Elsevier

American Heart Journal

Volume 152, Issue 1, July 2006, Pages 85.e1-85.e7
American Heart Journal

Clinical Investigation
Imaging and Diagnostic Testing
Effect of teaching and type of stethoscope on cardiac auscultatory performance

https://doi.org/10.1016/j.ahj.2006.04.013Get rights and content

Background

Auscultation of the heart is a routine procedure. It is not known whether auscultatory skills can be improved by teaching or with the use of an advanced stethoscope.

Methods

This study was a randomized trial with a 2 × 2 factorial design. Seventy-two house officers were randomized to a simple or an advanced stethoscope and to a 4-hour course in auscultation or no course. The doctors auscultated 20 patients' hearts and categorized findings as normal or as one or more of 5 categories of heart diseases. Patients were selected such that 16 had a known heart disease as well as a corresponding murmur and 4 had no heart disease or murmur. Auscultatory performance was assessed as concordance with echocardiographic findings and interobserver variation.

Results

Doctors using the advanced stethoscope diagnosed 35% of the patients correctly, as compared with doctors using the simple stethoscope who did 33% of the patients (P = .27). Similarly, 34% of the patients were diagnosed correctly by doctors who had received teaching as compared with 33% of those who were by doctors who had received no teaching (P = .41). The κ values were higher for doctors who had received teaching for aortic stenosis (0.43 vs 0.28, P = .004) and ventricular septum defect (0.07 vs 0.01, P = .003). There was no difference between groups for any other single murmur or for the detection of murmurs as such.

Conclusion

Heart auscultation findings were in poor accordance with echocardiographic findings and had high interobserver variation. Neither outcome improved to any important extent with the subjects' use of an advanced stethoscope or attending of a course in heart auscultation.

Section snippets

Methods

We conducted a randomized trial with a 2 × 2 factorial design. Seventy-two observers were randomized to use 1 of 2 types of stethoscopes and to either teaching or no teaching. All observers performed heart auscultation on the same 20 patients.

Results

All 20 patients who were included finished the study. There were 13 men (65%), and the patients' median age was 69 years (range 30-88 years). Seven patients had aortic stenosis, 5 patients had mitral regurgitation, 1 patient had atrial septal defect, 1 patient had aortic regurgitation, 2 patients had aortic stenosis, and 4 patients had no valve disease or septal defect. All the participating doctors auscultated all the patients' hearts (1440 examinations).

Main results

We did not find that the performance of heart auscultation was importantly improved by the type of stethoscope or by teaching of doctors. A small effect of teaching was however seen on the mean κ values in 2 of 5 examinations and on a nonsignificant trend for the specificity of auscultation.

On average, only one third of the patients were diagnosed correctly; in addition, in general, the sensitivity of diagnosing the different heart diseases was low. The sensitivity in detecting any murmur was

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    The study was supported by unrestricted grants given by Pfizer Denmark, Medicon Denmark, and the Diamond Foundation. None of the grantors had any influence on the design and conduct of the study; collection, management, analysis, and interpretation of the data; as well as preparation, review, and approval of the manuscript.

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