CLINICAL EXAMINATION - Europe PMC

TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION, VOL. 113, 2002

CLINICAL EXAMINATION: STILL A TOOL FOR OUR TIMES? JACK ENDE and (by invitation) KEVIN M. FOSNOCHT PHILADELPHIA, PENNSYLVANIA

ABSTRACT Physical diagnosis, as an integral part of the diagnostic process and as a central component of the physician-patient relationship, is at a crossroad. Technology offers a more sophisticated and, in many instances, more accurate solution to diagnostic problems, while evidence mounts suggesting that students' and residents' physical diagnosis skills are inadequate. For several reasons, however, physical diagnosis must remain a core skill for clinicians, particularly for those who practice in outpatient settings. Recent literature critically appraising specific physical diagnosis maneuvers has identified the components of physical exam that are well worth learning and using, as well as the specific clinical conditions in which physical exam can and should play a central diagnostic role. Interestingly, critical appraisal of physical diagnosis also underscores the importance of proper technique. Thus, physical examination now can be approached as a science, based upon sound evidence, and as an art as well.

INTRODUCTION A few decades ago the symbol of the physician was the head mirror. More recently it was the stethoscope. The message was the same: physicians examined patients, and examined them well. Or so it was. Today's physicians, and the medical profession as a whole, are symbolized by technology. Television commercials advertising medical centers rarely include scenes of physicians sitting at the bedside, examining a patient for jugular venous distention or checking for clubbing. Instead, they highlight technology, with scenes from the cardiac catheterization laboratory or the CT radiology suite. The impact of technology, of course, has been more than symbolic (1). Over the past 50 years, and certainly since the 1980's technology has changed how medicine is practiced. Much of that change has been enormously beneficial. When Buerger (2) described the physical findJack Ende, M.D., Department of Medicine, Presbyterian Medical Center, University of Pennsylvania Health System, 39th & Market Streets, Philadelphia, Pennsylvania 19104-2699; Phone: 215-662-8989; Fax: 215-243-3208; e-mail: [email protected]. 137

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ings of peripheral vascular disease, or when Homans (3) described the physical findings of venous thrombosis, few modalities for making the correct diagnosis other than careful physical examination at the bedside were available. Today, however, a suspicion of vascular insufficiency based upon blanching with elevation can be confirmed (or excluded) by sophisticated technologies for measuring blood flow and arterial caliber, while the diagnosis of deep vein thrombosis based upon pain behind the knee upon dorsiflexion of the foot can be validated (or refuted) with compression ultrasonography and contrast venography. These and similarly sophisticated approaches to diagnosis have revolutionized medical practice, which is as it should be. The diagnostic armamentarium available to modern clinicians has improved immeasurably, and the accuracy of diagnosis and prognosis has risen accordingly. Technology saves lives, decreases morbidity, and spares patients unnecessary invasive procedures such as exploratory laparotomy. At the same time, while accelerating the cost of medical care (1), technology also has altered the diagnostic process fundamentally. Technology has not just substituted more precise and accurate tests for those that are less reliable or valid, it has changed how patients are approached. In their introduction to the Rational Clinical Examination series in the Journal of the American Medical Association, Sackett and Rennie (4) describe a senior gastroenterologist who was asked to consult on a patient with abdominal pain. The case presentation to the consultant included a rather long and weighty list of endoscopic, radiologic and biochemical tests that already had been performed. Hearing the full presentation the senior consultant responded, "All that there is left for us to do is a history and physical."

Physical Examination in Today's Teaching Hospital In no other venue of medical practice has the reliance upon technologic diagnosis become more entrenched than in the teaching hospital. That, of course, is not surprising; nor is the reliance upon technology the only force that has changed how medicine is practiced in academic medical centers, and how it is taught. In concert with the ascendancy of technology, there has been a decline in the presence of the teaching clinician at the bedside. Ken Ludmerer's recent book (5) explains why bedside teachers have become so scarce; while others (6) including Louis Thomas (7), provide an historical context. Thomas, who was a medical student in the 1940's, contrasts his own experience with that of students of the 1980's, as portrayed in Melvin Konner's book, On

