In 1998, JAMA began an ongoing series of articles entitled The Rational Clinical Examination to evaluate the role of the physical examination as it pertained to specific diagnostic questions. Well received, the series remains ongoing with more than 50 topics covered thus far. This book, bearing the same title, is an effort to consolidate that knowledge into a single reference text, while refreshing each topic with previously unpublished updates and the latest studies.
The book begins with a well-written refresher course in biostatistics, using actual studies (which will be seen again in later chapters) to demonstrate the role of sensitivity, likelihood ratios, and the remainder of the usual statistics. Rather than present raw calculations alone, the update to this section also tackles more subjective questions such as “What is a ‘good’ symptom to look for?” and “Why do we look at every exam sign [separately]?”
The chapters that follow each address a single diagnostic question (e.g., chapter 35: Is this patient having a myocardial infarction?), and each shares a very similar structure. A full-color reprinting of the original JAMA article is followed by a separate update to the original content based on any newly available literature. Each chapter includes clinical scenarios typical of the condition, a tutorial on performing each of the exam maneuvers discussed (often with illustrations), a meta-analysis of studies pertaining to the exam, and an evidence-based resolution to the clinical scenario at the beginning of the chapter. Most importantly, however, is “the bottom line.” This section at the end of every chapter's original article aims to cut to the quick with simple statements of what exam techniques should be brought to bear for that condition.
There is a great deal to like about this book. It is focused on common clinical dilemmas and is well organized, and most chapters are a quick read. Even without the table of contents, the alphabetical organization of the chapters makes it simple to find the desired topic. Also to its credit, The Rational Clinical Examination seems well aware of its role in an age where a “zero miss” attitude toward conditions such as myocardial infarction, pulmonary embolism, and cholecystitis all but demand further testing regardless of clinical suspicion. The limitations of the book, then, are found not in its approach but in the limitations of the evidence itself. A sufficient body of evidence must exist for evaluation of an exam feature, and thus not every aspect of the exam can be covered. By the same token, only common diagnostic problems allow for such studies. Some will also argue that the updates should have been incorporated into the original articles, but this is more a matter of style than of substance.
The evidence-based examination techniques put forth by The Rational Clinical Examination are the sort that can be brought to bear on a daily basis—to save time, increase confidence in medical decisions, and help decrease unnecessary testing for conditions that do not require absolute diagnostic certainty. In the end, the whole of this book is greater than its parts and can serve as a worthy companion to a traditional manual of physical examination.