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On Being a Doctor |

Shirts and Skins

Joel Stein, MD
[+] Article, Author, and Disclosure Information

From Columbia University, New York, New York.

Requests for Single Reprints: Joel Stein, MD, Columbia University, 180 Fort Washington Avenue, Harkness Pavilion Room HP-1-165, New York, NY 10032; e-mail, js1165@columbia.edu.

Ann Intern Med. 2013;158(7):564-565. doi:10.7326/0003-4819-158-7-201304020-00011
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I walk into hospital rooms every day, but this time was different. My father was in this particular hospital room, trying to recover from total hip arthroplasty. As physicians, my father and I both knew that surgery is never risk-free, but neither of us anticipated this much postoperative drama.





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More than superficial
Posted on April 4, 2013
Stuart C. Ray, M.D.
Janeway Firm, Osler Medical Residency Program, Johns Hopkins Hospital, Baltimore, MD
Conflict of Interest: None Declared

Thanks for this - we all need a little wit & wisdom to lift the soul. Your message has multiple layers, each worth considering. I will ask my trainees to read this, and decide which team they want to be on. I suspect they'll only skim it, and conclude that it's just about the disrobed exam.

Thanks for making me glad I still get the Annals.

-- Stuart

Bravo to both Doctors Stein
Posted on April 6, 2013
Henry Schneiderman MD FACP
Professor of Medicine (Geriatrics) and Associate Professor, Anatomic Pathology, University of Connecticut Health Center; Clinical Professor, Nursing, Yale University; Vice-President for Medical Servic
Conflict of Interest: None Declared

Stein’s editorial on the importance and irreplaceability of the bedside diagnostic encounter, unencumbered by both the literal and figurative barrier of clothing that one could not be bothered to remove or displace (1), will warm the hearts of all of us who proudly count ourselves as Skins (2). I am grateful for his father’s impatience and nonresponsiveness to the Shirts, and not a bit surprised that he responded with warmth and openness in the presence of a Skin.

Although Doctor Stein’s experiment suggested satisfactory audibility of heart tones through clothing, in fact a highly accomplished lung-sound researcher (3) explored the phenomenon with high technology (4) and concluded that, at least for his sophisticated simulator, one could overcome the dampening effect of an intervening layer by pressing the stethoscope more firmly against the sound source. However, in his discussion at the end of that paper, Doctor Kraman specifically noted that the sound frequencies of cardiovascular sound unlike those of lung sounds, did not permit this workaround. Nor has anyone addressed the other findings of every serious examiner who has tried the parallel experiment: that clothing, like excessive body hair at the site, produces distracting sound that has nothing to do with events inside the body; that inspection is precluded; and that palpation is impaired. Is it not challenging enough to garner useful diagnostic information without building in increased artifact and at the same time diminishing the strength of a signal that one actually wishes to study?

Finally, one cannot help but note that a namesake of the family of the author has published with distinction in the field of cardiac auscultation (5). Even if this is nothing more than coincidence, how apt!


1. Stein J. Shirts and skins [On being a doctor]. Ann Intern Med. 2013;158(7):564-565.

2. Schneiderman H. Cardiac auscultation and teaching rounds: how can cardiac auscultation be resuscitated? Am J Med. 2001;110:233-235.

3. Kraman SS. Lung sounds for the clinician. Arch Intern Med. 1986;146:1411-1412.

4. Kraman SS. Transmission of lung sounds through light clothing. Respiration; international review of thoracic diseases. 2008;75(1):85-88.

5. Stein PD, Sabbah HN, Lakier JB, Kemp SR, Magilligan DJ. Frequency content of heart sounds and systolic murmurs in patients with porcine bioprosthetic valves: diagnostic value for the early detection of valvular degeneration. Henry Ford Hosp Med J. 1982;30:119-123.

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