We frequently discussed this topic in our clinic – especially when there is a patient with diagnostic delays and errors. In about 80% of these the main reason for delayed/erroneous diagnosis is related to underestimation/unpropper check of patients’ history and/or physical examination. So despite current advances in technology still nothing can replace the experienced physician. The basic and essential tools – anamnesis and physical examination are more and more underestimated today.

In my specialty Vascular Surgery and Endovascular consider the history and physical examination almost 90% of the diagnosis, consider vascular metric for syndromic diagnosis of arterial diseases mainly topography.

To my experience clinical history and examination, theoretical knowledge of genetic, epidemiology, pathophysiology and natural history of diseases as well as stand of the art knowledge of modern laboratory, radiologic, ultrasound etc. diagnostics and a thorough understanding of side effects of drugs, a sensitive consideration of psychological and intervening environmental and personal factors and practical skills together with an empathic relationship building with the patient are pieces of a puzzle each of them as valuable as the others. Though undoubtedly diagnostic modalities have improved considerably and are very helpful to find the correct diagnosis it would be a nightmare for me to rely on a doctor overwhelmingly being dependent from his technical surrounding but not being able to consider differential diagnoses without his entourage (e.g. In case of a failure of electricity supply) when in a situation to rely on his own communication with the patient, invited to examine his body and urged to think and assess his findings without secondary help.

As a gastroenterologist I invite you to consider a situation where the laboratory findings show an elevation of Koproporphyrin I and the doctor is not skilled to distinguish a porphyria from an acute lead poisoning (e.g. by anamnesis) or a hypermetabolism due to a thyreotoxikosis (both situations may coincide with an elevation of Koproporphyrin I) or is simply missing the urgent need for an immediate intervention because of an appendicitis or cholezystitis, a situtation which might have lead to a turnaround of the differential diagnoses by thorough examination of the body. On the other hand up to 50 % of patients with a porphyria loose their appendix in the first incidence of abdominal pain. Trusting your fingers only may be risky as well. Each component mentioned above helps to encircle the most appropriate diagnosis and intervention. A sloppy anamnesis and a hit and run examination together with a devoutness towards technical techie behavior would be the best way to reduce professionalism as a standard of medical occupation and reputation.

I am working as family doctor and teaching in medical school some aspect of clinical examination. I have observed in the past year a very important decrease in the quality of the clinical examination as performed by trainees (teaching modalities staying the same). My hypothesis is that improvement of diagnostic, techniques essentially due to a really easy access to technology, has "darwinistic" consequences on clinical skills : the function create the organ and the underuse of it make it disappear ... This could have dramatic consequences on the health care expenses if technology become the first step of the diagnostic approach.

I would be plenty interested to know what kind of pedagogical methods all of you use to teach this amazing part of our job ?

85% of the diagnosis is history, 10% physical examination, and the rest can't be satisfactorily be determined by tests either.

If you listen carefully to the patient, and don't interrupt after 18 sec as the average doctor does, you will get the answer, and you will confirm it by your physical examination and support it by the right investigations.

We fail to appreciate these proven traits of the praxis, and we ever more fail to teach it (in the name of technology).

Thanks for bringing this to the forefront of the discussion.

Such a good question!

I would argue that there is a growing body of research demonstrating the utility of clinical skills in diagnostic reasoning, that teaching and learning clinical skills properly requires the application and consolidation of a great deal learning, climbing Bloom’s taxonomy and strengthening recall by elaboration of knowledge. Good clinical skills protects patients from unnecessary investigations with the risk of false positive results and clinical risks that these investigations entail.

There are certainly problems with the teaching and learning of clinical skills (Goldstein, 2005; Rolfe, 2002, Evans, 2007)

In terms of the utility of clinical skills, much of what we do is not proven to be helpful, and indeed there is difficulty conducting this research. However, there is a growing body of evidence on the validity and reliability of different aspects of the physical examination: McGee (2007) is one of my favourite texts and JAMA’s Rational Clinical Exam Series (eg Barton (99)) both make good attempts to highlight where there is a strong evidence base for what we do. Where there is poor evidence, there have been attempts to gain consensus on best or acceptable practice (eg Bradding (99)), although I personally argue that there is rarely one right way of performing a skill (Evans, 2009), there are certainly approaches that are more appropriate than others.

My working definition of “clinical skills” is something like: “the human interface between medical knowledge and the patient”. I've argued that to learn clinical skills you need knowledge, practice and feedback (Evans, 2009). Martina Michels (2012) proposes that this knowledge includes not only the (1) steps of the skill, but also the linkage to (2) basic science (so that we can adapt these steps to different patients – think of a knee exam in a patient with a below knee amputation, and so that we can understand what we are doing, rather than follow an unthinking ritualized procedure), and also (3) linkage to reasoning – both diagnostic reasoning (what do my findings tell me?) and clinical decision making (which bits of the examination are important in *this* patient? – this links in with the “reflective clinical examination” Benbassat (2005) ). If clinical skills are taught and learnt via integration with basic science and reasoning, then it will ensure a deep understanding of both these essential areas, great revision and improved encoding and recall from memory through repetition, building links within and across domains and elaboration. It asks learners to apply basic science, weigh and judge, and so teaches at a higher level of Bloom’s taxonomy than simple factual recall of basic science. This has to be a good thing. It goes against some of the methods used to teach clinical skills (eg Head To Toe examination), but does not stand alone in its criticism of such approaches (eg Yudkowsky, 2009)

I have misplaced a reference (can anyone help?) that showed in US state-run hospitals, that patients who saw doctors who did more “thorough” examinations and investigations ended up with more investigations and referrals to other doctors, but no more final diagnoses than those patients whose doctors had a more focused and reflective approach. One needs a lot more knowledge and skill to do only what is relevant, rather than to do everything.

I personally believe that clinical skills are UNDER-RATED, particularly in our undergraduate curricula… but perhaps that’s a different question!

BARTON, M. B., HARRIS, R. & FLETCHER, S. W. (1999) The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA, 282, 1270-80.

BENBASSAT, J., BAUMAL, R., HEYMAN, S. N. & BREZIS, M. (2005) Viewpoint: suggestions for a shift in teaching clinical skills to medical students: the reflective clinical examination. Acad Med, 80, 1121-6.

BRADDING, P. & COOKSON, J. B. (1999) The dos and don'ts of examining the respiratory system: a survey of British Thoracic Society members. J R Soc Med, 92, 632-4.

EVANS, D. & BROWN, J. (2009) How to succeed at medical school : an essential guide to learning, Oxford, Wiley-Blackwell.

EVANS, D. E. (2007) Shibboleths of incompetence. International Journal of Clinical Skills, 1.

