Clinical Auscultation Skills in Pediatric Residents

DISCUSSION

Previous studies of internal medicine and family medicine residents have demonstrated less than optimal clinical auscultation skills^2,,3 with diagnostic accuracy rates ranging from 20% to 54%.^2,,3 The present study conducted in pediatrics and medicine/pediatrics programs at Duke University Medical Center demonstrates that there is similar room for improvement in their auscultation skills. The accuracy rate in this study is comparable to that for internal medicine residents, being 23% to 41% and 33% overall.

There was a trend noted toward improvement in auscultation skills as training progressed, but this did not reach statistical significance. Nonetheless, there was a wide separation between the skills of even senior residents and cardiologists in training or faculty members. Auscultation skills did not differ significantly by type of program (pediatrics vs medicine/pediatrics).

Only 6 residents completed a cardiology elective. Their score (11.6) was higher than their other colleagues (10.8), although not statistically different. The small size of this group may have hampered efforts to detect a difference.

One major limitation of this study is the adult size of the mannequin and the associated slower heart rate. However, this should have biased results to a higher score because the auscultatory findings are easier to discern at a slow heart rate. Further, Harvey is immobile and is not programmed to demonstrate auscultatory findings in the back, neck, or axilla. The ability to assess radiation of murmurs and the changes in character of the murmur with change in position may have limited the ability of the residents to make an accurate diagnosis. In contrast, it is certainly easier to examine the mannequin than a small child who might be moving or crying. It would be of interest to have similar studies of auscultatory skill repeated at other training institutions.

Of note in this study, the innocent systolic ejection murmur was the 1 most frequently misdiagnosed. This murmur, however, was a pulmonary flow murmur, not the typical Still's murmur commonly seen in childhood. A nonspecific, soft (grade 2/6) pulmonary flow murmur (without vibratory or musical quality) without either a wide fixed split in S2 or a tricuspid flow rumble is a common finding in young children with atrial septal defects. This may well have affected the diagnostic accuracy of the examiners. The innocent pulmonary flow murmur with normal splitting and a physiologic S3 is easily reproduced using the Harvey model. The difficulty in reproducing the musical or vibratory (Still's murmur) with this model, is a limitation of this study.

In this era of managed care, there is a greater focus on the cost of delivery of health care, while at the same time attempting to preserve quality of patient care. Pediatricians are faced daily with decisions about which patients should be referred for evaluation of a heart murmur. Smythe and associates⁵ also found that in 69% of the patients referred by pediatricians to pediatric cardiologists, the referral diagnosis was inaccurate, and only 30% of patients referred were found to have definite or possible underlying heart disease. Although it has been found to be more cost-effective for pediatricians to refer patients to a pediatric cardiologist for murmur evaluation than to request an echocardiogram,⁶ their ability to accurately screen for innocent or functional murmurs and avoid the referral to the subspecialist would certainly be more cost-effective. This requires more emphasis during residency training on developing auscultatory skills that would permit the physician to differentiate in most situations a murmur associated with underlying heart disease from 1 not associated with cardiovascular pathology.

Improved training in physical diagnosis should reduce the number of unnecessary referrals and may even enhance the accuracy of specific cardiac diagnosis. Greater skill in cardiac auscultation may also prove to be life saving for the occasional patient with a significant congenital heart defect. The pediatrician should be aware that the pediatric cardiologist always remains available as a consultation resource.

In the past, skills in the cardiovascular examination, including auscultation, were acquired during rotations on the pediatric inpatient service. The recent emphasis on decreasing the length of in-hospital stay severely limits the number of patients available for resident training. In addition, patients undergoing heart catheterization or cardiovascular surgery are frequently admitted on the day of the procedure and, therefore, are not readily available for examination by the house officer. To improve the situation, it would be appropriate and necessary to place more emphasis on training in the pediatric cardiology subspecialty clinic and private office settings.