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  • 1. Comparison of Two Educational Interventions on Pediatric Resident Auscultation Skills C. Becket Mahnke, Andrew Nowalk, Dena Hofkosh, James R. Zuberbuhler and Yuk M. Law Pediatrics 2004;113;1331-1335 DOI: 10.1542/peds.113.5.1331 The online version of this article, along with updated information and services, is located on the World Wide Web at: PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2004 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from by on July 22, 2010
  • 2. Comparison of Two Educational Interventions on Pediatric Resident Auscultation Skills C. Becket Mahnke, MD*; Andrew Nowalk, MD, PhD‡; Dena Hofkosh, MD‡; James R. Zuberbuhler, MD*; and Yuk M. Law, MD* ABSTRACT. Objective. Multiple cross-sectional phy- ical competencies during residency training. Pediatrics sician surveys have documented poor cardiac ausculta- 2004;113:1331–1335; auscultation, murmurs, educational tion skills. We evaluated the impact of 2 different edu- intervention, computer-based learning. cational interventions on pediatric resident auscultation skills. Methods. The auscultation skills of all first-year ABBREVIATIONS. PGY1, first-year pediatric residents; PGY2, sec- ond-year pediatric residents; ASD, atrial septal defect; VSD, ven- (PGY1; n 20) and second-year pediatric residents tricular septal defect; PVS, pulmonary valve stenosis; BAV/AI, (PGY2; n 20) were evaluated at the beginning and end bicuspid aortic valve with aortic regurgitation; S2, second heart of the academic year. Five patient recordings were pre- sound. sented: atrial septal defect, ventricular septal defect, pul- monary valve stenosis, bicuspid aortic valve with insuf- C ficiency, and innocent murmur. Residents were asked to ardiac murmurs are common in pediatric pa- classify the second heart sound, identify a systolic ejec- tients, with an incidence of up to 90%.1–11 tion click, describe the murmur, and provide a diagnosis. Because 1% of children have congenital car- All PGY1 and most PGY2 (14 of 20) participated on the diac defects, the overwhelming majority of murmurs inpatient cardiology service for 1 month. PGY2 on the are innocent and do not require additional evalua- cardiology service also attended outpatient clinic. PGY1 did not attend outpatient clinic but were allotted 2 hours/ tion or therapy.12,13 Evaluation of a new murmur is week to use a self-directed cardiac auscultation computer the most common reason for referral to the pediatric teaching program. cardiologist.8,9,14 Although pediatric cardiologists Results. Resident auscultation skills on initial evalu- can diagnose accurately an innocent murmur with a ation were dependent on training level (PGY1: 42 15% high degree of sensitivity and specificity,7–10 the high correct; PGY2: 53 13% correct), primarily as a result of incidence of innocent murmurs makes routine pedi- better classification of second heart sound (PGY1: 45%; atric cardiology evaluation cost-prohibitive.11 There- PGY2: 63%) and diagnosis of an innocent murmur (PGY1: fore, primary care physicians who care for pediatric 35%; PGY2: 65%). There was no difference in the ability patients must be able to determine which patients to identify correctly a systolic ejection click (20% vs 23%) require additional evaluation, because unnecessary or to arrive at the correct diagnosis (35% vs 40%). At the end of the academic year, the PGY1 scores improved by referral is both costly and stressful for the family.15,16 21%, primarily as a result of improved diagnostic accu- Multiple investigators have documented poor aus- racy of the innocent murmur (35% to 65%). PGY2 scores cultation skills regardless of training level, medical remained unchanged (53% vs 51%), regardless of partic- specialty, or country of training.17–25 Most of these ipation in a cardiology rotation (cardiology rotation: 50%; studies are cross-sectional surveys that recommend no cardiology rotation: 51%). Combined, diagnostic accu- development of educational strategies to address racy was best for ventricular septal defect (55%) and these auscultatory deficiencies. Few studies have innocent murmur (60%) and worst for atrial septal defect evaluated the effectiveness of such educational strat- (18%) and pulmonary valve stenosis (15%). However, egies,21–23 and none has involved pediatricians, who 40% identified the innocent murmur as pathologic and will encounter the highest frequency of innocent 21% of pathologic murmurs were diagnosed as innocent. Conclusions. Pediatric resident auscultation skills murmurs that require no additional evaluation or were poor and did not improve after an outpatient car- therapy. This study was designed to assess the base- diology rotation. Auscultation skills did improve after line cardiac auscultation skills of our pediatric resi- the use of a self-directed cardiac auscultation teaching dents and subsequently measure the impact of 2 program. These data have relevance given the American different teaching interventions on auscultatory abil- College of Graduate Medical Education’s emphasis