Course Director's Guide to the Professional Skill Builder

The Professional Skill Builder (PSB) has been designed to give students in the health sciences an opportunity to practice their cognitive cardiovascular and pulmonary skills conveniently. Like a batting cage in baseball, it allows the learner to practice his/her skill with the help of a coach. A skill by definition is learned only by practice with expert guidance. The PSB provides both.

The overriding objective of the PSB is to improve learner confidence in their observational and interpretive skills through practice.

The PSB requires no classroom time and can be accessed by the learner anywhere any time. It is not intended to replace any part of the curriculum and certainly not direct interaction with patients. On the other hand, all of the simulated case problems in the PSB are authentic; they are realistically presented, and the mentors are academic cardiologists and pulmonologists.

There are over sixty long and short cases and exercises in the PSB. There is also a “Toolbox” which provides the learner with crucial “Just-in-Time” factual information when needed. The over-all content is divided into three levels of complexity:

  • Level I - A supplement to an introductory course in clinical skills.
  • Level II - Short (five minute) clinical problems designed to augment specific cardiology and pulmonary lectures and at the same time give the learner the opportunity to practice their observational skills.  (Bring the patient into the classroom).
  • Level III - Advanced cases and exercises designed to augment the learner's clinical experience and to insure the opportunity for one-on-one contact with some important clinical problems which might not be available  during their clerkship or senior medical rotations in a tertiary medical center.

You may select any or all of these clinical tutorials to reinforce your course, clerkship or specialty rotation. Student access to the PSB can be easily provided. IMPORTANT: Please advise your learners to use headphones or earbuds when listening to the heart and lung sounds used in this program.

Twenty years of experience with the PSB at the University of Michigan has shown conclusively that in order for it to be effective, the PSB cases and exercises selected by the course director must be made a required part of the course curriculum. Learner use can be easily tracked. Skill proficiency assessments are available for Levels II and III.

Level I

Level I is a supplement to an introductory course in clinical skills. Its most important contribution is a tutorial on cardiac auscultation which is designed to imprint eight basic sound cadences permanently into the learner's fast, (automatic), thinking. This is achieved by means of repetition in the Heart Sound Challenge.

The other components include:

  • Introduction to the directed CV physical exam which includes not only the methods of examination, but also what one is looking for and why.
  • The technique of two-handed palpation of the apex impulse
  • Two basic science correlations
    • The physiologic basis for the normal jugular pulse
    • The physiologic basis for transient splitting of S2
  • Five very simple practice cases are included which demonstrate the application of the sound cadences which have been mastered by means of the Heart Sound Challenge.

Level II

The objectives of the level II PSB tutorials are:

  • To augment cardiovascular and pulmonary didactic presentations by allowing learners at the same time to review short examples of related clinical problems. (Bring the clinic into the classroom). At the same time, these case reviews provide the learners with an opportunity to practice their cardiac and pulmonary auscultatory skills.
  • To allow the learner to audit a faculty expert taking a history from a patient with a common clinical problem; for example neuro-cardiogenic syncope.
  • To provide the learner with a Heart Sound and Murmur Library which can be downloaded to any mobile device and accessed when needed in the clinical setting.

There are twenty short (ten minute) cardiac cases in level II. Topics include:

  • CAD with a normal physical examination and a normal resting ECG
  • MR due to coronary artery disease
  • Physiologic S3
  • S4 due to LVH
  • Acute mitral regurgitation due to chordal rupture
  • Mid-systolic click due to mitral valve prolapse
  • Aortic regurgitation due to a bicuspid aortic valve
  • Mitral regurgitation with infective endocarditis
  • Aortic stenosis
  • Atrial septal defect
  • Anterior myocardial infarction
  • Ventricular septal defect
  • Mitral valve prolapse with mitral regurgitation
  • Hypertrophic cardiomyopathy
  • Mitral stenosis
  • Inferior myocardial infarction with ruptured septum
  • Normal splitting of S1
  • Aortic regurgitation due to dissection of the ascending aorta
  • Aortic stenosis with atrial fibrillation
  • Dilated cardiomyopathy

There are also four short (fifteen minute) pulmonary cases which deal with a chief complaint of chronic cough. Topics include:

  • Drug-induced cough
  • Cough due to gastroesophageal reflux disease
  • Sarcoidosis
  • Bronchiectasis

The history tutorials are called “Roadmaps”. Although they are designed primarily to allow the learner to audit an expert taking a medical history from a patient with an important clinical problem, they are also interactive and contain much helpful factual information. Topics include:

  • Syncope
    • Neuro-cardiogenic
    • Orthostatic
    • Bradycardia (AV Block)
    • VT
  • Chest Pain
    • Angina
    • GERD
    • Pulmonary Embolus
    • Pericarditis
  • Palpitation
    • SVT
    • Panic Attack
    • Atrial Fibrillation
    • PVCs

The two basic science correlations deal with:

  • The physiologic basis for normal splitting of S2 with inspiration
  • The physiologic basis for the effects of the Valsalva maneuver

The Heart Sound and Murmur Library presents twenty three important sound abnormalities and murmurs along with the position of the patient, the location on the chest where they are heard, and the end piece used.

Level III

The objectives of the level III tutorials are:

  • To provide an opportunity for the learner to have one-on-one contact with some important cardiac and pulmonary problems which might not have been available for work up during their third year internal medicine clerkship or their specialty rotations.
  • To provide the learner with a way to practice ECG interpretation as applied to specific clinical problems.
  • To allow the learner to audit a faculty expert taking a history from a patient with an important clinical problem. This is the same series which is available in Level II.
  • To allow the learner to review three basic science correlations.
  • To allow the learner to down load the Heart Sound and Murmur Library to a mobile device.

Exit interviews of graduating students at the University of Michigan Medical School have shown that a substantial percentage did not have an opportunity to evaluate and examine patients with a number of very common cardiac and pulmonary disorders, such as innocent murmurs in competitive athletes, panic attacks, mitral valve prolapse, community-acquired pneumonia etc. Level III PSB was initially created to give third and fourth year students a chance to “fill in the gaps” with a series of realistic computer-based simulations of authentic cases using academic specialists as mentors. Level III PSB now includes ten cardiac and five pulmonary disorders which learners might not have had the chance to evaluate one-on-one during their clinical years. These cases are far more comprehensive than level II cases. Chest radiographs and ECGs are included, and the appropriate selection of complex technology is required. Clinical decisions are often requested.

Topics include:

  • Aortic stenosis with CAD
  • Asymptomatic mitral regurgitation
  • Atrial fibrillation in a patient with stable coronary disease
  • Panic attack
  • Cardiovascular evaluation of the athlete
  • CHF due to diastolic dysfunction
  • Aortic regurgitation
  • Mitral valve prolapse with mitral regurgitation
  • Hypertrophic Cardiomyopathy
  • CHF due to systolic dysfunction
  • Cough-variant asthma
  • Acute pulmonary embolus
  • Acute viral bronchitis
  • Community acquired pneumonia with plural effusion
  • COPD

There is also a series of eleven clinical ECG problems along with sixty practice ECGs.

The twelve history roadmaps from level II are again made available.

Three basic science correlations are also included:

  • The physiologic basis for the Frank-Starling Principle
  • The physiologic basis for the prompt squatting maneuver
  • And again the physiologic changes occurring with the Valsalva Maneuver

The Sound and Murmur Bank from level II is also available.