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Becoming a Medical Student. "The biggest difference", Thomas writes, "between Konner's clerkship in 1983-84 and those of the students I remember from earlier decades-all the way back to my own third year at Harvard-seems to be the near absence of senior physicians. As I recall, they were nearly always at hand, in and out of the wards, making rounds at all hours, displaying for the students' benefit the complete repertoire of seasoned highly skilled doctors. Where on earth were these people in Konner's Harvard? . .. these professors [these days] are elsewhere, trying to allocate their time between writing out their research grants (someone has estimated that 30% of the medical school faculty's waking hours must be spent composing grant applications), doing or at least supervising the research in their laboratories, seeing their own patients and worrying continually about tenure (and parking)." Physicians of Konner's generation are now in the 'prime' of their academic lives and to a large extent responsible for the clinical education of our students and house officers. They are the teachers of today, while their students will be the teachers of tomorrow. Concerns about the declining level of bedside skills among students, residents and younger faculty can be heard from several sources (8-10). In fact, the profession may be reaching a point of no return beyond which generations of physicians will enter the practice of medicine with substandard physical examination skills. While every medical school provides formal instruction in physical diagnosis, the outcome of this instruction, particularly when tested at the residency level, is disturbing. Mangione and Nieman (11) reported that internal medicine and family medicine residents correctly identified only 20% of cardiac sounds and murmurs, even when tested in ideal settings, using recordings and listening to each event for a minute and a half. Similar findings are reported elsewhere (12).

Developing the Case for Physical Examination Although reports such as these have been made in the past (13), there is a now a more general impression that bedside skills are declining. Concern has been expressed within the profession and in the lay press as well (14). But perhaps the question that is more important than, Are bedside skills declining, and even more important than, What can be done to arrest this decline, is the question, Should anything be done at all. Perhaps, as some have suggested, the era of auscultation (and bedside examination in general) is over, and the era of echocardiography (and similar technology) has arrived. That, of

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course, is not necessarily bad. Perhaps bedside exam should be set aside and clinical examination be redefined to include principally technologic assessment. Is physical examination worth saving? Or more to the point, if it goes away completely, what would be lost? The downside of medical practice in which physical examination is relegated to a minimal role can be assessed along several parameters. First, as already mentioned, would be the symbolic loss. That loss, however, is just what it is: symbolic, and should not matter much at all. Next, and recently the subject of some research, is the importance of physical diagnosis in meeting the needs and expectations of patients, while enhancing the physician-patient relationship (15). A recent publication (16) associated patient dissatisfaction with doctors' failure to perform an adequate examination. When asked to explain why he was dissatisfied with an office physician, one patient commented, "He didn't touch me. I have been having symptoms of dizziness and everything. He came in and talked to me and that was all. He didn't listen to my heart, my lungs, or anything." Another patient noted, "He didn't look in my eyes, my fingernails, he didn't check my temperature. Hell, I'm 68-years old and things can happen." The laying on of hands, it seems, still matters, at least in the opinion of the public.

Assessing the Evidence for Physical Examination: From Art to Science But that is not to imply that a technological approach to medicine is necessarily at odds with empathetic medical practice, or with establishing beneficial relationships with patients. A physician might order an echocardiogram and then spend more time with the patient explaining the results than otherwise he might if he had taken precious minutes to auscultate the patient's heart. Technology and empathy are not mutually exclusive. And so the key parameter by which the value of physical examination-and, therefore, its appropriateness within the context of a highly technologic profession-is its measurable utility in identifying the correct diagnosis. A physical exam maneuver should be assessed as we assess any diagnostic test, based upon its reliability, accuracy and diagnostic value. Physical diagnosis should be assessed based upon sound evidence. "There is a science to the art of medicine", Sackett and Rennie (4) write. "The rational evaluation of a symptom or sign in today's patient", they continue, "demands our critical appraisal of how this finding has behaved previously among groups of patients with the same differential diagnosis." These and other recent contributors to