on ities. measuring educational outcomes and documenting clin- METHODS From the *Division of Pediatric Cardiology, Children’s Hospital of Pitts- All first-year (PGY1) and second-year pediatric residents burgh, Pittsburgh, Pennsylvania; and ‡Department of Pediatrics, Children’s (PGY2) were asked to participate in auscultation skills testing. Hospital of Pittsburgh, Pittsburgh, Pennsylvania. Residents in combined programs (pediatrics/internal medicine Received for publication Apr 16, 2003; accepted Sep 10, 2003. and pediatrics/psychiatry) were excluded. Third-year pediatric Reprint requests to (C.B.M.) Pediatric Cardiology, Tripler Army Medical residents do not participate in a cardiology rotation and therefore Center, 1 Jarrett White Rd, Honolulu, HI 96859-5000. E-mail: christopher. were excluded as they were unavailable for testing. The project was approved by the Human Rights Committee, and neither PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- study participation nor testing results were used in the residents’ emy of Pediatrics. evaluation. PEDIATRICS Vol. 113 No. 5 May 2004 1331 Downloaded from by on July 22, 2010
  • 3. All PGY1 completed a 3-week cardiology inpatient rotation. by lesion type. We also noted the percentage of physiologically After a brief orientation to the computer program, PGY1 received incongruent answers (eg, noted diastolic murmur and diagnosed 2 hours/week of protected time to use a self-directed cardiac PVS), inappropriate referral (diagnosed pathology for innocent auscultation computer teaching program (CD-ROM) and were murmur case), and inappropriate nonreferral (diagnosed innocent allowed additional time at their discretion. The CD-ROM is an murmur when pathology was present). These scores were then interactive cardiac auscultation teaching program with 300 combined by year group (PGY1 and PGY2) and time of testing (T1 sound files. It includes an auscultation tutorial, detailed case re- and T2). The residents were not given the answers to the pretest or view of specific lesions (including normal murmurs), and self- allowed to revisit the sound files before follow-up testing. The assessment quizzes. PGY1 did not participate in the cardiology same scenarios and sound files, presented in a different order, outpatient clinic. Most PGY2 completed a month-long cardiology were used at the end of the academic year (T2). The residents were rotation, caring for inpatients and also participating in the outpa- not aware that the same scenarios/sound files were used for both tient clinic 4 half-days/week. During this outpatient clinic expe- pre- and posttesting. rience, PGY2 evaluated patients and discussed findings with an After the final auscultation test, all residents were asked to attending cardiologist, who then examined the patient and pro- complete an auscultation attitudes survey. Each resident was vided feedback to the resident. PGY2 were not given access to the asked to rate how important auscultation skills are in the practice cardiac auscultation computer teaching program. All residents on of general pediatrics, their own auscultation skills, and whether the cardiology service received teaching during cardiology inpa- they believed that their skills needed improvement. In addition, tient rounds with additional lectures at the discretion of the at- each was asked to estimate the time spent using the cardiac tending cardiologist. However, the teaching of auscultation skills auscultation teaching program and the amount of didactic teach- specifically was not standardized during the cardiology rotation ing that they received during their cardiology rotation. for either the PGY1 or the PGY2. We compared baseline auscultation skills by year group (PGY1 Auscultation skills testing occurred at the beginning (T1) and vs PGY2) and time of testing (T1 vs T2). Mean scores for each end (T2) of the 2001-2002 academic year. Five different scenarios group were computed and compared using the t test. P .05 was were tested: secundum atrial septal defect (ASD), restrictive ven- considered significant. tricular septal defect (VSD), moderate pulmonary valve stenosis with variable ejection click (PVS), bicuspid aortic valve with aortic RESULTS regurgitation (BAV/AI), and an innocent Still’s murmur. These cases were chosen because they represent common lesions en- All 40 pediatric residents (PGY1 20, PGY2 20) countered in a pediatric practice. A diastolic murmur (BAV/AI) volunteered and completed testing at the beginning was included to assess the residents’ ability to time the murmur in and end of the academic year. All PGY1 completed a the cardiac cycle. The residents were told that all patients were asymptomatic and that the patients were undergoing a routine cardiology rotation and reported the following for physical examination. They were also told the stethoscope’s posi- cardiac auscultation computer teaching program tion on the chest and that the diaphragm was used in all cases. The (CD-ROM) use: 10% none, 60% 1 to 3 hours, 15% 3 to sound files were obtained from the cardiac auscultation computer 