GOLDSTEIN, E. A., MACLAREN, C. F., SMITH, S., MENGERT, T. J., MAESTAS, R. R., FOY, H. M., WENRICH, M. D. & RAMSEY, P. G. (2005) Promoting fundamental clinical skills: a competency-based college approach at the University of Washington. Acad Med, 80, 423-33.

MCGEE, S. R. (2007) Evidence-based physical diagnosis, Philadelphia, Pa., Saunders.

MICHELS, M. E., EVANS, D. E. & BLOK, G. A. (2012) What is a clinical skill? Searching for order in chaos through a modified Delphi process. Med Teach, 34, e573-81.

ROLFE, I. E. & SANSON-FISHER, R. W. (2002) Translating learning principles into practice: a new strategy for learning clinical skills. Med Educ, 36, 345-52.

YUDKOWSKY, R., OTAKI, J., LOWENSTEIN, T., RIDDLE, J., NISHIGORI, H. & BORDAGE, G. (2009) A hypothesis-driven physical examination learning and assessment procedure for medical students: initial validity evidence. Med Educ, 43, 729-40.

Dear,

It seems no doubt that we agree that valorization of the current and previous history of our patients and fisical examination are the gold stand art .In fact technological advancement especially in the imaging industry has revolutionized our ability to diagnose and it cannot be used incorrectly, nothing replace the initial clinical evaluation of the direct approach to the patient.

I think that part of the problem arises from the way that clinical examination skills are taught, which is often as a set of psychomotor skills for information-gathering during the clinical assessment process. Experienced clinicians recognise the role that clinical examination skills play in information-processing and clinical reasoning and use their clinical examination skills to test hypotheses formed during the other parts of the clinical assessment. Teaching clinical assessment skills is different from teaching clinical examination skills and yet both medical and nurse education courses tend to focus more on teaching the latter than the former.

I have argued that there is a need to teach symptom-based, patient safety-focused clinical assessment, in which the clinical examination represents but one of the sources of information that needs to be gathered and processed. This does not reduce the role of the clinical examination but places it within the context of the clinical assessment as a whole. I also emphasise the need to understand the limitations of a clinical assessment, in terms of false positives and negatives and in terms of the limitations placed by the dynamic nature of illness on the diagnostic process. Clinical assessment is not a perfect tool and neither are any of its components. A holistic approach to clinical assessment is required, along with an understanding of its imperfections.

Thank you for such insightful responses above..

Dr Silverton, I think you are spot on in saying that clinical assessment is the skill we should be focussing more on...

Dr Schapera: In my humble opinion, clinical skills or clinical assessment is the basis from where you start seeing a patient... no doubt there are limitations to clinical assessment, but this can never justify omitting it from the diagnostic process.. so these skills are vital to a practicing clinician...

I am at a loss as to how we can improve teaching of these skills to the students of the new era, which was the second part of my question... any ideas???

This is diffucult as many of our colleagues believe in technology and not in clinical skills! How did you learn clinical skills?? I had the chance that I met a surgeon who accompanied me to the patients bed and then he showed me how to ask questions and how to examine and he demonstrated clinical signs and their definitions to me. I think this is the best way to learn. We can produce lots of videos or simulator sessions, but teaching with real patients is most important.

Dear Raza

Of course not!

In times of so much technology available in the medical field , some people forget the importance of the clinical examination for the diagnosis and treatment of diseases , the clinical examination is divided into two stages : a history and physical examination . From them it is possible to obtain information about the general health of the patient , diseases can be identified from the signs and symptoms .

The signal is a physical characteristic that can be detected by the physician as a blemish on the skin caused by a fungal infection . Have a symptom is a subjective characteristic reported by the patient , such as dizziness .

The interview, which consists of an interview conducted by the professional when the consultation is very important as a stage of clinical examination

In a query , the professional makes use of clinical examination may identify factors that may influence treatment. It can also suspected of certain pathologies, such as , for example , the patient reports that the child of diabetic parents. From this information , we can suggest an investigation of metabolic changes .

The objective clinical examination also create a bond between doctor and patient, because from it begins a story that will be redeemed for future reference . Now the complementary technological tests or not , as the name implies, complement the diagnosis and therefore should be requested only after the clinical examination

In regards to the second part of the question - we need to rethink what health and healthcare is all about. Health - from the old English hal - means whole/ness. Thus we are talking about the patient as a WHOLE - consider how we teach and practice medicine today - in parts. Is it a wonder that students and so many of our colleagues are just interested in ever smaller and narrower approaches? Why does, e.g. a cardiologist still need to properly learn to auscultate a heart, if s/he will use (and get paid extra) for doing an echocardiogram as a matter of a "standard examination"?

The crisis here is one of appreciation and basic attitude. Healthcare has forgotten that we treat PEOPLE, many of whom do not present to us with "identifiable" pathologies, and who are often seen as "misusing/abusing" the healthcare system, or are given derogatory labels like malingerers, neurotics or somatisers.

Such views are ingrained into students in the tertiary hospital education environment - keep in mind that these populations represent 0.8% of the whole community - where the sickest of the sick are treated. We expose students to the rarities, and hardly ever expose them to the much richer variability of health, illness and dis-ease (the real meaning of the term), the complexities behind people's life that affects their health and health experiences.

We view everything in isolation, we teach everything as if it only exists in neat boxes, and we rarely think and teach context. We need an upside down approach, get students connected to patients over time, and let them follow them through their healthcare journey - we showed that this gets a completely different outcome in as short a time as one year.

For those interested in more detail on these broad issues can find more detailed information on my ResearchGate site.

I totally agree with Anthony, In the meantime, I was reading an editorial in JAMA otolaryngology which I thought would be interesting for you as well:

http://archotol.jamanetwork.com/article.aspx?articleid=1812651

The physical examination is like a roadmap of the patient's body - you do it to get an understanding of the total picture. And yes, it has great value in establishing a relationship and "laying on of hands". But the physical examination has marked limitations as a means of diagnosis. It was designed for obviously sick people (especially in the era of tuberculosis) and is insensitive in picking up early disease (broad generalization) and can be misleading in evaluating people as well (for example, in fitness for duty or for prevention). But then, what in medicine does not have its limitations? It is a modality with many purposes and one uses it to complete the big picture. When it is sufficient to make the diagnosis in itself, it is invaluable, inexpensive, and can be life-saving. It will be a long time before physicians stop doing physical examinations in favor of handheld devices.

I agree with previous answers. Clinical examination is the core to understanding and diagnose of the patients.

In our country (Sweden) this skill is, if not vanishing, at least decreasing by the year. Young doctors rely heavily on different diagnostic tools and forget their clinical skills. This is very evident when we have students from foreign countries, foremost underdeveloped countries where the lack of diagnostic tools have made them keep (and teach) clinical examination skills.

