The Rational Clinical Examination To the Editor.\p=m-\Iwas pleased to read your introduction to the new series on clinical examination. I thought the initial article1 and Editorial2 were both excellent. I would like to present the following case to pose a question: Four weeks ago, an 82-year-old woman came into my office with a 1-month history of right leg swelling. During this month, she had three separate episodes of pleuritic chest pain, the first two of which resolved spontaneously. She came to the office after the third episode of pain. On examination, she was found to have r\l=a^\lesmedial to her left scapula without audible rub. Her right leg was swollen and tender with a circumference of 40 cm compared with a left leg circumference of 35 cm. I felt absolutely certain that she had a deep-vein thrombosis with recurrent pulmonary emboli. I admitted her to the hospital where a venous Doppler study showed a proximal thrombus with the proximal end of the clot waving in the current. A perfusion lung scan showed several peripheral defects in both lungs and was interpreted as having high probability for pulmonary embolus. In this instance, the expensive imaging studies in reality added nothing to the diagnosis and treatment of this patient. In such a case, would you feel comfortable to start a patient on heparin and commit them to anticoagulant therapy on the basis of the history and clinical examination without confir¬ matory imaging studies? If such a decision was questioned during the quality assurance audit, how would you respond? Neal Devitt, MD University of New Mexico School of Medicine Santa Fe 1. Sackett DL. A primer on the precision and accuracy of the clinical examination. JAMA. 1992;267:2638-2644. 2. Sackett DL, Rennie D. The science of the art of the clinical examination. JAMA.
1992;267:2650-2652.
To the Editor.\p=m-\Inthe May 20th issue of JAMA, the word majuscular appears on page 2650.1 Do you know what the author means by this reference to a printing term implying a capital? Is it a slang term in his circle? Does it have meaning? Do the readers of the JAMA deserve this word? The article is otherwise interesting and useful. Robert K. Horton, MD Sacramento, Calif 1. Sackett
DL, Rennie D. The science of the art of the clinical examination. JAMA. 1992;267:2650-2652.
To the Editor.\p=m-\Manyof us have high hopes for the series JAMA will publish on the science and art of clinical examination1 because our traditional methods require objectification and reevaluation in the light of continuous acquisition of knowledge. I hope the authors will emphasize those elements that have been not only tested by verifiable standards, but also by appropriately designed observer variability studies. Time-honored methods can become time-dishonored when subjected to closer scrutiny. For example, there is only one interobserver study of the bedside estimation of aortic stenosis via the rate of rise of the carotid pulse.2 In prospective, mutually blinded, sequential examinations of patients referred to an echocardiographic laboratory, three well-trained obEdited by Drummond Rennie, MD, Deputy Editor (West), and Bruce B. Dan, MD, Senior Editor.
could not reach any statistically significant agreements. Moreover, there was no agreement with quantitative measurements of the blindly recorded carotid displacement servers
pulse.2 This study engendered no controversy even in the journal's active letters section or by contrary investigations. The fully developed pericardial rub during sinus rhythm was finally established as usually three-component—not the text¬ book's "to-and-fro" phenomenon by multiple-observer stud¬ ies further objectified (for timing) by phonocardiography.3 Comparable work with the fourth heart sound has, in con¬ trast, engendered a certain amount of dispute.4 I hope the authors will set the parameters for adequate evaluation of items like jugular venous pulsation, which at the bedside is rarely as "clean" as is depicted in textbooks and is, perhaps, frequently impossible at high heart rates and with poor neck tissue.
