For each of the two levels of training, i.e. pre-clerkship and clerkship, for the physical examination of each body system, a numerical competency level (range 1-4) has been assigned.

The student will be able to:

Level 1: Describe the physical sign or manoeuvre but not elicit it.

Level 2: Perform the manoeuvre, and explain the rationale for the test. Elicit the physical sign.

Level 3: Perform the manoeuvre or recognize the physical sign and interpret the findings in terms of pathophysiology.

Level 4: Perform the manoeuvre or recognize the physical sign and may know the evidence justifying the use of the test; interpret the findings and generate a differential diagnosis based on the findings.

A similar 4-level scale of competencies has been applied to the procedural skills, although the descriptors of each competency level are different. A narrative description of competencies has been applied to the Communication Skills and Mental Status Examination sections.

It must be appreciated that the signs/manoeuvres/techniques identified in this document do not constitute an exhaustive catalogue of all possible physical diagnostic tests available but their inclusions reflects the consensus of the National Clinical Skills Working Group that these tests are frequently used in “general” clinical practice and are currently taught to medical students.

The "Evidence" column cites articles which have critically reviewed the diagnostic performance of the manoeuvre or technique. There has been no attempt to critique the studies cited or grade the level of the evidence available in this first edition of the Clinical Skills Document. However, several of these references are systematic reviews of examination manoeuvres which do provide "grade of recommendation" for the level of evidence. In general, there are no double-blind randomised controlled trials from which to draw conclusions about the diagnostic value of physical examination manoeuvres, but for those readers interested in a reasonably useful grading scheme that can be applied to any study of physical examination techniques being reviewed, the one developed by Guyatt and Sackett (1998) is appropriate:

Grade A: Independent, blind comparison of sign or symptom with a "gold standard" of diagnosis among a large number of consecutive patients suspected of having the target condition.

Grade B: Independent, blind comparison of sign or symptom with a gold standard of diagnosis among a small number of consecutive patients suspected of having the target condition.

Grade C: Independent, blind comparison of sign or symptom, with a gold standard of diagnosis among non-consecutive patients suspected of having the target condition; or non-independent comparison of sign or symptom with a gold standard of diagnosis among samples of patients who obviously have the target condition plus, perhaps, normal individuals; or non-independent comparison of sign or symptom with a standard of uncertain validity.