As academic surgeons we are teaching surgery to our students and residents transferring them skills and knowledge in this field. But we should never forget the third/last but not least/ element - attitude. Taking history and physical examination of the surgical patient has been always been a "must" in the clinical approach to the surgical patient. "Qui bene interrogat bene diagnosci, qui bene diagnosci - bene curat" - this latin postulate is even more actual in modern "high-tech" medicine and surgery. Can you imagine the following: famous consultant surgeon observes the CT, brought by a relative of a patient and states - "Operation" - even without seeing the patient. Streaming into modern techniques, should not distract the surgeon from the classical, proved clinical physical examination. Otherwise you will loose your abilities of "clinical thinking" and go on only on algorhythms.

I definetly disagree that physical examination being overrated for it is still a very important armametorium for the clinician as is often seen we end up treating investigations

For the current day teacing I feel we need to teach on correlation of investigative medicine and clinical examination.

Good clinical skills definetly aid in the direction of management and diagnosis

Raza has asked us to contribute our thoughts as to how clinical assessment teaching can be improved, which is something that we are discussing within our department at present. We are having the same discussion about the relative merits of teaching psychomotor clinical examination skills within the clinical assessment process. In many cases we are still teaching 19th century clinical examination skills, which would only have positive findings in patients with well-established disease and are no longer related to the decision-making process that takes place within the clinical workplace. Clinical assessment is being used as a screening tool to decide who needs referral (using scoring systems), or advanced investigations. Modern clinical assessment teaching needs to reflect this. The fact that it doesn't do so is seen by the difference in the way that a medical student examines a patient and the way that it is done in clinical practice by his or her peers. Clinical assessment teaching needs to be symptom-based, patient safety-focused (to meet the WHO Patient Safety Curriculum objectives) and clinical workplace-linked.

If we take clinical assessment back to its fundamental principles, we should ask "What IS a clinical assessment and what is its PURPOSE?" I take a very mechanistic view of this. Clinical assessment is the process that links the symptom that the patient comes into the consulting room with and the diagnosis and management plan that they leave the room with and its primary purpose is to rapidly identify the patient who is "Big Sick" and the one who has the potential to become so later. That is why I take a symptom-based, patient safety-focused approach to clinical assessment teaching. So, where do clinical examination skills fit into this? Clinical assessment involves gathering and processing information from multiple sources and it is probably the most complex skill that we learn, as it involves psychomotor and technical skills, along with clinical reasoning and decision-making skills. Clinical examination is one of the sources of information that can be gathered but it has to be seen within the context of the symptoms that the patient is presenting with. For example, a patient presenting during the early stages of illness will not yet have developed disease-specific clinical signs and the clinical examination will be misleading, with potentially serious consequences for both patient and clinician. We must teach the information-processing skills that go with the clinical examination and not just the information-gathering ones and also what the limitations of clinical examination are in early illness and with specific symptoms. This is why I prefer to teach symptom-based, patient safety focused clinical assessment, in which the clinical examination is used as a diagnostic tool that is taken out of the clinical assessment toolbox for a specific purpose, with a warning that its limitations also have to be considered.

Clinical examination can be an extremely useful tool for gathering information during a clinical assessment and good clinical assessment skills are essential in primary care, where immediate access to investigations are limited. However, clinical examination skills need to be taught within the context of the clinical assessment as a whole, so that it is understood what the purpose of the clinical examination is for each set of symptoms and how they are used to test hypotheses related to those symptoms. As medical students, we spent huge amounts of time acquiring and honing the clinical examination skills that we were taught and yet at the end of our careers we recognised that most of the information required to make a diagnosis comes from the patient's history, combined with a set of observations. It is relatively unusual to find something on the clinical examination that we did not suspect before we began the examination. If clinical examination is to remain relevant in the 21st century, it needs to adapt to modern clinical practice. We need to teach its value as a screening tool and also what its role is in symptom-based, patient safety-focused, hypothesis-testing, within the context of the clinical assessment as a whole. However, we also need to teach students about its limitations in clinical practice, along with the limitations of all the other components of clinical assessment.

Paul, I agree with your sentiments, however, one has to be reminded about a few simple facts.

(1) as you rightly emphasize, the patient usually tells you the diagnosis, if you are listening carefully

(2) the rule of thumb says that every diagnosis has three (3) key features, never more than 5 (Page, 1995), no three key features - no disease

(3) tests - including the physical examination - are there to confirm your diagnosis, not to be a "fishing expedition"

(4) pre-clinical disease is hugely overrated as many of these changes have been shown to revert back to normal or not progress - do we do more harm than good by overemphasizing medicolegal safety (which now is a real big problem in many jurisdictions) and contradict the first principle of medicine - primum non nocere

(5) if you order 20 test you will find 1 abnormality, the problem of false-positives (or: there are no healthy people, only underinvestigated ones)

and (6) keep in mind that repeated x-ray exposure especially CT-scanning will induce disease

Thanks for the feedback, Joachim. A couple of points:

1. The reason that I suggest that physical examination has 2 roles, that of forming part of the clinical reasoning process but also in screening, is that occasionally one does pick-up something unexpected! It is particularly helpful in detecting atypical presentations of illness, for example. The other side of the coin is that an opportunity to make a diagnosis may be missed by failing to examine the patient appropriately.

2. You are absolutely correct in saying that many illnesses that present in their early stages with non-specific symptoms and signs are self-resolving. Equally, no amount of tests & investigations will enable the clinician to determine whether the patient has a serious illness or not, as the positive findings have yet to develop. I prefer to talk about "Protective Medicine" than "Defensive Medicine", which involves simply spending a couple of minutes at the end of each consultation in which diagnostic uncertainty exists explaining the dynamic nature of illness and safety-netting. This is non-invasive, costs nothing and prepares the patient or relative for the limitations imposed by a single point in time clinical assessment performed during an evolving illness process.

Sorry to push in again. Physical examination or imaging armament? Let everyone of us confess how many times he had decided to operate a patient for peptic ulcer perforation with negative X ray, relying only on his palpation finding. Or acute appendicitis? Isn't it a physical examination diagnosis and indication for an operation? As for teaching.... we must transform the teaching process in our students into a learning one allowing them to contact real patients as early as possible

I agree that we need technology to confirm our clinical suspicion that was formed by a combination of ideas based on the patient's history and examination , but the initial assessment is required even to good use and saves both, the technology currently available.

I completely agree with Joackim Sturmberg that 85% of the diagnosis is history, 10% physical examination, and the rest can't be satisfactorily be determined by tests either..

