Abstract
Observer variability in the pulmonary examination was assessed by having four blindfolded observers (two medical students and two pulmonary physicians) twice examine 31 patients with abnormal pulmonary findings. Examiners were consistent in the repetitive detection of pulmonary abnormalities in 74–89% of the examinations; conversely, 11–26% of the time they disagreed with themselves. Although pulmonary specialists recorded fewer (55% of observations) abnormal findings than did medical students (74%), they were significantly (p=0.008) less self-consistent than were the students. There was no clear trend in agreement between examiners (kappa=0.20−0.49). Each examiner’s findings were compared with those of physicians specially trained in pulmonary examination. Dichotomous variables (wheezes, crackles, rubs) were more reliably detected (kappa=0.30−0.70) than graded variables (tympany, dullness, breath sound intensity), where kappa=0.16−0.43. The authors suggest that dichotomous variables deserve greatest clinical reliance; that time in training, alone, does not improve clinical performance; and that there is a disconcertingly large amount of inter- and intraobserver disagreement in this fundamental clinical task.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Keen WW. Quoted in: Lewiston M, Freilich EB. Manual of physical diagnosis with special consideration of the heart and lung. Chicago: Year Book Publishing Company, 1941
Schneider IC, Anderson AE. Correlation of clinical signs with ventilatory function in obstructive lung disease. Ann Intern Med 1965;62:477–85
Pyke DA. Variability in detecting clubbing. Lancet 1954;2:352–3
Godfrey S, Edwards RHT, Campbeil EJM, Armitage P, Oppenheimer EA. Repeatability of physical signs in airway obstruction. Thorax 1969;24:4–9
Smyllie HC, Blendis LM, Armitage P. Observer disagreement in physical signs of the respiratory system. Lancet 1965;2:412–3
Gjorup T, Bugge PM, Jensen AM. Interobserver variation in assessment of respiratory signs. Acta Med Scand 1984;216:61–6
Fletcher CM. The clinical diagnosis of pulmonary emphysema — an experimental study. Proc R Soc Med 1952;45:577–84
The ACCP-ATS Joint Committee on Pulmonary Nomenclature: Pulmonary terms and symbols. Chest 1975;67:583–93
The ATS Ad Hoc Committee on Pulmonary Nomenclature: Updated nomenclature for membership reaction. ATS News 1977;5–6
Koch GG, Landis JR, Freeman JL, Freeman DH. A general methodology for the analysis of experiments with repeated measurement of categorical data. Biometrics 1977;33:133–58
Landis JR, Koch GG. An application of hierarchial kappa-type statistics in the assessment of majority agreement among multiple observers. Biometrics 1977;33:363–74
Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–74
Dolmatch BL, Ware RE, Ackerman R. Prediction of pulmonary disease using clinical lung findings. Clin Res 1982;30:837A
Author information
Authors and Affiliations
Additional information
Received from the Division of General Internal Medicine, Department of Medicine; the Division of Biometry, Department of Community and Family Medicine, Duke University Medical Center, Durham, North Carolina; and the Ambulatory Care Service and Health Services Research Field Program, Durham V.A. Medical Center, Durham, North Carolina.
Rights and permissions
About this article
Cite this article
Mulrow, C.D., Dolmatch, B.L., Delong, E.R. et al. Observer variability in the pulmonary examination. J Gen Intern Med 1, 364–367 (1986). https://doi.org/10.1007/BF02596418
Published:
Issue Date:
DOI: https://doi.org/10.1007/BF02596418