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the growing body of literature on physical examination challenge us to appraise critically the operating characteristics of a physical diagnosis maneuver or test with the same rigor we apply to the critical appraisal of technology. The value of physical diagnosis cannot be assessed as a field or a genre any more than the value of radiology or non-invasive cardiology can be measured. Each physical exam finding (e.g. the JVP, the S3) should be assessed individually in the context of specific clinical questions (e.g. Is this patient in heart failure?). The recent literature of physical diagnosis supports a selective and quantitative approach to physical examination, one in which each finding can be viewed as a test, and its utility expressed in terms of precision and accuracy. Precision, or inter-rater agreement, measures variation between two examiners across a study population. Accuracy is assessed in terms of sensitivity and specificity. These are familiar concepts. Sensitivity measures how often a test is positive when a disorder is present, while specificity measures how often a test will be negative when a disorder is not present. The predictive value of a physical exam finding follows from Bayes Theorem, accounting for disease prevalence, and expresses the probability that a patient has or does not have a disorder if the finding is present or absent, respectively. However, the calculation of predictive value can be complex and cumbersome, and it changes depending on the prevalence of the disorder. A faster and more powerful metric for describing the accuracy of a physical exam finding, and the convention used in much of the modern literature on the topic, is the likelihood ratio (17,18). Likelihood ratios can be positive or negative: a positive likelihood ratio expresses the likelihood of the presence of a physical finding in a patient with, as opposed to a patient without a specific disorder. A negative likelihood ratio expresses the likelihood of the absence of an exam finding in a patient with, as opposed to without, a specific disorder. Calculated from sensitivity and specificity, and therefore not dependent on disease prevalence, likelihood ratios can be used to increase or decrease the clinician's determination of the probability of disease. The greater the positive likelihood ratio the more powerful is the physical exam finding in establishing that the disease is present. Conversely, the smaller the negative likelihood ratio for a given finding, the less likely a disease is present. In general, more useful physical findings are those with positive likelihood ratios above 4 and negative likelihood ratios below 0.5. In using likelihood ratios, it is important to realize that probability and odds are not the same. Suppose, for example (Figure 1), you are asked to see a 70-year old man with dyspnea and a history of hyper-

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JACK ENDE Using likelihood ratios to determine the probability of congestive heart failure

(CHF), based on the finding of an S3 gallop

Given:

A 70 year-old man with dyspea, hypertension and coronary artery disease

Assume: Pre-test probability of CHF is .33 Then: Pre-test odds (positive/negative) of CHF is one out of two, or .5 Knowing that: The likelihood ratio of S3 is 6 Then: Post-test odds of CHF is .5 x 6, or 3 So: Post-test probability (odds/l+ odds) of CHF is 3/4, or .75 FIG. 1. Actual likelihood ratio or S3 in CHF is 5.7 (see Ref. 18). Rounding to 6.0 was done to facilitate the calculation.

tension and coronary artery disease. In that population you might estimate the probability of congestive heart failure (CHF) to be .33. Odds (positives divided by negatives) is probability divided by 1-probability. In this case, .33/1-.33, or 0.5. Now suppose in this patient you hear an S3 gallop, a physical finding that has a likelihood ratio of 6.0 (18). The post-test odds of congestive heart failure if an S3 is present is 0.5 x 6, or 3. Probability equals odds divided by 1+ odds. This odds of 3:1 corresponds to a post-probability of 3/4 or .75. Admittedly, conversion back and forth between probability and odds can be burdensome. This step can be obviated by using the nomogram reproduced in Figure 2. As mentioned above, likelihood ratios are calculated from sensitivity and specificity but are superior to those measures for several reasons. First, likelihood ratios provide a single number that indicates the diagnostic power of a test. By comparing likelihood ratios of various physical examination maneuvers, clinicians can appreciate the diagnostic value of one vs. the others. And second, likelihood ratios allow clinicians to assess the diagnostic value of tests performed in series, one test after another, just as physical exam maneuvers are performed one after another. Assuming the physical findings are independent, i.e. typically arising from separate pathophysiologic mechanisms, such as an S3 gallop and edema as independent physical findings of congestive heart failure, the clinician can assess first the impact of one likelihood ratio upon the probability of disease, and then use that post-test probability as the pre-test probability when the second physical finding is applied. A second case will illustrate further how likelihood ratios can be