Previoulsy acute appendicitis was diagnosed only by history taking and physical examination, then leucocytes were introduced and then CRP. Currently some studies show that 80% of patient undergo abdominal CT for acute appendicitis. I do not know how much is the diagnosis more precise and how much were negative appendectomies minimized by this approach

Diagnostic (imaging) tools also have false negative and false positive results and after all the decision is on the clinician. Then my final decision is based on clinical grounds - general condition of the patient and physical examination

I completely agree but right now i cannot remember article from american centre with abdominal CT scan performed in around 80% of patients. Probably it is not only driven by diagnostic need but some sort of 'finantial need'

Another problem are law suits. What if you indicate an operation only on clinical grounds and the intraoperative findings were negative. It happens rarely but some can take that as a good ground for a law suit. Therefore some diagnostic modalities are used only to confirm clinical findings and are 'measurable' and 'visible' and can be proof if there is a law suit.

Physical examination to patients by the health care professionals especially the physician deals with the diagnostic, prognostic aspect of the clinical condition in his mind. Any number of invasive or non invasive diagnostic tests used will not satisfy the patient unless a tender care by the physician while he is conducting the examination.

In many situations history given by the patient may not be focusing to the particular system but on examination it could be a co incidental findings sometimes which may be having the good or bad prognosis in the patient.

Not all issues raised by patient in his history can be handled through diagnostic tests. Example it is important while patient is recovering from episode of disease or surgery requires to be assessed only through physical examination. It may be clinical improvement or reduction in size or area of the inflammation , swelling, tumor etc..

In my opinion the physical examination is a subjective matter to the physician but it always have his expert in his sensory system to pick up what is right or what is most probably wrong in the patient.

My opinion is that physical examination could be subjective but status of the patient is objective and it is known that the eye cannot see what the brain does not know. It means that the more experienced I got the more I relied on clinical examination. It shoud be noted that all diagnostic modalities have some percentage of error. Thereore if a young physician does not have a clue about the diagnosis then sometimes diagnostic modalities could be misleading.

Thank you for the question. This is a refreshing one because it is very timely. Yes I think it is over rated. The diagnostic exam should be only one tool used in the encounter and is not important in the chronically I'll (in primary care) without having conversation for a few minutes. Patients are not stupid. They have thought about what to say while waiting for us and have valid impressions as to what they think is wrong. I tell my students to enter the room, introduce yourself, look them in the eye, shake their hand, sit down and LISTEN. Only then do you do your exam. Then you can leave the room, assimilate the information and create a treatment plan.

Thank you all for such a thought provoking discussion..

One cannot negate the importance of either the clinical examination/assessment or sophisticated diagnostic modalities. Perhaps a more logical way is to guide one's choice of investigations in the light of the clinical assessment..

regards, raza

I agree with Alice Myers 100%!

Clinical examination is not completely reliable, as well as imaging. In my practice, being a surgeon, a physical examination is also essential, and often dispenses additional tests. In the diagnosis of abdominal wall hernias, for example, there is no need for additional tests, only in cases where there is doubt on physical examination. Moreover, in most cases in medicine, the physical examination which comes to guide or complementary tests which will be best for the case. There is still need to teach the complete physical exam to graduate students, even if they themselves deem to be in their daily practice is required or not performing this procedure.

I agree with Alice Myers, also.

Three things pertaining to clinical examinations that have always disillusioned me are:

i) How internists and cardiologists identify cardiac murmurs regardless and despite of the patient's habitus, environmental ambience (esp. in noisy E.Rs./ E.Ds.), quality of stethoscope, et.c.;

ii) How some doctors comment on the dimensions/ extent of abdominal organomegaly;

iii) Protocol-based, urgent, digital rectal examinations in patients who have presented after a car accident or with new-onset back-pain and lower-limb-weakness, who do have preserved perianal sensation, no history of incontinence, et.c..

The saying, "eyes of a hawk (with the 'add-on X-ray Vision pack') and ears of a wolf" spring to mind - as does a Pinocchio-style nose!

I am not saying that clinical examination should not be taught; what I am saying is that its emphasis needs to be decreased in some situations.

GOOD MEDICINE COMES WITH EXPERIENCE, COMMON SENSE, AND UNDERSTANDING OF PROCESSES AND PROTOCOLS. I RECOGNIZE THAT DOCUMENTATION, ESP. IN TODAY'S AMBULANCE-CHASING MEDICOLEGAL WORLD, IS IMPORTANT AND THAT A NEGATIVE OUTCOME OF A TEST IS, DEPENDING ON THE SITUATION, JUST AS VALID AS A POSITIVE OUTCOME.

MEDICINE IS, VERY DISAPPOINTINGLY, BECOMING MORE ABOUT ALGORITHMS, TICK-BOXES, AND BLANKET POLICIES. NOT ONLY IS THIS SITUATION COMMONLY UNNECESSARY, THEY DEVOLVE PROFESSIONALISM, AND FACILITATE JOBSWORTHS WHO INCORRECTLY BELIEVE THAT GUIDELINES ARE SYNONYMOUS WITH POLICIES.

I agree Niroshan,

It is actually the critical thought being taken out of clinical examination that has raised questions about its value. There is a need to add an element of rationality rather than, as you very rightly said, protocol..

regards, raza

I teach my students that in the UK, GP's are some of the very best at clinical reasoning - they work out from this history the key parts of the examination that might confirm or refute their working diagnosis, and then conduct just that -part task-. The student often misinterprets this as "not doing a proper examination". this fits in with Alice Myers' and Paul Silverston's comments.

I think Niroshan Sivathasan highlights that most diagnoses are made before the "key" part of the examination. I love teaching with Harvey (a cardiovascular manikin) as you can teach the students through vignettes and the peripheral examination (character of pulse, JVP, blood pressure, heaves) to try and predict what murmurs they expect to hear, and which ones they would be surprised to hear. I think that many of us play this "game" clinically, and so long as we avoid premature closure is a good tool to improve clinical reasoning skills.

We must move away from teaching and assessing "steps" (which results in the learning of a ritualised performance). Remember that bad assessment drives bad learning.

For all levels of seniority, but notably for junior ones, steps and pathways ensure standardization, minimize omissions, and facilitate consolidation/ fluency.

However, as Dason rightly says, a good teacher explains steps as opposed to demanding that his student 'blindly' follows a ritual.

Yes, and a key question that I have grappled with over the years, is when to add in the justifications? Many add it in after the steps are learnt, but I think that some students will then lean on habitual recitation rather than thinking examination later on, especially under stress etc.

Adding it in at the start can lead to congnitive overload (too much information about anatomy and phsyiology to think about, stops them from developing fluency)

I think one answer is part-task training initially, linked to the "why" and then later glueing them together when the basic science has been appropriately encapsulated.

