Why teach medical students aspects of the respiratory examination that do not aid in diagnosis?

Dear Sir

For years medical students worldwide have been taught the long routine of the respiratory clinical examination and rehearse it religiously so that it can be repeated in their clinical OSCE's. However, it is unlikely that they require all aspects of the taught clinical examination to develop a differential diagnosis. There is much evidence to demonstrate that certain aspects are less reliable and have low specificity, most notably tactile vocal fremitis, whispering pectoriloquy and tracheal deviation (Benbassat and Baumal 2010). We do not teach our medical students to carry out investigations that have very low specificities, therefore why do we teach them to carry out examinations that do?

We hypothesised that doctors only carry out aspects of the respiratory examination that aid diagnosis in clinical practice. To find out whether this is true, a questionnaire was sent out to all doctors in a large teaching trust. 105 responses were received from a range of different grades and specialities, including 10 respiratory specialists. The results overwhelmingly showed that the majority of doctors do not carry out tactile vocal fremitis, whispering pectoriloquy and vocal resonance and only sometimes carry out tracheal deviation. Doctors also felt less confident picking up signs with aspects of the respiratory examination that are less reliable.

Medical students should be taught to perform the respiratory examination with the aim of exploring a diagnostic hypothesis. When teaching the respiratory examination, focus should be given to the more reliable aspects of the examination, which can aid the diagnosis of life threatening conditions. Less reliable aspects should be mentioned as “nice to know” but do not necessarily have to be performed routinely and should not be assessed in OSCE's.

Rahil H. Kassamali, Rahul Mukherjee, Heart of England NHS Foundation Trust, Birmingham, UK. E-mail: [email protected]

Saqib Noor, Royal Orthopaedic NHS Trust, Birmingham, UK