{"version":"1.0.0","segments":[{"startTime":0.215,"endTime":3.123,"body":"[intro music]"},{"startTime":3.123,"endTime":5.65,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.123,"endTime":5.65,"body":"to Harrison's Podclass,"},{"startTime":5.65,"endTime":7.085,"body":"where we discuss important concepts"},{"startTime":7.085,"endTime":9.91,"body":"in internal medicine. I'm Cathy Handy."},{"startTime":9.91,"endTime":11.69,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.91,"endTime":11.69,"body":"Wiener, and we're coming to you"},{"startTime":11.69,"endTime":15.832,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.832,"endTime":17.91,"body":"[Dr. Handy] Welcome to today's"},{"startTime":15.832,"endTime":17.91,"body":"episode, which is about"},{"startTime":17.91,"endTime":20.78,"body":"a 45-year-old with an"},{"startTime":17.91,"endTime":20.78,"body":"asymptomatic heart murmur."},{"startTime":20.78,"endTime":23.08,"body":"[Dr. Wiener] Okay, Cathy,"},{"startTime":20.78,"endTime":23.08,"body":"well, today in clinic,"},{"startTime":23.08,"endTime":26.35,"body":"you're seeing a 45-year-old,"},{"startTime":23.08,"endTime":26.35,"body":"previously healthy man"},{"startTime":26.35,"endTime":29.53,"body":"who comes in for a new"},{"startTime":26.35,"endTime":29.53,"body":"patient physical examination."},{"startTime":29.53,"endTime":33.09,"body":"This is his first time coming"},{"startTime":29.53,"endTime":33.09,"body":"to a doctor for over 20 years."},{"startTime":33.09,"endTime":35.74,"body":"On examination, his vital signs are normal"},{"startTime":35.74,"endTime":37.95,"body":"and the only finding that is notable,"},{"startTime":37.95,"endTime":41.15,"body":"is that you auscultate a grade 2/6"},{"startTime":41.15,"endTime":44.2,"body":"diastolic murmur along"},{"startTime":41.15,"endTime":44.2,"body":"his left sternal border."},{"startTime":44.2,"endTime":46.9,"body":"[Dr. Handy] A grade 2"},{"startTime":44.2,"endTime":46.9,"body":"murmur, really? I'm impressed"},{"startTime":46.9,"endTime":49.09,"body":"that the physician heard"},{"startTime":46.9,"endTime":49.09,"body":"the diastolic murmur."},{"startTime":49.09,"endTime":51.71,"body":"There are studies of accuracy"},{"startTime":49.09,"endTime":51.71,"body":"in cardiac auscultation"},{"startTime":51.71,"endTime":54.28,"body":"that suggest residents may miss almost 60%"},{"startTime":54.28,"endTime":56.52,"body":"of cardiac murmurs, so good pickup."},{"startTime":56.52,"endTime":58.83,"body":"[Dr. Wiener] Well, let's talk"},{"startTime":56.52,"endTime":58.83,"body":"about what grade 2 means."},{"startTime":58.83,"endTime":61.58,"body":"Can you briefly review"},{"startTime":58.83,"endTime":61.58,"body":"how to grade murmurs?"},{"startTime":61.58,"endTime":63.96,"body":"[Dr. Handy] Yeah, so the grading"},{"startTime":61.58,"endTime":63.96,"body":"refers to the Levine scale"},{"startTime":63.96,"endTime":66.27,"body":"that was introduced back in the 1930s,"},{"startTime":66.27,"endTime":68.16,"body":"but it's really stood the test of time."},{"startTime":68.16,"endTime":70.4,"body":"So, grade 1 is barely audible,"},{"startTime":70.4,"endTime":72.88,"body":"grade 2 is audible with a stethoscope,"},{"startTime":72.88,"endTime":76.38,"body":"grade 3 is louder than"},{"startTime":72.88,"endTime":76.38,"body":"grade 2, or easily audible,"},{"startTime":76.38,"endTime":78.29,"body":"but doesn't have a palpable thrill,"},{"startTime":78.29,"endTime":80.86,"body":"grade 4 is loud with a palpable thrill,"},{"startTime":80.86,"endTime":82.81,"body":"and grades 5 and 6 are even louder"},{"startTime":82.81,"endTime":84.01,"body":"to the point of being heard"},{"startTime":84.01,"endTime":85.9,"body":"with the stethoscope off the chest,"},{"startTime":85.9,"endTime":88.19,"body":"but diastolic murmurs only go to grade 4."},{"startTime":88.19,"endTime":89.97,"body":"[Dr. Wiener] Okay, so"},{"startTime":88.19,"endTime":89.97,"body":"there's some subjectivity,"},{"startTime":89.97,"endTime":92.33,"body":"but at least, we're all"},{"startTime":89.97,"endTime":92.33,"body":"speaking the same language."