As laboratory science must be held to external standards, bedside science must equally be technically objectified24 and quantified with appropriate sensitivities, specificities, and predictive values for each method for each population. David H. Spodick, MD, DSc
University of Massachusetts Medical School Worchester
1. Sackett
DL, Rennie D. The science of the art of the clinical examination. JAMA. 1992;267:2650-2652. Spodick DH, Sugiura T, Doi YL, Paladino D, Haffty BG. Rate of rise of the ca-
2.
rotid pulse: an investigation of observer error in a common measurement. Am J Cardiol. 1982;49:159-162. 3. Spodick DH. The pericardial rub: a prospective, multiple observer investigation of pericardial friction in 100 patients. Am J Cardiol. 1975;35:357-362. 4. Spodick DH, Quarry VM. Prevalence of the fourth heart sound by phonocardiography in the absence of cardiac disease. Am Heart J. 1974;87:11-14.
To the Editor.\p=m-\DrSackett1 is to be commended for his statistical approach to the problems of clinical diagnosis. I hope that this type of logic becomes more popular among physicians. One reason that this type of thinking has not yet taken hold may be because of physicians' fears of liability when they rely on clinical judgment and not on test results. For example, in the case of possible ascites in an alcoholic patient cited by Sackett, if a physician is 90% sure that the patient does not have ascites based on his clinical acumen and does not order a confirmatory test, he may be held accountable for complications of that problem if his diagnosis is wrong. On the other hand, he will never be criticized (except perhaps in Sackett's teaching program) or sued for obtaining an abdominal ultrasonogram. Another problem I have with Sackett's calculations is with
Guidelines for Letters Letters will be published at the discretion of the editors as space permits and are subject to editing and abridgment. They should be typewritten double-spaced and submitted in duplicate. They should not exceed 500 words of text. References, if any, should be held to a minimum, preferably five or fewer. Letters discussing a recent JAMA article should be received within 1 month of the article's pub¬ lication. Letters must not duplicate other material published or sub¬ mitted for publication. A signed statement for copyright, authorship responsibility, and financial disclosure is essential for publication. Letters not meeting these guidelines are generally not acknowl¬ edged. We do not routinely return unpublished letters. Also see In¬ structions for Authors.
Downloaded From: http://jama.jamanetwork.com/ by a Georgetown University Medical Center User on 05/24/2015
the idea of pretest probability. This figure, in the example cited, is not arrived at with any precision, and is based on the gut feeling of the clinician. How then can it be relied on to calculate posttest probabilities?
Joseph M. Scheller,
MD
Children's National Medical Center Washington, DC
1. Sackett DL. A primer on the JAMA. 1992;267:2638-2644.
precision and accuracy of the clinical examination.
To the Editor.\p=m-\Thearticle by Drs Williams and Simel1 is a laudable contribution to the study of bedside diagnosis to which JAMA has wisely made a commitment. I would like to add some additional comments concerning the diagnosis of ascites by physical examination. In my experience, the combination of abdominal distention, bulging flanks, and an everted umbilicus is almost always due to ascites. Rarely, false positives such as a large ovarian cyst will produce this sign. Unfortunately, the sign of the everted umbilicus has not been subjected to rigorous study. A valuable technique taught by Jack Myers, MD, (famed clinician and professor emeritus at the University of Pittsburgh [Pa]) consists of placing the examiner's hands, volar side up, under both bulging flanks of the supine patient, followed by flicking the flanks upward a few inches. If ascites is present, a fluid wave will be felt falling into the flanks. Myer's maneuver in the hands of those experienced with it is as accurate as the conventional technique and has the advantage of not requir¬ ing an assistant. Useful for detecting small amounts of fluid is the percussion variant of the "puddle sign" advocated by Osier in 1898.2 It requires placing the patient in the kneeelbow position, but since a stethoscope is not required, it is easier to interpret for many physicians. This technique can still be quite useful when other signs of ascites are equivocal and the patient can cooperate. Finally, one must realize that the science of bedside diag¬ nosis will always be somewhat limited by the human element (ie, not all examiners are created equal). This limitation should not dissuade us from trying to perfect as far as possible the scientific use of such techniques, although it should at times qualify our judgments. This is evidenced in the significant ranges of sensitivity and specificity reported in most studies of