6 hours, and 5% 6 hours. Fourteen of the 20 PGY2 teaching program and looped continuously for 3 minutes of lis- tening time (all with heart rates 100 bpm). While listening, each participated in a cardiology rotation, and all indi- was asked to answer the same 4 questions for each case: 1) define cated that they would have used the CD-ROM if it the second heart sound (S2; single, physiologically split, widely had been available. Among all residents, the amount split), 2) presence/absence of a systolic ejection click, 3) murmur of general cardiology lecture time (but not specifi- schema (Fig 1), and 4) presumptive diagnosis (ASD, VSD, PVS, cally cardiac auscultation) was reported as 10% none, innocent murmur, aortic insufficiency, patent ductus arteriosus, none of the above). The test was administered to a senior cardi- 52% 1 to 3 hours, 28% 3 to 6 hours, and 10% 6 ologist and 3 pediatric cardiology fellows, who correctly identified hours; only 41% of residents believed that this was 19 of 20 questions. The senior cardiologist and cardiology fellows adequate. PGY2 reported slightly more lecture time, could not accurately characterize the S2 of the Still’s murmur case corresponding to slightly longer rotation (3 weeks vs (recording was made from the lower left sternal border), so the characterization of S2 was discarded for this scenario and the 1 month). remainder of the analysis was performed on the remaining 19 The results of the auscultation skills test, by year questions. Using this test format, random guessing would result in group and test time, are summarized in Table 1. a total correct score of 29%. A single investigator (C.B.M.) scored Resident auscultation skills at T1 were dependent on the tests, and the results were entered into a database for analysis. training level (PGY1: 42 15% correct; PGY2: 53 For each resident, we recorded the total score (of 19) and the ability to identify correctly S2 (4 cases), a widely split S2 (ASD 13% correct; P .01), primarily as a result of better case), a systolic ejection click (2 cases), a diastolic murmur classification of S2 (PGY1: 45%; PGY2: 63%) and (BAV/AI case), correct diagnosis (all cases), and correct diagnosis correct diagnosis of the innocent murmur (PGY1: Fig 1. Murmur schema options for auscultation test. 1332 TEACHING RESIDENTS CARDIAC AUSCULTATION SKILLS Downloaded from by on July 22, 2010
  • 4. TABLE 1. Auscultation Test Results PGY1 (N 20) PGY2 (N 20) T1 T2 T1 T2 (% Correct [SD]) (% Correct [SD]) (% Correct [SD]) (% Correct [SD]) Overall score 42 (15) 51 (10) 53 (12) 51 (14) S2 correct 45 (19) 51 (21) 63 (22) 54 (27) Identify wide S2 29 25 30 20 Identify systolic click 20 10 23 23 Identify diastolic murmur 35 35 40 30 Correct diagnosis 27 (25) 37 (20) 34 (23) 33 (21) (all 5 cases) Correct diagnosis (by lesion) ASD 5 15 15 20 VSD 45 55 45 55 PVS 30 15 30 15 BAV/AI 20 35 15 30 Innocent murmur 35 65 65 55 T1 indicates beginning of academic year; T2, end of academic year. 35%; PGY2: 65%). There was no difference in the tion/feedback from trained cardiologists. After us- ability to identify correctly the systolic ejection click ing the self-directed cardiac auscultation computer (20% vs 23%) or to arrive at the correct diagnosis teaching program, however, auscultation skills im- (27% vs 34%). On repeat testing, cumulative scores proved by 21%. Roy et al23 documented similar im- improved for 14 of 20 PGY1 and 8 of 20 PGY2 (5 of 14 provements in auscultation skills among family prac- participating in a cardiology rotation). Combined, titioners using an interactive CD-ROM, but this is the PGY1 total score improved by 21% (P .03), primar- first study to demonstrate a positive effect on pedi- ily as a result of improved diagnostic accuracy of the atric residents. This improvement was not related to innocent murmur (35% to 65%). PGY2 scores re- time from cardiology rotation to retesting, indicating mained unchanged (53% vs 51%), regardless of par- that the skills attained are durable at least over the ticipation in a cardiology rotation (cardiology rota- time frame of this study. tion: 50%; no cardiology rotation: 51%). For residents Given the high incidence of innocent murmurs in who participated in a cardiology rotation (PGY1 and children detected on routine examination, pediatri- PGY2), the change in score from T1 to T2 did not cians and other pediatric caregivers will encounter a correlate with the time from cardiology rotation to large number of patients with auscultatory findings. the time of retesting (T2). Combined, diagnostic ac- Forty percent of our residents diagnosed pathology curacy was best for VSD (55%) and innocent murmur for the innocent murmur case (inappropriate refer- (60%) and worst for ASD (18%) and PVS (15%). At ral), and these patients would presumably be sent for T2, 40% of residents identified the innocent murmur cardiology evaluation and/or echocardiography. as pathologic (inappropriate referral) and 21% iden- Given the frequency of innocent murmurs in the tified a pathologic murmur as innocent (inappropri- pediatric population, this