Background: Cardiac examination is an essential aspect of the physical examination. Previous studies have shown poor diagnostic accuracy, but most used audio recordings, precluding correlation with visible observations. The training spectrum from medical students (MSs) to faculty has not been tested, to our knowledge.Methods: A validated 50-question, computer-based test was used to assess 4 aspects of cardiac examination competency: (1) cardiac physiology knowledge, (2) auditory skills, (3) visual skills, and (4) integration of auditory and visual skills using computer graphic animations and virtual patient examinations (actual patients filmed at the bedside). We tested 860 participants: 318 MSs, 289 residents (225 internal medicine and 64 family medicine), 85 cardiology fellows, 131 physicians (50 fulltime faculty, 12 volunteer clinical faculty, and 69 private practitioners), and 37 others.Results: Mean scores improved from MS1-2 to MS3-4 (P=.003) but did not improve or differ significantly among MS3, MS4, internal medicine residents, family medicine residents, full-time faculty, volunteer clinical faculty, and private practitioners. Only cardiology fellows tested significantly better (PϽ.001), and they were the best in all 4 subcategories of competency, whereas MS1-2 were the worst in the auditory and visual subcategories. Participants demonstrated low specificity for systolic murmurs (0.35) and low sensitivity for diastolic murmurs (0.49).Conclusions: Cardiac examination skills do not improve after MS3 and may decline after years in practice, which has important implications for medical decision making, patient safety, cost-effective care, and continuing medical education. Improvement in cardiac examination competency will require training in simultaneous audio and visual examination in faculty and trainees.

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The administration of a large amount of water to the normal subject results in the copious excretion of a dilute urine. An extensive body of evidence indicates that this response is primarily dependent upon a decrease in the effective osmotic pressure of the plasma and extracellular fluid, with resultant inhibition of the secretion of antidiuretic hormone (ADH) by the neurohypophysis and decreased facultative reabsorption of water by the renal tubules (2-5).Although alterations of this normal response to water loading have been studied in a variety of abnormal conditions, factors which influence the magnitude of water diuresis in normal man have received scant attention, even though Haldane and Priestley in 1916 noted that the initial high rates of urine flow which followed the ingestion of water subsequently underwent a gradual moderate decline despite a continued large fluid intake (6). Depletion of body sodium in man and experimental animals has been shown to diminish the excretion of administered water, but under the conditions of these studies general impairment of renal excretory function was evident (7-9) or was not excluded (10, 11).The present communication describes observations which indicate that in man the maintenance of a large water load evokes a diuresis the magnitude of which is. greatly influenced by factors which evoke concomitant changes in the renal excretion of solutes, particularly sodium. These influences include the dietary intake of sodium, postural effects, and the administration of various solute loads. METHODSThe subjects were three normal men and seven adult male patients, of whom four had neurodermEititis, one psoriasis, one bronchial asthma, and one rheumatoid ar-1A preliminary report (1) thritis. All were free of renal or cardiovascular disease. Dietary intake was controlled only with regard to its sodium content. The regimens employed were: 1) "saltfree" diet providing approximately 15 mEq. of sodium daily; 2) "salt-poor" diet providing 35-70 mEq. of sodium daily; 3) "regular" diet of unrestricted salt content containing approximately 170-250 mEq. of sodium; 4) "high-salt" diet consisting of the "regular" diet with 170 mEq. of added sodium chloride. The same regimen was employed for a minimum of three days before each experiment, except that the "high-salt" diet was given for only one day prior to an experiment in subjects who had previously been taking the regular diet. Repeated studies were performed on the same subjects at intervals which ranged from one week to 10 months. Hence weight changes unrelated to dietary salt intake occurred.The subjects came to the laboratory one to two hours after breakfast, voided, and were weighed on a scale sensitive to + 10 gm. Arterialized venous blood (12) was then obtained and a water load established by the ingestion of tap water at room temperature. In most experiments, 1500 ml. were drunk during a period of 10 to 40 minutes. The subject was again weighed and the water load was maintained throughout the experiment by oral administration ...

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The retention of water without a physiologically equivalent amount of sodium following abdominal paracentesis has been studied in two patients with advanced cirrhosis of the liver. In each there developed manifestations considered characteristic of sodium deficit, although there was no change in the total body sodium at the time these appeared. Such retention of water in excess of salt, regularly observed when large external losses of salt and water are replaced with water alone (1-3), has been noted in certain cases of heart failure and chronic renal disease (4-6) as well as in decompensated hepatic cirrhosis (7,8

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