physical examination. The sensitivity of a fluid wave was .50 in the study by Cattau et al3 and .80 in that of Williams and Simel.1 In a study by Cummings et al,4 bulging flanks had a specificity of .70, yet the specificity was only .44 in the study by Cattau et al.8 Examiner 3 in the study by Cattau et al was much more accurate than his colleagues and for him the puddle sign was much more sensitive (15 of 19 patients). In fairness to Cattau et al, one must realize that their study was exclusively directed toward the diagnosis of "equivocal" ascites. Also, most of these studies do not comment on how often an obvious modifier—obesity—was present. In thin patients, one would find the sensitivity and specificity of the classical signs of ascites to be quite good. Guarino's methods are quite accurate in his hands, yet auscultatory percussion has never quite caught on because it, like the auscultatory puddle sign, involves using the stethoscope in percussion, a technique that is not usually taught in medical schools or even mentioned in many of the current physical diagnosis text¬ books.5 One textbook that does superficially describe this technique concludes that "none of these maneuvers is specific or reliable and generally all have been replaced by sonographic examination of the abdomen."6 What is unfamiliar is often described as cumbersome and of little use, as is obvious if one remembers how Laenec's 19th-century colleagues responded to the use of the stetho¬ scope. Unfortunately, such human foibles are still with us and
will
always techniques.
limit to
some
extent the accuracy of bedside
Those who wish to relegate physical diagnosis to the scrap heap are mistaken; these physicians simply may not be very good at it. Dr Myers often summed this up by saying, "If a marble is found in a room, that is a positive observation. If the doctor finds no marble in searching the room, it may mean there is no marble there, but many times it will mean that the doctor is not good at finding marbles."7 Michael G. Lamb, Wexford, Pa
MD
1. Williams JW, Simel DL. Does this patient have ascites? how to divine fluid in the abdomen. JAMA. 1992;267:2645-2648. 2. Osler W. The Principles and Practice of Medicine. New York, NY: D Appleton and Co; 1898:470-471. 3. Cattau EL, Benjamen FB, Knuff TE, Castell DO. The accuracy of physical examination in the diagnosis of ascites. JAMA. 1982;247:1164-1166. 4. Cummings S, Papadakis M, Melnick J, Gooding GAW, Tierney LM. The predictive value of the physical examination for ascites. West J Med. 1985;142:633-639. 5. Guarino JR. Auscultatory percussion to detect ascites. N Engl J Med. 1986;315: 1555-1556. 6. Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby's Guide to Physical Examination. St Louis, Mo: Mosby Year Book Inc; 1988. 7. Wagners GS, Cebe B, Rozear MP, Stead EA. What This Patient Needs Is a Doctor. Durham, NC: Duke University Press; 1988:168.
In Reply.\p=m-\ConcerningDr Devitt's patient with a history and physical examination strongly suggesting deep-vein thrombosis and pulmonary embolism, both of us (as well as the chief of one of our hospital's thromboembolism service) would have started heparin "on spec" at the conclusion of our examination. However, given the imperfect specificity of her symptoms and signs (which will be the topic of a later overview in this series) and in light of the risks of anticoagulation and of labeling her a vasculopath, we also would have ordered one of the noninvasive tests for deep-vein thrombosis. If that initial investigation was positive, we would have stopped testing, continued her heparin, and prepared to switch her treatment over to long-term therapy with warfarin sodium. Only if noninvasive testing for deep-vein thrombosis was negative would we have proceeded to lung scanning or invasive testing. Finally, if we found the above course of action challenged by a quality assurance audit, we would have posed the question that is central to this entire series: "What's your evidence for challenging that?" The editors can assure Dr Horton that they indeed know what the authors mean by the term "majuscular," one of the authors being one of the editors. It is a favorable conjunction or combination of "majestic" and "muscular," as in "Ben Johnson's anabolic steroids spawned a majuscular display of sprinting." We thought that the word nicely described many of the new diagnostic technologies. Its other meaning, de¬ rived from the fact that "majuscule" is the opposite of "mi¬ nuscule," means large or capital, of course, and usually is applied to letters. We admit our usage is slangy, but suggest that journals worth reading must celebrate language, and suggest new uses for good, old words. As another Johnson, Samuel, ought to have said, to limit to this minuscule role such a powerful adjective would be less than majuscular. The readers of JAMA have always deserved this word. It wasn't until Horton's letter that we realized how much they
needed it.
