Author + information
- Thomas S. Metkus, MD∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Thomas S. Metkus, Johns Hopkins School of Medicine, Division of Cardiology, 1800 Orleans Street, Sheikh Zayed Tower 7125, Baltimore, Maryland 21287.
There are 4 cardinal maneuvers of physical diagnosis: inspection, percussion, palpation, and auscultation. The concept of cardiac auscultation is synonymous with clinical cardiology; however, our collective skills in auscultation have suffered a dramatic decline over the past 20 years (1,2). Yet, concurrent with this decline, novel and wonderful multimedia educational tools for teaching and augmenting cardiac auscultation proliferate (3–7). Furthermore, echocardiography is ubiquitous in the modern hospital setting, which should offer unparalleled opportunities for us as examiners to correlate our physical findings with corroborating and complementary data.
Why, then, have our collective auscultation skills continued to decline? A large contributor is underemphasis on the “fifth” maneuver of physical diagnosis as described by Dr. Osler: cogitation (8). It is only after careful cogitation and reflection on the clinical meaning of the cardiac sounds we hear (or do not hear) in the context of the patient’s history, electrocardiography, and, increasingly, echocardiography that cardiac auscultation adds value. We should challenge ourselves as fellows to perform careful physical examinations and auscultation, to use the auscultation to inform our clinical care directly, and to always correlate the results of our auscultation with available imaging modalities. Thus, it is not additional physical diagnosis curricula (valuable as they are) or auscultation simulators that will reverse the decline in physical diagnosis skills, but rather holding ourselves and our trainees accountable for the physical cardiac findings, being explicit in our teaching and clinical documentation as we use findings to advance care, and following up to cogitate on the meaning of the findings and correlate with multimodal imaging.
To that end, I propose a series of principles that could potentially guide lifelong learning in the art and science of cardiac physical diagnosis.
Principle 1: Cardiac Auscultation Is Critically Important in Taking Care of Patients
Early in my training, I underestimated the value of cardiac auscultation. I felt that echocardiography and other imaging modalities were surely more accurate, more precise, and more valuable than my own eyes and ears. I now appreciate that echocardiography and cardiac auscultation complement each other, and thoughtful auscultation should not be supplanted by imaging. In residency, I cared for a patient with a prosthetic aortic valve who presented with fever. Transthoracic echocardiography was reported as normal. I went about my work day; however, my attending paged me to the bedside that evening. He demonstrated for me a murmur of aortic insufficiency, clearly heard with the patient sitting up and learning forward. We asked the sonographer to return and, with off-axis and unconventional views, we were able to document clearly the eccentric jet of aortic insufficiency. More recently, a patient presented with heart failure and had a late-peaking, harsh systolic murmur of aortic stenosis. The echocardiogram demonstrated a moderate aortic gradient with decently preserved aortic valve opening. It was only after again asking the sonographer to return and take additional echocardiographic views that we realigned the Doppler cursor and documented a severely elevated gradient across the outflow tract. The aortic valve was again seen to open well, however, and a subaortic membrane was sought and clearly delineated. As a final example, a patient with repaired Tetralogy of Fallot presented with exercise intolerance, right ventricular heave, and notable pulmonary insufficiency on examination. Echocardiogram reported only mild pulmonary insufficiency, but the echo windows were indeed suboptimal, and a follow-up cardiac magnetic resonance imaging examination demonstrated torrential pulmonary insufficiency. The published data is replete with similar vignettes (9,10). Just as with auscultation, echocardiography is a human endeavor that is dependent on someone procuring the correct images and a second person interpreting them. For example, the aortic valve gradient in aortic stenosis can depend completely on choosing the correct echo window (11). Thus, auscultation complements and informs echocardiography and vice versa. Integrating both in a thoughtful manner is imperative, rather than underemphasizing auscultation in lieu of echocardiography.
Principle 2: Accurate and Precise Diagnoses With Cardiac Physical Examinations
We should emphasize that it is indeed possible to use the physical examination to make an accurate cardiac diagnosis. Dr. Procter Harvey was renowned for his diagnostic acumen and “five finger” approach (12). As described in Sapira’s textbook of physical diagnosis (8), in the era before echocardiography, 80% of patients with congenital heart disease were diagnosed accurately solely on the basis of clinical findings (13). Our forebears in cardiology did not have sharper hearing or hyperacute senses. Without noninvasive diagnostic technology, they relied on the tools available—their eyes and ears—and committed to excellence in physical diagnosis. I imagine that they also endeavored to learn more, correlating what they heard or did not hear with catheterization and operative findings. Perhaps they insisted that their trainees do the same, providing feedback when an important murmur was not appreciated. We do not do the same in today’s medical practice. There is actually pressure to listen less carefully, such as listening through clothes. After an echocardiogram demonstrates an unappreciated valve lesion, we do not always return as a team to the bedside to re-examine the patient and query why we did not appreciate the diagnosis earlier. It is only by doing this, however, that we reinforce to our trainees and ourselves the importance of careful cardiac auscultation.