For anyone questioning the validity of history taking and the clinical examination itself I highly recommend reading

"The Rational Clinical Examination" Evidence-based Clinical Diagnosis, published in JAMA evidence by David L. Simel and Drummond Rennie.

This book basically does what the title say, and the authors compile all possible evidence ranging from auscultation to abdominal palpitation for making the correct diagnosis. Also some history taking tests (CAGE for alcoholism) are analysed.

I tell the students the same thing over and over: The first test we as doctors always perform is listening to ask the proper questions and then examining the patient to know if any further tests are required.

Cheers,

Oliver

Human beings are not machines. They have feelings and very comlex psychology.So contact with a physcian remains a cornerstone in management of patients. A good history and a systemic physical examination will yield more than 80% of the diagnosis. Besides history and clinical examination will enable the doctor to choose the appropriate relevant investigations which is economically sound and time saving. Some unnecessary invistigations may sometimes be harmful to the patients and adding stress to the health workers.

Ahmed

I couldn't agree more. We currently have a Taylorist approach to medical service provision. We need the conversation with our patients to really understand them.

Sufficient time, that is, 'a certain slowness', is an essential element of the healing relationship in the consultation. It creates a sufficiently stable, but adaptive, environment that can withstand changing demands. Hence a more complete understanding of the consultation and its time demands will not only lead to more effective treatment, it will also humanize a situation which has become to a large extent purely instrumental. This process of humanization is important not only for the patient, but also for the doctor. (from a paper I wrote with Paul Cilliers a few years ago)

Thank you Joachim for approprate comment and I hpoe that we are not going to see medical services delivered by robosts.

There is one more aspect I would like to add (as a practicing GP and Professor of general practice). Every question we are asking and every physical exam we are performing can be seen as a diagnostic test - with it's particular sensitivity and specificity regarding the detection of a disease. Even though aspects of the patient's history and results of physical examination usually don't have high sensitivites and specificities, the complete picture (often referred to as "physician's judgement") often does - and it surely increases pretest probabilities of any further technical examination, imaging or laboratory. Bayes' Theorem clearly demonstrates that any diagnostic test (including high tech Investigation) performs badly in the low prevalence Setting. Thorough physical examnination and history taking increase the prevalence (pretest-probability) for subsequent exams by filtering out patients with a low probability for the disease. This helps us to avoid false positives and overdiagnosis, a medical problem of our time yet highly underestimated. This is the message I try to get across to my students.

Clinician focused medical education is essential to quality, cost, and health access. As an MD from a top school and a hands-on residency and then 25 years of practice and teaching experience, it would seem that I had the clinical skills. After 3 years learning clinical skills at a clinician specific osteopathic medical school so that I could teach the first year medical students and then after directing clinical skills courses, I found out that skills must be a higher priority across medical education and across medical students from the very start of their training.

Clinical skills has more dimensions than anyone has yet to evaluate, often because few have had the awareness and perspective to be able to evaluate this vast area.

Disease focused basic science years with clinical skills sprinkled in is not a way to prepare physicians.

Admissions of physicians most exclusive in origins and background and least like 60% of Americans is also a reason for poor doctor-patient interactions, poor distribution, and limitations of health access.

The sad lack of understanding of social determinants, patient situations, and other aspects that drive health status and health care outcomes is the result of our current deficiencies in preparation, admissions, and early training. This is also why our leaders continue to fail to lead well in primary care, basic services, and clinician specific medical education – what separates us from those less experienced and too technical.

Cognitive must be appreciated and rewarded for any hope of recovery of health access and the appreciation of clinical skills must win out over more specialties created with more in each specialty and ever higher costs – including failed abilities with regard to the most basic physician skills.

How many times have you entered a patient room after reviewing all appropriate data, having a preconceived idea as to how to address the plan on a patient and completely changed you mind after the interview portion? I have done that plenty of times. No matter what your skills are you must not be hesitant to engage the patient! Yes there is a chance that they won't stop talking and droning on and on. But so what? I think med students need to be taught that to be a good clinician you must incorporate all of your skills including taking the time to address the humanality of the patient.

After 40 years of medicine I have found no substitute for an accurate history and physical exam. I have personally found tumors on physical exams that were incidental to the patient's complaints. The skill do do distracted exams and to not ask leading questions in history taking is something all should learn. I am always brought back to the old addage"treat the patient" not the test.

Congratulations Edmond,

It`s a pleasure to see how we think to closer instead of the distance and culture . That`s it.

Physical exam remains the cornerstone of medical practice without which diagnostic and therapeutic errors are bound to occur, including deaths. Examples include a patient who walks with a limp to see his Physician. When asked what was the problem, the patient stated that he had h/o of arthritis for which he took pain medications. Without performing physical exam, the physician ordered an X-Ray of the knee and it was normal. So ended up prescribing Ibuprofen for Osteoarthritis . The following morning found the patient dead. He died of Pulmonary embolism. Had the physician performed a physical exam, the patient would have been referred to the hospital for angioplasty with stent placement. Similarly, many patients get injured or die because of failure to perform physical exam, which could have led to the correct diagnosis.

Finally, and I agree with the above colleagues, that there is no better exam than physical exam in conjunction with labs and other pertinent studies. To minimize or prevent diagnostic errors, physical exam should be taught along with basic sciences and not until later.

Thanks,

Ben Olwe, Alumni, Walden University

With tanks of your this important question.i think that relation between patient and doctor have a important role in treatment. Physical exam and taking a good history of present illness and past history is the first step for this relationship.in recent years medical students have missed inspection, palpitation ,touch,becouse of frequent use in paraclinical exams .so that they want to treat the present illness only,no the patient.i thik that the aim of treatment and healths must bequre all body ,no one organ like as kidny or cardiac,liver .....missing the physical exam leads to exessive use of oaraclinical techniques, which are so exoensive .

I believe the teaching and learning of clinical skills is an essential component of medical education, both from the scientific and the cultural/human point of view. A good patient interview (part of the clinical set) is often missing in today's fast-paced, technology-driven office, and provides not only essential clues to a particular acute condition, but also to necessary lifestyle and environmental influences on long-term health that can be the basis for further counseling.

In addition, thorough clinical exam and interview point the way to use of necessary diagnostic tools....I emphasize the word "necessary"...which can otherwise be over-utilized and add both cost and even hardship, when these costs are out-of-pocket. Clinical examination has been coupled with cost-effective "stratified use" of technology to the benefit of patients in resource-scarce settings, especially in some developing countries. Such "reverse innovation" could certainly help contain over-reliance on technology, and make more rational use of it in developed nations as well. One last thing: physicians need to be allotted the TIME for a good clinical exam and interview...this is a serious problem, at least in the United States.

