2014, 18, Early Online

TWELVE TIPS

Twelve tips for teaching evidence-based

physical examination
SOMNATH MOOKHERJEE1, SUSAN HUNT1 & CALVIN L. CHOU2
1
University of Washington, USA, 2University of California, USA

Abstract
Background: Practicing evidence-based physical examination (EBPE) requires clinicians to apply the diagnostic accuracy of PE
findings in relation to a suspected disease. Though it is important to effectively teach EBPE, clinicians often find the topic
challenging.
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Aims: There are few resources available to guide clinicians on strategies to teach EBPE. We seek to fill that need by presenting tips
for effectively teaching EBPE in the clinical context.
Methods: This report is based primarily on the authors experience and is supported by the available literature.
Results: We present 12 practical tips targeting the clinician educator. The first six tips condense key preparatory steps for the
teacher, including basic statistics underpinning EBPE. The final six tips provide specific guidance on how to teach EBPE in the
clinical environment.
Conclusions: By practicing the 12 tips provided, clinicians will develop the confidence needed to effectively teach EBPE in
inpatient or outpatient settings.
For personal use only.

Introduction disease (or pre-test probability, in Bayesian parlance).

The medical literature has long issued periodic warnings of the
demise of physical examination (PE), primarily as a result of
emerging technologies and decreased bedside teaching
(Fletcher & Fletcher 1992; LaCombe 1997; Flegel 1999;
Jauhar 2006). While it is clear that PE can be an important
diagnostic tool when used in an evidence-based fashion
(Sackett 1992; Ende & Fosnocht 2002; Reilly 2003; Joshua et al.
2005), a survey of internal medicine faculty, housestaff, and
third- and fourth-year medical students showed significant
heterogeneity in confidence with examination skills, as well as
in the perceived utility of these skills (Wu et al. 2007).
Furthermore, numerous studies have shown deficiencies in the
PE skills of medical students and housestaff (Mangione &
Nieman 1999; Mangione 2001; Ortiz-Neu et al. 2001; Ozuah
et al. 2001; Wilkerson & Lee 2003).
Leaders in medical education have called for an early
emphasis on clinical reasoning skills (Alexander 2008). The
recent emergence of reflective (Benbassat et al. 2005) or
hypothesis-driven (Yudkowsky et al. 2009) approaches to
teaching PE echoes this perspective. Both approaches require
that learners consider the clinical context in which they are
performing an examination rather than relying on a rote
execution of checklists based on organ systems. Evidence-
based physical examination (EBPE) shares considerable
overlap with these frameworks; in particular, clinicians must
continually appraise PE findings based on their suspicion of
Nonetheless, teaching EBPE is particularly challenging
because teachers must understand and apply the diagnostic
accuracy of PE findings [e.g. sensitivity, specificity, and
likelihood ratios (LRs)] in relation to the suspected disease.
Applying these measures of diagnostic accuracy to estimate
the post-test probability of disease allows clinicians to make
rational management decisions, which may improve cost-
effectiveness of medical care (Shaver 1995; Zoneraich &
Spodick 1995). Not surprisingly, learners and clinicians alike
struggle with EBPE (Herrle et al. 2011). Despite these
obstacles, EBPE has been taught with success, typically in
the setting of a clerkship or elective with extensive formal
didactic sessions (Fagan et al. 2003; Chou 2005; Mookherjee &
Chou 2011; Mookherjee et al. 2011). Since much of clinical
education, and therefore PE education, occurs informally on
the wards, it is desirable to optimize the teaching of this
important competency by providing guidance to clinicians
who regularly supervise learners at all levels.
Several literature reviews have explored best practices in
teaching PE these include a thematic review (Easton et al.
2012) and systematic reviews of simulation training for cardiac
auscultation (McKinney et al. 2013), teaching musculoskeletal
skills (ODunn-Orto et al. 2012), and PE training in graduate
medical education (Mookherjee et al. 2013). Though best
practices in teaching PE in general (Ramani 2008) have
recently been reviewed, a practical resource focused on EBPE
is lacking. We offer a framework for teaching EBPE, based on

