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Am Fam Physician. 2000;62(5):957

to the editor: An article by Barton and colleagues,1 reviewed in “Tips from Other Journals,”2 discusses the clinical breast examination. The authors correctly encourage careful technique and thorough examination. However, I would like to suggest that, during the examination, the patient should be seated on the end of the examination table with her hands on the stirrups, while leaning forward at about a 45 degree angle to allow the breast tissue to fall away from the chest wall. This position allows the examiner to place the fingers behind the deep tissue so as not to confuse a breast mass with a rib. The room should be one that can be absolutely darkened so that adequate transilluminations can be done. Physicians might be amazed at what they can see under these conditions. Highly pigmented skin will not allow the breasts to be transilluminated well.

Axillae can be examined with one hand, but the breasts are best examined with a bimanual technique using digital pads. With one hand on each breast, using the digital pads with tissue between the finger and the thumb, the examiner can compare the texture and pick up differences that would otherwise be missed. All of the examiner's findings can be conveyed to the patient during the examination and, at the same time, the physician can encourage and educate the patient about breast self-examination and desexualize the process.

The most important part of the examination is the information assimilated in the examiner's mind. The examiner must create a picture of what the fingers feel (but cannot see) in the breast structures. This is best done with the eyes closed. The patient, too, should be reminded that she must learn to differentiate between what her fingers tell her and what her breasts tell her.

I do not have any statistics to support this technique; I am just a country doctor trying to catch cancer early, but this technique enables me to know what I am doing when performing a breast examination.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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