Thank you for your response.1 Writing is sometimes about trying to engage the reader even if you have serious points to make! In fact I do not suggest that examination has no value, merely that this value is over-stated. Clinical examination has huge potential for false positive and false negative results, so as a diagnostic tool it has only limited value. I suggest that we teach students a cut-back version of examination and impress on them the limitations of clinical examinations. Much of what I was taught should be cast down.
Bimanual examinations miss more than one in three masses, even in hospital patients under general anaesthetic. The error rate is likely much higher in low-risk GP populations.2 The clinical value of all bimanual examinations in any setting is highly questionable. Speculum examinations clearly do have value but not routinely, as was the practice in the past. For example, there is no indication to do a speculum examination when taking diagnostic swabs, which is still common practice. Also, a normal examination in a symptomatic patient does not exclude malignancy of the cervix or the uterus.
The research you quote is interesting, although it is retrospective observational data.3 I agree that if patients are referred they should be examined (speculum and inspection), but there is no evidence that short delays by GPs adversely affect outcome. The delays in diagnosis are greatest in the hospital sector. The real issue is that patients need quick access to definitive diagnostics like ultrasound, and that current delays in accessing hospital care are unacceptable.
Clinical examination is an overvalued belief system that the profession is emotionally invested in. We need to challenge and rethink our beliefs.
- © British Journal of General Practice 2017