A thorough clinical exam coupled with patient interview is an essential component of medical education. This is true not only from the scientific and human/cultural vantage point, but also from the standpoints of health promotion and cost. Health promotion because application of the clinical approach can uncover not only provide important diagnostic conclusions for an acute problem, but also warn of lifestyle and environmental changes needed to counsel patients on long-term health. Cost, because technology poorly used, or unnecessarily used, can add to the burden of institutions and families (the latter particularly when payment is out-of-pocket). The clinical duo of examination and interview has been effectively coupled with a "stratified approach" to use of complementary diagnostic tools in resource-scarce settings, particularly in some developing countries. Technology-rich industrialized nations could learn from this, an experience in reverse innovation.

Thanks Gail. I agree that limited exam time is a major problem in the United States today!

I agree with many precious responders clinical examination is part of the support for medical dignosis and getting on well with patient. Many new practitioners do not conduct clinical examination and accept patients symptoms without checking for evidence. This may be problematic and addtional tests negattive, giving you a wrong dignosis and increasing costs of of getting the correct dignosis. Clinican may also loose patient to another practitoner. Good interview and clinical testing is essential for good practice.

While I personally agree with you and do not allow anything to influence my actions, the push is there whether tangible or not. We are not saying that this is an excuse or that we are not caring for our patients . Just saying.

I totally tend to agree with Danuta and Anthony and I can not imagine there will come a day when patients will not have close rapapport with their doctors including taking a good history and having a detailed physical examination.

Like you, I've been a clinician, surgeon and anatomy lecturer for 33 years and I have found clinical skills to be the primary way in which to get a working diagnosis and establishing a relationship with my patients. However, on frequent occasions, doubt/suspicion/equivocation has obliged me to perform a few very basic investigations to establish the more likely diagnosis. The investigations are usually just simple X-rays, as we call them, and a few basic blood tests. Where there are patients whose clinical differential diagnosis is broad, I have found that in-patient investigations much more suitable with the establishment of a diagnosis fairly quickly. Naturally with progress of the disease certain messages become clearer, and even then clinical acumen comes first. Some of the older more senior consultants who taught us in surgery had amazing clinical skills and were able to make definitive diagnoses using their experienced hands and senses only. Perhaps, with time, and technology enabling deeper images of the anatomy to be exposed so easily, clinical acumen may very well become less important. I hope not.

The best way to arrive at a diagnosis is to use clinical history , physical examination & laboratory tests to confirm the diagnosis . For eg , in a patient with acute febrile illness , laboratory tests are needed to confirm the diagnosis . This is the basis of evidence based medicine . But tests may not become positive early & empiric therapy is suggested to treat the patient on the basis of history & clinical examination . This is based on experience based medicine & depends on the experience of the physician to arrive at a rapid clinical diagnosis to save the life of the patient . For doctors working in remote areas , this may be the only treatment option available . Therefore in primary care , history & physical examination may play an important role with limited laboratory facilities , while in secondary & tertiary care laboratory diagnosis will play a major role . The ultimate aim is to treat patients & it is essential for doctors to decide whether they are dealing with a mild or serious illness & to decide on utilizing laboratory diagnosis to manage patients . Clinical history & physical examination are still relevant in this era of rapid technological advances to diagnose illness .

If we rely too much on tests and investigations, we risk losing the skill and art of medicine, becoming mere technicians.

The doctor themselves is a powerful tool - think of the general practice concept of the 'doctor as the drug'.

Let's keep the art of communication and history-taking alive and central to clinical practice!

I totally agree with lain Lawrie

A consultation is about gathering and processing information from multiple sources, in the knowledge that information can be gleaned from each of these sources. For example, in performing a clinical assessment on a patient who has developed a severe headache, the history may indicate that the patient may have a migraine, cerebral malaria, or a brain tumour. A set of observations may add to information to this by showing that the patient is either febrile, or hypertensive. The clinical examination may or may not reveal any positive findings but both the presence and absence of clinical findings assists us in our clinical reasoning. Tests and investigations provide yet more information, which, again, can be helpful in confirming or refuting what we suspect, or may show something that we did not suspect as being the cause!

The point is this: The components of a clinical assessment all have their uses and they all have their limitations, in terms of false positives/negatives and their lack of reliability in early vs established disease. During a clinical assessment, we use these components for two different purposes, namely for screening for positive findings and to confirm or refute the diagnosis of a specific condition, as part of the clinical reasoning process. We need to teach students how to use the components competently and safely, which is why I like symptom-based, patient safety-focused clinical assessment teaching, as it aims to teach the students how to link the diagnostic process to the symptom that the patient is presenting with, but it also the emphasises the limitations of that process.

I cann provide references on the statement that dianostic accuracy has not improved significantly in our time ' although tools like CT' MRi' and others when the Golden Rule is the classic PM examination.

However PM's are very rarely performed....

I have kept an eye on this thread over the last few weeks, and have enjoyed the contributions from many, especially from Dason Evans and Paul Silverston in particular.

I certainly support clinical examination, and I agree with many that this art is being lost, particularly amongst recent graduates. However, we absolutely must not undertake clinical examination in a robotic fashion just because an algorithm forces such.

Whether the examination is to include or exclude a finding, there has to be rationale behind the process of the examination - and NOT regimented examination. I think that those who are O.T.T. in support of clinical examination should pay particular note to the following:

1) "Clinical assessment is the process that links the symptom that the patient comes into the consulting room with and the diagnosis and management plan that they leave the room with and its primary purpose is to rapidly identify the patient who is "Big Sick" and the one who has the potential to become so later. That is why I take a symptom-based, patient safety-focused approach to clinical assessment teaching." [P.S.]

2) "Clinical examination is one of the sources of information that can be gathered but it has to be seen within the context of the symptoms that the patient is presenting with. For example, a patient presenting during the early stages of illness will not yet have developed disease-specific clinical signs and the clinical examination will be misleading, with potentially serious consequences for both patient and clinician." [P.S.]

3) "If clinical examination is to remain relevant in the 21st century, it needs to adapt to modern clinical practice. We need to teach its value as a screening tool and also what its role is in symptom-based, patient safety-focused, hypothesis-testing, within the context of the clinical assessment as a whole. However, we also need to teach students about its limitations in clinical practice, along with the limitations of all the other components of clinical assessment." [P.S.]

4) "In many cases we are still teaching 19th century clinical examination skills, which would only have positive findings in patients with well-established disease and are no longer related to the decision-making process that takes place within the clinical workplace." [P.S.]

5) "the linkage to (2) basic science (so that we can adapt these steps to different patients – think of a knee exam in a patient with a below knee amputation, and so that we can understand what we are doing, rather than follow an unthinking ritualized procedure) " [D.E.]

