By Shiv Gaglani

In a Health Tech column earlier this year, I wrote about the latest in digital and mobile stethoscope technology, which enables the listener to record and even view heart sounds. Medical education is an obvious, yet underutilized, application of this capability that, as a medical student, is close to my heart. I recently came across MurmurLab (www.murmurlab.com), a large database of more than 1,200 patient cases with recorded heart sounds, and had the opportunity to speak with its creator, pediatric cardiologist W. Reid Thompson, MD, from Johns Hopkins Children's Center, about MurmurLab and why it is still relevant to current medical students.

What is your background in medicine, education, and tech?
I am a pediatric cardiologist on the faculty at the Johns Hopkins School of Medicine. I do not have any particular tech training, other than being a cardiologist, which usually means an open attitude to technological innovations since so much of what we do involves technology. My main interest, other than research and teaching heart sounds, is in echocardiography—especially newer techniques of diagnosing and following patients with cardiomyopathy. Outside of medicine, I am somewhat of an amateur musician, which may explain why listening to heart sounds has always been interesting to me.

How did you decide to start MurmurLab?
I began working on a project with the Johns Hopkins Applied Physics Lab in 1999, which leveraged knowledge used to develop submarine detection algorithms to detect pathological heart murmurs. We needed to record heart sounds from hundreds of patients to develop the algorithm and reasoned that this could be a dual-purpose database useful for both research and teaching. I approached a brilliant Hopkins medical student, Charles Tuchinda, about the possibility of using the then-new medium known as the Internet to distribute our teaching tool to the public, which we thought might have an advantage over the other smaller heart sound collections that were available only on tape or CD at that time.

Can you discuss the evolution of the site both in terms of features and user base?
From the beginning, we wanted to create a system for uploading heart sounds that would eventually be a repository for interesting auscultation cases from all over the world. We have more than 1,200 cases to date, each of which has at least five recordings from different locations on the chest, as well as pertinent clinical data including history, general physical exam, ECG, and echocardiogram findings. We created a robust search feature that allows the user to look for cases by lesion or by heart sound, tag cases of specific interest, and enter a description of the heart sounds to test their skills against other users and the echo findings. Our user base is diverse, and includes teachers, students, clinicians, and researchers from around the world.

What are your thoughts on the growing number of clinicians who believe the stethoscope is a relic?
I keep hearing this, especially from some prominent cardiologists with easy access to echocardiography and at echo meetings, but I haven't yet seen many cardiologists without a stethoscope in their pocket and very few with a handheld echo device instead. And for most non-cardiologists who do any patient care, it is still considered one of the essential tools of the trade. This will probably continue to be the case as long as auscultation remains so much quicker, easier, and cheaper to perform than other alternatives. We understand its proper role and limitations. We now have an opportunity to improve auscultation training and accuracy through use of digital recordings, distance learning, and potentially decision-assist algorithms.

If you could change one thing about medical education, what would it be?
That's not a simple question. Medical education needs to constantly reinvent itself to keep up with increasing knowledge, shifting priorities, and changes in the workforce, as well as the health care needs of our patients. There is a temptation to follow the advances in ever more sophisticated diagnostic imaging and other testing, sometimes without looking carefully at what the incremental improvements have cost and whether they justify a paradigm shift to replace other, very useful, simpler methods.

With regard to clinical skills, including auscultation, I am concerned about the paradigm shift away from interacting directly and physically with the patient, ceding all data gathering to "The Machine." In the age of personalized medicine, we need to avoid the depersonalization of the basic clinician-patient interaction, and instead find ways to improve the accuracy of the exam so that we will continue to feel it is a vital, relevant, indispensable part of taking care of patients. If we don't do this, medicine will not continue to be the choice of bright young empathetic students who want to make a difference in people's lives at a personal level. In addition, we will miss opportunities for seeing, feeling, and hearing connections between facial expressions, pulse intensity, and subtle heart sounds that may quickly rule in or out multiple diagnoses that even the most sophisticated, expensive machine would probably miss.

The greatest doctors, the ones that everyone remembers from their training, are not the ones who were most adroit at ordering the right tests and responding with the right treatment, but rather those who walked into a patient's room, looked, touched, listened, and showed the patient that they were personally interested in them and that their problems were important.

How do you see technology playing a role in the education of clinicians?
Technology can greatly enhance the educational experience through use of simulation centers, the instant ability to find evidence-based treatments, and opportunities for decision-assist devices to help the clinician sort through myriad data and facts, and also to apply machine-learning technology modeled on some of the most complicated neural circuitry, the brain of the seasoned clinician. These technologies themselves will have a learning curve both for the teachers and the students, and the challenge is to find ways to engage both with the exciting new opportunities that now exist.

Shiv Gaglani is an MD/MBA candidate at the Johns Hopkins School of Medicine and Harvard Business School. He writes about trends in medicine and technology and has had his work published in Medgadget, The Atlantic, and Emergency Physicians Monthly.