Principle 3: When You Examine a Patient, You Examine a Person
Depersonalization and burnout is rampant in the medical profession (14). The causes are multifactorial, and the rise in burnout is contemporaneous with the rise of electronic medical records and increased emphasis on efficiency and volume. The actual patient becomes abstracted into a collection of objective data (15). The physical examination and cardiac auscultation are underemphasized; however, it is in talking to the patient, performing a careful examination, and listening to the heart that the collection of data becomes a person again. Emphasis on shared values of cardiac physical diagnosis could contribute an infusion of humanism to medical practice. Nothing is as satisfying in clinical cardiology as talking to a patient, listening to his or her story, listening to his or her heart, making an accurate diagnosis that is confirmed by modern cardiac imaging, and prescribing effective therapy. The physical examination and proper cardiac auscultation are central to that satisfaction.
As fellows, we will witness a sea change in cardiac auscultation through our careers. As handheld ultrasound technology becomes more ubiquitous (16,17), there is a risk that cardiac auscultation will become further marginalized. Thoughtful cardiac auscultation has a pivotal role yet to play and remains a cornerstone of clinical cardiology. To achieve excellence in cardiac auscultation, we should not only master the actual ability to recognize abnormal heart sounds, but also commit to Osler’s fifth maneuver of cogitation. Heart sounds should inform the differential diagnosis and be actively correlated with findings of cardiac imaging. We should emphasize the same to our trainees, providing direct feedback on their examination skills. As our own clinical practices in cardiac auscultation grow, hopefully trainees, teammates, and peers also come to value cardiac auscultation. It is in this manner, supplemented by the excellent educational resources in cardiac physical diagnosis available, that we can reverse the declining emphasis on cardiac auscultation.
- Kim A. Eagle, MD ()
RESPONSE: Unraveling the Scenes in the Complex Story of Our Patients’ Health
Congratulations to Dr. Metkus on his paper. His points regarding the importance of and professional satisfaction surrounding careful and compassionate bedside care are poignant and important for all of us to consider. In particular, his comments regarding a call back to the bedside for proper auscultation are timely. Today’s cardiovascular trainees find themselves in the midst of knowledge explosions in virtually all aspects of cardiovascular diagnosis and treatment. Similar to senior cardiologists, they find themselves challenged by training requirements, regulatory shifts surrounding documentation and quality/safety, as well as a literal explosion of distractions that surround a rapidly changing health care system. In this context, it is easy to lose emphasis on something so critical to our basic professional function of embracing a proper and complete history, a careful physical examination, and as Dr. Osler would posit, cogitation and reflection on how the history, physical examination, and initial testing merge together into a personal and medical story that all fits together.
When I round, I like to tell the trainees that the most important test the patient can have is a fabulous history. The second test that is critical, when the story line is not clear, is a second history! Then, the next most important test is the physical examination, where our initial differential diagnosis based on the history is either confirmed or refuted. The key here is that the patient’s story line should roll out like a masterful play, where each scene builds logically from the last.
I agree with Dr. Metkus that the first task for our fellows is to embrace the art and importance of this part of our professionalism. The second is far more directed. Find mentors and tools that will allow you to develop this skill. Ask your teachers to go over the examination on patients with confusing or important findings. Actively seek training tools that further develop your skillset. Build your standard templates for the electronic medical record in ways that force you to think about heart sounds, clicks, gallops, and types of murmurs and other key findings. Studies show that both cardiology trainees and senior cardiologists properly identify only about 50% of basic heart murmurs and a similar percentage of more advanced murmurs (1). Remarkably, repetitive exposure to these murmurs using computer-based training tools allows these percentages to increase dramatically. Our fellows-in-training should actively seek these tools, in addition to actively seeking this emphasis from their mentors throughout the training period. Proper physical diagnosis skills demand effort, repetition, and then a lifelong commitment to the art of careful bedside medicine. Patients appreciate the notion that we will find the best health care path for them by starting with a relationship built on our oral interactions and the careful laying on of hands, followed by judicious use of technologies to further guide therapy.
- American College of Cardiology Foundation
- Stanford Medicine. Stanford Medicine 25: an initiative to revive the culture of bedside medicine. Available at: http://stanfordmedicine25.stanford.edu/. Accessed August 19, 2015.
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