David L. Sackett, MD McMaster University Hamilton, Ontario Drummond Rennie, MD American Medical Association Chicago, Ill
In Reply.\p=m-\Onbehalf of the over 60 collaborators in The Rational Clinical Examination enterprise, I thank our cor-
Downloaded From: http://jama.jamanetwork.com/ by a Georgetown University Medical Center User on 05/24/2015
1992;267:2650-2652.
To the Editor.\p=m-\Inthe May 20th issue of JAMA, the word majuscular appears on page 2650.1 Do you know what the author means by this reference to a printing term implying a capital? Is it a slang term in his circle? Does it have meaning? Do the readers of the JAMA deserve this word? The article is otherwise interesting and useful. Robert K. Horton, MD Sacramento, Calif 1. Sackett
DL, Rennie D. The science of the art of the clinical examination. JAMA. 1992;267:2650-2652.
To the Editor.\p=m-\Manyof us have high hopes for the series JAMA will publish on the science and art of clinical examination1 because our traditional methods require objectification and reevaluation in the light of continuous acquisition of knowledge. I hope the authors will emphasize those elements that have been not only tested by verifiable standards, but also by appropriately designed observer variability studies. Time-honored methods can become time-dishonored when subjected to closer scrutiny. For example, there is only one interobserver study of the bedside estimation of aortic stenosis via the rate of rise of the carotid pulse.2 In prospective, mutually blinded, sequential examinations of patients referred to an echocardiographic laboratory, three well-trained obEdited by Drummond Rennie, MD, Deputy Editor (West), and Bruce B. Dan, MD, Senior Editor.
could not reach any statistically significant agreements. Moreover, there was no agreement with quantitative measurements of the blindly recorded carotid displacement servers
pulse.2 This study engendered no controversy even in the journal's active letters section or by contrary investigations. The fully developed pericardial rub during sinus rhythm was finally established as usually three-component—not the text¬ book's "to-and-fro" phenomenon by multiple-observer stud¬ ies further objectified (for timing) by phonocardiography.3 Comparable work with the fourth heart sound has, in con¬ trast, engendered a certain amount of dispute.4 I hope the authors will set the parameters for adequate evaluation of items like jugular venous pulsation, which at the bedside is rarely as "clean" as is depicted in textbooks and is, perhaps, frequently impossible at high heart rates and with poor neck tissue.
As laboratory science must be held to external standards, bedside science must equally be technically objectified24 and quantified with appropriate sensitivities, specificities, and predictive values for each method for each population. David H. Spodick, MD, DSc
University of Massachusetts Medical School Worchester
1. Sackett
DL, Rennie D. The science of the art of the clinical examination. JAMA. 1992;267:2650-2652. Spodick DH, Sugiura T, Doi YL, Paladino D, Haffty BG. Rate of rise of the ca-
2.
rotid pulse: an investigation of observer error in a common measurement. Am J Cardiol. 1982;49:159-162. 3. Spodick DH. The pericardial rub: a prospective, multiple observer investigation of pericardial friction in 100 patients. Am J Cardiol. 1975;35:357-362. 4. Spodick DH, Quarry VM. Prevalence of the fourth heart sound by phonocardiography in the absence of cardiac disease. Am Heart J. 1974;87:11-14.
