Bad medicine: chest examination
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4569 (Published 04 July 2012) Cite this as: BMJ 2012;345:e4569
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Most of the reasons I think chest examination (with hands and tubes) is still essential have already been made in preceding rapid responses. To these I would add a few more:
- The lack of radiation exposure entailed in chest examination (except perhaps in Cornwall or Aberdeen)
- CXRs are not uncommonly normal whilst symptoms and clinical examination suggests interstitial lung disease, which is then confirmed on CT thorax. Clinical examination justifies the CT request. Or does Des suggest we do CTPA with hi res cuts (plus full pulmonary function tests including gas transfer) on everyone with breathlessness, every time?
- The ability to repeat examinations at will to monitor treatment, at the bedside, allowing rapid (re-)assessment without needing to wait for lab/Xray results. I would not like to be cared for by a doctor who has eschewed the stethoscope
I agree that clinical exam findings change rapidly with time, and are sometimes difficult to elicit, which makes them more variable. Like history taking, clinical respiratory examination is a skill which must be maintained and refined over a lifetime, and elements applied selectively (especially the more arcane, such as tactile vocal resonance).
On my ward rounds I cheerfully acknowledge to students and junior doctors that the signs I elicit (or fail to) may not be in concordance with lab/radiological findings at that point - but that is a starting point for discussion and thought rather than a reason to put my stethoscope away.
Come along to a respiratory X-ray meeting Des!
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I can not agree more with the author. He raised an issue which many find controversial though it is as clear as water.
Physical signs are unreliable, have very high interobserver variability most of the time making them useless in terms of changing the management of the patient.
I think we need to readdress all physical signs/techniques page by page inlight of new tests and come up with a guideline regarding their usefulness. They may be useful in a jungle where you do not have any tests available but in a modern healthcare facility, they are waste of time, most of the time.
I still remember my MRCP paces, where on one case, I got 4(clear pass) from one examiner, and 1 (clear fail) from another. It means 2 out of 3 of us, were wrong. Unfortunately, I was the one who had to take the test again.
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Once again Spence has some interesting and provocative things to say. Whilst it is always appropriate to reassess why and how we do and teach things, suggesting we ditch teahcing clinical signs seems a step to far.
Understanding the mechanisms involved in the production of classical physical signs be they stoney dullness, vocal resonance or mid-diastolic rumbles is crucial to the understanding of disease processes and the scientific basis for medicine.
I agree, the signs are not always textbook in nature or even there, but the process of thinking about which signs you are looking for and why, in every patient directly informs your diagnostic reasoning.
It is definitely not time to stop teaching out students about the importance of clinical examination.
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In his highly readable articles on Bad Medicine, Spence often rightly raises issues too controversial to be discussed in a more formal context. I too am sceptical about the value of some of the clinical signs we were taught as students, in a manner of almost religious fervour. However, this attitude must not be extended to clinical examination in general. Surely clinicians should be able to distinguish a rib from a breast lump, or diagnose a sebaceous cyst or a hernia without an ultrasound scan? If, as he implies, chest auscultation is replaced by an Xray, how will our radiology departments cope with the demand; or will they be performed by untrained enthusiasts in primary care whose opinion is of limited value?
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The reliable clinical examination.
We echo Spence’s sentiments that the clinical examination could be improved.1 In our experience of the respiratory examination, we often teach and assess medical students and doctors performing the examination in a traditional way rather than based on evidence.2 Reliability (or inter-observer reliability) is the agreement between physicians that a clinical sign can be independently elicited in the same patient when it is present.
When learning and applying the respiratory examination, we should have knowledge of the reliability of the different elements. Studies have identified the reliability of different elements of the respiratory examination based on Cohen’s kappa coefficient values; a reliability scale where -1 is very unreliable and +1 is very reliable. On this scale, for example, percussion note has a reliability of 0.52 whereas tactile vocal fremitus only has a value of 0.01 – making it no better than chance (Other kappa values; wheeze 0.51, crackles 0.41, chest expansion 0.38, whispering pectoriloquy 0.11, tracheal position 0.01, tactile vocal fremitus 0.01).3 Furthermore, the rational clinical examination series sought to refine clinical examination to suit specific clinical presentation (addressing reliability and validity); such as in suspected pneumonia or pleural effusion.4,5 There is a need for further studies within this area to guide evidence based stratification and diagnosis.
Studies have shown that doctors naturally perform the more reliable elements of the respiratory examination.6 Medical students also have good knowledge of the reliability of elements of the respiratory examination and correctly value percussion note, wheeze and crackles as being the most reliable. Furthermore, as their experience increases, they correctly associate signs such as whispering pectoriloquy as being less reliable.7
We disagree with Spence that chest examination is largely redundant; however we must adapt our clinical examination to suit the clinical situation and it is essential for doctors and students to have knowledge of the reliability and limitations of elements of the examination. Surprisingly, few studies address the interplay of symptoms and signs in an evidence based manner. In an age of rapidly advancing investigations, chest examination still has a role in refining or altering a working diagnosis based on symptoms. We agree that we need to move towards an evidence based approach to performing, teaching and assessing chest examination, for students and doctors, rather than the traditional dogmatic regime.
