Author’s reply to Armour, Coll, Thomas, and WithamBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3989 (Published 25 June 2013) Cite this as: BMJ 2013;346:f3989
- Kinesh Patel, junior doctor1
There is a middle ground when it comes to clinical examination.1 2 3 4 5 Clearly never examining anyone is not a safe or prudent course for any medical professional. However, recognising the limitations of clinical examination is important, limitations that become more apparent as medical technology progresses and the other tools in our armamentarium become safer and more reliable than our hands.
Clinical examination, just like anything else, improves with volume. Teaching the detection of rare signs as routine is futile because that which we repeatedly do not find we discount subconsciously as unimportant. The clinical skill required to make a competent doctor is not reflected in what we teach. How many times outside an examination setting have I seen splinter haemorrhages, xanthelasma, koilonychia, peri-oral freckling, or Osler’s nodes? Yet I teach these signs to students as mandatory for every examination. There is a profound difference between being able to detect a heart murmur, which I would argue is essential, and picking up subtle pulmonary regurgitation.
We spend years teaching clinical examination to medical students and then to junior doctors. Is it really too much to expect that even a minor degree of competency be attained with an ultrasound probe during the same length of time? This really would be a forward thinking move, especially given that many doctors are now expected to use ultrasonography routinely during invasive procedures.
The traditional way of history, examination, and then investigations does not always serve patients best, and this modus operandi is likely to become increasingly disrupted by new technology in the forthcoming years, decades, and centuries. So clinical examination is not dead, but it is dying slowly both as an art form and in its utility: with the inexorable march of technology, this is one patient that is unlikely to be saved indefinitely.
Cite this as: BMJ 2013;346:f3989
Competing interests: None declared.