To the Editor.\p=m-\DrSackett1 is to be commended for his statistical approach to the problems of clinical diagnosis. I hope that this type of logic becomes more popular among physicians. One reason that this type of thinking has not yet taken hold may be because of physicians' fears of liability when they rely on clinical judgment and not on test results. For example, in the case of possible ascites in an alcoholic patient cited by Sackett, if a physician is 90% sure that the patient does not have ascites based on his clinical acumen and does not order a confirmatory test, he may be held accountable for complications of that problem if his diagnosis is wrong. On the other hand, he will never be criticized (except perhaps in Sackett's teaching program) or sued for obtaining an abdominal ultrasonogram. Another problem I have with Sackett's calculations is with
Guidelines for Letters Letters will be published at the discretion of the editors as space permits and are subject to editing and abridgment. They should be typewritten double-spaced and submitted in duplicate. They should not exceed 500 words of text. References, if any, should be held to a minimum, preferably five or fewer. Letters discussing a recent JAMA article should be received within 1 month of the article's pub¬ lication. Letters must not duplicate other material published or sub¬ mitted for publication. A signed statement for copyright, authorship responsibility, and financial disclosure is essential for publication. Letters not meeting these guidelines are generally not acknowl¬ edged. We do not routinely return unpublished letters. Also see In¬ structions for Authors.
Downloaded From: http://jama.jamanetwork.com/ by a Georgetown University Medical Center User on 05/24/2015
the idea of pretest probability. This figure, in the example cited, is not arrived at with any precision, and is based on the gut feeling of the clinician. How then can it be relied on to calculate posttest probabilities?
Joseph M. Scheller,
MD
Children's National Medical Center Washington, DC
1. Sackett DL. A primer on the JAMA. 1992;267:2638-2644.
precision and accuracy of the clinical examination.
To the Editor.\p=m-\Thearticle by Drs Williams and Simel1 is a laudable contribution to the study of bedside diagnosis to which JAMA has wisely made a commitment. I would like to add some additional comments concerning the diagnosis of ascites by physical examination. In my experience, the combination of abdominal distention, bulging flanks, and an everted umbilicus is almost always due to ascites. Rarely, false positives such as a large ovarian cyst will produce this sign. Unfortunately, the sign of the everted umbilicus has not been subjected to rigorous study. A valuable technique taught by Jack Myers, MD, (famed clinician and professor emeritus at the University of Pittsburgh [Pa]) consists of placing the examiner's hands, volar side up, under both bulging flanks of the supine patient, followed by flicking the flanks upward a few inches. If ascites is present, a fluid wave will be felt falling into the flanks. Myer's maneuver in the hands of those experienced with it is as accurate as the conventional technique and has the advantage of not requir¬ ing an assistant. Useful for detecting small amounts of fluid is the percussion variant of the "puddle sign" advocated by Osier in 1898.2 It requires placing the patient in the kneeelbow position, but since a stethoscope is not required, it is easier to interpret for many physicians. This technique can still be quite useful when other signs of ascites are equivocal and the patient can cooperate. Finally, one must realize that the science of bedside diag¬ nosis will always be somewhat limited by the human element (ie, not all examiners are created equal). This limitation should not dissuade us from trying to perfect as far as possible the scientific use of such techniques, although it should at times qualify our judgments. This is evidenced in the significant ranges of sensitivity and specificity reported in most studies of physical examination. The sensitivity of a fluid wave was .50 in the study by Cattau et al3 and .80 in that of Williams and Simel.1 In a study by Cummings et al,4 bulging flanks had a specificity of .70, yet the specificity was only .44 in the study by Cattau et al.8 Examiner 3 in the study by Cattau et al was much more accurate than his colleagues and for him the puddle sign was much more sensitive (15 of 19 patients). In fairness to Cattau et al, one must realize that their study was exclusively directed toward the diagnosis of "equivocal" ascites. Also, most of these studies do not comment on how often an obvious modifier—obesity—was present. In thin patients, one would find the sensitivity and specificity of the classical signs of ascites to be quite good. Guarino's methods are quite accurate in his hands, yet auscultatory percussion has never quite caught on because it, like the auscultatory puddle sign, involves using the stethoscope in percussion, a technique that is not usually taught in medical schools or even mentioned in many of the current physical diagnosis text¬ books.5 One textbook that does superficially describe this technique concludes that "none of these maneuvers is specific or reliable and generally all have been replaced by sonographic examination of the abdomen."6 What is unfamiliar is often described as cumbersome and of little use, as is obvious if one remembers how Laenec's 19th-century colleagues responded to the use of the stetho¬ scope. Unfortunately, such human foibles are still with us and
will
always techniques.
