According to that old story, a local giving directions to a lost traveler says, "If I wanted to get there, I wouldn't start from here." Medicine finds itself far from the bedside, seeking a way back, unsure where to begin. That we have wandered far afield is plain to see. Core bedside skills of history taking and physical examination-still vital to comprehensive assessment, diagnostic accuracy, and truly patient-focused care-are taught and assessed in the first two years of medical school but largely ignored once the student reaches the clinical years. During residency, development of these skills is assumed when in fact they wither further. The physical examination of newly admitted patients is often cursory and, what is worse, perverted by drop-down boxes into an exaggerated and invented form that reads better than the truth. Technology drives diagnosis, but it often merely substitutes our fears of uncertainty with delusions of certainty. We seem increasingly chained to the computer, providing perfect care to ourvirtualpatient, the iPatient. More has seemed better than less for so long that we now need a national campaign6 to alert our patients to "Just Say No" and save themselves from the hazards and costs of diagnostic misadventure. While we all agonize over the spiraling costs of a "Hi-Tech, Lo-Think" approach, many stand to gain from its persistence. But we have to start somewhere. The way physicians are taught is fundamental to the type of health care they deliver. The road back to the bedside will, we believe, start at the bedside, in the way that clinical skills are taught and assessed. We in the United States stand out among other major Western health care professionals in having a summative postgraduate medical certification process that is entirely dependent on the assessment of knowledge. Elsewhere, for example, the United Kingdom, internal medicine trainees must additionally pass a clinical skills assessment in which independent faculty-level examiners directly observe resident-level trainees assessing real patients.
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