Iversen Kasper, Søgaard Teisner Ane, Dalsgaard Morten, Greibe Rasmus, Timm Hans Bording, Skovgaard Lene Theil, Hróbjartsson Asbjørn, Copenhagen O, Copenhagen S, Copenhagen K
Clinic of Cardiology, Rigshospitalet, Copenhagen Ø, Denmark.
Am Heart J. 2006 Jul;152(1):85.e1-7. doi: 10.1016/j.ahj.2006.04.013.
Auscultation of the heart is a routine procedure. It is not known whether auscultatory skills can be improved by teaching or with the use of an advanced stethoscope.
This study was a randomized trial with a 2 x 2 factorial design. Seventy-two house officers were randomized to a simple or an advanced stethoscope and to a 4-hour course in auscultation or no course. The doctors auscultated 20 patients' hearts and categorized findings as normal or as one or more of 5 categories of heart diseases. Patients were selected such that 16 had a known heart disease as well as a corresponding murmur and 4 had no heart disease or murmur. Auscultatory performance was assessed as concordance with echocardiographic findings and interobserver variation.
Doctors using the advanced stethoscope diagnosed 35% of the patients correctly, as compared with doctors using the simple stethoscope who did 33% of the patients (P = .27). Similarly, 34% of the patients were diagnosed correctly by doctors who had received teaching as compared with 33% of those who were by doctors who had received no teaching (P = .41). The kappa values were higher for doctors who had received teaching for aortic stenosis (0.43 vs 0.28, P = .004) and ventricular septum defect (0.07 vs 0.01, P = .003). There was no difference between groups for any other single murmur or for the detection of murmurs as such.
Heart auscultation findings were in poor accordance with echocardiographic findings and had high interobserver variation. Neither outcome improved to any important extent with the subjects' use of an advanced stethoscope or attending of a course in heart auscultation.
心脏听诊是一项常规操作。目前尚不清楚听诊技能是否可以通过教学或使用先进听诊器得到提高。
本研究是一项采用2×2析因设计的随机试验。72名住院医师被随机分配使用简单听诊器或先进听诊器，并参加4小时的听诊课程或不参加课程。医生们对20名患者的心脏进行听诊，并将检查结果分类为正常或5种心脏病类型中的一种或多种。所选患者中，16名患有已知心脏病并有相应杂音，4名没有心脏病或杂音。听诊表现通过与超声心动图检查结果的一致性以及观察者间的差异来评估。
使用先进听诊器的医生正确诊断了35%的患者，而使用简单听诊器的医生正确诊断了33%的患者（P = 0.27）。同样，接受教学的医生正确诊断了34%的患者相比未接受教学的医生正确诊断了33%的患者（P = 0.41）。对于主动脉瓣狭窄，接受教学的医生的kappa值更高（0.43对0.28，P = 0.004），对于室间隔缺损也是如此（0.07对0.01，P = 0.003）。对于任何其他单一杂音或杂音的检测，组间没有差异。
心脏听诊结果与超声心动图检查结果的一致性较差，观察者间差异较大。受试者使用先进听诊器或参加心脏听诊课程后，这两个结果均未得到显著改善。
