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October 28, 1992

The Rational Clinical Examination

Author Affiliations

University of Massachusetts Medical School Worchester

JAMA. 1992;268(16):2164. doi:10.1001/jama.1992.03490160034008

To the Editor.  —Many of 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 observers could not reach any statistically significant agreements. Moreover, there was no agreement with quantitative measurements of the blindly recorded carotid displacement pulse.2 This study engendered no controversy even in the journal's active letters