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Lessons from a master clinician
  1. Vladimir Hachinski
  1. Professor of Neurology, University of Western Ontario, University Hospital London, Ontario, Canada; Vladimir.Hachinski@lhsc.on.ca

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    J Clifford Richardson was a master clinician. He was Professor of Neurology at the University of Toronto, Canada from 1960 to 1975, and best known for his description of progressive supranuclear palsy.1 He was shy, thoughtful, and low key – until you saw him in action. A skillful interrogator and a meticulous examiner, he pursued diagnoses with relentless logic. I had my first rotation in neurology with him. My previous experience of neurology during my internal medicine training at McGill University, in Montreal, Canada, had not prepared me for the lessons I was about to learn.

    Instead of the then prevalent approach of chief complaint, history of present illness, functional inquiry, and so on, Dr Richardson preferred that after the chief complaint we then obtained an extensive family history followed by a social and occupational history before documenting the history of the present illness. It was not unusual for my handwritten admission history and examination to run over a dozen pages. Dr Richardson would read the history thoroughly and critique not only the content, but the English. He forbade abbreviations, discouraged technical terms such as “ataxia” as descriptors and encouraged simple, accurate accounts of the patient’s history, preferably in his or her own words.

    While requiring extensive documentation of the patient’s history and examination, and additional information from family, friends, and any other relevant sources, he would then insist on a succinct formulation after consideration of the relevant diagnostic possibilities. He discouraged a long differential diagnosis and preferred one, or at the most two, alternatives to the primary diagnosis. He banished the word “impression” as a lame substitute for “opinion”, saying that whoever …

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