High marks for the physical exam
================================

* Finlay A. McAlister
* Sharon E. Straus
* David L. Sackett

We agree with Kenneth Flegel1 that the clinical examination plays a critical role in the evaluation of patients. We would like to highlight a fact often neglected by those physicians who argue for more widespread use of technologically advanced "definitive investigations" rather than "old-fashioned" tools such as the history and physical examination in the assessment of patients: definitive investigations are not always as definitive as we think. For example, experts often disagree in their interpretations of definitive investigations and the clinician's use of such test results often depends heavily on pretest clinical assessment.2 For instance, we would view 1.8 mm of ST depression on an exercise stress test very differently in a 55-year-old man with a history of exertional, crushing retrosternal chest pain than in a 20-year-old woman with a history of fleeting, non-exertional, stabbing left-sided chest pain.3

However, despite the importance of the clinical examination, reviews of the literature consistently reveal substantial gaps in the knowledge base.2 Many of the physical examination pearls we were taught in medical school have never been properly evaluated. This presents a quandary: should we cast aside all signs or symptoms that have not been validated in rigorous studies, or continue to use and teach all but those that have been disproven? We believe this question is unanswerable and such a debate will generate far more heat than light; instead, we view this situation as a rallying call for clinicians to reevaluate what we do. We call on our colleagues to join us in an international collaborative effort to design and execute large, simple studies of the history and physical examination. Since the inception of the CARE (Clinical Assessment of the Reliability of the Examination) group 1 year ago, over 350 clinicians from 30 different countries have joined the group and have carried out 2 of the 3 largest high-quality studies ever done assessing the accuracy of the clinical examination for obstructive airways disease (manuscripts currently under review). The CARE group ([www.carestudy.com](http://www.carestudy.com)) is open to health care professionals at any stage of training and in any setting, and all members can participate in the design, execution and analysis of these studies.

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## References

1.  1. Flegel KM. Does the physician examination have a future? CMAJ 1999;161:1117-8.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMDoiMTYxLzkvMTExNyI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xNjIvNC80OTMuMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  2. McAlister FA, Straus SE, Sackett DL, on behalf of the CARE-COAD1 group. Why we need large, simple studies of the clinical examination: the problem and a proposed solution. Lancet 1999;354:1721-4.
    
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3.  3. Diamond GA, Forester JS. Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. N Engl J Med 1979;300:1350-8.
    
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    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=A1979GY53800002&link_type=ISI)