Correspondence: Somnath Mookherjee, Assistant Professor, Department of Medicine, Division of General Internal Medicine, Magnuson Health
Sciences Center, University of Washington School of Medicine, Room B-503, Box 356429, Seattle, WA 98195, USA. Fax: +1 206 221 8732; E-mail:
smookh@u.washington.edu
ISSN 0142-159X print/ISSN 1466-187X online/14/0000018 2014 Informa UK Ltd. 1
DOI: 10.3109/0142159X.2014.959908
 S. Mookherjee et al.

our own experience in teaching EBPE and supported by the
available literature. In order to make this a practical guide for
bedside application, we emphasize the concept of diagnostic
accuracy but do not address other aspects of evidence-based
medicine, such as study appraisal and validity. Furthermore,
we suggest that clinicians may effectively teach EBPE in
parallel with the more foundational aspects of PE, such as
understanding how to perform an examination maneuver or
confidently detecting PE findings.
Tip 1
Practice teaching concepts of diagnostic
accuracy
Many clinicians lack confidence in the practice and teaching of
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wheezing, undergo pulmonary function tests, and are categor-
ized as having or not having asthma. The prevalence of
disease differs in each example, but the calculated sensitivity
and specificity are the same.
Table 1 presents the definitions and formulas for positive
predictive values (PPVs), negative predictive values (NPVs),
positive LRs and negative LRs. Positive and negative
predictive values depend completely on the specific preva-
lence used to calculate them. For patients with this prevalence
of disease, an individuals post-test probability of disease after
a positive test is the PPV, whereas the post-test probability of
disease after a negative test is (1  NPV).
In contrast, LR and LR are measures of diagnostic
accuracy that may be used to estimate post-test probability for
any pretest probability, which in clinical practice is based on

multiple factors, including the patient interview, epidemiologic

evidence-based medicine because their fluency with common risk factors, other clinical findings, and most importantly, the
measures of diagnostic accuracy, typically encountered earlier types of patients being referred to the clinicians practice.
during training, diminishes over time. Here we remind Thus, both LRs are important statistical concepts for EBPE
teachers of the basic concepts of diagnostic accuracy that teachers to master.
provide a fundamental framework for teaching EBPE. We
encourage teachers to re-create the figures and tables provided
here and use them to explain these concepts. Tip 2
Figure 1 provides formulas for sensitivity and specificity
Practice estimating the pre-test probability
and illustrates that measures of diagnostic accuracy remain
of disease
stable even when the prevalence of disease changes. In each
of the two hypothetical 2  2 tables shown, 200 patients Both practicing clinicians (Agoritsas et al. 2011) and learners
For personal use only.

presenting with shortness of breath are examined for (Noguchi et al. 2002) tend not to appreciate the importance of

Figure 1. Sensitivity and specificity. For each of the 2  2 tables at the top of the figure, the rows tabulate the presence or
absence of wheezing (the test), contrasting two hypothetical examples: (1) when prevalence of asthma (the disease) is 50% (left)
and (2) when prevalence of asthma is 15% (right). Definitions and formulae for sensitivity and specificity are given in the bottom
table and calculated for both examples, illustrating that the sensitivity of wheezing is 80% and specificity of wheezing is 90% are the
same in both examples, despite differing prevalence of disease. TP, true positive; TN, true negative; FP, false positive; FN, false
negative.
2
 Teaching evidence-based physical examination

Table 1. Definitions of positive and negative likelihood ratio, and positive and negative predictive value, with example calculations from
examples 1 and 2 from Figure 1.

Term
Positive predictive value (PPV)
Negative predictive value (NPV)
Positive likelihood ratio (LR)
Negative likelihood ratio (LR)
Meaning
% correctly diagnosed
with disease
% correctly diagnosed
without disease
Change in likelihood of
disease with a positive test
Change in likelihood of
disease with a negative test
Example 1: Example 2:
Formula prevalence 50% prevalence 15%
TP/(TP FP) 80/(80 10) 0.89 24/(24 17) 0.59
TN/(FN TN) 90/(20 90) 0.82 153 (153 6) 0.96
(Sensitivity)/ 0.8/(1  0.9) 8.0
(1  Specificity)
(1  Sensitivity)/ (1  0.8)/0.9 0.22
(Specificity)