referral rate would create ate nonreferral), with no difference from T1 or by significant health care expenditures. Furthermore, level of training. Physiologically incongruent an- even when reassured by their pediatrician that the swers were given for 8% of the scenarios at T2 and findings are probably normal, most parents experi- were not affected by training level or participation in ence significant anxiety when referred for pediatric a cardiology rotation. cardiology evaluation.15,16 In a recent study,16 two All but 1 PGY2 completed an auscultation atti- thirds of parents believed that their child would tudes survey. Most residents indicated that auscul- require medication or cardiac surgery, have sports tation skills were very important (4.7 0.7 on a 1-5 limitation, or be at risk of premature death; that other scale, 5 being very important). Self-reported assess- children in the family could have cardiac problems; ment of auscultation skills was not dependent on or that the murmur resulted from something that level of training and was reported as poor in 13%, they did wrong during pregnancy. Despite cardiol- fair in 64%, good in 23%, and excellent in none. All ogy evaluation and reassurance, a small percentage residents indicated that their auscultation skills reported persistent anxiety after the diagnosis of an needed improvement. innocent murmur was made, which could lead to vulnerable child syndrome. Therefore, general pedi- DISCUSSION atricians require effective auscultation skills to accu- Overall, this study demonstrated that the auscul- rately triage these patients to prevent unnecessary tation skills of our pediatric residents were poor. Our family stress and inappropriate health care expendi- findings are similar to those previously described, tures via pediatric cardiology consultation and/or regardless of medical specialty, training level, or echocardiography. country of training.17–22,24,25 Participation in the car- Given the overall poor auscultation skills, multiple diology outpatient clinic did not improve ausculta- authors have called for improved teaching of auscul- tion skills, despite that this experience provided tation or inclusion of physical diagnosis skills in more “hands-on” patient experience and observa- board certification examinations.17–19 In addition, the ARTICLES 1333 Downloaded from by on July 22, 2010
  • 5. American College of Graduate Medical Education chance to examine an actual patient may have im- now emphasizes educational outcomes assessment, proved diagnostic accuracy. Some of the cases that with documentation of clinical competencies before were presented to our residents could have had as- completion of residency training. Our data suggest sociated physical examination findings (eg, accentu- that participation in an outpatient cardiology clinic ated right ventricular impulse associated with ASD; alone does not further auscultation skills. Other ed- increased pulses/pulse pressure with aortic insuffi- ucational interventions are required, and computer- ciency). However, these nonauscultatory findings based learning is 1 option and was found to be are subtle and usually not appreciated by noncardi- beneficial in our residents. Standardization of teach- ologists. Furthermore, auscultatory skills were simi- ing curricula using interventions with documented larly poor in previous studies that used real patients educational efficacy provides an avenue for improv- for evaluation.19,20 The use of recorded sounds al- ing medical educational outcomes. lowed for an identical, reproducible testing tool that Given the difficulty in obtaining cardiac ausculta- could be used for both pre- and postintervention tion skills, perhaps the focus of teaching auscultation evaluation of auscultation skills. In addition, our skills should shift from making the correct diagnosis testing scenario allowed for careful evaluation of to making the appropriate referral. The 6 cardinal auscultatory findings in a quiet environment, which signs of murmur pathology described by McCrindle rarely is present with real patients in a busy clinical et al8 could serve as a framework so that the truly practice. For assessing the impact of our interven- important auscultatory findings are stressed in the tions and eliminate confounding variables, postint- limited amount of time allowed for cardiology teach- ervention testing needed to be done in a timely man- ing during residency. Even with this framework, ner. This protocol allowed us to compare the impact however, it is clear that our residents likely would of the 2 educational interventions but was unable to have made the same mistakes, as the identification of assess the durability of our interventions over time an abnormal S2, diastolic murmur, or a systolic ejec- periods of 1 year. We compared interventions in 2 tion click, all indicative of pathology, was poor. different year groups with different baseline scores; It has also been suggested that instead of focusing therefore, the observed improvement in auscultation on the correct diagnosis, the focus of assessing