Demonstrating the therapeutic value of physical examination and the art of reassurance to undergraduate medical students.

The therapeutic value of history and physical examination has long been recognised but little evidence exists to support its teaching in the undergraduate context. This article describes demonstrating therapeutic examination to year four students at Brighton and Sussex Medical School. A student volunteer is invited to be the patient. The presentation is clearly marked as a 'middling case' of sore throat, i.e. one where the condition is painful but not dangerous. In this example I explain that the patient has a Centor score of 2-3 and that my examination seeks to be therapeutic to the patient and the GP. The demonstration highlights the importance of practical preparation (one's clinical equipment laid out), physical touch (e.g. starting with the hands/pulse as non-threatening), some 'technology' (e.g. pulse oximeter), demonstrating thoroughness and using reassuring language during the examination. Students are reminded that therapeutic examination may elicit important clinical signs, e.g. atrial fibrillation or hypertension. The session consistently receives positive quantitative and qualitative feedback. The latter reveals that some students would prefer teaching focused on specific diagnoses (rather than their absence). Here I present my own model of the 'craft' of general practice called TPAP: Trust built upon implementing the Process (history, examination, basic tests, incremental management etc), Art (thinking strategically) and Practice ('knowing one's tools') of medicine. Finally, this article considers the important notion of 'conserving clinical energy' and makes the claim that effort expended upon the physical examination reaps benefits later in the consultation and in forging long term therapeutic relationships.