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Nomogram for determining probability from likelihood ratios

Pretest Probability

Likelihood Ratio

Posttest Probability

FIG. 2. Nomogram for determining probability from likelihood ratios. Legend: The clinician estimates the pre-test probability of the diagnosis, and then can align a straightedge across the likelihood ratio associated with the positive (or negative) physical diagnosis maneuver. Extending the straightedge to the axis or on the right will yield the post-test probability of the diagnosis. From Sackett DL. JAMA, (Ref. 17), with

permission.

used in actual clinical practice and how they distinguish the physical exam maneuvers that are most helpful. Suppose a 28-year old woman comes to a general internist's office for a routine examination. She reports that she is in good health but has been noticing a sense of fatigue with exertion. She has had two normal childbirths and reports menstrual bleeding that is a bit heavier then normal. The physician wonders about anemia and performs a physical examination.

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As shown in Table 1, not all physical exam findings of anemia are of a equivalent diagnostic utility. Recalling that positive likelihood ratios increase the probability of a diagnosis, the usefulness of conjunctival pallor to identify patients with anemia is quite apparent. The positive likelihood ratio for conjunctival pallor is 16.7, compared with the likelihood ratio of nail bed pallor, which is only 1.7. Assuming that the probability of anemia in a woman her age in the general population is 4%, and adjusting that pre-test probability to 20% based upon her gynecologic history and her history of fatigue. Even if her nail beds did seem pale (a physical finding with an LR of only 1.7), that finding will only increase the post-test probability of anemia to 28% (Figure 2). But if she had conjunctival pallor, which has a likelihood ratio of 16.7, that would increase the post-test probability to 80%. Of course a CBC, which will be the definitive test, can be done in either case. Often, however, we are dealing not with tests costing $10 but with tests costing in excess of thousands of dollars, and decisions that entail whether or not a patient should be hospitalized, surgery canceled, or other diagnoses pursued. For example, Fink et al (19) determined the clinical utility of specific heart exam findings in determining the significance of systolic murmurs. By applying the utility of these findings to the diagnostic decision making process, the authors concluded that nearly half of the echocardiograms that were ordered could have been omitted. From Science to Art This case illustrates how physical diagnosis can be assessed as a science, based on critical appraisal and evidence. But that is not to imply that physical examination is not an art, requiring experience and skill. Several points illustrated by this case of anemia are worth noting. First, as mentioned, certain physical exam findings are worth seeking while others are not. Second, the post-test probability depends upon the pre-test probability, so the clinician's assessment remains paramount. And third, and most important for our discussion here, but TABLE 1 Physical Exam Findings of Anemia Positive LR Finding 1.7 Nail bed pallor 2.5 Palmar pallor 16.7 Conjunctival rim pallor Abbreviation: LR, likelihood ratio. Adapted from McGee (Ref. 18), with permission.

Negative LR 0.6 0.5 0.6


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not always emphasized even in the recent literature on the value of physical examination, is that the powerful likelihood ratios associated with certain physical exam findings depend upon the examiner's skill. For example, how does one detect conjunctival pallor? It is not by arriving at a vague sense that the conjunctiva look pale. Rather it is by knowing that in a normal person without anemia the anterior rim of the palpebral conjunctiva has a bright red color that contrasts that with the pale color of the posterior portion (Figure 3). In a patient with a hemoglobin less than 11 grams per dl, the anterior rim has the same pale fleshy color as the posterior aspect. The study from which the likelihood ratio of 16.7 was derived (20) used trained physicians who were taught how conjunctival pallor should be detected. Recall that likelihood ratios are calculated from sensitivity and specificity; like all tests, they are operator dependent. As shown in Table 2, likelihood ratios will vary as a function of the examiner's skill. The sensitivity and specificity of detecting IHSS based upon the Valsalva maneuver (21), for example, will likely differ among groups, based upon experience and skill; and so the likelihood ratio, i.e., the discriminating value of the test differs as well. The message here is clear: unless we teach our students well, physical diagnosis can be an exercise in frustration rather than a way to make an educated decision about the likelihood of a disease and the need for more costly and definitive tests. That is one point: that the power of physical diagnosis varies based upon the examiner's skill. The other point, which can be seen from Table 3, is that not only are certain physical diagnosis maneuvers more useful in detecting a particular disease than others, but that there are diseases that are amenable to bedside diagnosis, and there are diseases that are not. The range of conditions, as McGee (18) has pointed out, includes disorders like stroke in which the physical exam is the