},{"startTime":92.33,"endTime":94.04,"body":"In this case, we're presuming that"},{"startTime":94.04,"endTime":95.87,"body":"because it was said to be grade 2,"},{"startTime":95.87,"endTime":97.98,"body":"that it's a faint murmur"},{"startTime":95.87,"endTime":97.98,"body":"and like you said,"},{"startTime":97.98,"endTime":99.82,"body":"nice pickup by the examiner."},{"startTime":99.82,"endTime":101.82,"body":"[Dr. Handy] Yeah, and you only"},{"startTime":99.82,"endTime":101.82,"body":"make the correct diagnosis"},{"startTime":101.82,"endTime":104.41,"body":"25% of the time in patients with a murmur."},{"startTime":104.41,"endTime":106.47,"body":"There are a lot of studies"},{"startTime":104.41,"endTime":106.47,"body":"out there on this topic"},{"startTime":106.47,"endTime":108.21,"body":"and all suggest that we can do better,"},{"startTime":108.21,"endTime":109.6,"body":"but keep going with the case."},{"startTime":109.6,"endTime":112.57,"body":"[Dr. Wiener] Okay, so the"},{"startTime":109.6,"endTime":112.57,"body":"patient is asymptomatic."},{"startTime":112.57,"endTime":115.07,"body":"He denies any chest pain, dyspnea, edema"},{"startTime":115.07,"endTime":117.71,"body":"or any syncopal or pre-syncopal episodes."},{"startTime":117.71,"endTime":119.76,"body":"He's been well for the past 20 years."},{"startTime":119.76,"endTime":123.09,"body":"Examination, as I mentioned,"},{"startTime":119.76,"endTime":123.09,"body":"reveals no other abnormalities,"},{"startTime":123.09,"endTime":126.12,"body":"but specifically, his"},{"startTime":123.09,"endTime":126.12,"body":"carotid pulses are normal,"},{"startTime":126.12,"endTime":128.56,"body":"his PMI or his point of maximal impulse"},{"startTime":128.56,"endTime":130.93,"body":"on cardiac palpation"},{"startTime":128.56,"endTime":130.93,"body":"is in the normal place"},{"startTime":130.93,"endTime":133.55,"body":"below the nipple, his"},{"startTime":130.93,"endTime":133.55,"body":"lung fields are clear,"},{"startTime":133.55,"endTime":136.66,"body":"his extremities have no edema whatsoever."},{"startTime":136.66,"endTime":139.7,"body":"You go on and get an"},{"startTime":136.66,"endTime":139.7,"body":"ECG and a chest X-ray,"},{"startTime":139.7,"endTime":141.3,"body":"both of those are normal."},{"startTime":141.3,"endTime":143.9,"body":"So, the question is going to ask you,"},{"startTime":143.9,"endTime":146.35,"body":"which of the following"},{"startTime":143.9,"endTime":146.35,"body":"is the next best step"},{"startTime":146.35,"endTime":149.54,"body":"for evaluation of this"},{"startTime":146.35,"endTime":149.54,"body":"murmur? And the options are"},{"startTime":149.54,"endTime":152.78,"body":"A. cardiac computed tomography;"},{"startTime":152.78,"endTime":155.371,"body":"B. cardiac MRI;"},{"startTime":155.371,"endTime":157.996,"body":"C. carotid ultrasound;"},{"startTime":157.996,"endTime":160.129,"body":"D. echocardiogram;"},{"startTime":160.129,"endTime":163.27,"body":"or E. no further workup is required."},{"startTime":163.27,"endTime":164.46,"body":"[Dr. Handy] All right, well,"},{"startTime":163.27,"endTime":164.46,"body":"here are the three things"},{"startTime":164.46,"endTime":166.11,"body":"that you want to"},{"startTime":164.46,"endTime":166.11,"body":"consider, that I would say"},{"startTime":166.11,"endTime":167.75,"body":"are the key components to deciding"},{"startTime":167.75,"endTime":170.08,"body":"whether or not you"},{"startTime":167.75,"endTime":170.08,"body":"pursue further evaluation"},{"startTime":170.08,"endTime":171.78,"body":"when you hear a heart murmur."},{"startTime":171.78,"endTime":174.59,"body":"So, one is the type of murmur,"},{"startTime":171.78,"endTime":174.59,"body":"two is the patient's age,"},{"startTime":174.59,"endTime":176.32,"body":"and then, three, you need to consider"},{"startTime":176.32,"endTime":177.66,"body":"the history of the patient."