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The Reply

  • Michael Tanael
    Correspondence
    Requests for reprints should be addressed to Michael Tanael, MD, Flight Medicine, Maxwell Air Force Base, 300 South Twining Street #760, Montgomery, AL 36112.
    Affiliations
    Flight Medicine, Maxwell Air Force Base, Montgomery, Ala
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      I thank Dr. Reiffel for his thoughtful engagement with my commentary.
      • Tanael M
      Why clinicians disagree about the usefulness of the physical exam.
      Drawing on his clinical experience, Dr. Reiffel argues for the usefulness of the physical examination. And he makes a convincing case if one grants substantial probative weight to clinical experience. However, evidence-based medicine (EBM) has made many clinicians skeptical of this form of evidence. As its founders point out, “Evidence-based medicine de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision making.”
      Evidence-Based Medicine Working Group
      Evidence-based medicine. A new approach to teaching the practice of medicine.
      EBM places clinical expertise at the bottom of its hierarchy of evidence—and so do newer approaches to the levels of evidence such as Grading of Recommendations Assessment, Development, and Evaluation (GRADE).
      • Burns PB
      • Rohrich RJ
      • Chung KC
      The levels of evidence and their role in evidence-based medicine.
      ,
      • Atkins D
      • Best D
      • Briss PA
      • et al.
      Grading quality of evidence and strength of recommendations.
      Lack of systematic study of many of its proposed benefits and a growing number of studies demonstrating that many physical examination maneuvers have limited accuracy leads clinicians strongly influenced by EBM's assessment of the levels of evidence to justifiably view the physical examination as having limited usefulness. The accumulated wisdom of generations of clinicians coupled with the countless encounters it appears to have benefitted their patients in a multitude of ways leads clinicians with a higher view of the probative value of clinical experience to justifiably view the physical examination as indispensably useful. The disagreement over the worth of the physical examination is epistemological.

      References

        • Tanael M
        Why clinicians disagree about the usefulness of the physical exam.
        Am J Med. 2021; 134: 156-157
        • Evidence-Based Medicine Working Group
        Evidence-based medicine. A new approach to teaching the practice of medicine.
        JAMA. 1992; 268: 2420-2425
        • Burns PB
        • Rohrich RJ
        • Chung KC
        The levels of evidence and their role in evidence-based medicine.
        Plast Reconstr Surg. 2011; 128: 305-310
        • Atkins D
        • Best D
        • Briss PA
        • et al.
        Grading quality of evidence and strength of recommendations.
        BMJ. 2004; 328: 1490