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Anales de la Facultad de Ciencias Médicas (Asunción)

versión impresa ISSN 1816-8949

An. Fac. Cienc. Méd. (Asunción) vol.55 no.3 Asunción dic. 2022 


Teaching the physical examination in the 21st century: challenges and possible solutions

1Universidad de Missouri, Servicio de Reumatología. Columbia, Estados Unidos.

It would seem that the advances in technology would minimize the importance of the physical examination in clinical medicine but the opposite is actually true. Even in the 21st century, the physical exam allows early diagnoses and to minimize unnecessary costs and also helps to strengthen the patient physician relationship. The crisis in the teaching of the physical examination is due in part to the learning style of today's medical students and also in part to the manner that the physical examination is taught. In this editorial, I will review the importance, the challenges, and possible solutions and the teaching of the physical examination and medical school.

The physical examination is still important

Both general physicians and specialists see many diseases that require only the physical examination to make a diagnosis. Common examples include: Cellulitis, herpes zoster, Parkinson's disease, small fiber neuropathy, rheumatoid arthritis, pericarditis, early stage pulmonary fibrosis, and streptococcal pharyngitis 1. It is important that the teaching of the physical examination puts emphasis on these examples.

The well performed physical examination also permits the responsible management of limited resources. The American Board of internal medicine initiated in 2011 contained to reduce unnecessary diagnostic testing that is called "choose wisely". These tests are not justified by the medical evidence and can be replaced by a good physical examination. For example, the American College of physicians recommends not ordering spinal imaging in patients with nonspecific back pain nor advanced brain imaging in patients with syncope and a normal neurological exam. The American College of cardiology recommends not performing an echocardiogram to follow-up patients with mild valvular diseases without new symptoms. In all these cases, a good physical exam and nation that includes the musculoskeletal system, neurological system, and cardiac system would save the patient (and subsided) time and money.

The physical semination is also important in the care of the patient. It is common for patients to be unhappy when "the doctor did not even examine me". This is a lost opportunity to establish a strong patient physician relationship that may in itself be therapeutic. The "ritual" of the physical exam is important and may also have a placebo effect 2.

Today's medical students are different

We see in the clinics and in the wards of our teaching hospitalist that students do not give the appropriate importance to the physical examination. This is due in part to characteristics of the 21st Century medical student 3. The medical student of the so-called "generations Z" favors interactive education and is often self learning. The student is a specialist in seeking out information and the relevance of the information is the most important thing. This makes it hard when they start seeing patients and they realize that neither residents nor attending physicians utilize the techniques that they have learned in their physical examination courses. Today student also looks for constant feedback but this is hard to do sometimes in the middle of a busy clinic or hospital ward.

Feasible solutions exist

The teaching of the physical examination based on systems is artificial. In practice, the physician examines only the pertinent organs. Despite this many physical examination curriculum still focus on systems-based teaching. A physical examination curriculum based on common reasons for consultation (for example, patient with palpitations, patient with numbness) is more realistic and would improve learning.

Another problem is that we teach techniques that are important historically but are of little value today. And then the student when they go to the wards see that these techniques are not being used. It is therefore better to teach the evidence-based physical examination. There are textbooks about this and the most recommended 1 is "evidence-based physical diagnosis" 4. The jam a series of articles called "rational clinical examination series" is also useful. In this series of articles the most important features of the history and physical examination are reviewed for different adult and pediatric presentations.

Another common problem is that there often are not enough patients in our clinics or warts to allow for the large number of medical students that we have. Other factors include the clinical status of our patients and their emotional state and also that sometimes the patient and the family members may not wish to have students. There are also clinical history is that for ethical reasons cannot be performed on real patients (for example the evaluation of a patient with sexual abuse) and there are techniques that cannot be practice on real patients (for example in the rectal exam). This can be solved using simulated patients 5. Simulated patients are persons who have been trained to present a clinical history and to serve as exemplars for physical examination techniques. Often they are healthy persons but sometimes they have their own history and real physical examination findings.

The student will examine real patients when they have learned the physical examination techniques and have developed a sense of what the normal findings are (having learned these in simulated patients). In this way the the student will discover what is abnormal. It is possibly unethical that the student practice physical examination techniques on real patients until they have demonstrated once and again on a simulated patient. After this and when the student goes to the outpatient clinic or into the warts they will be able to detect what is abnormal and little by little understand the significance of the abnormal findings.

Technology sometimes puts distance between the physician and the patient and this may depersonalize the patient and create with has been called the "iPatient" 6. The advance of technology has never been stopped so we should probably start to incorporate hand-held technology in the teaching of the physical examination. There are hand-held ultrasound machines on the market today (for example, Butterfly iQ® y Philips Lumify®) that are priced reasonably for a hospital service 7. It would not be surprising that by the time students have completed their postgraduate training these have become even less expensive so therefore it is in medical school where they should learn how to use these without putting more distance with the patient.


Educators must reinforce to the medical students of this current generation the importance of the physical examination as a diagnostic tool and as part of the ritual of care. These recommendations, some easy and some harder, may have big results.


1. McGee S. Bedside teaching rounds reconsidered. JAMA. 2014;311:1971-1972 [ Links ]

2. Verghese A, Brady E, Kapur C, et al. The bedside evaluation: ritual and reason. Ann Intern Med. 2011;155:550-553 [ Links ]

3. Lerchenfeldt S, Attardi S, Pratt R, et al. Twelve tips for interfacing with the new generation of medical students. Med Teach. 2021;43:1249-1254 [ Links ]

4. McGee S. Evidence-Based Physical Diagnosis, 4th Edition, 2017. Elsevier. [ Links ]

5. Cleland G, Abe K, Rethans JJ. The use of simulated patients in medical education: AMEE Guide No 42. Med Teach. 2009;31:477-486 [ Links ]

6. Verghese A. Culture shock - patient as icon, icon as patient. N Engl J Med 2008;359:2748-2751 [ Links ]

7. Díaz-Gómez JL, Mayo PH, Koenig SJ. Point-of-care ultrasonography. N Engl J Med 2021; 385:1593-1602. [ Links ]

Received: October 17, 2022; Accepted: October 24, 2022

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