},{"startTime":177.66,"endTime":180.47,"body":"The majority of heart murmurs"},{"startTime":177.66,"endTime":180.47,"body":"are midsystolic and soft,"},{"startTime":180.47,"endTime":182.44,"body":"so, grades 1 to 2 out of 6,"},{"startTime":182.44,"endTime":185.15,"body":"and when such a murmur occurs"},{"startTime":182.44,"endTime":185.15,"body":"in an asymptomatic child"},{"startTime":185.15,"endTime":187.05,"body":"or a young adult without other evidence"},{"startTime":187.05,"endTime":188.97,"body":"of heart disease on examination,"},{"startTime":188.97,"endTime":191.61,"body":"and if they have a normal"},{"startTime":188.97,"endTime":191.61,"body":"EKG, it's usually benign"},{"startTime":191.61,"endTime":194.32,"body":"and no additional evaluation is required."},{"startTime":194.32,"endTime":196.02,"body":"When further evaluation is needed,"},{"startTime":196.02,"endTime":198.28,"body":"the next step is typically"},{"startTime":196.02,"endTime":198.28,"body":"an echocardiogram"},{"startTime":198.28,"endTime":200.61,"body":"with Doppler imaging,"},{"startTime":198.28,"endTime":200.61,"body":"and this is indicated"},{"startTime":200.61,"endTime":204.0,"body":"if a patient has a grade 3"},{"startTime":200.61,"endTime":204.0,"body":"or greater systolic murmur."},{"startTime":204.0,"endTime":207.26,"body":"And in fact, echocardiogram"},{"startTime":204.0,"endTime":207.26,"body":"is indicated for all diastolic"},{"startTime":207.26,"endTime":209.33,"body":"or continuous murmurs that you hear."},{"startTime":209.33,"endTime":211.13,"body":"[Dr. Wiener] Okay, so the answer is"},{"startTime":211.13,"endTime":213.86,"body":"in this case D. echocardiography."},{"startTime":213.86,"endTime":216.55,"body":"[Dr. Handy] Correct and the"},{"startTime":213.86,"endTime":216.55,"body":"other ones wouldn't be necessary"},{"startTime":216.55,"endTime":218.23,"body":"but since it is a diastolic murmur,"},{"startTime":218.23,"endTime":220.47,"body":"you would want to do further workup."},{"startTime":220.47,"endTime":223.43,"body":"[Dr. Wiener] Great. One of the"},{"startTime":220.47,"endTime":223.43,"body":"innovations for season three"},{"startTime":223.43,"endTime":225.97,"body":"of Harrison's Podclass is"},{"startTime":223.43,"endTime":225.97,"body":"that we're going to have"},{"startTime":225.97,"endTime":227.81,"body":"some of the editors from the Harrison's"},{"startTime":227.81,"endTime":231.16,"body":"Internal Medicine textbook"},{"startTime":227.81,"endTime":231.16,"body":"be guests on our podclass"},{"startTime":231.16,"endTime":233.78,"body":"to discuss some of our interesting cases."},{"startTime":233.78,"endTime":236.74,"body":"We're starting off with"},{"startTime":233.78,"endTime":236.74,"body":"Dr. Joseph Loscalzo."},{"startTime":236.74,"endTime":239.88,"body":"Dr. Loscalzo is the chairman"},{"startTime":236.74,"endTime":239.88,"body":"of the Department of Medicine"},{"startTime":239.88,"endTime":241.71,"body":"and is the physician in chief at the"},{"startTime":241.71,"endTime":244.49,"body":"Brigham and Women's Hospital in Boston."},{"startTime":244.49,"endTime":248.65,"body":"He is a renowned physician"},{"startTime":244.49,"endTime":248.65,"body":"scientist, vascular biologist,"},{"startTime":248.65,"endTime":252.38,"body":"and cardiologist. So"},{"startTime":248.65,"endTime":252.38,"body":"welcome, Dr. Loscalzo."},{"startTime":252.38,"endTime":254.59,"body":"[Dr. Loscalzo] Thank you."},{"startTime":252.38,"endTime":254.59,"body":"Thanks very much for having me."},{"startTime":254.59,"endTime":257.32,"body":"I appreciate the opportunity"},{"startTime":254.59,"endTime":257.32,"body":"to be here with you both."},{"startTime":257.32,"endTime":259.68,"body":"[Dr. Handy] Welcome, Dr."},{"startTime":257.32,"endTime":259.68,"body":"Loscalzo to our podclass."},{"startTime":259.68,"endTime":261.88,"body":"So, we wanted to get your"},{"startTime":259.68,"endTime":261.88,"body":"thoughts on this case"},{"startTime":261.88,"endTime":264.91,"body":"of a 45-year-old with"},{"startTime":261.88,"endTime":264.91,"body":"an asymptomatic grade 2"},{"startTime":264.91,"endTime":268.38,"body":"diastolic murmur that was"},{"startTime":264.91,"endTime":268.38,"body":"picked up on physical exam."