Sound Judgement: Key Auscultation Insights from Q1 2025

An 11-year longitudinal analysis published in the American Heart Journal confirms what many clinical educators have long suspected: cardiac auscultation skills are systematically declining across all medical training levels. The study by <a href="https://www.sciencedirect.com/science/article/abs/pii/S0002870325000857?via%3Dihub" rel="nofollow">Kelshiker et al. (2025)</a> examined 411 simulation tests completed by medical students (84.7%), residents (9.0%), and cardiology fellows (6.3%) between 2008 and 2018, revealing a concerning downward trend in auscultation proficiency of 0.15 points per year (p=0.003).

Though fellows performed better than medical students by an average of 2.1 points (p<0.001) and residents by 1.1 points (p=0.008), the universal decline suggests a system-wide issue rather than individual failings. The researchers found variable performance on specific heart sounds and murmurs, with no significant change in performance on individual questions over time.

This decline represents more than academic concern—it reflects the real-world tension between advanced imaging technology and fundamental clinical assessment. While echocardiography offers remarkable detail, it cannot replace the immediacy of a stethoscope in hand during those first critical moments with a patient. The researchers suggest multiple contributing factors: increasing volume of medical knowledge taught in schools, growing reliance on advanced imaging, higher documentation burdens decreasing direct patient care time, and possibly declining auscultation teaching skills among instructors.

For those committed to clinical excellence, this trend signals an urgent need to reinvigorate how we teach and value auscultation skills. We need deliberate strategies to preserve the skill that bridges technology and touch—one that remains irreplaceable in immediate patient assessment.

How do we counter declining skills in the wake of COVID-19's disruption to bedside teaching? Recent research by <a href="https://www.cureus.com/articles/298625-teaching-cardiac-auscultation-effectiveness-of-virtual-simulation-based-training-on-improving-cardiac-auscultatory-skills-in-post-graduate-trainees-in-the-covid-19-era" rel="nofollow">Hidalgo et al. (2025)</a> explored the effectiveness of virtual simulation-based training in improving cardiac auscultation skills among postgraduate medical trainees. The intervention proved promising—even through remote means, focused training significantly improved diagnostic proficiency.

In a single-center study at Broward North Medical Center, 58 residents (43 in internal medicine and 15 in transitional year) participated in a seven-hour virtual simulation-based training course on cardiac auscultation held one hour monthly from November 2023 to May 2024. Using video demonstrations of Harvey, the Cardiology Patient Simulator, residents were taught to recognize characteristic findings based on timing, location, intensity, duration, frequency, shape, quality, and variation with respiration.

Pre-test and post-test assessments measured residents' ability to identify 12 important heart sounds and murmurs correctly based solely on auscultation. The results were striking—overall identification scores increased from 27.44% to 39.08%, representing a 42% improvement in diagnostic accuracy (p<0.001). Particularly notable improvements occurred in identifying innocent murmurs (24% to 52%), mitral regurgitation (26% to 47%), and S3 gallop sounds (14% to 31%).

The researchers acknowledged limitations—their single-center design with a relatively short intervention (seven hours over seven months) and the test-taker's inability to perform a physical exam during the assessment. Nevertheless, their findings demonstrate that virtual simulation is viable for enhancing auscultatory skills when in-person bedside teaching is limited.

This research offers clinical educators a practical avenue to support skill development. While virtual simulation cannot replace hands-on bedside teaching, it offers a vital supplementary method for maintaining and enhancing this fundamental clinical skill when direct patient contact is limited. This approach aligns with growing evidence that simulation-based education effectively develops auscultation proficiency when structured with clear learning objectives and opportunities for guided practice.

As traditional auscultation skills face concerning trends, innovative wearable technology approaches demonstrate promising capabilities. A groundbreaking study by <a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC11965935/" rel="nofollow">Baronetto et al. (2025)</a> explored how pattern-spotting algorithms can detect rare bowel sound events in continuous abdominal recordings using specialized "smart" clothing, with remarkable results for inflammatory bowel disease (IBD) detection.

The researchers equipped participants with the GastroDigitalShirt—a specialized garment embedding eight miniaturized microphones connected to a belt-worn computer—positioned according to a nine-quadrant abdominal map. They collected approximately 281 hours of audio data from 24 patients with IBD (varying disease activity) and 21 healthy controls across different digestive phases. The audio was captured during fasting and post-meal periods, with the shirt's elastic fabric ensuring optimal sensor-skin contact.

The team developed a deep-learning-based audio pattern spotting algorithm (EffUNet) to identify bowel sound events and then extracted acoustic features from these sounds to build a gradient boosting classifier. Cross-validation experiments yielded an impressive area under the receiver operating characteristic curve of ≥0.83 regardless of whether sounds were manually annotated or detected automatically. Particularly compelling was the finding that just 10 minutes of recorded bowel sounds provided sufficient data for accurate classification.

