This post was authored by Akhil Narang, MD, a fellow-in-training at the University of Chicago.

Over lunch, Jafar Al-Sadir, MD, FACC, a master clinician and often described by trainees as a “human echo,” introduced us to his long time patient, Mr. Jones. For years, Mr. Jones has been driving more than an hour to join fellows-in-training (FITs) at the monthly Bedside Physical Exam Rounds. At each of these sessions, Al-Sadir carefully selects a patient with excellent physical exam findings and then spends the entire hour helping us hone our skills, appreciating pericardial knocks, describing jugular venous pulsations, or ensuring we all hear the posteriorly radiated murmur of mitral regurgitation due to a flail posterior leaflet.

Mr. Jones came to Al-Sadir’s office for the first time more than a decade ago after his internist noted a murmur on exam. It was readily apparent after examining Mr. Jones that he had mitral valve prolapse (MVP). The classic mid-systolic click followed by a late systolic murmur was a textbook example of MVP. After confirmation by echocardiography, Al-Sadir continued to monitor Mr. Jones who was asymptomatic and otherwise in good health.

More recently, Al-Sadir began to detect a mild diastolic, decrescendo in the lower left sternal border. Once again echocardiography confirmed what he already knew: Mr. Jones was developing mild aortic insufficiency after his aortic-root began to dilate.

During lunch, Mr. Jones graciously answered questions on his health, symptoms and family history. At one point one of my co-fellows inquired if he enjoys the yearly “prodding” of first year FITs. He was quick to point out how grateful he was to Al-Sadir and his internist for detecting an abnormality on his physical exam that lead to a diagnosis and ultimately a plan. While there was no need to intervene at this point, the time may come where Mr. Jones will need surgery.

After dessert, we all shifted to a nearby examination room and took turns examining Mr. Jones. Al-Sadir instructed us to auscultate continuously while Mr. Jones went from the supine position to standing, noting how the click moved towards S2 with standing. We also listened carefully when Mr. Jones performed handgrip maneuvers and leaned forward. If we weren’t convinced of the murmurs, we listened….and listened...and listened again.

The physical exam is a lost art. Cardiologists like Al-Sadir are rare. While patient simulators and online auscultation recordings are nice adjuvants to learning the physical exam, there is no substitute for practicing on the patients we see on a daily basis.

Echoing my last blog entry, our attendings are often the best teachers we have. I just finished my rotation in Pulmonary Hypertension where I spent time in clinic with Mardi Gomberg-Maitland, MD, FACC. Much like Al-Sadir, her physical exam skills, especially in patients with pulmonary hypertension and right ventricular dysfunction are remarkable. When examining patients together, she ensured I palpated the right ventricular heave and heard the prominent right-sided S4 and loud P2. Next, I rotate on the Advanced Heart Failure Service, where I have already started a list of exam findings I want my attendings to focus on.

Any proponents of the physical exam must also acknowledge the technology-heavy era we practice medicine in. A team of cardiologists at my hospital utilizes handheld echocardiography as part of their daily decision-making. Using pocket-sized ultrasounds, slightly larger than a mobile phone, the house staff can globally determine ventricular function, generally appraise volume status from the inferior vena cava and can recognize pericardial effusions. These point-of-care ultrasounds guide management at times (nights, weekends) when formal echocardiography is less available.

Just as the stethoscope took decades before being absorbed into general medical practice, I believe the handheld ultrasound will become soon become integrated into many clinicians’ armamentarium. Even though prices may fall dramatically for these newer technologies, the cost will still be prohibitively expensive for routine incorporation of anything beyond a stethoscope in the developing world.

There will never be a substitute for an excellent physical exam. It is imperative our generative of FITs learn to master the cardiovascular physical exam. The extra time it takes to perform a modified Allen’s test before transradial angiography, to perform pulsus paradoxus on a patient with an effusion, or to use a handheld ultrasound to look for poor cardiac contractility in the middle of the night, will inevitably lead to a generation of cardiologists better equipped to serve our patients.

To stay connected as an FIT, check out the FITs on the GO video blog featuring interviews from leaders in cardiovascular disease, follow the ACC’s Facebook page, and use the hashtag #ACCFIT on Twitter. Also check out the FIT Center on CardioSource.org. To get involved email fellowsintraining[at]acc.org.

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