considering pre-test probability when estimating post-test probability of 89%. In a non-wheezing patient, a similar
probability of disease. Given the difficulties inherent in process with the LR reveals a post-test probability of 18%.
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estimating meaningful pre-test probabilities (Richardson
2002), this is not surprising and highlights the importance of
explicitly helping learners practice this skill.
Clinicians commonly use two approaches (or a combin-
ation thereof) to estimate pre-test probability: relying on
experience and judgment or utilizing published reports of
prevalence of disease. A helpful technique to practice this skill
is to encourage learners to commit to estimating the probability
of disease as low (20% or less), moderate (around 50%) or high
(80% or higher). The teacher should keep in mind that for most
clinical problems, if a patient seriously entertains a diagnosis,
For personal use only.
Using Fagans nomogram does not require precise determin-
ation of the LR (e.g. for the LR of 8, the line intersects the
middle column between 5 and 10).
Clinicians can use a second, simpler method of estimating
post-test probability when the pre-test probability is between
20 and 80% (which is most of the time). Here, the clinician
estimates post-test probability by adding or subtracting a
percentage change in probability from the pre-test probability
(Table 2). Using the same example as above, if wheezing is
present, add 40% (corresponding to a LR of 8) to a pre-test
probability of 50%, for a post-test probability of 90%.

the pretest probability of the suspected disease is generally
around 2040% (this is not an accurate estimate when
screening for disease). The teacher can then validate these
estimates or adjust when appropriate based on clinical
experience or by referencing published data. Feeling comfort-
able in estimating pre-test probability is a critical step in
effectively teaching and practicing EBPE.
Tip 3
Practice teaching methods to estimate
post-test probabilities
Two methods are commonly used to estimate post-test
probability from LRs; both methods can be taught to EBPE
learners: (1) Fagans nomogram (Fagan 1975) (Figure 2) and
(2) application of simple bedside estimates of change in
probability (McGee 2002) (Table 2). Many clinician educators
feel uncomfortable with these skills; by rehearsing the
methods shown here they will be prepared to both practice
and teach the basics of EBPE.
To use Fagans nomogram, draw a line starting at the
pre-test probability of disease (left column) through the LR
(middle column). Continue the line rightwards, indicating
the post-test probability in the third column. As an example,
use the data from Figure 1 and Table 1 in a hypothetical
patient who presents with dyspnea. The clinician estimates
a 50% pre-test probability of asthma based on the history,
and the examination in positive for wheezing. Using Figure 2,
the clinician starts drawing a line at 0.5 on the first
column, through the LR of 8 in the middle column, and
extends the line to the third column, revealing a post-test
If wheezing is absent, subtract 30% (corresponding to a LR
of 0.2) from 50%, for a post-test probability of 20%. These
estimates are very similar to the probabilities derived using
Fagans nomogram in the first method.
It can be useful to practice teaching these skills to
colleagues or a pilot group of learners. This extra preparation
will optimize teaching clarity and identify areas that need
further practice. We encourage educators to use the concrete
examples that we have provided above.
Tip 4
Know where to find EBPE data and prepare
to use it
It is important for the educator to demonstrate the practical
utility of EBPE to the learner, both in the course of intentionally
teaching the topic as well as in the course of routine care
of patients. We find it helpful to create abbreviated
pocket cards with tables of the salient LRs for commonly
encountered clinical syndromes. For example, a clinician
teacher can quickly refer to a pocket-sized card for pneumonia
with the most useful LRs and LRs, both for the clinicians own
practice as well as for teaching at the bedside. An excellent
resource to create these cards is the ongoing Rational Clinical
Examination series in the Journal of the American Medical
Association (Sackett 1992); collated articles and updated
data can be found in The Rational Clinical Examination:
Evidence Based Clinical Diagnosis (Simel & Rennie 2008).
Another major textbook of evidence-based physical diagnosis
also addresses specific syndromes or diseases and provides
tables of PE findings with their LRs (McGee 2012).
3
 S. Mookherjee et al.
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For personal use only.
Figure 2. Fagans Nomogram (Fagan 1975). See Tip 2 for discussion.
Tip 5
Prepare an answer to the common question:
Can the LRs of multiple findings be
combined?
Learners will commonly ask if the LRs for several findings can
be combined when estimating the post-test probability of
disease. This difficult question requires understanding of the
concept of independent clinical findings, that is, if the findings
potentially being combined have distinct pathophysiological
mechanisms. Even though all physical manifestations of
disease in a single patient must be related to some extent,
generally, if the proximate physiological or anatomical cause is
4
different, the findings can be considered independently.
For example, in a patient suspected of having chronic
obstructive pulmonary disease (COPD) who has both
unforced wheezing (LR 2.8) and hyper-resonance of the
upper right chest (LR 5.1), the pretest probability can be
increased stepwise using Figure 2 or Table 2, because these
two findings have distinct pathophysiology (wheezing is due
to bronchoconstriction, and hyper-resonance due to hyperin-
flation of the lungs) and are probably independent of each
other. On the other hand, the clinician should not combine the
findings of absent cardiac dullness on percussion (LR 11.8)
and hyper-resonance because both findings likely are based
on the same mechanism (hyperinflation of the lungs) (McGee
2012).

