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Teaching and Learning Moments

Making Scents of Residency

Twohig, Patrick MD, MPH

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doi: 10.1097/ACM.0000000000003763
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As medical students, we are introduced to the physical examination and learn to correlate abnormal findings with pathognomonic features of different diseases. As residents, we continue developing our physical exam skills while mastering daily patient workflows—checking laboratory values, ordering tests, and following up on diagnostic studies. However, our early education in the physical exam means that a new admission still brings the thrill of a new set of lungs and heart to auscultate, an abdomen to palpate, and legs to check for pitting edema.

As a resident, I have learned many new things that have enhanced my understanding of medicine and patient care. Although our education comes from many sources, including lectures, teaching rounds, and medical literature, some of my most memorable lessons have been at the bedside. I have gained an appreciation for a certain aspect of the patient encounter that typically does not appear in a progress note or morning presentation but has become one of the most useful diagnostic and prognostic tools in my clinical acumen—smell.

In certain cases, it is the odors that emanate in a patient’s room that have proven to be as important in making a diagnosis as their renal function or the opacity on their chest X-ray.

The unforgettable odor of Mrs. D was one that I had become intensely familiar with during the early months of my intern year. Mrs. D was a 65-year-old with diabetes and chronic kidney disease who presented to the emergency room with 2 days of worsening diffuse abdominal pain and diarrhea. On admission, the initial clinical suspicion was that she had viral gastroenteritis—but the odor that emanated throughout her room gave me the diagnosis—Clostridium difficile colitis. Although the medical literature detailed the pathophysiology, diagnostic criteria, and treatment of her condition, there was no mention of the disease’s smell. In that moment, I experienced the Proust Effect, a theory in which odors have the exceptional ability to assist with memory recall.

Stool tests would take 1 to 2 days to confirm my suspicion, but given her unique malodor, I initiated empiric treatment. Test results confirmed the diagnosis, but starting the treatment earlier saved her a day in the hospital (as well as a few trips to the toilet).

Although I will never remember the white blood cell count and serum creatinine that were used to assess the severity of Mrs. D’s infection, I will never forget that scent. This reflection has helped me realize why medical educators preach the holy grail of the physical examination. It is not a feeble attempt to reach a diagnosis, but rather a valuable resource that can provide clues and lessons that can teach us much more than a test result on a computer screen. It also reminds me of our true calling in this profession—spending time at the bedside directly interacting with and caring for patients.

While my understanding of evaluating anemia, interpreting cardiac catheterization reports, and analyzing lipid profiles has made me a more competent doctor, the intangible bedside skills of consoling patients, explaining their conditions to loved ones, and using all available information to truly know how they’re doing have made me a better physician. Until artificial intelligence develops an olfactory nerve, the utility of a patient’s aroma will still be an unparalleled experience exclusive to the bedside.


The author wishes to thank Jaclyn Rivington for providing editorial feedback on this essay.

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