aus- skills may have been attributable to factors related to cultation skills should be on patient outcomes.26 Ob- training level. In addition, residents who used the viously, if the patient is referred to the pediatric cardiac auscultation teaching program (PGY1) may cardiologist for pulmonary valve stenosis and later have become more comfortable with listening to re- receives a diagnosis of an ASD, the patient does not corded sounds, thereby improving their posttest suffer because appropriate care will be provided. For scores. Finally, the residents’ didactic lecture time this reason, we chose to calculate the rate of inappro- during their cardiology rotation was not controlled, priate nonreferral (ie, cases in which pathology was and some residents may have had more time dedi- present and the diagnosis of innocent murmur was cated to auscultation skills than others. Because of made). Approximately one fifth of our scenarios the demonstrated improvement with the cardiac aus- would have been diagnosed with innocent murmurs cultation computer teaching program, it has now when pathology was actually present. Although the been made available to all of our residents. Had we patients in our study were asymptomatic at the time, decided to increase the number of subjects by ex- all of the lesions have the potential for cardiovascular tending the study for an additional academic year, compromise and/or endocarditis; therefore, this rate we may have documented a more robust improve- of inappropriate nonreferral represents a significant ment. However, we wanted to ensure that the car- amount of potentially undetected congenital heart diac auscultation computer teaching program was disease. Furthermore, because the residents were in a available to all residents before completion of their test situation and probably expected a high incidence residency training. of pathologic cases, the rate of inappropriate nonre- In conclusion, our findings demonstrate poor aus- ferral may be underestimated in this study. cultation skills among our pediatric residents, which Given the difficulty in teaching and maintaining did not improve after an outpatient cardiology teach- adequate auscultatory skills, perhaps it is time for ing experience. Auscultation skills did improve after the generalist to use technology and/or telemedicine the use of a self-directed cardiac auscultation pro- to determine the need for additional cardiology eval- gram. uation. With technologic advances in electronic stethoscopy, cardiac auscultatory findings can be ACKNOWLEDGMENTS easily digitized and sent to pediatric cardiologists for The cardiac auscultation computer teaching program (EarsOn) review. Using this method, Dahl et al27 obtained was provided free of charge from Corsonics, Inc. We have no sensitivity and specificity similar to that of an actual financial relationship with Corsonics, Inc. pediatric cardiology evaluation. Alternatively, mul- We thank the pediatric residents who participated in this study. In addition, we are grateful for the technical assistance provided tiple authors have reported the utility of automated by Corsonics, Inc, who produced the cardiac auscultation com- analysis of recorded heart sounds to differentiate puter teaching program (CD-ROM). normal from abnormal.28,29 Once perfected, these de- vices could serve as useful screening tools for the REFERENCES general pediatrician. 1. van Oort A, Hopman J, de Boo T, van der Werf T, Rohmer J, Daniels O. This study has numerous limitations. Only elec- The vibratory innocent heart murmur in schoolchildren: a case-control tronic recordings were provided, and being given the Doppler echocardiographic study. 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Circulation. 2001;103:2711–2716 BRITAIN RULES TO CUT MULTIPLE BIRTHS “In an effort to reduce the number of twins and triplets born after fertility treatment, the Human Fertilization and Embryo Authority, Britain’s regulator of the treatment, told clinics they can no longer implant more than 2 embryos in women under 40. The agency set a limit of three embryos for women over 40, who have a harder time getting pregnant. More than half the infants born as a result of fertility treatment are twins or triplets, said Suzi Leather, chairwoman of the agency.” New York Times. January 7, 2004 Noted by JFL, MD ARTICLES 1335 Downloaded from by on July 22, 2010
  • 7. Comparison of Two Educational Interventions on Pediatric Resident Auscultation Skills C. Becket Mahnke, Andrew Nowalk, Dena Hofkosh, James R. Zuberbuhler and Yuk M. Law Pediatrics 2004;113;1331-1335 DOI: 10.1542/peds.113.5.1331 Updated Information including high-resolution figures, can be found at: & Services References This article cites 26 articles, 13 of which you can access for free at: Citations This article has been cited by 3 HighWire-hosted articles: les Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Heart & Blood Vessels s Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Reprints Information about ordering reprints can be found online: Downloaded from by on July 22, 2010