Table 2. Estimated changes in
probability of disease based on posi-
tive and negative likelihood ratios
(McGee 2002).
LR % Change
0.1 45
0.2 30
0.3 25
0.4 20
0.5 15
1 0
2 15
3 20
4 25
5 30
6 35
7 Tip 7
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8 40
9 In the conference room: Teach the basics of
10 45
Applicable if the pre-test probability is between
20 to 80%.
Tip 6
Prepare an answer to the common question:
Why should we examine patients if it is
so unhelpful? (3) estimation of pre-test probability of disease and (4) use of
EBPE is a double-edged sword: learning the utility of certain
For personal use only.
findings is inevitably accompanied by learning the disutility of
others. We have found that students can become nihilistic
about the utility of the PE, once they learn the test character-
istics of specific findings (Mookherjee et al. 2011). To counter
this attitude, we emphasize four key points.
For many disease processes, PE itself represents the
diagnostic standard: sensitivity, specificity, and LRs are not
applicable. Many dermatologic and neurologic diagnoses are
defined by characteristic findings that can only be detected
with methodical examination; cellulitis (Levell et al. 2011) and
Parkinsons disease are just two examples.
Many PE findings are evanescent (e.g. pericardial rub, S3)
or apparent only after repeated examinations over time
(e.g. a patient with undifferentiated abdominal pain may
develop peritoneal signs), thus emphasizing the dynamic Tip 8
nature of PE findings and the importance of careful, serial
examinations.
Regardless of the LR of a finding, identifying PE abnorm-
alities can still be clinically relevant. For example, elevated
jugular venous pressure (JVP) in a patient suspected of
congestive heart failure does not clinch the diagnosis but
certainly suggests that this abnormality needs further investi-
gation and characterization.
Finally, it is helpful to place the concept of diagnostic
accuracy in clinical practice in perspective. Learners may wish
to dismiss PE findings as being diagnostically unhelpful, yet
the LRs for many PE findings are comparable to well-
established technologic tests. For example, in detecting Is this plan OK with you? In cases where the bedside teaching
prostate cancer, the commonly used prostate specific antigen
(PSA) test (cut-off value of 4.1 Ng/mL) has a LR of 3.3 and
LR of 0.9 (Thompson et al. 2005). Using Table 2, a negative learners to examine the patient, and explain to patients that
PSA does not markedly decrease the probability of disease, nor
Teaching evidence-based physical examination
does a positive test markedly increase the probability.
Nevertheless, despite these test characteristics, a PSA test can
be clinically useful when used in the correct clinical context
and interpreted on the basis of a pre-test probability of disease.
Another example is the diagnostic utility of the exercise
electrocardiogram in detecting coronary artery disease; the
LR is 3.0 and LR is 0.4 (Gianrossi et al. 1989). Learners often
assume that these technologically-based tests have much
greater accuracy than bedside tests; it is useful to present these
and other examples to illustrate that PE findings vary in their
clinically usefulness, comparable to other commonly used
diagnostic tests.
EBPE, and prepare the learners for bedside
teaching
Learners must be reasonably confident with the concepts
outlined in tips 1, 2 and 3 before going to the bedside. Thus,
prior to meeting patients, the teacher should address four
specific learning objectives: (1) derivation of sensitivity and
specificity using a 2  2 table; (2) derivation of LR and LR;
LR and LR to convert pre-test probability to post-test
probability. Learners will appreciate this review even if they
have previously heard these concepts.
Teachers should also define learning objectives, set an
agenda, and pre-assign roles, all steps shown to be critical in
effective teaching (Janicik & Fletcher 2003; Ramani 2003;
Williams et al. 2008). For example, the teacher may say,
Today we are going to examine Mr. X, who was admitted
with shortness of breath. Our learning objectives are to
(1) accurately describe his PE findings with a focus on the
lung examination; (2) decide how these PE findings change
our suspicion of COPD; and (3) decide how this affects our
clinical management. After we go into the room, we will each
introduce ourselves, and I will explain our plan to Mr. X.
At the bedside: Orient the patient to the
purpose of the visit, and explicitly discuss
EBPE
To maintain patient-centeredness, teachers should orient
patients to the agenda for the session and clearly tell them
what to expect. Teachers should also ask permission to discuss
findings and possible implications of findings. For example,
Mr. Smith, how are you? Today we are on teaching rounds.
With your permission, we each would like to listen to your
lungs, and then describe and discuss what we hear. Feel free to
ask questions - we will summarize our conclusions at the end.
occurs more spontaneously during patient care rounds,
teachers must still orient the patient, ask permission for
there will be discussion of the findings and their implications.
5
 S. Mookherjee et al.
In all cases, teachers should assure patients that all questions
will be answered and any jargon explained.
Tip 9
Encourage learners to commit to their own
description of findings
Learners should be asked to describe what they see or hear
during the examination. This concept of committing is a key
