Aim-To determine the diagnostic accuracy of physical examination by oYce based (general practice) paediatricians in the evaluation of heart murmurs. Design-Each of 30 oYce based paediatricians blindly examined a random sample of children with murmurs (43% of which were pathological). Sensitivity and specificity were calculated and were related to paediatricians' characteristics. Results-Mean (SD) sensitivity was 82 (24)% with a mean specificity of 72 (24)% in diVerentiating pathological from innocent murmurs, with further investigations requested for 54% of assessments. The addition of a referral strategy would have increased mean sensitivity to 87 (20)% and specificity to 98 (8)%. Diagnostic accuracy was not significantly related to the paediatricians' age, education or practice characteristics, but was related to referral practices and confidence in assessment. Conclusions-Diagnostic accuracy of clinical assessment of heart murmurs by oYce based paediatricians is suboptimal, and educational strategies are needed to improve accuracy and reduce unnecessary referrals and misdiagnosis. (Arch Dis Child 1999;81:409-412)

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