Clinical examination: evidence and eminence

We introduce a new MJA series outlining essential clinical skills for generalists, doctors in training and medical students

All clinicians and medical students are excited when they make a diagnosis from taking a patient’s history or after a physical examination. Most diagnoses can be made by taking a full history followed by targeted clinical examination.2 If and when necessary, this can be followed by appropriate cost-effective investigations. A targeted and thorough physical examination can avoid the ordering of inappropriate tests that return results that are very difficult or impossible to interpret. Inappropriate tests often lead to further tests to try to clarify unexpected (and usually false-positive) results. In the past, investigations used to follow and complement, rather than replace, clinical examination.

We need to bring this philosophy back to medicine to save costs and connect with our patients. For example, if you hear a systolic murmur at the apex and are not sure whether it results from aortic stenosis or mitral regurgitation, by all means confirm the diagnosis with an echocardiogram. But be sure to refine your clinical acumen. For example, if you thought it was mitral regurgitation but the echocardiogram reported aortic stenosis, this is your opportunity to improve your clinical skills.

While the uninitiated may think investigations lessen the importance of clinical skills, good history taking and physical examination is the way to gain patients’ confidence and connect with them.3

Reliability and accuracy are two separate entities in a clinical examination. Reliability is how two clinicians agree on a finding, yet they may both be inaccurate when objectively assessed.4 Some physical signs were described decades ago, when disease patterns and population characteristics were different. Could some of these signs be obsolete now? What is the evidence base in 2016?

As David Sacket, a pioneer of evidence-based medicine, observed, there are many reasons for paucity of evidence in clinical examination.5 Sackett identified several reasons for this problem: the challenges of designing and undertaking studies of physical examination; the difficulty of analysing a single sign when a diagnosis is made up of constellations of symptoms and signs; academic staff showing little inclination to investigate the physical examination as they spend little time at the bedside; the realities and pressures of modern medicine discouraging a careful history and physical examination; and the unpopularity of research when it challenges authority and the “art of medicine”.5 The reduction of length of stay and teaching being mainly confined to tertiary hospitals are other modern problems.

When there is no evidence, what should the physician do?6 For example, should we still percuss the cardiac border for a pericardial effusion in an obese patient when we could get an echo in a few minutes? Is the ankle jerk absent because of poor technique or peripheral neuropathy? What is the best way to elicit shifting dullness during ward rounds to avoid the shifting dullness of ward rounds (from patient to patient)?

This MJA medical education series will outline some essential clinical skills for generalists, doctors in training and medical students. As series editors, we will invite eminent clinicians to write about clinical skills that are important but poorly done and to evaluate the current clinical relevance of those skills. The series begins with some common topics. We will be very interested to receive your feedback about the skills you think are important.

Along with Sapira,7 we believe that history taking and physical examination are an art and a science. This MJA series is for people “who consider medicine to be a human and humane endeavour, not an industry”.7 We are passionate about bringing the art and science back to clinical teaching. We hope that many of you are too.