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Elizabeth Cooney is a health reporter for the Worcester Telegram & Gazette.
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Thursday, September 27, 2007

Short White Coat: Learning my 'doctoring style'

Short White Coat is a blog written by second-year Harvard medical student Ishani Ganguli. Ishani's posts appear here, as part of White Coat Notes. E-mail Ishani at

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As we learn how to perform the neurological exam, a string of prominent lecturers stand before us and offer us the versions of these techniques that they swear by. To test peripheral vision, one neurologist always asks his patients to point to his wiggling fingers, while another flashes numbers, and so on.

Weíve been practicing elements of the exam on our classmates for a few weeks now, but last week was our first chance to test our skills on actual patients.

My charge at Massachusetts General Hospital, Mr. B, had wisps of white hair and a permanently flexed hand that made him look much older than his 52 years. A stroke had paralyzed his right side and he now lived alone with occasional visits from a nurse. Mr. B was gracious though confused, and eager to chat.

I began the exam, shining a light into his eyes while taking quick glances back at my notes. I wiggled my fingers to test his peripheral vision and made him say ahhhh, marveling at the deviated ďpunching bagĒ at the back of his throat that signaled damage in a particular nerve. But he tired quickly, I felt badly about making him uncomfortable, and after a series of botched attempts to test my increasingly alarmed patient's hearing with a tuning fork, I found myself rushing through the rest of the exam. Near the end of the allotted time, I decided that my second attempt to take his blood pressure would be my last.

In the debriefing session that followed, I presented the patientís history and my exam findings to the group: "Mr. B is a 52-year-old former smoker with chronic obstructive pulmonary disease. ..." I followed the blood pressure with the caution that it was "not well heard" -- my stab at medicalese to mean "wow, I canít believe I literally picked these two numbers at random."

My preceptor was quick to reassure me that physical exams are inherently subjective. One manís dilated pupil is another manís constricted one. Our job, she said, was to state our findings as we saw them, with little apology, and to leave room for alternative interpretations.

It was, in large part, kindness that prompted my preceptorís gross understatement. But I realized that while I fumble my way towards acquiring a standard set of skills, Iím also starting to figure out my doctoring style, pieced together from trial, error, and the wisdom of my instructors. For the first time in my training, I can make my own choice to wiggle if I want to. As for the random-number-generator method for taking blood pressure? -- not so much my style.

Posted by Ishani Ganguli at 11:15 AM
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