Thank you for such a fantastic set of ideas! Very well said, especially number 4.. The concept you postulated in number 3 is where my concern lies. .With how FUTURE healthcare providers fit the physical exam in with the paradigm as a whole. What I perceive and am seeing in younger clinicians is that they need better teaching as to how to assimilate both clinical findings from the exam and the achievement of a HEALING patient interaction. Leaders. whether mentoring or teaching, have a responsibility in this role and must "pay-it-forward."

Great comment, Alice. Doctor means HEALER and TEACHER. You can teach "nearly every" monkey to do a trick, in this context doing a physical or performing a procedure, but it takes great "healing" role models to transfer the knowledge about medicine and the art to heal. After all this is why the apprentice model of medical education has survived the millennia.

Investigations are only adjuncts to properly performed clinical examination .

Talking to the patient will reveal a lot of things, especially the psychological state of the patient. This will confer an atmosphere of confidence and reassurance to the patient. Then a thotough systematc examination will comlete the picture. The doctor should be very patient and should be a good listner. If we hurry things and ignore remarks of the patient, however trivial they are, physical exam. will be useless and boring to the patient and he/she will not be cooperative. In that case machines will be better!!!!

So, in short, we must use the right standard methods and attitude when examining patients.

Mark Arnold, School of Rural Health, Sydney University.

I would suggest that reading Goodman RG. Health Care Technology and Medical Education: Putting Physical Diagnosis in Its Proper Place. Academic Medicine 2010;85:945-946, would reflect many of the views expressed, and is a paper which I try - sometimes successfully - to challenge students with.

In a purely utilitarian sense, the purpose of history taking is to formulate a list of contextualised hypotheses that can be refined by an accurate, well performed physical examination - accurate and well performed being the operative words - after which investigations can be considered to confirm or refute the hypotheses generated.

In a humanistic sense, I would strongly suggest that Howard Brody's "The Healer's Power" would clarify why human interaction is laden with meaning for a patient, and (paraphrasing) how one can function as a "walking placebo", or for that matter a nocebo.

What Mark Arnold wrote is a real summary of most of the opinions and views expressed. So most, if not all, of the conributors are for high rating of physical examination.

I agree with many of the answers above.

Clinical examination has not yet been surpassed by radiological or biochemical tests. There may be a day that is it is, but that day has not yet come. If a patient presents with a history demonstrating symptoms of Small bowel obstruction , an Abdominal X-ray or CT-scan may confirm dilated bowel loops....but it is only from clinical examination that the management plan can be established... i.e. is there a strangulated hernia (can it be reduced?), is there widespread tenderness warranting laparotomy or soft abdominal distension warranting drip and suck approach).

This is a simple example of the many decisions which are based on basic clinical examination and hence demonstrate it cannot yet be completely omitted by the presence of tests.

I agree with Gurdeep and most of the conributions, so far, are for clinical examination and it thus seems that this art of medicine will be with us for the forseeable future.

Interesting blog in the NEJM on this subject here:

http://blogs.jwatch.org/general-medicine/index.php/2013/08/teaching-ultrasound-to-internal-medicine-residents/

In any clinical encounter for proper diagnoses and to make a efficient doctor patient relationship history taking and physical examination is an art in medicine which will lead which investigation to offer. But also there are places in the world where not all modern investigations are available where diagnoses rely on history and physical examination.

The importance of the interview ("history") and physical exam challenges the current popularity of telemedicine technology and remote consultations. Certainly you can interview a patient remotely and some physical features can be identified with telemedicine such as skin and wound lesions, peripheral edema, heart and lung sounds (with a skilled nurse and stethoscope) but telemedicine is no substitute for palpation of body parts such as neck, abdomen, prostate, inguinal hernia, and peripheral pulses. Many telemedicine proponents would want you to be convinced that telemedicine can replace the local physician. Telemedicine is better than nothing but does have limitations.

Thank you James for this comment and I think the majority of us agree that history and physical examination have no better substitues.

Working with children is another topic, since skilled clinician can spare many painful procedures to a child, can evaluate certain milestones not through parental history but through observation, not to mention having hands on the child when evaluating the tone, quality of child''s movement etc. Engaging in playful way can give insight into child's psychology, cognition, social interaction as well as gross and fine motorics, language development. Moreover, clinician's eye is cheaper, faster, and in some cases even better than expensive gait analyzer, though the latter can be quite useful in some, rare cases. Even more, evaluating infants spontaneous movement by following gestalt principle, is accurate in predicting CP in first months, for example.

So, in children the clinician's hands-on examination is effective, cheaper and spares anaesthesia for MRI ( though the procedure is sometimes needed), many mililiters of blood that an infant has not much, sometimes in infants it is just gut feeling, before CRP and PCT rise, that an infant has incipient sepsis...And yet, a good clinician knows, when gut feeling is not enough and spinal tap and MRI is needed.

Therefore, a balance between procedures and clinial exam is essential, esp. because we do not want to do every procedure, that is possible, but only the pertinent ones.

I totally agree with Tina as she brought this imortant issue of examining children.

It is always imortant to avoid many procedures which are frighting to kids and many a times they will not be cooperative, especially if the procedure is painful. Sedation and anaethesia are sometimes needed in that case.

Los tiempos han cambiado, hay cada vez tecnología, pero cada vez menos valores y mas deshumanizacion. En general la anamnesis y el examen clinico orientan mejor para pedir examenes auxiliares; pero sobre todo nos aproximan al paciente que no solo busca solucion para problemas de salud organica, si no tambien mental y social, y la historia clinica contribuye a ese acrecamiento

Cesar Cabezas

Universidad de San Marcos, Lima

No, it is not. It is essential for a correct and accurate plan for both outpatients and inpatients in the best hospitals in the world. Imaging and labs, and electronic records of vitals will never replace clinical exam, will just make it easier to have a final diagnostic and the appropriate plan. Learning the skills of clinical exam it's a challenge but also is the essential of becoming a doctor. The only correct way to get this training is at the patient bedside. This was available 100 years ago and will be available in the next 100 years.

@Cesar Cabezas:

I think you have made some fair points, but my knowledge of Spanish is limited - a problem that, I suspect, the majority of readers shall have - and Google Translate was unable to fully translate your phrases.

P.S. It would be useful to make comments in English only (por favor haga comentarios en Inglés solamente)

During medical school, approximately one year ago, I wrote a review regarding the added value of bedside teaching in learning clinical skills for medical students with the professor of medical education at our institution (http://www.ncbi.nlm.nih.gov/pubmed/24049043). Furthermore, we analyzed the reasons for the substantial decline which is noticed globally in the teaching of essential clinical skills to medical students and future solutions to increase the amount of bedside teaching.

The reasons for this analysis was the increasing decline we noticed in our medical center (in which bedside teaching is almost non-existent during many courses).