limit to
some
extent the accuracy of bedside
Those who wish to relegate physical diagnosis to the scrap heap are mistaken; these physicians simply may not be very good at it. Dr Myers often summed this up by saying, "If a marble is found in a room, that is a positive observation. If the doctor finds no marble in searching the room, it may mean there is no marble there, but many times it will mean that the doctor is not good at finding marbles."7 Michael G. Lamb, Wexford, Pa
MD
1. Williams JW, Simel DL. Does this patient have ascites? how to divine fluid in the abdomen. JAMA. 1992;267:2645-2648. 2. Osler W. The Principles and Practice of Medicine. New York, NY: D Appleton and Co; 1898:470-471. 3. Cattau EL, Benjamen FB, Knuff TE, Castell DO. The accuracy of physical examination in the diagnosis of ascites. JAMA. 1982;247:1164-1166. 4. Cummings S, Papadakis M, Melnick J, Gooding GAW, Tierney LM. The predictive value of the physical examination for ascites. West J Med. 1985;142:633-639. 5. Guarino JR. Auscultatory percussion to detect ascites. N Engl J Med. 1986;315: 1555-1556. 6. Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby's Guide to Physical Examination. St Louis, Mo: Mosby Year Book Inc; 1988. 7. Wagners GS, Cebe B, Rozear MP, Stead EA. What This Patient Needs Is a Doctor. Durham, NC: Duke University Press; 1988:168.
In Reply.\p=m-\ConcerningDr Devitt's patient with a history and physical examination strongly suggesting deep-vein thrombosis and pulmonary embolism, both of us (as well as the chief of one of our hospital's thromboembolism service) would have started heparin "on spec" at the conclusion of our examination. However, given the imperfect specificity of her symptoms and signs (which will be the topic of a later overview in this series) and in light of the risks of anticoagulation and of labeling her a vasculopath, we also would have ordered one of the noninvasive tests for deep-vein thrombosis. If that initial investigation was positive, we would have stopped testing, continued her heparin, and prepared to switch her treatment over to long-term therapy with warfarin sodium. Only if noninvasive testing for deep-vein thrombosis was negative would we have proceeded to lung scanning or invasive testing. Finally, if we found the above course of action challenged by a quality assurance audit, we would have posed the question that is central to this entire series: "What's your evidence for challenging that?" The editors can assure Dr Horton that they indeed know what the authors mean by the term "majuscular," one of the authors being one of the editors. It is a favorable conjunction or combination of "majestic" and "muscular," as in "Ben Johnson's anabolic steroids spawned a majuscular display of sprinting." We thought that the word nicely described many of the new diagnostic technologies. Its other meaning, de¬ rived from the fact that "majuscule" is the opposite of "mi¬ nuscule," means large or capital, of course, and usually is applied to letters. We admit our usage is slangy, but suggest that journals worth reading must celebrate language, and suggest new uses for good, old words. As another Johnson, Samuel, ought to have said, to limit to this minuscule role such a powerful adjective would be less than majuscular. The readers of JAMA have always deserved this word. It wasn't until Horton's letter that we realized how much they
needed it.
David L. Sackett, MD McMaster University Hamilton, Ontario Drummond Rennie, MD American Medical Association Chicago, Ill
In Reply.\p=m-\Onbehalf of the over 60 collaborators in The Rational Clinical Examination enterprise, I thank our cor-
Downloaded From: http://jama.jamanetwork.com/ by a Georgetown University Medical Center User on 05/24/2015
