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As part of their training, medical students and postgraduates are usually required to demonstrate competency in conducting physical examination skills for graduation and advancement. This is typically done by observing them perform a checklist of physical examination maneuvers in real or standardized patients. It is important that medical educators emphasize the importance of the art of physical examination to their learners and encourage them to master it. Sir William Osler once said: "Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert." Nevertheless, a question is often asked by medical students and residents: are all the physical examination skills traditionally taught in medical schools as important now as they used to be in the past?
As I tried to explain in another paper,1 physical examination skills are essential for good medical care even in the presence of the advanced diagnostic surrogates. Yet, medical educators now need to reconsider the physical examination checklist that they use to assess the physical examination skills of their learners. The contemporary checklist should emphasize maneuvers that are useful in terms of their sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) and exclude those which no longer provide such diagnostic strength. In my own teaching, I do not criticize my learners if they omit or deemphasize certain exam maneuvers during their presentation since the data argues that these maneuvers are not statistically useful or can be replaced by other better examination tests. Here are some examples of such maneuvers that are commonly taught by medical educators.
Tactile vocal fremitus and vocal resonance
Tactile vocal fremitus (TVF) is the vibration sensation felt by the examining hand during palpation of the patient's chest wall (specifically the intercostal spaces) while the patient speaks (e.g. saying "toys for tots" or "ninety-nine"). It is commonly performed as part of the chest examination to detect pathologies such as pneumothorax or pleural effusion (decreased TVF) or consolidation (increased TVF). However, similar findings can be elicited by listening with a stethoscope...