},{"startTime":268.38,"endTime":270.46,"body":"As part of the question we"},{"startTime":268.38,"endTime":270.46,"body":"determined that the next"},{"startTime":270.46,"endTime":273.67,"body":"best step in the management"},{"startTime":270.46,"endTime":273.67,"body":"was an echocardiogram."},{"startTime":273.67,"endTime":275.93,"body":"Can you teach us a little bit"},{"startTime":273.67,"endTime":275.93,"body":"about what you would look for"},{"startTime":275.93,"endTime":277.82,"body":"on an echocardiogram for this patient"},{"startTime":277.82,"endTime":281.08,"body":"and more broadly, your approach"},{"startTime":277.82,"endTime":281.08,"body":"to diastolic heart murmurs?"},{"startTime":281.08,"endTime":282.76,"body":"[Dr. Loscalzo] Sure,"},{"startTime":281.08,"endTime":282.76,"body":"Cathy, I'd be delighted."},{"startTime":282.76,"endTime":285.06,"body":"Let's step back for a"},{"startTime":282.76,"endTime":285.06,"body":"second and think about"},{"startTime":285.06,"endTime":286.93,"body":"diastolic murmurs in general first,"},{"startTime":286.93,"endTime":289.2,"body":"then talk about the echo, if I may."},{"startTime":289.2,"endTime":292.16,"body":"So, this patient has a"},{"startTime":289.2,"endTime":292.16,"body":"2 presumably out of 4"},{"startTime":292.16,"endTime":295.25,"body":"diastolic murmur which defines it as soft."},{"startTime":295.25,"endTime":297.02,"body":"And if that murmur was identified"},{"startTime":297.02,"endTime":299.17,"body":"by a non-cardiologist in particular,"},{"startTime":299.17,"endTime":301.86,"body":"it's likely indicative of real pathology."},{"startTime":301.86,"endTime":304.16,"body":"So, diastolic murmurs almost always"},{"startTime":304.16,"endTime":306.76,"body":"require evaluation of some sort."},{"startTime":306.76,"endTime":309.14,"body":"On physical examination to begin with,"},{"startTime":309.14,"endTime":312.1,"body":"one would want to focus on"},{"startTime":309.14,"endTime":312.1,"body":"whether or not the pulse pressure"},{"startTime":312.1,"endTime":316.35,"body":"is widened, seek signs of"},{"startTime":312.1,"endTime":316.35,"body":"heart failure, including an S3,"},{"startTime":316.35,"endTime":319.44,"body":"and determine the timing"},{"startTime":316.35,"endTime":319.44,"body":"and qualities of the murmur."},{"startTime":319.44,"endTime":322.53,"body":"Is it early diastolic or mid-diastolic?"},{"startTime":322.53,"endTime":325.08,"body":"Is it blowing, especially when sitting up,"},{"startTime":325.08,"endTime":329.73,"body":"leaning forward, at end"},{"startTime":325.08,"endTime":329.73,"body":"expiration, decrescendo as well,"},{"startTime":329.73,"endTime":333.35,"body":"or is it a rumble that"},{"startTime":329.73,"endTime":333.35,"body":"occurs in mid-cycle?"},{"startTime":333.35,"endTime":336.06,"body":"Does the murmur increase with inspiration?"},{"startTime":336.06,"endTime":338.59,"body":"These are all the kinds"},{"startTime":336.06,"endTime":338.59,"body":"of features of the exam"},{"startTime":338.59,"endTime":340.88,"body":"that I would focus on in order to sort out"},{"startTime":340.88,"endTime":343.407,"body":"precisely what kind of"},{"startTime":340.88,"endTime":343.407,"body":"lesion I think it is."},{"startTime":343.407,"endTime":345.62,"body":"And the electrocardiogram"},{"startTime":343.407,"endTime":345.62,"body":"and to a certain extent,"},{"startTime":345.62,"endTime":348.73,"body":"the chest X-ray can help"},{"startTime":345.62,"endTime":348.73,"body":"in this regard as well."},{"startTime":348.73,"endTime":351.34,"body":"So in this case, the patient was sent"},{"startTime":351.34,"endTime":356.32,"body":"for a transthoracic echocardiogram"},{"startTime":351.34,"endTime":356.32,"body":"and given the likelihood"},{"startTime":356.32,"endTime":358.85,"body":"that this patient of middle age,"},{"startTime":358.85,"endTime":361.65,"body":"that he's likely to have an aortic lesion,"},{"startTime":361.65,"endTime":364.95,"body":"but we don't know that from"},{"startTime":361.65,"endTime":364.95,"body":"any other features of the exam."