Mangione S, Nieman L Z
Department of Medicine, Allegheny University of the Health Sciences, Philadelphia, Pa 19129, USA.
JAMA. 1997 Sep 3;278(9):717-22.
Medical educators have had a growing sense that proficiency in physical diagnostic skills is waning, but few data have examined the question critically.
OBJECTIVE, DESIGN, AND SETTING: To compare the cardiac auscultatory proficiency of medical students and physicians in training. A multicenter cross-sectional assessment of students and house staff. A total of 8 internal medicine and 23 family practice programs of the mid-Atlantic area.
A total of 453 physicians in training and 88 medical students.
All participants listened to 12 cardiac events directly recorded from patients, which they identified by completing a multiple-choice questionnaire.
scores were expressed as the percentage of participants, for year and type of training, who correctly identified each event. Cumulative scores were expressed as the total number of events correctly recognized. An adjusted score was calculated whenever participants selected not only the correct finding but also findings that are acoustically similar and yet absent.
Trainees' cumulative scores ranged between 0 and 7 for both internal medicine and family practice residents (median, 2.5 and 2.0, respectively). Internal medicine residents had the highest cumulative adjusted scores for the 6 extra sounds and for all 12 cardiac events tested (P=.01 and .02, respectively). On average, internal medicine and family practice residents recognized 20% of all cardiac events; the number of correct identifications improved little with year of training and was not significantly higher than the number identified by medical students.
Both internal medicine and family practice trainees had a disturbingly low identification rate for 12 important and commonly encountered cardiac events. This study suggests a need to improve the teaching and assessment of cardiac auscultation during generalists' training, particularly with the advent of managed care and its search for more cost-effective uses of technology.
医学教育工作者越来越感觉到，物理诊断技能的熟练程度正在下降，但很少有数据对这个问题进行严格审查。
目的、设计与背景：比较医学生和实习医生的心脏听诊能力。对学生和住院医生进行多中心横断面评估。大西洋中部地区共有8个内科项目和23个家庭医学项目。
共有453名实习医生和88名医学生。
所有参与者听取了直接从患者身上记录的12个心脏事件，并通过完成一份多项选择题问卷来识别这些事件。
分数以按培训年份和类型划分的正确识别每个事件的参与者百分比表示。累积分数以正确识别的事件总数表示。每当参与者不仅选择了正确的发现，还选择了声学上相似但不存在的发现时，就会计算调整分数。
内科和家庭医学住院医生的累积分数在0至7之间（中位数分别为2.5和2.0）。内科住院医生在6种额外声音和所有12个测试心脏事件中的累积调整分数最高（分别为P = 0.01和0.02）。平均而言，内科和家庭医学住院医生识别出所有心脏事件的20%；正确识别的数量随着培训年份的增加改善不大，且并不显著高于医学生识别的数量。
内科和家庭医学实习生对12个重要且常见的心脏事件的识别率低得令人不安。这项研究表明，在全科医生培训期间，需要改进心脏听诊的教学和评估，特别是在管理式医疗出现以及寻求更具成本效益的技术应用的情况下。