FIG. 3. Features of conjunctival pallor. Legend: In the anemic patient (left) the anterior rim of the conjunctiva is as pale as the posterior aspect, while in the normal subject (right) the anterior conjunctival rim is more red. Reprinted from Sheth, et al. (21), with permission.

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TABLE 2 Effect of Examiners' Levels of Skill Upon the Likelihood Ratio for Detection of IHSS Using the Valsalva Maneuver Positive LR Group Sensitivity Specificity 16.2 .96 Cardiologists* .65 Hypothetical Group A** .60 .90 6.0 3.3 Hypothetical Group B** .50 .85 * Ref (22). ** Hypothetical adjustment if examiners were less able to achieve the sensitivity and specificity of the expert cardiologists. Positive LR's, which are calculated from sensitivity and specificity are derived from the formula LR = sensitivity/i - specificity. Note the effect of the

examiners' level of skill upon the likelihood ratio for the physical diagnosis maneuver. Abbreviation: LR, likelihood ratio; IHSS, idiopathic hypertrophic subaortic stenosis. TABLE 3 The Variation in the Utility of Physical Findings for Diagnosing a Specific Disease, e.g. Peripheral Vascular Disease; and the Differences in the Utility of Physical Diagnosis for Certain Diseases, e.g. Peripheral Vascular Disease vs. Deep Venous Thrombosis

Peripheral Vascular Disease Finding Loss of hair Capillary refill >15 sec Asymmetrically cold Absent femoral pulse Absent foot pulses (both)

Positive LR 1.7 1.9 6.1 6.1 14.9

Negative LR NS NS 0.9 NS 0.3

Deep Venous Thrombosis

Finding Asymmetric calf swelling 2 cm difference Superficial venous dilatation Tendemness Palpable cord Homan's sign

Positive LR 2.1

Negative LR 0.6

1.9 1.4 NS NS

NS NS NS NS

Abbreviation: LR, likelihood ratio. Adapted from McGee (Ref. 18), with permission.

gold standard: a patient who presents with a stroke and has a negative CT scan still has a stroke. But the range also includes diseases in which physical diagnosis has little or no role. For example, in a patient expected of having peripheral vascular disease certain physical findings can be quite useful in ruling the disorder out; while in a patient suspected of having deep venous thrombosis, physical exam offers little or no help.


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CONCLUSIONS AND RECOMMENDATIONS What then is the value of physical exam in the diagnostic process? When based upon findings of demonstrated diagnostic utility, physical examination can be extremely helpful: it allows the clinician to make intelligent decisions about the next diagnostic steps. Sapira (22), in his paper entitled, "Why Perform a Routine History and Physical Examination?" reminds us that there are two kinds of data. The first type of data allow us to generate hypotheses and the second type of data to test them. At a minimum, physical examination is without equal in generating and refining hypotheses that then can be tested. Can it replace more sophisticated methods for establishing a diagnosis? No. But it orients us to the right diagnosis; and in settings in which patients present with unspecified problems, and in which technology is not appropriate either because of availability or cost, physical examination remains a key part of the diagnostic process. The next decade is likely to determine whether physical diagnosis remains central to the practice of medicine (8). On the one hand physicians now have access to an emerging body of literature that selectively validates specific components of the physical exam. On the other hand there is disturbing evidence suggesting a declining level of competence in physical diagnosis among our students and residents (the teachers of tomorrow) as well as among our younger faculty. Should physical diagnosis give way to diagnosis based principally on technology? Several points should be considered. First, technology is unlikely to replace physical examination for the office-based practitioner. Interestingly, studies contrasting "preparation" vs. "practice" (23) rate physical exam skills as among the most important lessons that should be learned during residency training. Second, society cannot continue to expend more and more resources on technology (1); there just is not enough money to go around. Physicians need to be selective in ordering tests and procedures, using physical exam findings to suggest that the likelihood of a disease is high, in which case expensive tests are appropriate. And physicians need "stop rules" (8) that is, negative physical exam findings that correlate with a likelihood of disease that is so low that costly tests can be omitted. And, third, patients expect to be examined. Although we cannot quantify the therapeutic value of touching, we can think of few ways to more directly meet a patient's expectations than through a comprehensive physical exam, nor a more certain way to leave a patient wondering about his new physician's competence than with an examination that is cursory or absent. Recent literature has brought bedside diagnosis into the evidence-