It seems that learning different clinical skills can be significantly increased using bedside teaching (for example cardiac auscultation). Furthermore, illness scripts can be learned in this way, in which the combination of the clinical presentation of a patient is connected to the knowledge about diseases to create a mental model guiding clinical reasoning. It is hard to imagine that such an elaborate mental structure can be successfully replaced by advanced diagnostic tests or even computer programs in the nearby future.

In addition, a broad consensus is present in the literature to maintain the teaching of clinical skills to medical students. It is always good to note that positive diagnoses can be made in more than 90% of cases for some diseases using only the history and the physical examination. Advanced tests should mostly be kept to confirm the diagnosis, especially when regarding cost-effectiveness (which is gaining increasing importance).

Also, most patients like the clinical encounter, in which we should not underestimate the positive effect of a good doctor-patient relationship (plus the added (psychological/placebo) effect of the actual history and physical examination).

To increase the amount of bedside teaching, not only the valuable time of senior staff members is needed. Successful training programs with younger doctors have been conducted (see my article and for example: http://www.ncbi.nlm.nih.gov/pubmed/?term=Clin+Teach.+2013%3B10%3A141%E2%80%935. and http://www.ncbi.nlm.nih.gov/pubmed/?term=Scott+Med+J.+2013%3B58%3A188%E2%80%93+92.).

The history and physical examination are important for a multitude of reasons and should not be subject to the decline which is seen in the last five decades.

Excellent sentence: The history and physical examination are important for a multitude of reasons and should not be subject to the decline which is seen in the last five decades.

It says everything.

Max, great contribution, and wholeheartedly agree.

I guess this whole discussion really requires an expansion on the whole philosophy of medical education. The general loss of person/patient centredness being replaced by disease-focused instrumentalism is at the heart of the demise of "health care" - the interactional relationship of healing. I have made suggestions in the past on how to think and teach differently about this:

How to teach holistic care--meeting the challenge of complexity in clinical practice.

http://www.ncbi.nlm.nih.gov/pubmed/16009617

Nothing could replace at least a basic body examination

For the time being and the time to be forseen.

Nevertheless Dr McCoy had a very sophisticated device

that could deliver many physical exam results. I refer of

course to the famous crew doctor from Enterprise.....

The above discussion (between clinical history-taking and examination and diagnostic tools) implies there is a conflict between the two, when in actual fact they are complimentary. There is no gain in doing the wrong test as much as there is no gain in asking the wrong questions or looking for the wrong signs. Furthermore the tests are just as open to misinterpretation as the clnical findings, not just in absolute terms but also in relevance. Some tests are also invasive and their value must be balanced according to the risks involved (viz. pleural aspiration; xray exposure of CT scans etc).

Then there is the overarching assumption that diagnostic tools improve clinical care when they may delay or confuse it. Furthermore, there is also the idea that good clinical care becomes impossible without an array of diagnostic technology. This notion is totally false, and also undermines the brilliant achievements of many clinicians in low- and middle-incme countries, whose results have often been superior to those blessed with high technology gadgetry.

The danger is that diagnostic tools supplant rather than enhance clinical skills; this is already happening in A&E departments where patients are CT-scanned before being examined, and where doctors come to greet and treat patients after they have looked at imaging before even assessing the patient concerned clinically.

Another pitfall is to know how to deal with the surplus of information provided by sophisticated diagnostic tools. A little knowledge, it is said, is a dangerous thing; too much knowledge might be a disaster!

There have been some very impressive comments in this section, but very few have touched upon a very basic practicality inherent to clinical practice - it is an act of service provision, in which the human element is crucial, as it would be in any other service-related business. Patients by and large are unable to appreciate the science behind modern medicine, and are not in a position to appraise the technical expertise of their doctors. They respond to the impression derive from their brief contact with the clinician (body language, speech, deportment).

Besides, a competently performed history-taking and clinical examination remains the most economical way of triaging patients and directing investigations. Whilst the ubiquity of CT imaging renders much of the more arcane clinical signs we used to memorize superfluous, the results of such investigations are only validated if they tally with clinical signs, symptoms and indications. There is no getting away from examining the patient.

There is a big gulf between primary care medicine and hospital based medicine when it comes to the utility of clinical examination. It is important in both situations, but where access to diagnostic tests and imaging is not immediately available, it becomes very important indeed. Primary care is largely taken up with distinguishing between minor illnesses and life - changing ones and recognising conditions which need further referral.In this basic observations and basic clinical examination are necessary and cost effective. They also prevent over-investigation, and can prevent referral to a narrow speciality, when a more holistic approach is needed.

I agree that the element of touch creates a bond between doctor and patient, that telephone consultations, video consultations and imaging technology does not. Whether it is actually therapeutic is debatable but it does forge a therapeutic relationship, if it is carried out in a caring and sensitive way.

Like much else within medical education, the utility of clinical examination depends on context. If you are in a country or region or healthcare environment where there is limited access to investigations, then physical examination is essential

The extent to which and H&P is helpful depends wholly on a physician's ability to create an empathic and trusting relationship with his or her patient, so as to encourage open and honest communication. Talk up front is key: everything else -- diagnostic reasoning, PE, labs -- follows from that. The extent to which touch is a factor in building rapport depends of the patient’s feelings about being touched.

Mastering doctor-patient communication is not trivial, and convincing most doctors that their difficulty in history-taking is a provider and not a patient problem is more difficult still. I expect that as new medical school curricula place greater emphasis on professional and communication competencies, and as older physicians leave practice, we will eventually see an improvement.

Thank you for the chance to talk about this interesting problem.

I suspect that much also depends on the patient - and especially on their age and background. When I worked in elderly care medicine, patients would often present with non-specific symptoms such as weight loss. On the advice of my consultant I would examine all systems thoroughly. It wasn't good enough to document "gastrointestinal tract: nothing abnormal discovered" - rather all systems had to be subject to inspection, palpation, percussion, and auscultation. And what was the response of the patients? It wasn't unusual for older patients to say - "thank you - I feel better after that". What made them feel better I am not sure.

Kieran, I couldn't agree more with your observation. Most people "experience illness" which translates into "physical" health concerns which in turn is still largely perceived to be the only "acceptable reason" for seeing a doctor.

Psychoneuroimmunology has untangled the link between the "brain function" of "experience" and the "bodily correlates" that we constructed to be a "disease (https://www.researchgate.net/publication/260252278_Diagnosis_-_the_limiting_focus_of_taxonomy?ev=prf_pub)". Taking the patient's experience seriously and explore it "with your hands" is the salutogenic act that allows "self-healing" to occur in the absence of "identifyable pathology".

Article Diagnosis - the limiting focus of taxonomy