Clinical examination is essential to reduce overdiagnosis and overtreatment

During a recent cardiology ward round, the consultant listened to a patient’s heart and described a harsh mid-systolic ejection murmur with a very quiet S2, on top of a higher pitched pan-systolic murmur heard best over the apex, with P2 being more audible than normal. To me this was uninterpretable. He postulated that the patient had severe aortic stenosis with moderate mitral regurgitation. Subsequent review of the echocardiography report confirmed that he was spot on. To me this was intellect and perspicacity at its most beautiful. Those with a more sceptical outlook may suppose that he had furtively inspected the echocardiography report beforehand.

Occasionally in the preceding weeks, I had found myself assessing patients and wondering whether it was worth listening to the heart and lungs if at first glance I knew that I was going to order an echocardiogram and chest x ray examination. During a hectic and time pressured on-call shift physical examination of patients can seem difficult to justify. It wasn’t until I reflected on Kinesh Patel’s view in The BMJ arguing against clinical examination that I thought, yes: it is absolutely necessary.1

Of course, I appreciate the necessity of investigations, but we rely on them too much. Some are not as good as we think. A single 12 lead echocardiogram fails to diagnose about 45% of acute myocardial infarctions.2 And other investigations detect clinically unimportant disease for which patients are then overtreated, such as computed tomography for pulmonary emboli.3

As the Stanford physician Abraham Verghese put forward in his talk at a 2011 TED conference, clinical examination is much more than inspect, palpate, percuss, and auscultate.4 Clinical examination is essential to forming a good doctor-patient relationship, and its roots interweave the history of pioneering medical greats.

As medical students, seeing and learning how to examine patients not only inspires but allows us to aspire, and it encourages academic discipline. It helps us to understand many aspects of human science: it develops the medical mind and encourages us to apply logic and to actually think. I can recall many times when examination has been the key to diagnosis. I fear for students if the only reason they can aspire to be consultants is to be able to order investigations without running it by someone else.

Some might argue that in the developed world clinical examination is a way of holding on to history and rituals, with a Western air of “we do know best,” but surely globally there are even better reasons for doctors to have good examination skills.

In many parts of the world medicine is gritty, inaccessible, and impoverished. Resources are scarce, and patients present with advanced disease. An adept understanding of the use of clinical examination is essential in these settings since other investigations may simply not be possible. What UK general practitioners have at their fingertips when assessing patients is not too dissimilar to what’s readily available in resource poor environments. When rapid access to blood tests and imaging is not available we may find that we are lost without honed clinical acumen and confidence in our senses.

And in the current financial climate in the UK, cuts in NHS budgets mean that we struggle with staffing, our emergency departments are bursting at the seams, and we have to invoke major incident response procedures because our medical wards are too full. Sadly, fingers of blame are often pointed in the direction of general practitioners. You often hear a bit of GP bashing for “inappropriate referrals” while on acute medical and surgical takes, but few secondary care doctors would have the confidence to discharge a patient without the back-up of extra investigations.

I am forever filling in forms for Wells scores and deep vein thrombosis algorithms, ticking boxes to indicate that clinical signs are present, racking up points so that the scan gets the go ahead. These algorithms were introduced to reduce overinvestigation, but they can be manipulated to reach thresholds, so what does it matter if we don’t know how to look for the signs? Sadly, our practice is becoming governed by fear of litigation so we overinvestigate and overdiagnose—and become dismayed that we are losing our autonomy. Perhaps if doctors had more confidence in examination techniques and the interpretation of signs we would have fewer referrals from primary care, have quicker discharge from secondary care, save some money, and free some beds.

Maybe clinical examination is outdated in some specialties. Perhaps this ancient dogma will go down with the NHS. Perhaps we should don the shackles of private practice and become overpaid technicians. But, and I’m sure I speak for many doctors when I say this, for those of us who want to be real physicians, clinical examination is still very much alive.