This approach offers notable advantages over conventional IBD diagnostic tools. It is non-invasive, relatively inexpensive, and can monitor gastrointestinal processes continuously without requiring repeated uncomfortable examinations. The technology signals a potential shift toward accessible screening tools that could identify IBD patterns before more invasive diagnostics become necessary, particularly valuable in telemedicine applications and remote patient monitoring.

For clinicians working with gastrointestinal conditions, this research suggests we may soon have additional tools that augment—rather than replace—the skills of auscultation. By combining the art of listening with advanced signal processing, we may develop approaches that extend our diagnostic capabilities beyond what either technology or human skill could achieve alone.

Though published in late 2024, the following study deserved an honorable mention in our Q1 2025 review due to its significant implications for pulmonary auscultation reliability. Pulmonary auscultation presents unique challenges, particularly in identifying subtle abnormal sounds. The study published in Primary Care Respiratory Medicine by <a href="https://pubmed.ncbi.nlm.nih.gov/39406795/" rel="nofollow">Huang et al. (2024)</a> examined the reliability of crackle identification, comparing the performance of physicians and artificial intelligence models using thousands of labeled breath sound files.

The study analyzed 11,532 breath sound recordings labeled by five physicians and six artificial intelligence breath sound interpretation models. After identifying 579 doubtful labels requiring further evaluation, the researchers established 305 final labels as their gold standard. The results revealed a striking difference in identification accuracy: for wheezing, both human physicians and AI demonstrated good sensitivities (89.5% vs. 86.0%) and specificities (96.4% vs. 95.2%). However, for crackles, while sensitivities remained high (93.9% vs. 80.3%), specificities were notably poor (56.6% vs. 65.9%).

This finding presents a significant clinical concern, as humans and AI systems frequently misclassify normal breath sounds as crackles. The authors concluded that "crackles remain unreliable for its low specificity, low inter-rater agreement, and potential for confusion with normal breath sounds." From a signal processing perspective, the challenges stem from crackles' ill-defined frequency ranges, shorter durations, and susceptibility to contamination by regular segments—essentially creating a lower signal-to-noise ratio than wheezes' more distinctive musical quality.

These findings align with other research showing limited agreement among respiratory physicians on the presence and changes of audible crackles, even in patients with fibrotic lung diseases, where these sounds are considered diagnostic hallmarks. Broader studies of lung auscultation have found an overall pooled sensitivity of just 37% across respiratory conditions, though specificity was better at 89%. This humbling reality reminds us that even skilled listening remains imperfect, with specific acoustic patterns continuing to challenge expert human ears and sophisticated algorithms.

For those of us who teach and practice auscultation, these results suggest we should exercise caution in diagnostic decisions based primarily on crackles. They remind us to consider auscultatory findings within the broader clinical context and to pursue additional confirmation when crackles are the primary finding. The study also highlights an area where technology and machine learning may need further refinement to overcome the natural limitations of human perception.

These studies collectively underscore what those at the bedside already know: auscultation matters. From early simulation training to innovative tools for emergency responders, deliberate practice shapes clinical confidence. The challenge of identifying complex sounds like crackles reminds us that this skill demands continual refinement.

One analysis notes, "Later and higher-pitched crackles often represent interstitial lung disease, whereas earlier and lower-pitched crackles tend more toward chronic obstructive lung disease." These nuanced distinctions matter for patients and require both acoustic sensitivity and clinical judgment to interpret.

At Apex, we understand both sides of this equation—providing precision-engineered instruments that deliver clarity without compromise while respecting the human expertise that interprets each sound. Your stethoscope remains the bridge between technology and touch, science and intuition, sound and certainty.

The research highlighted in this quarterly review reveals both challenges and opportunities in the realm of auscultation. We face declining proficiency among trainees yet see promising results from early simulation training. We witness the limitations of human perception in identifying crackles yet find innovative technologies that may extend our capabilities in new directions.

Amid the technological advances of modern medicine, the stethoscope remains an essential tool—not as a relic of tradition but as an instrument of immediate, accessible, and invaluable clinical assessment. The studies we have reviewed suggest that by combining deliberate skill development with technological innovation, we may strengthen rather than diminish the art and science of auscultation.

Your hands hold both legacy and future—a stethoscope tuned for clarity and the judgment to know what each sound means for the person in your care. At Apex, we remain committed to supporting that critical connection where sound becomes certainty.

This article highlights recent research findings and is intended for informational purposes. For detailed study methodologies, please refer to the original publications.