Medical Science Educator

https://doi.org/10.1007/s40670-020-00982-5

SHORT COMMUNICATION

A Decision-Directed Cardiac Exam in Medical School

Daniel M. Gelfman 1 & Sarah B. Zahl 2

# International Association of Medical Science Educators 2020

Abstract
What most physicians need when performing a physical examination is the ability to be able to recognize normal from abnormal
and, if abnormal findings are present, to be able to diagnose or categorize disease in a useful fashion. This manuscript describes a
technique that is feasible and acceptable in accomplishing this by changing the learning objectives for teaching cardiac auscul-
tation to focus on recognizing audible decision-making findings and ensuring competency by requiring passing an auscultation-
only examination that is limited to such findings. Medical students indicated the program was helpful and increased their
confidence in performing cardiac auscultation.

Keywords Cardiac auscultation . Medical education . Assessment . Harvey®

Background recognition of the need for additional testing or consultation

In the practice of medicine, it is important that physicians have
the ability to perform cardiac auscultation [1–3]. Delays in
diagnosis of cardiac disease can lead to irreversible cardiac
muscle damage, arrhythmias, stroke, and premature death [4,
5]. Despite this critical importance, many new trainees in med-
icine have a difficult time mastering the skill of cardiac aus-
cultation. This problem persists in spite of many efforts to
remedy it [2, 3].
So, how can medical schools adequately train prospective
physicians to recognize significant heart disease using auscul-
tation in a busy curriculum? Logically, methodologies for
teaching auscultation will be successful only if students are
willing to actively participate and reflect on their learning. In a
recent commentary in the American Journal of Medicine, it
was proposed that a more limited, decision-based cardiac ex-
amination be taught at the medical school level [6]. For most
physicians, definitive diagnosis is not necessary; only the
is required. This commentary suggested that a more limited,
decision-based physical examination should be acceptable to
students and achievable and should potentially improve stu-
dents’ ability to provide quality patient care in the future [6].
The conclusion that better utilization of the physical examina-
tion could improve patient care echoed a previous editorial by
Alpert [7].
In this program, we limited student assessment to the abil-
ity to recognize findings that would logically result in a med-
ical decision and not necessarily make a diagnosis (Table 1).
We wanted to determine the feasibility and acceptability of a
mandatory auscultation-only examination that students were
required to pass in order to successfully complete a specific
course. The students’ scores on the auscultation examination
and the students’ perceptions of the program will be described
in this paper.

Activity
* Daniel M. Gelfman
dgelfman@marian.edu The following are the learning objectives for the students in
this program:
1
Division of Clinical Affairs, Marian University College of
Osteopathic Medicine, 3200 Cold Spring Road, 1. Recall how to perform an orderly cardiac physical
Indianapolis, IN 46222, USA examination.
2
Marian University College of Osteopathic Medicine, 2. Apply this examination technique to multiple unknown
Indianapolis, IN, USA cardiac auscultation examples (Table 2).

