Your editorial [1] and the articles by St. Clair and colleagues [2] and Noel and colleagues [3] echoed my concern about the diminishing emphasis on clinical skills in publications about cardiovascular disease research and management [4].

The temptation to reach immediately for the diagnostic tool rather than obtaining a history and carrying out a physical examination must be resisted for the reasons you stated admirably. The impulse to order every possible test instead of selecting the most appropriate one on the basis of clinical judgment can lead to the investigative machinery taking over from the investigator. When the latest high-tech procedure does not yield the answer, proceeding to yet another test often leaves the cardiologist confused [5] and the patient anxiously bewildered.

Modern high technology investigations must be the servants, not the masters, of the physician. Their immense contribution to the care of patients and the advance of knowledge will be squandered if incorrectly used. The development of sophisticated technology has increased the need for a meticulous clinical approach. Neglecting clinical skills makes it impossible for the patient and the physician to find a path through the burgeoning jungle of extensive and sometimes conflicting technologic results. For example, the mention of mitral regurgitation on the echocardiography report can suggest serious valve disease and can convert a virtually normal person into a patient. Only full clinical assessment of the patient and careful explanation can avoid this pitfall.

The disturbing data in the two Annals articles [2, 3] strongly suggest that the appropriate examining bodies should convene a conference to determine how best to assure that candidates for graduation and board examinations can demonstrate good clinical skill.