a self-directed cardiac auscultation teaching program. These data have relevance given the American College of Graduate Medical Education's emphasis on measuring educational outcomes and documenting clinical competencies during residency training.
Key Words: auscultation • murmurs • educational intervention • computer-based learning
Abbreviations: PGY1, first-year pediatric residents • PGY2, second-year pediatric residents • ASD, atrial septal defect • VSD, ventricular septal defect • PVS, pulmonary valve stenosis • BAV/AI, bicuspid aortic valve with aortic regurgitation • S2, second heart sound
Cardiac murmurs are common in pediatric patients, with an incidence of up to 90%.1–11 Because <1% of children have congenital cardiac defects, the overwhelming majority of murmurs are innocent and do not require additional evaluation or therapy.12,13 Evaluation of a new murmur is the most common reason for referral to the pediatric cardiologist.8,9,14 Although pediatric cardiologists can diagnose accurately an innocent murmur with a high degree of sensitivity and specificity,7–10 the high incidence of innocent murmurs makes routine pediatric cardiology evaluation cost-prohibitive.11 Therefore, primary care physicians who care for pediatric patients must be able to determine which patients require additional evaluation, because unnecessary referral is both costly and stressful for the family.15,16 Multiple investigators have documented poor auscultation skills regardless of training level, medical specialty, or country of training.17–25 Most of these studies are cross-sectional surveys that recommend development of educational strategies to address these auscultatory deficiencies. Few studies have evaluated the effectiveness of such educational strategies,21–23 and none has involved pediatricians, who will encounter the highest frequency of innocent murmurs that require no additional evaluation or therapy. This study was designed to assess the baseline cardiac auscultation skills of our pediatric residents and subsequently measure the impact of 2 different teaching interventions on auscultatory abilities.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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All PGY1 completed a 3-week cardiology inpatient rotation. After a brief orientation to the computer program, PGY1 received 2 hours/week of protected time to use a self-directed cardiac auscultation computer teaching program (CD-ROM) and were allowed additional time at their discretion. The CD-ROM is an interactive cardiac auscultation teaching program with >300 sound files. It includes an auscultation tutorial, detailed case review of specific lesions (including normal murmurs), and self-assessment quizzes. PGY1 did not participate in the cardiology outpatient clinic. Most PGY2 completed a month-long cardiology rotation, caring for inpatients and also participating in the outpatient clinic 4 half-days/week. During this outpatient clinic experience, PGY2 evaluated patients and discussed findings with an attending cardiologist, who then examined the patient and provided feedback to the resident. PGY2 were not given access to the cardiac auscultation computer teaching program. All residents on the cardiology service received teaching during cardiology inpatient rounds with additional lectures at the discretion of the attending cardiologist. However, the teaching of auscultation skills specifically was not standardized during the cardiology rotation for either the PGY1 or the PGY2.
Auscultation skills testing occurred at the beginning (T1) and end (T2) of the 2001-2002 academic year. Five different scenarios were tested: secundum atrial septal defect (ASD), restrictive ventricular septal defect (VSD), moderate pulmonary valve stenosis with variable ejection click (PVS), bicuspid aortic valve with aortic regurgitation (BAV/AI), and an innocent Still's murmur. These cases were chosen because they represent common lesions encountered in a pediatric practice. A diastolic murmur (BAV/AI) was included to assess the residents' ability to time the murmur in the cardiac cycle. The residents were told that all patients were asymptomatic and that the patients were undergoing a routine physical examination. They were also told the stethoscope's position on the chest and that the diaphragm was used in all cases. The sound files were obtained from the cardiac auscultation computer teaching program and looped continuously for 3 minutes of listening time (all with heart rates <100 bpm). While listening, each was asked to answer the same 4 questions for each case: 1) define the second heart sound (S2; single, physiologically split, widely split), 2) presence/absence of a systolic ejection click, 3) murmur schema (Fig 1), and 4) presumptive diagnosis (ASD, VSD, PVS, innocent murmur, aortic insufficiency, patent ductus arteriosus, none of the above). The test was administered to a senior cardiologist and 3 pediatric cardiology fellows, who correctly identified 19 of 20 questions. The senior cardiologist and cardiology fellows could not accurately characterize the S2 of the Still's murmur case (recording was made from the lower left sternal border), so the characterization of S2 was discarded for this scenario and the remainder of the analysis was performed on the remaining 19 questions. Using this test format, random guessing would result in a total correct score of 29%. A single investigator (C.B.M.) scored the tests, and the results were entered into a database for analysis. For each resident, we recorded the total score (of 19) and the ability to identify correctly S2 (4 cases), a widely split S2 (ASD case), a systolic ejection click (2 cases), a diastolic murmur (BAV/AI case), correct diagnosis (all cases), and correct diagnosis by lesion type. We also noted the percentage of physiologically incongruent answers (eg, noted diastolic murmur and diagnosed PVS), inappropriate referral (diagnosed pathology for innocent murmur case), and inappropriate nonreferral (diagnosed innocent murmur when pathology was present). These scores were then combined by year group (PGY1 and PGY2) and time of testing (T1 and T2). The residents were not given the answers to the pretest or allowed to revisit the sound files before follow-up testing. The same scenarios and sound files, presented in a different order, were used at the end of the academic year (T2). The residents were not aware that the same scenarios/sound files were used for both pre- and posttesting.
