The lost art of listeningHas bedside auscultation given way to imaging?

Police officers carry a badge. Carpenters have a tool belt. Doctors have stethoscopes. Children putting together Halloween costumes intuitively understand that certain objects symbolize certain professions. But in the case of the stethoscope, is actual use declining?

“Physicians do carry stethoscopes and it certainly is a badge that shows they are a physician, but the sad thing is a large percentage of them don’t know how to use it and use it improperly when they do,” said Michael Criley, MD, professor emeritus of medicine and radiological sciences and the University of California, Los Angeles’ David Geffen School of Medicine in an interview.

Criley sees bedside auscultation, or simply listening to a patient’s heart, as a lost art in modern medicine. Rather than emphasize the physical examination, physicians are quick to turn to imaging to provide the answer to any diagnostic question.

“When two-dimensional echocardiography became available in the mid-1970s it could have, and should have, provided a noninvasive way of seeing what the heart chambers and valves were doing when extra sounds or murmurs were created, but instead replaced bedside auscultation,” said Criley.

Criley’s opinion on the state of auscultation skills is not based simply on a hunch. He was the senior author on a study of physicians’ cardiac examination skills published in the December 2010 issue of Clinical Cardiology.

The study involved a multimedia test administered at 19 U.S. teaching centers to more than 500 trainees and faculty. Results showed that cardiac exam test scores increased with seniority when comparing test scores to the number of years after completing training.

Does this mean experience leads to better scores? Not quite, said Criley. The other interpretation is that more senior faculty members were trained in an era of superior cardiac auscultation training, and this is more evident when scores are grouped by training level. While academic cardiologists outperform other medical faculty, scores for noncardiologists at any training level past medical school did not significantly differ. A review of classroom testing showed that trainees in their third year of medical school, when they first really begin to see patients, score as well as internal medicine faculty.

While some educational programs may stress cardiac auscultation skills more than others, since bedside exam skills are not tested on board exams for internal medicine and cardiology, overall emphasis may be lacking, said Criley. “It’s not going to be on the test, so why study it?”

The American College of Cardiology has sponsored “Heart Songs,” an audio-only program of recorded simulated heart sounds, but Criley pointed out that the audible cues alone are not all that goes into an effective bedside investigation. To this end, he helped create a series of online tutorials that combine heart sounds with a visible patient avatar.

A few examples of visual cues to look for during a bedside cardiac exam, according to Criley, are:

• Cyanosis: Blue tinged lips, tongue or mucous membranes could indicate a right-to-left shunt in the heart.

• Slow-rising, late peaking carotid pulse: This change in pulsation can indicate aortic stenosis, a condition affecting 10 percent of people over the age of 65 years.
• Corrigan’s pulse: A bounding carotid pulse where the arteries appear to jump out of the neck is indicative of aortic regurgitation. Sometimes the patient’s head bobs up and down.

Criley said imaging has its uses, but should not be a substitute for a physician at a bedside. Instead of using echo imaging or CT in isolation, they should be combined with the cardiac exam, and auscultation can help rule out certain conditions. “If you are not thinking ahead and are just saying ‘I think I hear a murmur, maybe I should get an echo,’ that is a very wimpy way to go about it.”

If a physician hears something unusual that leads to an imaging study, Criley said he or she should review the image and link the visual with what was heard rather than waiting for the typed summary in the report.

“It sort of devolves into a dependence on expensive technology and a lack of attention to something that you should take some pleasure in learning. Very much like being a good tennis player or a good chess player or a good musician, it’s something that requires practice and unfortunately is falling out of favor much to our patient’s disadvantage.”

To access Criley's online tutorials, which provide interactive examples of aortic stenosis, aortic regurgitation and other common conditions, click here.