tion findings at the bedside represents an independent clinical
skill, distinct from the medical knowledge necessary for
success in multiple choice examinations.
This study has several limitations. First, it represents the
performance of a single group of students over a short time
period at one medical school. However, standard setting data
used to set the MPS was obtained from 100 students at three
medical schools. Second, not all cardiac diagnoses were
studied. Third, we used the clinical assessment of experienced
cardiologists and not echocardiography because there is no
gold standard for assessing cardiac physical examination
We believe this is the most appropriate reference
standard as not all valvular abnormalities produce ausculta-
tory findings and some important examination findings have
no direct echocardiographic equivalent. Fourth, we used the
UMedic self-study tutorial and Harvey cardiac patient simula-
tor for testing and education. Although Harvey is widely used
in medical education,
we do not know if use of other
would produce similar findings. Last, durability
of enhanced cardiac auscultation proficiency is unknown and
is an appropriate area for further study.
In summary, a simulation based mastery learning program
dramatically improved cardiac auscultation skills in medical
students. Skills improved in both assessments of simulated
heart sounds and examination of actual patients. The program
was rated favorably by students. Use of a mastery learning
program allows all learners to meet or exceed a predetermined
MPS and is a valuable model to achieve and document
competence in important clinical skills.
Acknowledgements: We thank the Northwestern medical students
who participated in this study for their dedication to patient care
and education. We acknowledge Drs. Douglas Vaughan and John X.
Thomas for their support and encouragement of this work. Funding
was provided through the Augusta Webster, MD Office of Medical
Education and Faculty Development. Dr. McGaghie’s contribution
was supported in part by the Jacob R. Suker, MD, professorship in
medical education at Northwestern University and by grant UL 1
RR025741 from the National Center for Research Resources,
National Institutes of Health. The National Institutes of Health had
no role in the preparation, review, or approval of the manuscript.
Funding: Office of Medical Education and Faculty Development,
Northwestern University Feinberg School of Medicine, Chicago, IL
Conflicts of interests: Dr. McGaghie has been consultant to, and
received honorariums from, the Gordon Center for Research in
Medical Education at the University of Miami Miller School of
Medicine where the "Harvey" mannequin is manufactured. None of
the other authors have conflicts of interest, financial interests or
relationships or affiliations relevant to the subject matter or
materials discussed in this manuscript.
Corresponding Author: John Butter, MD; Department of Medicine,
Northwestern University Feinberg School of Medicine, 675 N. St.
Clair Street, Suite 18 -200, Chicago, IL 60611, USA (e-mail:
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