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We compared baseline auscultation skills by year group (PGY1 vs PGY2) and time of testing (T1 vs T2). Mean scores for each group were computed and compared using the t test. P < .05 was considered significant.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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The results of the auscultation skills test, by year group and test time, are summarized in Table 1. Resident auscultation skills at T1 were dependent on training level (PGY1: 42 ± 15% correct; PGY2: 53 ± 13% correct; P = .01), primarily as a result of better classification of S2 (PGY1: 45%; PGY2: 63%) and correct diagnosis of the innocent murmur (PGY1: 35%; PGY2: 65%). There was no difference in the ability to identify correctly the systolic ejection click (20% vs 23%) or to arrive at the correct diagnosis (27% vs 34%). On repeat testing, cumulative scores improved for 14 of 20 PGY1 and 8 of 20 PGY2 (5 of 14 participating in a cardiology rotation). Combined, PGY1 total score improved by 21% (P = .03), primarily as a result of improved diagnostic accuracy of the innocent murmur (35% to 65%). PGY2 scores remained unchanged (53% vs 51%), regardless of participation in a cardiology rotation (cardiology rotation: 50%; no cardiology rotation: 51%). For residents who participated in a cardiology rotation (PGY1 and PGY2), the change in score from T1 to T2 did not correlate with the time from cardiology rotation to the time of retesting (T2). Combined, diagnostic accuracy was best for VSD (55%) and innocent murmur (60%) and worst for ASD (18%) and PVS (15%). At T2, 40% of residents identified the innocent murmur as pathologic (inappropriate referral) and 21% identified a pathologic murmur as innocent (inappropriate nonreferral), with no difference from T1 or by level of training. Physiologically incongruent answers were given for 8% of the scenarios at T2 and were not affected by training level or participation in a cardiology rotation.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Given the high incidence of innocent murmurs in children detected on routine examination, pediatricians and other pediatric caregivers will encounter a large number of patients with auscultatory findings. Forty percent of our residents diagnosed pathology for the innocent murmur case (inappropriate referral), and these patients would presumably be sent for cardiology evaluation and/or echocardiography. Given the frequency of innocent murmurs in the pediatric population, this referral rate would create significant health care expenditures. Furthermore, even when reassured by their pediatrician that the findings are probably normal, most parents experience significant anxiety when referred for pediatric cardiology evaluation.15,16 In a recent study,16 two thirds of parents believed that their child would require medication or cardiac surgery, have sports limitation, or be at risk of premature death; that other children in the family could have cardiac problems; or that the murmur resulted from something that they did wrong during pregnancy. Despite cardiology evaluation and reassurance, a small percentage reported persistent anxiety after the diagnosis of an innocent murmur was made, which could lead to vulnerable child syndrome. Therefore, general pediatricians require effective auscultation skills to accurately triage these patients to prevent unnecessary family stress and inappropriate health care expenditures via pediatric cardiology consultation and/or echocardiography.
Given the overall poor auscultation skills, multiple authors have called for improved teaching of auscultation or inclusion of physical diagnosis skills in board certification examinations.17–19 In addition, the American College of Graduate Medical Education now emphasizes educational outcomes assessment, with documentation of clinical competencies before completion of residency training. Our data suggest that participation in an outpatient cardiology clinic alone does not further auscultation skills. Other educational interventions are required, and computer-based learning is 1 option and was found to be beneficial in our residents. Standardization of teaching curricula using interventions with documented educational efficacy provides an avenue for improving medical educational outcomes.