step in learning (Neher et al. 1992). Eliciting commitment from
learners requires a positive learning climate, which is fostered
by framing the session as a risk-free opportunity to practice
and by reassuring learners that there are rarely any completely
correct or incorrect descriptions of findings.
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Teachers can make several teaching points by hearing
learners descriptions of findings. If a learner reports that they
found ascites on an abdominal examination, the teacher can
make the point that physical findings are descriptions of
signs, not diagnoses. The teacher can elicit a more We have found that learners may become interested in
objective description of the finding (e.g. bulging flanks),
and then discuss what other processes besides ascites may
produce such a finding. Knowing exactly what the learner is
observing offers an ideal opening to give precise and timely
feedback, since the teacher will have just examined the patient
as well. Encouraging these objective descriptions of the PE,
rather than diagnoses, further emphasizes how the evidence-
For personal use only.
based approach may suggest alternative diagnoses. For
example, understanding that the LR of the finding of bulging
flanks is 2.0 for ascites (McGee 2012) can lead to discussion
about what else might cause bulging flanks, and what findings
might be more reliably associated with ascites.
Tip 10
Encourage learners to commit to a
next step in management
Learners and teachers alike tend to underestimate the value of
PE findings in making management decisions (Herrle et al.
2011). To overcome this cognitive bias, clinicians should
practice making management decisions based on an estimated
post-test probability of disease. Though seldom done, this step
helps learners develop confidence in making management
decisions based on the PE (Mookherjee & Chou 2011).
Consider a patient with a cardiac murmur that is early in
systole (LR 0.1 for severe aortic stenosis), blowing (LR 0.1),
with no radiation to the neck (LR 0.1), no apical-carotid delay
(LR 0.05) or brachioradial delay (LR 0.04) (McGee 2012).
The teacher can elicit a ballpark pre-test probability of
severe aortic stenosis from the learners (see Tip 2) most
learners will agree that the pre-test probability is low less
than 20%. Using the methods described in Tip 3, it is quickly
evident that the post-test probability of severe aortic stenosis is
extremely low.
Even after deciding that severe aortic stenosis is unlikely,
some learners will still want to order an echocardiogram
just to be sure. This moment gives an opening for the teacher
to ask the learner about their uncertainty with the PE findings,
6
to actively address learners biases against trusting the diag-
nostic accuracy of well-supported PE findings, and even to
seize an opportunity to teach about cost-effectiveness.
Tip 11
Facilitate deliberate practice and give
feedback to learn EBPE
Deliberate practice is an educational strategy known to be
effective in medical education. While this strategy has multiple
elements (Ericsson 2004), attention to four salient points can
help clinicians teach EBPE at the bedside: repetitive perform-
ance of skills by the learner, assessment of skills by the
teacher, specific feedback to the learner by the teacher, and
observation of improved performance (Wayne et al. 2006;
Duvivier et al. 2011).
Encouraging deliberate repetition of key points is particu-
larly important to help learners become competent in EBPE.
EBPE but are unsure on how to independently develop their
EBPE skills. The teacher must remind them to practice the
following key points: (a) estimate a pre-test probability of
disease (Tip 2), (b) commit to precise descriptions of findings
(it is helpful to encourage learners to put this in writing in their
documentation), (c) use available resources to determine LRs
for the findings (Tip4), (d) estimate post-test probability of
disease (Tip 3), and (e) determine next steps in management
based on the estimated post-test probability. Furthermore,
teachers must encourage learners to repeatedly examine
patients with normal examinations so that learners can
calibrate what is normal and out of the range of normal.
It is not sufficient for learners to repetitively practice EBPE
skills in isolation. The educator must commit to remain
engaged with the learning process; for example, teachers
can take advantage of opportunities to observe a learner
examining a patient, and query the learner to ascertain their
level of competence: What did you hear (or see, or feel)? How
does that change the probability of the disease that you
suspected? On the basis of this conversation, teachers can
give the learner specific feedback, including concise descrip-
tions of what the learner did correctly or incorrectly, and what
changes are recommended for the learner to practice and
demonstrate during subsequent teaching sessions. For exam-
ple, if a learner struggles to estimate a patients JVP, teachers
can provide specific guidance, such as first try gentle
abdominal pressure, then try lying the patient back. Finally,
in order to observe for improved performance and achieve-
ment of competence, the teacher should observe the learner
with multiple patients. By the last patient, the learner should
demonstrate competence in the targeted EBPE skill.
Tip 12
Acknowledge uncertainty and follow-up on
unresolved issues
Not surprisingly, many clinicians (particularly junior faculty
who are themselves just beginning to master key

