—Dr Nadoolman suggests that the simple detection of an auscultatory abnormality (without being able to better define it) might be sufficient. We disagree. First, it is not so easy to detect that "something is wrong" (many of our findings were missed entirely). Moreover, an acoustic event per se may not necessarily require much workup. For example, many systolic murmurs are benign. As Frye1 noted, the extraordinary increase in use of echocardiography "reflects a growing dependence on sophisticated imaging technology, even in settings where obtaining a thorough history, physical examination, chest x-ray film and electrocardiogram may suffice for clinical decision making."Dr Lewis argues that Butterworth and Reppert used different methods than ours, that physicians' ability to recognize recorded sounds may correlate poorly with bedside skills, and that subtracting clinical history from physical examination eliminates an important guidance. These are all valid points, and we did acknowledge them in our article.
Mangione S, Nieman LZ. Cardiac Auscultations Skills of Physicians in Training-Reply. JAMA. 1997;278(21):1741. doi:10.1001/jama.1997.03550210039027