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Am Fam Physician. 1998;57(7):1648-1653

Because of the recent shift toward managed care and the accompanying pressures to contain costs of diagnosis, physical examination skills are under increased scrutiny. Mangione and Nieman conducted a cross-sectional assessment of internal medicine and family practice residents to determine their proficiency in using cardiac auscultation to identify various cardiac events.

Auscultatory skills were evaluated in 198 internal medicine and 255 family practice residents. Study participants listened to 12 different cardiac events (such as mitral regurgitation or S3 gallops) and then answered a multiple-choice questionnaire regarding the presence or absence of the sound and its characteristics. The resident's cumulative score reflected accuracy in recognizing six extra sounds, six murmurs and 12 auscultatory events. Participants also completed a one-page questionnaire assessing their motivation to learn cardiac auscultation and their level of confidence in their skills. A smaller group of third- and fourth-year medical students was also assessed for comparison.

The internal medicine residents were significantly more proficient than the family practice residents at identifying the 12 cardiac events and the six extra sounds. However, the residents' scores were never significantly better than those of the medical students. Overall, internal medicine and family practice residents correctly identified about 20 percent of the cardiac sounds. Family practice residents were never more accurate than the medical students and were significantly less accurate than the medical students in identifying some sounds (specifically, early systolic clicks and aortic stenosis murmurs). Although some residents had had more training and felt more confidence in their auscultatory skills, this confidence did not actually manifest itself as improved accuracy. Those who listened to teaching audiotapes and those who could play a musical instrument were more proficient at cardiac auscultation.

The authors conclude that training in cardiac auscultation is lacking and that there were no significant improvements as residents progressed to higher levels of training. They recommend that the boards of internal medicine and family practice consider adding the evaluation of cardiac auscultation skills to their certifying examinations.

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