Teaching Physical Diagnosis of the Chest

Abstract

Physical diagnosis of the chest is a dying ar t in this country. The information provided by skilled, available roentgenologic examination has insinuously replaced observation, palpation, percussion and auscultation as the basis for decisions in diagnosis, therapy and prognosis of many chest diseases. Perhaps this is truest for those of us who have been trained during the recent, exciting advances in laboratory methods. And yet, in our haste to employ a definitive procedure, we are vulnerable through neglect of this fundamental discipline-competent, painstaking, time consuming physical diagnosis. All of us have studied cases in which physical diagnosis was the only accurate or available means of determining the cause of illness. Pneumonia, atelectasis, pulmonary edema, vascular anomalies and bronchial obstruction syndromes may be found by physical examination when chest x-ray films are not helpful. House officers frequently discard a diagnosis based on their physical diagnosis because roentgenograms fail to confirm their findings. Either their methods are faulty or they lack confidence in them. It can be a revealing experience to ask a student or house officer to demonstrate his concept of a complete physical examination of the chest, explaining the physiology and significance of his findings. Many of us might fare poorly also under such scrutiny. The need then, is for sounder instruction and more diligent practice of the art. Two remedies for our fading physical diagnostic acuity are (1) performance of comfortable, careful, complete examination in all chest cases as an example to junior members of the medical echelon and (2) reorientation of our methods in teaching physical diagnosis. It is axiomatic that medical students learn most by observing their house staff and attending physicians. Despite the number of formal presentations, the third and fourth year students are more impressed by watching internes, residents and attendings. The interne also learns from his resident and from the exceptional physician who demonstrates to him findings that he has missed and the method whereby the findings are elicited. The entire echelon profits by contact with the clinician who continually demonstrates his proficiency with physical diagnosis. But the a r t suffers by lack of example and by the attitude propagated a t ward rounds and chest conferences where examination of the patient is replaced by perusal of x-ray films. We cannot preach the theory of physical diagnosis and practice diagnosis by x-ray films without profoundly affecting .our students. It might be better to replace formal lectures by more demonstrative lessons of everyday practice.