Narrative Review: Should Teaching of the Respiratory Physical Examination Be Restricted Only to Signs with Proven Reliability and Validity?
- 987 Downloads
To review the reported reliability (reproducibility, inter-examiner agreement) and validity (sensitivity, specificity and likelihood ratios) of respiratory physical examination (PE) signs, and suggest an approach to teaching these signs to medical students.
Review of the literature. We searched Paper Chase between 1966 and June 2009 to identify and evaluate published studies on the diagnostic accuracy of respiratory PE signs.
Most studies have reported low to fair reliability and sensitivity values. However, some studies have found high specificites for selected PE signs. None of the studies that we reviewed adhered to all of the STARD criteria for reporting diagnostic accuracy.
Possible flaws in study designs may have led to underestimates of the observed diagnostic accuracy of respiratory PE signs. The reported poor reliabilities may have been due to differences in the PE skills of the participating examiners, while the sensitivities may have been confounded by variations in the severity of the diseases of the participating patients.
IMPLICATION FOR PRACTICE AND MEDICAL EDUCATION
Pending the results of properly controlled studies, the reported poor reliability and sensitivity of most respiratory PE signs do not necessarily detract from their clinical utility. Therefore, we believe that a meticulously performed respiratory PE, which aims to explore a diagnostic hypothesis, as opposed to a PE that aims to detect a disease in an asymptomatic person, remains a cornerstone of clinical practice. We propose teaching the respiratory PE signs according to their importance, beginning with signs of life-threatening conditions and those that have been reported to have a high specificity, and ending with signs that are "nice to know," but are no longer employed because of the availability of more easily performed tests.
KEY WORDSrespiratory physical examination diagnostic accuracy medical students
Conflict of Interest
- 9.Morgan WL, Engel GL, eds. The Clinical Approach to the Patient. Philadelphia: WB Saunders Co; 1969: 197–204.Google Scholar
- 11.DeGowin EL. Bedside diagnostic examination. 1st ed. New York: Macmillan Co; 1965.Google Scholar
- 12.LeBlond RF, Brown DD, DeGowin RL. DeGowin’s diagnostic examination. 9th ed. New York: McGraw-Hill; 2009.Google Scholar
- 13.Kampmeier RH. Physical examination in health and disease. 2nd ed. Philadelphia: FA Davis Co; 1957.Google Scholar
- 19.McGee S. Evidence based physical diagnosis. 2nd ed. Philadelphia: WB Saunders Co; 2007.Google Scholar
- 31.Gjorup T, Bugge PM, Jensen AM. Interobserver variation in assessment of respiratory signs. Physicians' guesses as to interobserver variation. Acta Med Scand. 1984;216:61–6.Google Scholar
- 47.Straus SE, McAlister FA, Sackett DL, Deeks JJ. The accuracy of patient history, wheezing, and laryngeal measurements in diagnosing obstructive airway disease. CARE-COAD1 Group. Clinical Assessment of the Reliability of the Examination-Chronic Obstructive Airways Disease. JAMA. 2000;283:1853–7.CrossRefPubMedGoogle Scholar
- 54.Saldias PF, Cabrera TD, de Solminihac LI, Hernandez AP, Gederlini GA, Diaz FA. Predictive value of history and physical examination for the diagnosis of community-acquired pneumonia in adults. Rev Med Chil. 2007;135:143–150.Google Scholar