Given the difficulty in obtaining cardiac auscultation skills, perhaps the focus of teaching auscultation skills should shift from making the correct diagnosis to making the appropriate referral. The 6 cardinal signs of murmur pathology described by McCrindle et al8 could serve as a framework so that the truly important auscultatory findings are stressed in the limited amount of time allowed for cardiology teaching during residency. Even with this framework, however, it is clear that our residents likely would have made the same mistakes, as the identification of an abnormal S2, diastolic murmur, or a systolic ejection click, all indicative of pathology, was poor.
It has also been suggested that instead of focusing on the correct diagnosis, the focus of assessing auscultation skills should be on patient outcomes.26 Obviously, if the patient is referred to the pediatric cardiologist for pulmonary valve stenosis and later receives a diagnosis of an ASD, the patient does not suffer because appropriate care will be provided. For this reason, we chose to calculate the rate of inappropriate nonreferral (ie, cases in which pathology was present and the diagnosis of innocent murmur was made). Approximately one fifth of our scenarios would have been diagnosed with innocent murmurs when pathology was actually present. Although the patients in our study were asymptomatic at the time, all of the lesions have the potential for cardiovascular compromise and/or endocarditis; therefore, this rate of inappropriate nonreferral represents a significant amount of potentially undetected congenital heart disease. Furthermore, because the residents were in a test situation and probably expected a high incidence of pathologic cases, the rate of inappropriate nonreferral may be underestimated in this study.
Given the difficulty in teaching and maintaining adequate auscultatory skills, perhaps it is time for the generalist to use technology and/or telemedicine to determine the need for additional cardiology evaluation. With technologic advances in electronic stethoscopy, cardiac auscultatory findings can be easily digitized and sent to pediatric cardiologists for review. Using this method, Dahl et al27 obtained sensitivity and specificity similar to that of an actual pediatric cardiology evaluation. Alternatively, multiple authors have reported the utility of automated analysis of recorded heart sounds to differentiate normal from abnormal.28,29 Once perfected, these devices could serve as useful screening tools for the general pediatrician.
This study has numerous limitations. Only electronic recordings were provided, and being given the chance to examine an actual patient may have improved diagnostic accuracy. Some of the cases that were presented to our residents could have had associated physical examination findings (eg, accentuated right ventricular impulse associated with ASD; increased pulses/pulse pressure with aortic insufficiency). However, these nonauscultatory findings are subtle and usually not appreciated by noncardiologists. Furthermore, auscultatory skills were similarly poor in previous studies that used real patients for evaluation.19,20 The use of recorded sounds allowed for an identical, reproducible testing tool that could be used for both pre- and postintervention evaluation of auscultation skills. In addition, our testing scenario allowed for careful evaluation of auscultatory findings in a quiet environment, which rarely is present with real patients in a busy clinical practice. For assessing the impact of our interventions and eliminate confounding variables, postintervention testing needed to be done in a timely manner. This protocol allowed us to compare the impact of the 2 educational interventions but was unable to assess the durability of our interventions over time periods of >1 year. We compared interventions in 2 different year groups with different baseline scores; therefore, the observed improvement in auscultation skills may have been attributable to factors related to training level. In addition, residents who used the cardiac auscultation teaching program (PGY1) may have become more comfortable with listening to recorded sounds, thereby improving their posttest scores. Finally, the residents' didactic lecture time during their cardiology rotation was not controlled, and some residents may have had more time dedicated to auscultation skills than others. Because of the demonstrated improvement with the cardiac auscultation computer teaching program, it has now been made available to all of our residents. Had we decided to increase the number of subjects by extending the study for an additional academic year, we may have documented a more robust improvement. However, we wanted to ensure that the cardiac auscultation computer teaching program was available to all residents before completion of their residency training.
In conclusion, our findings demonstrate poor auscultation skills among our pediatric residents, which did not improve after an outpatient cardiology teaching experience. Auscultation skills did improve after the use of a self-directed cardiac auscultation program.
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ACKNOWLEDGMENTS |
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We thank the pediatric residents who participated in this study. In addition, we are grateful for the technical assistance provided by Corsonics, Inc, who produced the cardiac auscultation computer teaching program (CD-ROM).
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FOOTNOTES |
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Reprint requests to (C.B.M.) Pediatric Cardiology, Tripler Army Medical Center, 1 Jarrett White Rd, Honolulu, HI 96859-5000. E-mail: christopher.mahnke{at}haw.tamc.amedd.army.mil
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  S. Dhuper, S. Vashist, N. Shah, and M. Sokal Improvement of Cardiac Auscultation Skills in Pediatric Residents With Training Clinical Pediatrics, April 1, 2007; 46(3): 236 - 240. [Abstract] [PDF]
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