I read the study by Silverman and Gertz. Contrary to what is implied by the authors in their discussion, I am a vocal proponent of the clinical examination—as my patients, colleagues, and trainees will attest. Indeed, I was wounded by their implication that I do not believe cardiac physical examination plays an essential role in patient care. If the authors had more thoroughly discussed my article, they would have recognized the comments they cited represented a “protagonist” view; my conclusions however were that the “antagonist” view—that is, the physical examination will continue to be an important and central part of patient care—will continue to rule for the foreseeable future. Moreover, although I agree there is a paucity of studies on the accuracy of bedside examination, I have contributed to the literature on honing the cardiac physical examination, a fact the authors have overlooked.

Their article points to a widespread problem that in my opinion and that of many others will only serve to increase health care costs due to a “dumbing down” of clinical assessment and clinical thinking. Particularly disturbing is their finding that some 75% of surveyed midlevel providers do not even recognize basic heart sounds! Poor clinical assessment will not only lead to more testing, but poor clinical judgment will stem from an inability to place the results of such testing in the context of overall patient health. I applaud the authors on their survey and hope this will further heighten attention to this important public health issue.