Michael R. Gooseman 1 David J. O’Regan
- Department of Cardiac Surgery
Leeds General Infirmary
Leeds Teaching Hospitals NHS Trust
Corresponding author: Mr David J. O’Regan Consultant Cardiac Surgeon
Leeds General Infirmary
Diminishing role of percussion in clinical practice
Changing face of the clinical examination
Clinical examination – percussion
Objective: To establish how the practice of a basic clinical examination skill, percussion, is viewed and used in current medical practice.
Design: Interested individuals from the four main groups of the traditional UK medical firm were invited to take part – medical students, SHOs, registrars and consultants.
Setting: This study was conducted in two institutions – the University of Leeds School of Medicine and Leeds Teaching Hospitals NHS Trust, a regional teaching hospital – both in the United Kingdom.
Methods: Participants were invited to perform chest percussion on one of the authors. The level of sound produced was measured by a decibel meter. The quality of the percussion was rated and each participant was asked to rate the relevance of percussion in the current clinical environment.
Participants: We obtained percussion data from 56 different subjects – medical students (29), SHOs (14), registrars (8), Consultants (6).
Results: There was a clear increase in the level of sound produced as level of seniority increased. While all of the consultants and registrars felt percussion remains relevant only 26% of the SHO/medical students felt it is relevant.
Conclusion: The role of percussion in current medical practice may be diminishing. This is reflected by reduced quality of percussion and also attitudes from the more junior medical staff who feel it is of limited clinical relevance.
Physical examination is undoubtedly an essential skill in clinical medicine. The structured approach of inspection, palpation, percussion and auscultation has been taught for many years. The ability to perform a thorough examination is important in both the diagnosis and management of a patient. We believe it should be viewed as a reflection of a clinicians’ underlying anatomical and basic science knowledge and should be taught with an understanding of the surface anatomy of the body.
In our specialty of cardiothoracic surgery the value of percussion has been clearly demonstrated in the assessment of pleural effusion – it can been likened to ‘clinical ultrasound.’ – the stony dull sound of an effusion can accurately determine the level of the effusion and appropriate site for drainage. Percussion is also recognised as an important tool in other systems examinations eg. Shifting dullness of ascites and percussion tenderness of peritonitis. The senior author, a recognised surgical trainer with two decades of consultant experience, has noticed a decline in the use of physical examination amongst students and surgical trainees. A review of the literature suggests this is not an isolated opinion (1,2).
We considered how we would be able to obtain quantitative data assessing ability to percuss – we do recognise there is no valid scoring system of percussion ability. However, it did seem sensible to consider its value in the clinical environment and acceptability to a patient. The first factor includes the ability to use it to produce clinically meaningful information and we felt the level of sound is important in this respect. We decided that this should be measured using a standard decibel meter. Maintenance of patient comfort is something that is now regularly assessed in medical examinations.
Finally, we asked for an opinion regarding the relevance of percussion in the clinical examination – not relevant, uncertain or relevant. We feel it is important but, regular comments from our students seem to suggest they see percussion as becoming redundant in an era with easy availability to many different forms of imaging.
We aimed to distinguish between different levels of medical staff in a manner that most likely reflects levels of training and experience. To this end we divided participants into four groups reflecting the traditional and widely recognised firm structure – medical student, senior house officer (SHO), registrar and consultant. Of note, all the medical students were in the ‘clinical years’ and had undergone system examination teaching.
One of the authors acted as the patient. A standard decibel meter (Figure 1) was placed on a table next to the seated author at a distance of 1 metre and the decibel level reached percussing over the clavicles was recorded. Of note, each participant was invited to percuss three times with the highest reading recorded. The author also made an assessment of the ‘quality’ of percussion; poor, satisfactory or good. Finally, the participant was asked to rate their impression of the relevance of percussion; relevant, uncertain or not relevant. The data was collected over a three-week period at the end of 2018.
Figure 1. Decibel meter used in study
Data was obtained from 56 different participants – medical students (29), SHOs (14), registrars (8), Consultants (6).
The minimum volume detected by the sound meter is 30 decibels.this is less than the volume of a normal conversation which is 60 dB The number unable to percuss and achieve this level is illustrated in Figure 2.
Figure 2 – Number of participants unable to percuss per group
The level of sound produced by the remaining participants is shown in the box and whisker plot figure 3.
Figure 3 – Box and whisker chart
Perhaps the most striking result of this study is that despite the fact that all participants had been formally taught clinical examination, some were unable to produce clinically meaningful percussion. Additionally, those at the earliest stages of their medical career were more likely to feel that clinical percussion had no relevance in current clinical practice.
Our data suggests that clinical percussion may well become redundant. The reason for this could well be related to changes in medical education over the last few years. Medical student teaching has reduced drastically with a much greater focus on self-directed learning (3). Many medical schools have reduced the amount of time that is dedicated to teaching the basic sciences (4).
For the clinical examination to be successful, we believe the practitioner must have a sound understanding of the underlying anatomy. Within the surgical community there have been major concerns that anatomy knowledge may be falling – this has even been translated into concerns about patient safety (5). It may also be a case that the clinical need for percussion has drastically reduced.; the availability of imaging such as ultrasound and computed tomography may well mean that the ‘head to toe’ examination has been superseded. Ultrasound and Computer tomography may be a more ‘accurate’ method of determining pathology, but it is not without exposure of a patient to radiation, inconvenience of reattending for investigations and discomfort. Furthermore, CT scans and Ultrasounds with expert staffing and reporting is not without considerable cost. The senior author remembers being told as a trainee that ultrasound is just a more deliberate and informed palpation!
We would also like to propose an ideal technique of performing percussion. Having observed many different attempts and techniques there was one particular method that seemed to be consistently successful. The clinician places their middle finger flat over the area of interest and using the middle finger of the other hand it is struck crisply at ninety degrees in the centre allowing the extended wrist to fall in a relaxed manner. It is much the same as the pianist striking a key. We must point out that effective percussion is not possible with long finger nails.
From our personal experience we recognise the value of percussion in our clinical practice as cardiothoracic surgeons we are sure many colleagues share this opinion. However, it would appear that the next generation of doctors may not agree with us. We believe that more attention should be paid to proper examination skills – after all the syndromes described in the back of the Oxford handbook of clinical medicine are really just a result of astute physicians understanding the relevance of a collection of sometimes subtle clinical signs Inspection, Palpation, Percussion and Auscultation, in that order, applies as much today as yesteryear. We record an over 90% 5/5 patient satisfaction in our clinic – we believe that is because our full examination attends to these precepts
We acknowledge that grouping students and doctors as we have does not always provide an accurate reflection of levels of experience – doctors at SHO and registrar level could quite easily have been practicing medicine before those in the consultant group. We also acknowledge that we may simply have highlighted the natural learning curve of clinical examination – consultants are more polished and practiced than those more junior to them. Finally, this is only a small study and the same results may not be borne out in bigger samples.
This study has shown that those earlier in their training are less proficient in clinical percussion and feel it is not relevant in current medical practice. These findings lend further support to the idea that basic clinical skills may be being eroded in an era with easy availability to advanced technology and imaging. We hope that it is able to highlight the need for re-emphasis on the fundamental aspects of clinical medicine.
Author contribution: Both authors contributed equally to the production of this article.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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