Is auscultation really better than echocardiography?

In a recent letter to the editor on the role of auscultation and echocardiography, “Point-of-care ultrasound: It’s no replacement for the stethoscope” (J Fam Pract. 2016;65:734), Dr. Fredricks claimed that “doppler ultrasound is not as precise as the stethoscope when used by a practiced listener for identifying the source and subtle characteristics of murmurs.” His citation for this claim was a review article from more than 20 years ago that offered no evidence in support of the superiority of auscultation over echocardiography to characterize murmurs.¹ The review did acknowledge the limitations and variability between examiners.

The notion that physical examination is superior to echocardiography is appealing, but likely incorrect. A study of medical students with basic training in echocardiography showed that they were able to characterize murmurs more accurately with point-of-care ultrasound than experienced cardiologists auscultating the murmur.²

The existence of a better test does not obviate the role of the physical examination, but it does highlight the need to understand its limits. Like an ultrasound study, physical examination maneuvers are tests, with sensitivities and specificities. We should approach them as such, and not romanticize their performance.

David Mackenzie, MD
Portland, Me