},{"startTime":364.95,"endTime":368.21,"body":"In patients who do have"},{"startTime":364.95,"endTime":368.21,"body":"aortic regurgitation"},{"startTime":368.21,"endTime":370.1,"body":"or are suspected of having it,"},{"startTime":370.1,"endTime":373.63,"body":"the important features to focus"},{"startTime":370.1,"endTime":373.63,"body":"on, on the echocardiogram,"},{"startTime":373.63,"endTime":377.03,"body":"include the integrity of"},{"startTime":373.63,"endTime":377.03,"body":"the aortic valve leaflets,"},{"startTime":377.03,"endTime":379.93,"body":"the number of leaflets, Doppler detection"},{"startTime":379.93,"endTime":384.19,"body":"of aortic regurgitation, the"},{"startTime":379.93,"endTime":384.19,"body":"dimensions of the aortic root,"},{"startTime":384.19,"endTime":386.93,"body":"the presence or absence of dissection,"},{"startTime":386.93,"endTime":389.81,"body":"and vegetations on the leaflets as well."},{"startTime":389.81,"endTime":392.44,"body":"And I would point out that"},{"startTime":389.81,"endTime":392.44,"body":"inter-observer precision"},{"startTime":392.44,"endTime":396.63,"body":"in detecting aortic"},{"startTime":392.44,"endTime":396.63,"body":"regurgitation is really moderate."},{"startTime":396.63,"endTime":400.4,"body":"Inter-observer agreement is"},{"startTime":396.63,"endTime":400.4,"body":"greater among cardiologists,"},{"startTime":400.4,"endTime":403.417,"body":"about 94%, than"},{"startTime":400.4,"endTime":403.417,"body":"non-cardiologists, about 78%."},{"startTime":403.417,"endTime":405.808,"body":"about 94%, than"},{"startTime":403.417,"endTime":405.808,"body":"non-cardiologists, about 78%."},{"startTime":405.808,"endTime":408.53,"body":"And the last point I'll make"},{"startTime":405.808,"endTime":408.53,"body":"about assessing patients"},{"startTime":408.53,"endTime":411.19,"body":"for the presence of aortic regurgitation,"},{"startTime":411.19,"endTime":413.94,"body":"is that among those"},{"startTime":411.19,"endTime":413.94,"body":"suspected of having aortic"},{"startTime":413.94,"endTime":417.48,"body":"regurgitation who are referred"},{"startTime":413.94,"endTime":417.48,"body":"for cardiac catheterization,"},{"startTime":417.48,"endTime":420.07,"body":"the positive likelihood"},{"startTime":417.48,"endTime":420.07,"body":"ratio is quite high,"},{"startTime":420.07,"endTime":423.69,"body":"between four and nine, while"},{"startTime":420.07,"endTime":423.69,"body":"the negative likelihood ratio"},{"startTime":423.69,"endTime":426.24,"body":"is quite low, between 0.1 and 0.2."},{"startTime":426.24,"endTime":428.4,"body":"So, if the patient gets to that stage,"},{"startTime":428.4,"endTime":431.41,"body":"in which a cardiac"},{"startTime":428.4,"endTime":431.41,"body":"catheterization seems indicated,"},{"startTime":431.41,"endTime":434.61,"body":"it's highly likely,"},{"startTime":431.41,"endTime":434.61,"body":"based on prior evaluation"},{"startTime":434.61,"endTime":437.45,"body":"by physical examination"},{"startTime":434.61,"endTime":437.45,"body":"and echocardiography,"},{"startTime":437.45,"endTime":439.92,"body":"that the diagnosis will be confirmed"},{"startTime":439.92,"endTime":442.84,"body":"and the hemodynamics"},{"startTime":439.92,"endTime":442.84,"body":"defined more precisely."},{"startTime":442.84,"endTime":444.5,"body":"[Dr. Wiener] Joe, I'm glad you mentioned"},{"startTime":444.5,"endTime":448.37,"body":"your accuracy comment and put"},{"startTime":444.5,"endTime":448.37,"body":"in a plug for cardiologists,"},{"startTime":448.37,"endTime":450.5,"body":"but what are your thoughts on the cardiac"},{"startTime":450.5,"endTime":452.67,"body":"physical examination in 2021,"},{"startTime":452.67,"endTime":455.17,"body":"particularly with the"},{"startTime":452.67,"endTime":455.17,"body":"growth of bedside ultrasound"},{"startTime":455.17,"endTime":457.55,"body":"amongst primary care"},{"startTime":455.17,"endTime":457.55,"body":"doctors and residents,"},{"startTime":457.55,"endTime":460.77,"body":"and what is the role of the"},{"startTime":457.55,"endTime":460.77,"body":"stethoscope as we move forward?"