Wednesday, March 29, 2006

The few, The chosen - The Cardiologists

They've now proven scientifically something we have always known, that cardiologists are better than anyone else. Before you let out a big gasp of disbelieve and chagrin, they proved that this was in the area of practicing cardiology. This should go down in the annals of the painfully obvious but nonetheless here comes the science.

In the 27th March 2006 issue of Archives of Internal Medicine, Dr. Jasminka M. Vukanovic-Criley, a medical educationist/teacher from Satnford who has been teaching medical students for 40+ years, published a study she conducted on cardiac examination skills. She tested 890 individuals (318 medical students, 289 internal-family medicine residents, 85 cardiac fellows and 131 physicians including faculty members and private practitioners.

The study focused on four aspects: heart physiology knowledge, auditory skills, visual skills, and integration of auditory and visual skills. It's good to know that third and fourth year students did better than their first and second year comrades. Only the cardiology fellows did any better than the third year students. Some of the others(private practitioners, residents, and physicians) tested did worse.

Then a second study was done by Dr. Andrew D. Michaels, assistant professor of cardiology at UCSF (University of California at San Francisco) and co-director of the Cardiac Catheterization Laboratory at UCSF Medical Center.

100 patients were evaluated for the third cardiac sound, which we call S3. The researchers pitted four levels of subjects each representing a different level of training and experience: board-certified cardiology attending physicians, cardiology fellows, internal medicine residents and internal medicine interns. The term used is auscultation which is a big word we use for "listening at the stethescope".

The results obtained by the subject was compared against a phonocardiographic device. Patients were also tested by echocardiography to measure left ventricular ejection fraction (LVEF), cardiac catheterization for measurement of left ventricular end-diastolic pressure (LVEDP) and for blood levels of B-type natriuretic peptide (BNP).

In their conclusions they indicate that poor performance by physicians in hearing the third heart sound may be a cause for lack of confidence in the value of using auscultation as a diagnostic tool. It's a vicious cycle since reduced confidence means less training in auscultation which could lead to even worse skills in the next cohort, and so it spins.

Eventually we reach a point where some will say that in this day and age, we do not really need to worry too much about murmurs. "Just echo them".

Along with a general availibility of modern day diagnostic tools and the practice of defensive medicine, no wonder the cost of medical care is going up. Will we ever see a modern day Sir William Osler.

What does everyone think?

1 comment:

That Girl said...

Im glad - by anecdotal evidence the cardiologist Ive known have had it together.

I laugh when I watch a regular doctor listen to my son's heart because sometimes the cardiologists cant even tell what it's supposed to sound like and some random pedatrician will know? Hah.

What's scary is how little regular pediatricians can know about heart babies.