Table 1 Assessment items
Question 1: Is there a regular rate and rhythm (RRR)? Does S2 sound
normal? (1 point)
A. RRR, normal S2
B. Irregular RR, normal S2
C. RRR, abnormal S2
D. Irregular RR, abnormal S2
Question 2: Is there a murmur? (2 points)
A. No murmur
B. Yes, systolic
C. Yes, diastolic
Question 3: If there is a murmur, describe the murmur. (1 point)
A. No murmur
B. Systolic, crescendo-decrescendo
C. Systolic, holo-systolic
D. Systolic, click murmur
E. Early diastolic blowing murmur
F. Mid to late diastolic rumble
Question 4: Is there an S3 present? (1 point)
A. Yes
B. No
Question 5: Is there a pericardial rub? (2 points)
A. Yes
B. No
3. Differentiate the findings on examination (Table 1) into
normal vs abnormal categories which would ultimately
result into clinically useful decisions.
The curriculum for the Introduction to Clinical Medicine
(ICM) course was modified to include more in-depth teaching
and assessment of cardiac auscultation in the second semester
of the first year after the students had exposure to cardiology
in the system’s courses. All first-year students enrolled in the
ICM course (n = 165 for year 1 and n = 169 for year 2 of the
program) participated in an enhanced clinical demonstration
using the Harvey® cardiac physical examination simulator. In
the first semester, students received an introduction to the
complete physical examination including a description of car-
diac auscultation with websites to hear examples. The
intended objective of the Harvey® simulation was to build
on this prior knowledge and provide specialized training re-
lated to cardiac auscultation clinical skills.
Prior to their auscultation demonstration with the Harvey®
simulator, students were provided with an introductory lecture
(in the form of a podcast) explaining what they would be
exposed to during the demonstration, and the descriptive text
from the Harvey® simulator manual. This helped prepare the
students for optimal learning by telling them what to expect
and reminding them of different auscultation findings. Eleven
Med.Sci.Educ.
different auscultation examples (Table 2) were demonstrated
using the Harvey® cardiac physical examination simulator.
The Harvey® mannequin can produce a wide range of path-
ologic cardiac conditions by producing and modulating find-
ings such as the point of maximal impulse (PMI), first heart
sound (S1), second heart sound (S2), gallops, murmurs, fric-
tion rubs, and carotid impulse. For this simulation, the stu-
dents were tested only on appropriate physical examination
findings needed for decision-making (Table 1). To ensure
adequate comprehension and application of the material, pass-
ing the auscultation exam (≥ 70%) using the Harvey® simu-
lator was required to pass the course.
Using a small-group learning model (10–13 students in
each group) to facilitate interactive learning, students received
instruction regarding the eleven examples of normal and ab-
normal cases, including PMI and carotid palpation, designed
within a 30-min timeframe. This instruction reinforced the
concepts covered in the podcast and handout. Students were
encouraged to ask questions if they did not recognize the
demonstrated sounds. If students did not properly recognize
the auscultation findings, these were clarified by using addi-
tional teaching techniques such as air hand motions or tapping
the timing of the sound on the student’s shoulder. The students
received guided instruction regarding multiple ways to prac-
tice clinical skills related to cardiac auscultation. They were
given access to the Harvey® simulator and lists of several
websites (updated in Table 3) and potential iPad applications
for study. The students received the list of five test questions
(Table 1) for each unknown and the list of eleven possible
cardiac diagnostic unknowns, e.g., aortic stenosis or an inno-
cent murmur (Table 2) as part of their study materials.
The assessment included the five questions with four of the
eleven possible audible diagnostic unknowns (Table 1 and
Table 2 Cardiac
auscultation examples Demonstrations and explanations of 11
cardiac auscultations were provided.
Students were given this list to serve as
potential unknowns when completing
the exercise
Aortic stenosis
Aortic insufficiency
Chronic mitral regurgitation
Mitral valve prolapse
Mitral stenosis
Hypertrophic obstructive cardiomyopathy
(HOCM)
Normal
Innocent murmur
Pericardial rub
Atrial septal defect
Patent ductus arteriosus
Med.Sci.Educ.

Table 3 Updated websites for heart sounds Table 4 Survey questions

https://depts.washington.edu/physdx/heart/index.html Q1 What was your grade on this exam?

www.practicalclinicalskills.com o 90–100 (1)
https://www.med.ucla.edu/wilkes/inex.htm o 80–89 (2)
o 70–79 (3)
The listings have been updated from the original ones used as these
o Below 70 (4)
change and improve over time
o I do not feel comfortable disclosing this information (5)
Q2 When you reflect on what you learned from the auscultation exercise,
Table 2). The relative scoring weight of each question varied
how useful was this activity?
to reflect the importance of the finding with respect to deci-
o Very useful (1)
sion-making. While the students were instructed on palpation
o Useful (2)
of the PMI and carotid upstroke, they were not tested on these
o Somewhat useful (3)
skills. It would have been impractical to test these palpatory
o Not at all useful (4)
skills in a reasonable amount of time. In fairness during test-
Q3 Did you feel you had too much time for each of the 4 unknown
ing, if an enlarged PMI was potentially visible to some stu- examples?
dents, it was pointed out to all of the students. o Yes (1)
o No (2)
Q4 If the time was decreased from approximately 5 minutes by about one
minute, leaving at least 3 minutes and 30 seconds for each unknown,
Survey would that still provide enough time for you to complete each exercise?
o Yes (1)
After the simulation and assessment were completed, the
o No (2)
course director notified students and encouraged participation
Q5 How many hours did you spend preparing for the auscultation
in a voluntary anonymous questionnaire (Table 4) by email. examination?
The survey was administered via Qualtrics survey software, o 0–5 hours (1)
which provided anonymity for participant responses and o 6–10 hours (2)
protected participant identities. The descriptive survey includ- o 11–15 hours (3)
ed seven multiple choice items that assessed participants’ con- o 16–20 hours (4)
fidence related to cardiac examination skill techniques, their o 21+ hours (5)
preparation strategy, and the overall impression of the exercise Q6 How did you prepare for this exam?
and assessment. The data from the descriptive survey were o Structured study time over several weeks (1)
aggregated and analyzed to identify potential relationships o Structured study time over several days (2)
between the variables. The researchers reviewed summary o Structured study time over 1–2 days preceding the exam (3)
statistics, including central tendency (mean), minimum/maxi- Q7 As a result of preparing for this exam, how comfortable would you
mum, and standard deviation for each questionnaire item. feel performing an orderly cardiac exam?
Data were analyzed using a 2-tailed chi-square test and eval- o Very comfortable (1)
uated at a significance level of 0.05. o Moderately comfortable (2)
The institutional review board reviewed and approved o Slightly comfortable (3)
(exempted) the study prior to collecting data. o Not at all comfortable (4)

