White Coat Underground

The color of flesh

In medicine we use all of our senses to evaluate patients. If I open up an abscess and I’m overwhelmed by the smell of rotted cheese, I can be pretty sure the abscess started as a sebaceous cyst. If I hear a “whooshing” sound over the abdomen in a smoker, I look more closely for an aortic aneurysm. A subtle buzzing sensed through my fingers can indicate an arterial fistula. And the glowing yellow of jaundiced skin can point me straight to the liver.

But what about subtle changes? With just our senses, distinguishing normal from abnormal is a coveted skill, one that some argue is being lost. Experience makes a difference and can help save patients from misdiagnosis and unnecessary testing. Where we train can make a big difference. As I wrote earlier, skin diseases look different depending on the underlying skin tone.

I bring this up because of the “flesh-colored dress” debacle. Michelle Obama wore a dress to a state dinner which an AP reporter described with the 1960s Crayola term “flesh color”, despite the fact that the dress’s color bore little resemblance to Mrs. Obama’s skin.

Distinguishing “normal” from “abnormal” is no trivial matter in medicine: one person’s “flesh color” is another person’s anemia. I frequently have residents report to me that a patient has scleral icterus, a yellow discoloration of the white of the eyes due to liver disease. Often enough, there is no icterus, but simply what we call “muddy sclera”, a common variant seen mostly in darker-skinned older people. “Flesh-colored” is a descriptor that would never fly in medicine. If anything, “identical in color to the surrounding skin”, but never “flesh-colored”.

The news story on Mrs. Obama revealed a deeply-ingrained bias on the part of the reporter and the editor. In medicine, these same biases exist of course. It’s interesting that even dark-skinned doctors often make these same errors (“I cannot tell if there is any redness because the patient is black.”) In training doctors we try to root out these biases and encourage objective descriptions with clear referents, but in medicine, it’s just as hard as everywhere else.


  1. #1 D. C. Sessions
    November 30, 2009

    Brown eyes outnumber blue even in people of northern European ancestry. Despite this, instructional materials on assessing pupil responses are remarkably lacking in advice on how to observe pupils in dark eyes.

    One might wonder.

    It took some training by an Apache paramedic before I was any better than hopeless — still not very good, but better now.

  2. #2 PalMD
    November 30, 2009

    That can be really, really challenging.

  3. #3 D. C. Sessions
    November 30, 2009

    That can be really, really challenging.

    … but neither are you free to refrain from it. I can understand showing blue eyes to get the idea across, but I swear I’ve never seen any guides even offering hints.

    Do we just say, “damn, that’s a hard one. I think I’ll do something easy instead?” or is it only some things like skin and eye color?

  4. #4 red rabbit
    November 30, 2009

    Pupillary responses in dark-eye people? I don’t know any tricks other than to use an LED light in a not over-bright room and look carefully. The slight blue tint of the LED light may or may not make it easier, I’m not sure, but that’s what I do.

  5. #5 PalMD
    November 30, 2009

    I’ll have to try the LED trick. I’ve always just played with the ambient light.

  6. #6 Whitecoat Tales
    December 1, 2009

    I second red rabbit.

    Mid neurology rotation I switched from “old fashioned crappy 5 dollar penlight I was bamboozled into buying by med school” to “2 dollar bright LED light.” It made a world of difference.

  7. #7 Joe
    December 1, 2009

    A note of caution: today, it is becoming difficult to find an LED light that isn’t so bright that it won’t fry your patients’ brains (0.5 W is way too bright). Also, the bluish ones are disappearing. A piece of blue cellophane on a regular light may be worth trying.

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