References
1) Spence D. Bad medicine: chest examination. BMJ 2012;345:e4569
2) Sackett DL. The rational clinical examination. A primer on the precision and accuracy of the clinical examination. JAMA 1992;267:2638–44.
3) Spiteri MA, Cook DG and Clarke SW. Reliability of eliciting physical signs in examination of the chest. Lancet 1988;1:873–5.
4) Metlay JP, Wishwa N, Kapoor MD. Does this patient have community acquired pneumonia? JAMA. 1997;278(17):1440-1445
5) Wong CL, Holroyd-Leduc J, Straus SE. Does this patient have a pleural effusion? JAMA 2009;301(3):309-317
6) Kassamali RH, Noor S, Mukherjee R. Rational clinical examination: A survey of the application of clinical skills taught in respiratory medicine. Proceedings of the Association for Medical Education in Europe 2010;11W15:473.
7) Newnham M, Jones E, Wall D, Mukherjee R, The reliability of the respiratory physical examination. Thorax 2012;66(4):A143
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Like many other correspondents I still enjoy reading Des’s polemics, although they probably tell us more about Des than about Medicine. I think we all agree that continual reappraisal of what we learn at Medical School is essential to keep practice relevant. If Des prompts even a few people to question dogma, the effort of writing his pieces might not be wasted; the problem is that his iconoclastic approach sometimes results in his substituting his own (evidence-free) dogmas for those of, possibly long-dead, teachers.
There was one potentially dangerous piece of Des dogma in this most recent article, “If patients have detectable signs they will also have symptoms”. This is frankly wrong for a number of signs where detection of the abnormality very commonly occurs before any symptoms but where it may be important then to investigate and act before symptoms occur. Others may well add their own examples but, in the chest, one concern might be not to miss even asymptomatic aortic stenosis. I appreciate that we need to distinguish between population screening (often of unproven benefit) and opportunistic examination of patients who may present for any number of reasons but where failure to forestall serious consequences of asymptomatic abnormalities can compromise both patient and doctor.
I can’t remember many occasions where Des has changed his mind in the face of even unanimous criticism but I live in hope. I would have to agree with him about the pointlessness of examining patients if the doctor is unable to elicit or interpret signs.
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It is increasingly unclear to me what motivates Des Spence other than his weekly attempts to be a rebellious iconoclast. Those of us who bother to use a stethoscope know full well, through continual practice that many signs are worthless and have subconsciously stopped using them. By contrast, we have realised that many signs are very useful and our diagnoses made at examination are confirmed by subsequent investigation. It strikes me that the very essence of 'bad medicine' is laziness. Too lazy to listen, Des?
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Cursory medical examination can be carried to extraordinary lengths as revealed by one of my relatives presenting to a doctor complaining of cough, not undergoing chest auscultation and being prescribed nose drops. When, an hour later, I took 1 minute of my time to listen to her chest, the obvious inspiratory and expiratory wheeze confirmed the need for more appropriate treament. Bad medicine? Indeed.
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I usually agree with Dr Spence, but not this time. Of course we should do the best we can for our patients, and most of the time that will mean getting the right investigations done as soon as possible. But sometimes clinical skills are all we have - for such as sick elderly patients in remote rural areas who don't want to go to hospital, or for frail terminally ill people at home or in a hospice who want comfort and symptomatic treatment with minimal disturbance. For those circumstances I think with practice you can improve your skills at distinguishing LVF, say, from infection or effusion; and your patients will be glad of it. And I'd rather be treated by a careful, listening doctor with a stethescope than some of the dead-eyed box-tickers [not usually their fault].
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Re: Bad medicine: chest examination
The chest examination taught to Dr Spence has undoubtedly been suboptimal (1). He says that he agreed that he had heard crepitations even when he had not, and eventually concluded that doctors continue to pretend hearing signs that they haven't. He denies the value of crepitation, a sign he considers to be of a bygone era, and concludes that definitive investigations should be organised on the basis of symptoms, irrespective of clinical findings.
Crepitations, an outdated term, include the velcro crackles (similar to the sound heard when gently separating the joined strip of velcro on the blood pressure cuff or jogging shoes) which are indeed a major sign of interstitial lung disease, especially idiopathic pulmonary fibrosis (IPF). IPF is a devastating disorder leading to death within a few years with no treatment available for long. Patients are still diagnosed at a too late a stage. However, two drugs - namely, pirfenidone and nintedanib - have recently demonstrated a benefit in patients with mild to moderate IPF, and a number of clinical trials have been conducted. We thus consider that velcro crackles present in almost all patients with IPF should be highlighted in good medicine teaching. Their finding at auscultation should prompt high resolution computed tomography and lung function tests to diagnose interstitial lung disease, especially IPF at an earlier stage with treatment possible (2,3). Neglecting velcro crackles as an early sign of IPF would be an unacceptable fault.
1. Spence D. Bad medicine : chest examination. BMJ 2012 : 345 : e4569
2. Cottin V, Cordier JF. Velcrocrackles : the key for early diagnosis of idiopathic pulmonary fibrosis. Eur Respir J 2012 : 40 : 519-21
3. Cottin V, Cordier JF. Subclinical interstitial lung disease : no place for crackles. Am J Respir Crit Care Med 2012 ; 186 : 289
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