Confidential testing of cardiac examination competency in cardiology and noncardiology faculty and trainees: a multicenter study

Abstract

Background: Many reported studies of medical trainees and physicians have demonstrated major deficiencies in correctly identifying heart sounds and murmurs, but cardiologists had not been tested. We previously confirmed these deficiencies using a 50-question multimedia cardiac examination (CE) test featuring video vignettes of patients with auscultatory and visible manifestations of cardiovascular pathology (virtual cardiac patients). Previous testing of 62 internal medical faculty yielded scores no better than those of medical students and residents.

Hypothesis: In this study, we tested whether cardiologists outperformed other physicians in cardiac examination skills, and whether years in practice correlated with test performance.

Methods: To obviate cardiologists' reluctance to be tested, the CE test was installed at 19 US teaching centers for confidential testing. Test scores and demographic data (training level, subspecialty, and years in practice) were uploaded to a secure database.

Results: The 520 tests revealed mean scores (out of 100 ± 95% confidence interval) in descending order: 10 cardiology volunteer faculty (86.3 ± 8.0), 57 full-time cardiologists (82.0 ± 3.3), 4 private-practice cardiologists (77.0 ± 6.8), and 19 noncardiology faculty (67.3 ± 8.8). Trainees' scores in descending order: 150 cardiology fellows (77.3 ± 2.1), 78 medical students (63.7 ± 3.5), 95 internal medicine residents (62.7 ± 3.2), and 107 family medicine residents (59.2 ± 3.2). Faculty scores were higher in those trained earlier with longer practice experience.

Conclusions: Academic and volunteer cardiologists outperformed other medical faculty, as did cardiology fellows. Lower scores were observed in more recently trained faculty. Remote testing yielded scores similar to proctored tests in comparable groups previously studied. No significant improvement was seen after medical school with residency training.

Figure 1

Screenshots from the introductory portion of the CE test (A–C) show intracardiac pressures, ECG, phonocardiograms, and animations representing normal, mitral stenosis, and aortic stenosis. Animation controls permit real‐time, stop‐frame, or slow motion. Heart sounds recorded from the base or apex can be selected. The Morph button permitted a comparison with the normal example. Multiple‐choice and true/false questions (not shown) addressed principal findings. (D) Virtual cardiac patient. A patient with a recording stethoscope at the base is shown in the left panel and the choice of listening positions can be selected from the right panel. Multiple‐choice questions (not shown) addressed principal findings. Abbreviations: CE, cardiac examination; ECG, electrocardiogram.

Figure 2

Mean CE test scores by training level. Classroom testing was conducted by the authors with a computer that projected animations and patient videos onto a screen, and sound transmission into headphones or stethophones, with answers recorded on paper. Remote testing used personal computers to administer the test individually; participants entered their answers directly into the computer. Abbreviations: CE, cardiac examination; IM, internal medicine; FM, family medicine.

Figure 3

Linear regression of CE test scores achieved by faculty members. Mean CE test scores for cardiologists and internists are plotted against 5‐year increments since completion of their training. Scores decrease linearly the more recently the physician was trained. Abbreviations: CE, cardiac examination.