},{"startTime":460.77,"endTime":462.38,"body":"[Dr. Loscalzo] That's a"},{"startTime":460.77,"endTime":462.38,"body":"wonderful question, Charlie,"},{"startTime":462.38,"endTime":465.09,"body":"and it really does speak to some of the"},{"startTime":465.09,"endTime":467.58,"body":"sort of natural sociological phenomena"},{"startTime":467.58,"endTime":470.68,"body":"associated with the uptake"},{"startTime":467.58,"endTime":470.68,"body":"of new technologies."},{"startTime":470.68,"endTime":474.54,"body":"So, remember that Laennec"},{"startTime":470.68,"endTime":474.54,"body":"invented the stethoscope in 1816,"},{"startTime":474.54,"endTime":477.02,"body":"and at that time, it met with skepticism"},{"startTime":477.02,"endTime":478.722,"body":"by physicians of the day, just as-"},{"startTime":478.722,"endTime":480.29,"body":"[Dr. Wiener] Including me, by the way,"},{"startTime":480.29,"endTime":484.421,"body":"- because I was skeptical."},{"startTime":480.29,"endTime":484.421,"body":"- [all doctors chuckle]"},{"startTime":484.421,"endTime":486.05,"body":"[Dr. Loscalzo] -just"},{"startTime":484.421,"endTime":486.05,"body":"as bedside ultrasound,"},{"startTime":486.05,"endTime":488.15,"body":"or any other new"},{"startTime":486.05,"endTime":488.15,"body":"technology for that matter,"},{"startTime":488.15,"endTime":491.54,"body":"has in some quarters"},{"startTime":488.15,"endTime":491.54,"body":"among cardiologists today."},{"startTime":491.54,"endTime":494.02,"body":"By and large though, the"},{"startTime":491.54,"endTime":494.02,"body":"uptake has been increasing,"},{"startTime":494.02,"endTime":497.02,"body":"especially among our trainees,"},{"startTime":494.02,"endTime":497.02,"body":"and to get to the point,"},{"startTime":497.02,"endTime":498.52,"body":"I think you're intimating about"},{"startTime":498.52,"endTime":501.88,"body":"cardiologists having better"},{"startTime":498.52,"endTime":501.88,"body":"ears, Kobal and colleagues"},{"startTime":501.88,"endTime":504.62,"body":"in 2006 published a"},{"startTime":501.88,"endTime":504.62,"body":"really interesting paper,"},{"startTime":504.62,"endTime":507.32,"body":"in which they looked at"},{"startTime":504.62,"endTime":507.32,"body":"point of care ultrasound"},{"startTime":507.32,"endTime":509.28,"body":"by first year medical students"},{"startTime":509.28,"endTime":511.15,"body":"and showed that the medical students"},{"startTime":511.15,"endTime":513.0,"body":"using point of care ultrasound"},{"startTime":513.0,"endTime":515.67,"body":"outperformed the bedside"},{"startTime":513.0,"endTime":515.67,"body":"cardiac examination"},{"startTime":515.67,"endTime":518.478,"body":"by Board certified cardiologists"},{"startTime":515.67,"endTime":518.478,"body":"75% to 49% respectively."},{"startTime":518.478,"endTime":521.103,"body":"by Board certified cardiologists"},{"startTime":518.478,"endTime":521.103,"body":"75% to 49% respectively."},{"startTime":521.103,"endTime":524.01,"body":"So it continues, based"},{"startTime":521.103,"endTime":524.01,"body":"on studies like Kobal's"},{"startTime":524.01,"endTime":526.76,"body":"and others more recently, it"},{"startTime":524.01,"endTime":526.76,"body":"continues to gain momentum"},{"startTime":526.76,"endTime":529.72,"body":"as an important part of"},{"startTime":526.76,"endTime":529.72,"body":"the bedside evaluation."},{"startTime":529.72,"endTime":531.49,"body":"[Dr. Wiener] Do you think"},{"startTime":529.72,"endTime":531.49,"body":"that this should be a part"},{"startTime":531.49,"endTime":533.16,"body":"of all general internal medicine"},{"startTime":533.16,"endTime":535.58,"body":"residency training programs"},{"startTime":533.16,"endTime":535.58,"body":"as we move forward?"},{"startTime":535.58,"endTime":537.19,"body":"[Dr. Loscalzo] Absolutely."