Letters Bad medicine: chest examination

The reliable clinical examination

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4990 (Published 23 July 2012) Cite this as: BMJ 2012;345:e4990
  1. Michael Newnham, respiratory registrar1,
  2. Naveed Mustfa, consultant in respiratory medicine1
  1. 1University Hospital of North Staffordshire, Stoke on Trent ST4 6QG, UK
  1. michaelnewnham{at}hotmail.com

We echo Spence’s sentiments that the clinical examination could be improved.1 In our experience, doctors teach and assess in a traditional rather than evidence based manner. Reliability is the agreement between doctors that a clinical sign can be independently elicited in the same patient when it is present.

When learning and applying the respiratory examination, doctors should know the reliability of the different elements; studies have identified these based on kappa coefficient values (−1 very unreliable, 1 very reliable). On this scale, percussion note has a reliability of 0.52 whereas tactile vocal fremitus has a value of only 0.01 (wheeze 0.51, crackles 0.41, chest expansion 0.38, whispering pectoriloquy 0.11, tracheal position 0.01, tactile vocal fremitus 0.01).2

Furthermore, clinical examination can be refined to specific clinical presentations such as suspected pneumonia or pleural effusion.3 4 Interestingly, clinicians naturally perform the more reliable elements of the respiratory examination, and students have good knowledge of the reliability, an effect enhanced by experience.5

We disagree that chest examination is largely redundant. However, examination must be adapted to suit the situation and accept the limitations. In an age of rapidly advancing investigations, chest examination still has a role in refining or altering a working diagnosis based on symptoms. Further studies are required to guide evidence based stratification and diagnosis. We agree that we need to move towards an evidence based approach to performing, teaching, and assessing chest examination rather than stay with the traditional regimen.


Cite this as: BMJ 2012;345:e4990


  • Competing interests: None declared.


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