competencies) lack confidence in teaching PE at the bedside
(Crumlish et al. 2009). Clinicians often find it difficult to simply
say, I dont know. Teachers who overcome this barrierfor
example, by acknowledging their inability to detect a particu-
lar finding or to understand it fullywill discover that
uncertainty is not a liability but instead a teaching opportunity.
Learners appreciate and respect intellectual honesty, and they
will learn to model in their own future careers how their
teacher specifically addresses such uncertainty. Teachers who
consult the literature or ask other more senior clinicians to
consult at the bedside (for second opinions) are providing
invaluable lessons for their learners and enriching their own
practice of medicine.
Conclusion
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EBPE is an important competency for practicing physicians but
is challenging to teach. We present a practical framework for
teaching EBPE in the clinical environment. We provide 12 tips
that lead the teacher through the statistical background needed
to teach EBPE, followed by practical steps to teach learners in
clinical settings.
Applying these 12 tips requires a commitment from
teachers to prepare and practice the principles discussed and
to demonstrate them consistently at the bedside with patients,
thus providing learners a powerful model of physicianship and
For personal use only.
the value of careful observation, description, and life-long
learning.
Notes on contributors
SOMNATH MOOKHERJEE, MD, is an Assistant Professor of Medicine at the
University of Washington, Seattle.
SUSAN HUNT, MD, is an Acting Instructor at the University of Washington,
Seattle.
CALVIN L. CHOU, MD, PhD, is a Professor of Clinical Medicine at the
University of California, San Francisco (UCSF). Dr. Chou holds the UCSF
Academy Chair in the Scholarship of Teaching and Learning and is the
Director of the UCSF VA-based Longitudinal Rotations (VALOR) program.
Acknowledgements
The authors wish to acknowledge Dr. Steven McGee for his
critical review of the manuscript.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the article.
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