},{"startTime":535.58,"endTime":537.19,"body":"I think, you know,"},{"startTime":537.19,"endTime":539.32,"body":"it's already been taken up to that degree"},{"startTime":539.32,"endTime":541.57,"body":"among emergency medicine"},{"startTime":539.32,"endTime":541.57,"body":"programs as you know,"},{"startTime":541.57,"endTime":544.12,"body":"and it's being taken up increasingly"},{"startTime":544.12,"endTime":545.54,"body":"among internal medicine programs"},{"startTime":545.54,"endTime":547.47,"body":"and I support that completely."},{"startTime":547.47,"endTime":549.47,"body":"Now, I would say one thing"},{"startTime":547.47,"endTime":549.47,"body":"before we, sort of, toss out"},{"startTime":549.47,"endTime":551.63,"body":"the physical exam, one"},{"startTime":549.47,"endTime":551.63,"body":"of the critical issues"},{"startTime":551.63,"endTime":553.59,"body":"about the weaknesses in the physical exam"},{"startTime":553.59,"endTime":555.54,"body":"is the quality of the teacher."},{"startTime":555.54,"endTime":557.07,"body":"I'm always disturbed by those studies"},{"startTime":557.07,"endTime":559.13,"body":"that suggest that the"},{"startTime":557.07,"endTime":559.13,"body":"physical examination has,"},{"startTime":559.13,"endTime":560.65,"body":"you know, a poor predictive accuracy"},{"startTime":560.65,"endTime":562.78,"body":"of some sort or another,"},{"startTime":560.65,"endTime":562.78,"body":"but it really depends upon"},{"startTime":562.78,"endTime":566.31,"body":"who taught the examiner"},{"startTime":562.78,"endTime":566.31,"body":"how to perform the exam"},{"startTime":566.31,"endTime":567.78,"body":"and I'm sure that you've seen differences"},{"startTime":567.78,"endTime":569.67,"body":"by generation in this regard as well."},{"startTime":569.67,"endTime":571.9,"body":"So, you're only as good"},{"startTime":569.67,"endTime":571.9,"body":"as your best teacher,"},{"startTime":571.9,"endTime":573.95,"body":"when it comes to using"},{"startTime":571.9,"endTime":573.95,"body":"the physical examination."},{"startTime":573.95,"endTime":575.5,"body":"There's no absolute gold standard,"},{"startTime":575.5,"endTime":577.79,"body":"as there might be if you're"},{"startTime":575.5,"endTime":577.79,"body":"doing point of care ultrasound."},{"startTime":577.79,"endTime":580.86,"body":"So I want to put a pitch in"},{"startTime":577.79,"endTime":580.86,"body":"for improving the quality"},{"startTime":580.86,"endTime":582.69,"body":"of teaching the physical examination"},{"startTime":582.69,"endTime":584.98,"body":"because coupling the physical examination"},{"startTime":584.98,"endTime":587.75,"body":"with observations made"},{"startTime":584.98,"endTime":587.75,"body":"by these technologies,"},{"startTime":587.75,"endTime":589.81,"body":"like ultrasound, is"},{"startTime":587.75,"endTime":589.81,"body":"absolutely the best way"},{"startTime":589.81,"endTime":592.58,"body":"to make management"},{"startTime":589.81,"endTime":592.58,"body":"decisions for our patients."},{"startTime":592.58,"endTime":594.017,"body":"[Dr. Handy] And I think"},{"startTime":592.58,"endTime":594.017,"body":"too, one of the things"},{"startTime":594.017,"endTime":596.29,"body":"you highlighted is that one"},{"startTime":594.017,"endTime":596.29,"body":"of the most important parts"},{"startTime":596.29,"endTime":599.15,"body":"is being at the bedside and"},{"startTime":596.29,"endTime":599.15,"body":"there are a lot of things that,"},{"startTime":599.15,"endTime":602.1,"body":"I think, pull us away, but"},{"startTime":599.15,"endTime":602.1,"body":"all of these new technologies"},{"startTime":602.1,"endTime":604.15,"body":"still are best at the bedside."},{"startTime":604.15,"endTime":605.5,"body":"[Dr. Loscalzo] Oh, I"},{"startTime":604.15,"endTime":605.5,"body":"absolutely agree with that."},{"startTime":605.5,"endTime":607.65,"body":"I mean, I think that's another"},{"startTime":605.5,"endTime":607.65,"body":"feature of the stethoscope,"},{"startTime":607.65,"endTime":610.05,"body":"it really connects us physically and,"},{"startTime":610.05,"endTime":612.37,"body":"if you will, emotionally to our patients."