To the Editor: Reilly et al draw attention to the lack of research on the impact of the findings of physical examination on patient care, and state that, in the United States, many doctors “do not know how to do it, and do not see why they should”.1 Should we continue to teach these skills in Australia?

Experience tells us, even if research does not, that the presence or absence of one or more physical findings may make a crucial difference to patient care. The important thing for teachers is that, while students learn the rituals, we should encourage them to think critically about what they are doing. They focus on passing the next objective structured clinical examination (OSCE), which often requires them to carry out a ritual. They are vaguely aware they will be required to think selectively about real patients and the necessity to make a diagnosis, but have little practice in selecting appropriate physical examination. We who teach them should formally recognise the distinction between ability to perform and ability to choose and interpret physical signs.

I learned an inductive process: take a history and perform a complete examination, and then engage the brain. Research would not tolerate such a “fishing trip”! The inductive method has been replaced by a hypothetico-deductive approach. This is criticised, but all doctors take intelligently selected short cuts. We should acknowledge this and critically examine the skill.

Students must learn systematic examination. This is the repertoire from which they choose when faced with a clinical problem. OSCEs early in the undergraduate course should assess their competence in this, and students should know exactly what they are to do. Our bedside clinical teaching and later OSCEs should explicitly challenge students to consider the selection of relevant clinical examination required in the light of the history, just as they should consider the value of all other tests, rather than using a blunderbuss approach.

Together, history and physical examination have two objectives. One is diagnosis; the other defines or excludes comorbidity. Without them, medical care cannot begin to function effectively or economically.

Neither I nor your authors are bewitched; their anecdotes make this clear, and they define the reasons for the lack of research. A focus on considering what can, and cannot, be gained by selective physical examination should reduce our own and our students’ bother and bewilderment.