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based era, while helping to separate physical exam findings that should be learned from those that can be discarded. There now are several new methods including electronic simulation, CD-Rom programs and both static and virtual models from which physical exam can be learned. These methods, however, have been available for over a decade; yet students today seem no more prepared in physical diagnosis at the bedside than did their recent predecessors (24). Clearly more needs to be done, and we close with several suggestions: Physical exam should be taught as an art but also as a science, and not just in physical diagnosis courses in the second year of medical school, but as part of the knowledge transmitted during pathophysiology courses and as part of the curriculum of the undergraduate clinical and postgraduate residency training years. Instruction in physical examination can be an opportunity to synthesize much of what has been learned in other branches in the curriculum. It can be used to review important elements of anatomy and pathophysiology, and its operating characteristics function well as exemplars of evidence-based medicine. Many medical schools and residency programs have implemented back-to-the-sciences courses and clinical epidemiology modules for the third and fourth year curriculum, and for postgraduate training as well. Physical examination can bring this together. Teaching without testing, however, is unlikely to be successful. Accordingly, more needs to be done along the lines currently being pursued by the Educational Commission on Foreign Medical Graduates and the National Board of Medical Examiners, which are including clinical skills assessment as necessary steps in the undergraduate medical education process. In the graduate medical education process, particularly in internal medicine, the American Board of Internal Medicine transfers responsibility for guaranteeing proficiency in physical examination to the residency program directors. For the most part, residents' skills in physical exam is not tested or observed (25); nor is it part of the Board certification process other than through the Board's Clinical Evaluation Exercise, which seems insufficient for something as important as bedside skills. The content of this instruction and evaluation needs to be more selective. The curriculum is crowed; there is much to learn. Time should not be wasted teaching signs and maneuvers that have been shown to add little to the diagnostic process (8,18). Inaccurate findings dampen learners' commitment to mastering the findings that are accurate, and leave learners and younger clinicians with the impression that physical examination as a whole should be placed on the shelf.


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That might be true for certain aspects of physical exam but it certainly is not for most of it. And lastly, today's clinical teachers must appreciate that the most potent tool for teaching lies with themselves, as role models (26). Physical exam needs to be taught at the bedside by teachers committed to the science as well as the art of clinical examination. How can teachers improve? The answer lies with giving physical exam the same attention that more typically is given to other aspects of continuing medical education. Physical exam is not an historical relic. It is an evolving science, one which incorporates much of the art of medicine, but also its scientific basis as well. We need to learn it and keep it alive, and through our research and scholarships enable it to grow.