Results and Discussion

In the first class of the program, students performed well on
the auscultation examination with an average score of 88%
and only 10 of 165 students (6%) failing on the first at-
tempt. Of the students that failed initially, all remaining
registered students passed on their second attempt. In the
second class of the program, the performance was almost
identical, with an average score of 90% and only 10 of 169
(6%) students failing on the first attempt. Again, of the
students that failed initially, all remaining registered stu-
dents passed on their second attempt.
The first class’s descriptive survey yielded a response rate
of 74% (123 of 165 potential respondents). The survey results
indicated that 93.5% of respondents found the exercise useful
or very useful for their learning, with 69.92% indicating that it
was very useful. The relationship between the exam grade and
perceived learning from this exercise was statistically signifi-
cant (χ2 = 68.84; p = 0.00001). The respondents who indicat-
ed the exercise was “very useful” or “useful” for their learning
were in the grading categories of 90–100 and 80–90,
respectively.
 Med.Sci.Educ.

When asked about their comfort level after the exercise,
82.27% of survey participants indicated that they would be
very comfortable (18.03%) or moderately comfortable
(64.75%) performing a cardiac auscultation exam because of
the demonstration and assessment. The first class’s survey
results are shown in Fig 1.
The findings from the descriptive survey of the second
class of the program validated the conclusions from the prior
data of the first class, but the response rate was much lower
(40%).
In response to the continuing problem in which new trainees
in medicine have mastering the skill of cardiac auscultation, we
developed a targeted educational program that focused on recog-
nizing findings for decision-making and not specifically making
a diagnosis. This program utilized the requirement of passing an
auscultation-only examination to ensure student proficiency.

Q1 - What was your grade on this exam?

Q2 - When you reflect on what you learned from the auscultation exercise, how useful was this
activity?

Q3 - Did you feel you had too much time for each of the 4 unknown examples?

Fig. 1 First class's survey results

Med.Sci.Educ.

Q4 - If the time was decreased from approximately 5 minutes by about one minute, leaving at
least 3 minutes and 30 seconds for each unknown, would that still provide enough time for you
to complete each exercise?

Q5 - How many hours did you spend preparing for the auscultation examination?

Q6 - How did you prepare for this exam?

Fig. 1 (continued)

Based on this feasibility study, students were able to
master the basics of auscultation without disruption to
the curriculum as evidenced by a high pass rate and
mean assessment score. Students’ acceptance of this
program was high, and the majority of the students re-
ported an increase in their confidence in performing
cardiac auscultation.
This program demonstrated the feasibility and ac-
ceptability of a different technique for instructing stu-
dents in the skill of cardiac auscultation, in an
otherwise busy curriculum. This technique required
auscultation mastery using an auscultation-only cardiac
examination but limited the testing to recognizing
decision-directed findings.
 Med.Sci.Educ.

Q7 - As a result of preparing for this exam, how comfortable would you feel performing an
orderly cardiac exam?

Fig. 1 (continued)

Acknowledgments The authors would like to acknowledge Wendy skills in medical students, trainees, physicians, and faculty: a multi-
Labuzan, the coordinator of examinations, for the support during the center study. Arch Intern Med. 2006;166(6):610–6.
exam administration process. 4. January Craig TC. 2014 AHA/ACC/HRS guideline for the manage-
ment of patients with atrial fibrillation: a report of the American
College of Cardiology/American Heart Association Task Force on
Compliance with Ethical Standards Practice Guidelines and the Heart Rhythm Society. JACC.
2014;64(21):1–76.
Conflict of Interest The authors declare that they have no conflict of 5. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP,
interest. Guyton RA, et al. 2014 AHA/ACC guideline for the management
of patients with valvular heart disease: executive summary. J Am
Coll Cardiol. 2014;63(22):2438–88.
6. Gelfman DM. Changing the learning objectives for teaching physical
References examination at the medical school level. Am J Med. 2020;133(3):
e77–e78
1. Alpert JS. Will physicians stop performing physical examinations? 7. Alpert JS. How accurate are the findings noted during a physical
Am J Med. 2017;130(7):759–60. examination? Will physicians stop performing physical examina-
2. Feddock CA. The lost art of clinical skills. Am J Med. 2007;120(4): tions? (Part 2). Am J Med. 2019;132(6):663–4.
374–8.
3. Vukanovic-Criley JM, Criley S, Warde CM, Boker JR, Guevara- Publisher’s Note Springer Nature remains neutral with regard to jurisdic-
Matheus L, Churchill WH, et al. Competency in cardiac examination tional claims in published maps and institutional affiliations.