• listen to numerous repetitions and comparisons of heart sounds and murmurs
• learn to distinguish between normal and abnormal murmurs through listening exercises arranged in 7 steps of progressive difficulty.

• over 90% accuracy is achieved after an average of one hour of training
• medical education is not necessary for success
• reinforcement sessions are necessary for maintaining skills

Rationale:   Conventional teaching of heart sounds and murmurs is often case based but seldom emphasizes repetition and comparison of sounds and murmurs. Auditory memory however requires about 500 repetitions of sounds for reliable recognition. The auditory training program is designed to supplement case based learning by emphasizing repetition and comparison of sounds. It teaches students how to distinguish between innocent and pathological heart murmurs as acoustic events; students are not asked to diagnose the cause for the murmurs. Rather, the focus is on learning to distinguish between the acoustic characteristics of innocent versus pathological heart murmurs through hearing only, with emphasis on much repetition.. The program also emphasizes repeated comparison of heart sounds which are clearly normal, clearly abnormal, and those with some features of both. The training program is based on the principle that the recognition of subtle differences between acoustic events can be improved with practice that involves listening to many examples. Similar to learning to play a musical instrument, over time one learns to "train one's ears" to the musical notes after repeated exposure to the sounds.

Instructions:   Students should listen to the heart sounds in a quiet room, using stethophones or good quality earbuds directly connected to the computer. Do not use computer speakers. First, recordings of an innocent and a pathological murmur are presented to demonstrate to the students the typical sounds of the two types of murmurs. Then the students' pre-training skills are assessed by listening to 20 heart murmurs and identifying each one as either an innocent or pathological murmur. A percentage correct score is provided after completing the pre-training test. The training program is then performed, usually in about an hour, immediately following which there is a post-test of twenty recordings similar to the pre-training test. A post-training percentage correct score is provided. These pre- and post-training tests include 20 heart murmurs randomly selected by the software from the entire pool of over 90 heart murmurs. A late followup test is provided, with a mastery format: 20 murmurs are presented initially. If the score is 90% or greater no more examples are provided. If the score is less than 90% a second 20 examples are provided, with a third and final group of 20 for scores on the second group less than 90%. Students can interrupt the main training program at any time and resume it where they left off, but not revise answers already given. Both the main training program and the followup tests can be accessed repeatedly as desired.

• Incorporates modern concepts of teaching sound recognition and memory
• rapid acquisition of murmur recognition skills
• over 60 murmur recordings from patients, half innocent and half pathological
• computer game format
• emphasizes repetition and comparison of murmur sounds
• concurrent feedback of scores as program progresses
• can be used for formative or summative testing or self learning at all levels in medical curricula
• can be used in a mastery learning model
• useful for continuing education/recertification
• well accepted in student trials
• validated with medical students in Canada and Australia
• flexible-additional sound recordings and reinforcement sessions can be added

References:    

Teaching Heart Auscultation to Health Professionals: Methods for improving the practice of an ancient but critical skill. Ed Finley JP. Toronto: Canadian Pediatric Cardiology Assoc. 2011

Finley JP, Caissie R, Nicol P. International trial of online auditory training programme for distinguishing innocent and pathological murmurs. J Paediatr Child Health. 2015 Aug;51(8):815-9

• John Finley MDCM, Professor, Pediatrics and Congenital Cardiologist, Dalhousie University, Halifax, Nova Scotia, Canada
• Rachel Caissie PhD, Assoc. Professor of Audiology, School of Human Communication Disorders, Dalhousie University, Halifax Nova Scotia, Canada
• Pam Nicol RN BSc MPH, Clinical Educator, School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia (Retired)
• Brian Hoyt MSc, Department of Physiology and Biophysics, Dalhousie University, Halifax, Nova Scotia, Canada (Retired)