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      The Murmur Online Learning Experience (MOLE) Curriculum Improves Medical Students’ Ability to Correctly Identify Cardiac Murmurs

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          Physical examination skills are receiving less attention in curricula and clinical practice, being supplanted by imaging and other technologies. We developed an online module to introduce auscultation of common cardiac murmurs to second-year medical students.


          The Murmur Online Learning Experience (MOLE) curriculum focused on nine common, unique, or highly testable cardiac murmurs, chosen collaboratively by the authors. The curriculum consisted of (1) a nine-item multiple-choice pretest containing a clinical vignette, a photo of stethoscope location, and an auditory clip; (2) nine modules each containing a several-minute-long auditory clip and a written description (location, quality, radiation, change with exam maneuvers); and (3) a nine-item multiple-choice posttest, identical to the pretest but randomly ordered. All second-year medical students at the University of Louisville were given access to MOLE during their cardiovascular curriculum and given an incentive to complete the ungraded activity.


          One hundred forty-seven (91.8%) students voluntarily completed the pretest and posttest. The mean pretest score was 3.76 out of 9 ( SD = 1.77). The mean posttest score was 7.14 out of 9 ( SD = 1.78). Paired t-test results demonstrated a p value of <.001.


          An online murmur curriculum consisting of repetitive auditory murmurs and narrative description of murmurs improved second-year medical students’ ability to correctly identify common cardiac murmurs. This method of learning murmurs via online curriculum is a practical and effective way to hone students’ physical exam skills in the modern era.

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          Most cited references 8

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          Benefits of multisensory learning.

          Studies of learning, and in particular perceptual learning, have focused on learning of stimuli consisting of a single sensory modality. However, our experience in the world involves constant multisensory stimulation. For instance, visual and auditory information are integrated in performing many tasks that involve localizing and tracking moving objects. Therefore, it is likely that the human brain has evolved to develop, learn and operate optimally in multisensory environments. We suggest that training protocols that employ unisensory stimulus regimes do not engage multisensory learning mechanisms and, therefore, might not be optimal for learning. However, multisensory-training protocols can better approximate natural settings and are more effective for learning.
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            The teaching and practice of cardiac auscultation during internal medicine and cardiology training. A nationwide survey.

            To assess the time and importance given to cardiac auscultation during internal medicine and cardiology training and to evaluate the auscultatory proficiency of medical students and physicians-in-training. A nationwide survey of internal medicine and cardiology program directors and a multicenter cross-sectional assessment of students' and housestaff's auscultatory proficiency. All accredited U.S. internal medicine and cardiology programs and nine university-affiliated internal medicine and cardiology programs. Four hundred ninety-eight (75.6%) of all 659 directors surveyed; 203 physicians-in-training and 49 third-year medical students. Directors completed a 23-item questionnaire, and students and trainees were tested on 12 prerecorded cardiac events. The teaching and proficiency of cardiac auscultation at all levels of training. Directors attributed great importance to cardiac auscultation and thought that more time should be spent teaching it. However, only 27.1% of internal medicine and 37.1% of cardiology programs offered any structured teaching of auscultation (P = 0.02). Programs without teaching were more likely to be large, university affiliated, and located in the northeast. The trainees' accuracy ranged from 0 to 56.2% for cardiology fellows (median, 21.9%) and from 2% to 36.8% for medical residents (median, 19.3%). Residents improved little with year of training and were never better than third-year medical students. A low emphasis on cardiac auscultation appears to have affected the proficiency of medical trainees. Our study raises concern about the future of this time-honored art and, possibly, other bedside diagnostic skills.
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              Mastering cardiac murmurs: the power of repetition.

              The ability of medical students to recognize heart murmurs is poor (20%), and does not improve with subsequent years of training. A teaching method to improve this skill would be useful. To determine whether intensive repetition of four basic cardiac murmurs improves auscultatory proficiency in medical students. Controlled intervention study. Fifty-one second-year medical students in an east coast medical school. Subjects were classified into three groups: (1) a monitored group, who listened to 500 repetitions of each murmur in a monitored setting, (2) an unmonitored group, who listened to 500 repetitions of each murmur in an unmonitored setting, and (3) a control group. All three groups were tested using a pretest and posttest methodology. The 20 subjects in the monitored group improved from 13.5 +/- 9.8 to 85 +/- 17.6% following the intervention (mean +/- SD). Similarly, 21 students in the unmonitored group improved from 20.9 +/- 10.9 to 86.1 +/- 15.6%. Ten control students showed no significant improvement (24 +/- 21.7 to 32 +/- 22.5%). The differences between the two intervention groups and the control subjects was significant at p < 0.001 by analysis of variance. Five hundred repetitions of four basic cardiac murmurs significantly improved auscultatory proficiency in recognizing basic cardiac murmurs by medical students. These results suggest that cardiac auscultation is, in part, a technical skill.

                Author and article information

                MedEdPORTAL : the Journal of Teaching and Learning Resources
                Association of American Medical Colleges
                29 May 2020
                : 16
                [1 ] Fellow, Cardiology, University of Minnesota Medical Center
                [2 ] Cardiology, Associate Professor of Medicine, Department of Internal Medicine, University of Nevada, Reno, School of Medicine
                [3 ] Professor of Cardiology, Department of Cardiology, Lehigh Valley Health Network
                Author notes
                Corresponding author: juliette.e.power@
                © 2020 Power et al.

                This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial license.

                Page count
                Figures: 2, References: 9, Pages: 6
                Original Publication


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