Methods

We interviewed private practice practitioners—physicians, PA, and NP—for a 3-month period at 3 community hospitals and attending physicians and cardiac fellows in the cardiac clinic at Grady Memorial Hospital in Atlanta, Georgia—to get a measure of how they performed the bedside cardiac examination and how they perceived their skill in carrying out the examination. Practitioners were asked to voluntarily complete a questionnaire on the bedside cardiac examination. Practitioners surveyed were ethnically and gender diverse. Questionnaires were distributed at hospital meetings, on the ward or in the clinic, and at the Georgia American College of Cardiology meeting in 2013. Cardiology patients in the author’s practice, before visiting their cardiologist for an initial or follow-up examination, answered a questionnaire to evaluate their opinions concerning the bedside physical examination during the month of July 2013. Patients were ethnically and gender diverse and were referral based, from the metro-Atlanta area.

Northside Hospital Institutional Review Board reviewed the study, and both surveys were completed anonymously.

Results

One hundred twenty-three cardiology patients agreed to participate in the study; the median age of participants was 63 years (range 19 to 91 years) including 65 (53%) women and 58 (47%) men. 74% expect to undress from the waist up when they visit the cardiologist; 51% of patients expect to undress for every cardiology visit; 29% of patients believe that undressing and putting on an examination gown is an inconvenience. However, 94% of patients did not mind undressing if it were necessary for the cardiac assessment. 98% had a better experience when their doctor examined their heart; 84% of patients surveyed did not care what their physician wore during an examination. This included scrubs, no tie, or a laboratory coat; 64% did mind if their physician wore strong perfume/cologne. 54% of women and 34% of men were more comfortable with a chaperone in the room during an examination in the hospital; 40% of women and 31% of men were more comfortable with a chaperone in the room during an office visit.

There were 135 practitioners. This included 14 internists (age 28 to 75 years, 12 men, 2 women with 9 physicians ≤55 years), 10 hospitalists (age 30 to 54 years with 5 men, 5 women), 20 emergency department physicians [age 25 to 61 years, 20 men with 18 physicians ≤55 years], 63 cardiologists (age 27 to 79 years, 55 men and 8 women with 41 physicians ≤55 years), and 28 PA/NP (age 30 to 61 years, 9 men and 19 women with 23 PA/NP ≤55 years).

The practitioners were asked how do you rate your skill at the bedside cardiac examination; 11 of 135 (8%) practitioners replied they had “exceptional skills”; 102 (76%) rated their bedside examination skills as average; and 22 of 135 (16%) rated themselves as very poor skills. When asked the question how often do you close the door, turn off the TV, or make an effort to be sure the room is quiet, 39 (29%) replied “rarely or never.” When asked the question how often do you remove the gown or completely expose the chest to examine a new patient, 26 (19%) responded they “always undress the patient” and 59 (44%) responded they “rarely or never undress the patient.” The response to the question how often do you examine the patient in the left lateral decubitus position was “rarely or never” in 108 practitioners (80%). The response to the question when a patient has a murmur, how often do you use maneuvers such as handgrip, standing, stooping, or exercise was “rarely or never” in 86 practitioners (64%). The response to does your stethoscope have a bell was “yes” in 92 practitioners (68%). The practitioners were asked how often they were accompanied by a chaperone when examining a patient of the opposite gender. The response “rarely or never” was 54 (40%).

Thirty-eight cardiologists were asked specific questions about the performance of the cardiac examination. Approximately 75% routinely palpate the apex, carotid artery, radial artery, and the dorsalis pedis or posterior tibial arteries. Just 39% routinely examined the parasternal position, the brachial artery, the femoral artery; 90% routinely auscultate the apex, the tricuspid area, and the aortic area. Other areas were auscultated infrequently. The response to what characteristics do you assess when palpating the carotid artery were 22 (58%) evaluate the size of the pulse, 30 (79%) assess the rate of rise, 7 (18%) judge the tension, and 14 (37%) consider the dynamic quality of the pulse.