REFERENCES 1. Heffler S, Levit K, Smith S, et al. Health Spending Up in 1999; Faster Growth Expected in the Future. Health Affairs 2001;20(2):193-203. 2. Buerger L. The Circulatory Disturbances of the Extremities: Including Gangrene, Vasomotor and Trophic Changes. Philadelphia: WB Saunders; 1924. 3. Moses WR. The early diagnosis of phlebothrombosis. N Engl J Med 1946;234:288-291. 4. Sackett DL, Rennie D. The science of the art of the clinical examination. JAMA 1992;267:2650-2652. 5. Ludmerer K. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York, NY: Oxford University Press; 1999. 6. Huddle TS, Ende J. Osler's clinical clerkship: origins and interpretations. Journal of the History of Medicine and Allied Sciences 1994;49:483-503. 7. Thomas L. What doctors don't know. New York Review of Books 1987 (24 September): 6-11. 8. Mangione S, Peitzman SJ. Physical diagnosis in the 1990s: art or artifact. JGIM 1996;11:490-493. 9. Fletcher RH, Fletcher SW. Has medicine outgrown physical diagnosis? Ann Int Med 1992;117:786-787. 10. Craige E. Should auscultation be rehabilitated? N Engl J Med 1988;318:1611-1613. 11. Mangione S, Nieman LZ. Cardiac auscultatory skill of internal medicine and family practice trainees. JAMA 1997;278:717-722. 12. St. Clair EW, Oddone EZ, Waugh RA, Corey GR, Feussner JR. Assessing housestaff diagnostic skills using a cardiology patient simulator. Ann Int Med 1992;117:751756. 13. Weiner S, Nathanson M. Physical examination: frequently observed errors. JAMA 1976;236:852-855. 14. Zuger A. Are doctors losing touch with hands-on medicine? July 13, 1999. NY Times. 15. Baldwin JG Jr. The healing touch. Am J Med 1986;80:1. 16. Kravitz R. Patients' perceptions of omitted examinations and tests. J Gen Intern Med 2000;15:38-45. 17. Sackett DL. A primer on the precision and accuracy of the clinical examination. JAMA 1992;267:2638-2644. 18. McGee S. Evidence-Based Physical Diagnosis. Philadelphia: W.B. Saunders Co; 2001. 19. Fink JC, Schmid CH, Selker HP. A decision aid for referring patients with systolic

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murmurs for echocardiography. J Gen Intern Med 1994;9:479-484. 20. Sheth TN, Choudry NK, Bowes M, Detsky AS. The relation of conjunctival pallor to the presence of anemia. JGIM 1997;12:102-106. 21. Lembo NJ, Dell'Italia LJ, Crawford MH, O'Rourke RA. Bedside diagnosis of systolic murmurs. N. Engl J Med 1988;318:1572-1578. 22. Sapira JD. Why perform a routine history and physical examination? Southern Med J 1989;82:364-365. 23. Kern DC, Parrino TA, Korst DR. The lasting value of clinical skills. JAMA 1985;254:70-76. 24. Ortiz-Neu C, Walters CA, Tenenbaum J, Colliver JA, Schmidt HJ. Error patterns of 3rd year medical students on the cardiovascular physical examination. Teaching and Learning in Medicine 2001;13:161-166. 25. Adolph RJ. In defense of the stethoscope. Chest 1998;114:1235-1236. 26. Ende J. What if Osler were one of us? Inpatient teaching today. JGIM 1997;12(supp2):S41-S48.

DISCUSSION Spivak, Baltimore: I greatly enjoyed the presentation and the concept of physical diagnosis now being subject to quantitative verification. I am totally for this, but I do find it a paradox. For example, I was looking through medical journals recently, trying to decide where I should submit a paper that contained case histories. But if you look in the leading medical journals, such as the Annals of Internal Medicine, the New England Journal of Medicine, the Lancet, or the American Journal of Medicine, virtually every clinical article published that involves internal medicine has no description of the histories or the physical examination of the patients being described. The case history has essentially disappeared from almost every medical journal with which I'm familiar with exception of the Journal of Medicine. So we have a situation where it's now possible to make the physical examination more informative on a quantitative basis but at the same time in most internal medicine journals, the case history, which is an excellent teaching tool, has virtually vanished except as part of the CPC. Ende, Philadelphia: I agree with you. A well-done case history can be enormously helpful. I've actually been impressed, however, with some of the innovative formats that we are beginning to see. The New England Journal of Medicine is now publishing a clinical reasoning piece. The Annals of Internal Medicine recently published a lovely paper that was essentially an expanded case history on making decisions to use warfarin in an octogenarian. I think that has relevance here because when you do present a case history you obviously include, I hope, a physical exam and now we are beginning to be able to really assess our physical exam quantitatively. Griner, Washington: Jack, a point of historical interest-Dr. Homans described the sign attributed to his name in the late 1920's by the 30's he had become so disenchanted with the sign that he tried to retract it but no one has believed it. We are glad to see that you are applying some science to the discriminating power of physical findings.