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During 2007, multimedia-based presentations of selected clinical findings were introduced into the United States Medical Licensing Examination. This study investigated the impact of presenting cardiac auscultation findings in multimedia versus text format on item characteristics.Content-matched versions of 43 Step 1 and 51 Step 2 Clinical Knowledge (CK) multiple-choice questions describing common pediatric and adult clinical presentations were administered in unscored sections of Step 1 and Step 2 CK. For multimedia versions, examinees used headphones to listen to the heart on a simulated chest while watching video showing associated chest and neck vein movements. Text versions described auscultation findings using standard medical terminology.Analyses of item responses for first-time examinees from U.S./Canadian and international medical schools indicated that multimedia items were significantly more difficult than matched text versions, were less discriminating, and required more testing time.Examinees can more readily interpret auscultation findings described in text using standard terminology than those same findings presented in a more authentic multimedia format. The impact on examinee performance and item characteristics is substantial.