},{"startTime":612.37,"endTime":613.94,"body":"While it may have its limitations,"},{"startTime":613.94,"endTime":617.75,"body":"it's really critical for"},{"startTime":613.94,"endTime":617.75,"body":"patient-physician connection."},{"startTime":617.75,"endTime":619.81,"body":"It's a symbol of our"},{"startTime":617.75,"endTime":619.81,"body":"profession and perhaps"},{"startTime":619.81,"endTime":622.68,"body":"even a talisman in some"},{"startTime":619.81,"endTime":622.68,"body":"cases among ill patients."},{"startTime":622.68,"endTime":624.47,"body":"So, I don't think we should toss it out"},{"startTime":624.47,"endTime":628.92,"body":"in any significant way until"},{"startTime":624.47,"endTime":628.92,"body":"we improve the quality of care"},{"startTime":628.92,"endTime":630.94,"body":"in other ways that would enhance"},{"startTime":630.94,"endTime":633.82,"body":"the physician-patient"},{"startTime":630.94,"endTime":633.82,"body":"relationship to the same degree."},{"startTime":633.82,"endTime":634.9,"body":"[Dr. Handy] Thank you so much for that."},{"startTime":634.9,"endTime":637.57,"body":"Any other final thoughts"},{"startTime":634.9,"endTime":637.57,"body":"or pearls for us today?"},{"startTime":637.57,"endTime":639.01,"body":"[Dr. Loscalzo] I think I"},{"startTime":637.57,"endTime":639.01,"body":"touched on all the points"},{"startTime":639.01,"endTime":640.73,"body":"I wanted to make, but I guess I would say"},{"startTime":640.73,"endTime":642.89,"body":"one other feature of"},{"startTime":640.73,"endTime":642.89,"body":"the physical examination"},{"startTime":642.89,"endTime":645.21,"body":"for aortic regurgitation"},{"startTime":642.89,"endTime":645.21,"body":"that I didn't mention"},{"startTime":645.21,"endTime":648.35,"body":"that most American-trained"},{"startTime":645.21,"endTime":648.35,"body":"physicians may not realize,"},{"startTime":648.35,"endTime":651.21,"body":"is that the best way to"},{"startTime":648.35,"endTime":651.21,"body":"listen for a diastolic"},{"startTime":651.21,"endTime":654.42,"body":"decrescendo murmur of AR is"},{"startTime":651.21,"endTime":654.42,"body":"not just having the patient"},{"startTime":654.42,"endTime":656.45,"body":"sit up, lean forward and end-expire,"},{"startTime":656.45,"endTime":659.81,"body":"but also placing one's"},{"startTime":656.45,"endTime":659.81,"body":"hands behind one's head,"},{"startTime":659.81,"endTime":662.76,"body":"that also enhances the"},{"startTime":659.81,"endTime":662.76,"body":"proximity of the aortic root"},{"startTime":662.76,"endTime":665.09,"body":"to the chest wall and improves the pickup."},{"startTime":665.09,"endTime":667.72,"body":"[Dr. Wiener] Great. Dr."},{"startTime":665.09,"endTime":667.72,"body":"Loscalzo, thank you so much"},{"startTime":667.72,"endTime":670.12,"body":"for joining us today and we"},{"startTime":667.72,"endTime":670.12,"body":"look forward to your wisdom"},{"startTime":670.12,"endTime":672.64,"body":"on future cases of Harrison's Podclass."},{"startTime":672.64,"endTime":673.473,"body":"[Dr. Loscalzo] Thank you."},{"startTime":673.473,"endTime":675.15,"body":"[Dr. Handy] And if you want to"},{"startTime":673.473,"endTime":675.15,"body":"learn more about this topic,"},{"startTime":675.15,"endTime":677.976,"body":"you can check out Harrison's"},{"startTime":675.15,"endTime":677.976,"body":"chapter on heart murmurs."},{"startTime":677.976,"endTime":682.17,"body":"[outro music]"},{"startTime":682.17,"endTime":685.04,"body":"[Mr. Shanahan] This is Jim"},{"startTime":682.17,"endTime":685.04,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":685.04,"endTime":686.65,"body":"Harrison's Podclass is brought to you"},{"startTime":686.65,"endTime":688.64,"body":"by McGraw Hill's Access Medicine,"},{"startTime":688.64,"endTime":691.25,"body":"the online medical resource"},{"startTime":688.64,"endTime":691.25,"body":"that delivers the latest"},{"startTime":691.25,"endTime":693.96,"body":"trusted content from the"},{"startTime":691.25,"endTime":693.96,"body":"best minds in medicine."},{"startTime":693.96,"endTime":696.513,"body":"Go to accessmedicine.com to learn more."}]}