We evaluated 20 PA/NP with a cardiac sound simulator; 5 successfully recognized the heart sounds, but the other 15 had difficulty with gallops, diastolic murmurs, and identification of the characteristics of systolic murmurs.

Fifty-seven percent practitioners responded that good bedside cardiac examination skills were “carefully taught in undergraduate medical training” and 30% responded that they had good instruction during postgraduate training. However, 28 of these 41 practitioners were in cardiology training programs.

Results

One hundred twenty-three cardiology patients agreed to participate in the study; the median age of participants was 63 years (range 19 to 91 years) including 65 (53%) women and 58 (47%) men. 74% expect to undress from the waist up when they visit the cardiologist; 51% of patients expect to undress for every cardiology visit; 29% of patients believe that undressing and putting on an examination gown is an inconvenience. However, 94% of patients did not mind undressing if it were necessary for the cardiac assessment. 98% had a better experience when their doctor examined their heart; 84% of patients surveyed did not care what their physician wore during an examination. This included scrubs, no tie, or a laboratory coat; 64% did mind if their physician wore strong perfume/cologne. 54% of women and 34% of men were more comfortable with a chaperone in the room during an examination in the hospital; 40% of women and 31% of men were more comfortable with a chaperone in the room during an office visit.

There were 135 practitioners. This included 14 internists (age 28 to 75 years, 12 men, 2 women with 9 physicians ≤55 years), 10 hospitalists (age 30 to 54 years with 5 men, 5 women), 20 emergency department physicians [age 25 to 61 years, 20 men with 18 physicians ≤55 years], 63 cardiologists (age 27 to 79 years, 55 men and 8 women with 41 physicians ≤55 years), and 28 PA/NP (age 30 to 61 years, 9 men and 19 women with 23 PA/NP ≤55 years).

The practitioners were asked how do you rate your skill at the bedside cardiac examination; 11 of 135 (8%) practitioners replied they had “exceptional skills”; 102 (76%) rated their bedside examination skills as average; and 22 of 135 (16%) rated themselves as very poor skills. When asked the question how often do you close the door, turn off the TV, or make an effort to be sure the room is quiet, 39 (29%) replied “rarely or never.” When asked the question how often do you remove the gown or completely expose the chest to examine a new patient, 26 (19%) responded they “always undress the patient” and 59 (44%) responded they “rarely or never undress the patient.” The response to the question how often do you examine the patient in the left lateral decubitus position was “rarely or never” in 108 practitioners (80%). The response to the question when a patient has a murmur, how often do you use maneuvers such as handgrip, standing, stooping, or exercise was “rarely or never” in 86 practitioners (64%). The response to does your stethoscope have a bell was “yes” in 92 practitioners (68%). The practitioners were asked how often they were accompanied by a chaperone when examining a patient of the opposite gender. The response “rarely or never” was 54 (40%).

Thirty-eight cardiologists were asked specific questions about the performance of the cardiac examination. Approximately 75% routinely palpate the apex, carotid artery, radial artery, and the dorsalis pedis or posterior tibial arteries. Just 39% routinely examined the parasternal position, the brachial artery, the femoral artery; 90% routinely auscultate the apex, the tricuspid area, and the aortic area. Other areas were auscultated infrequently. The response to what characteristics do you assess when palpating the carotid artery were 22 (58%) evaluate the size of the pulse, 30 (79%) assess the rate of rise, 7 (18%) judge the tension, and 14 (37%) consider the dynamic quality of the pulse.

We evaluated 20 PA/NP with a cardiac sound simulator; 5 successfully recognized the heart sounds, but the other 15 had difficulty with gallops, diastolic murmurs, and identification of the characteristics of systolic murmurs.

Fifty-seven percent practitioners responded that good bedside cardiac examination skills were “carefully taught in undergraduate medical training” and 30% responded that they had good instruction during postgraduate training. However, 28 of these 41 practitioners were in cardiology training programs.