BMJ  2005;330:1365 (11 June), doi:10.1136/bmj.330.7504.1365

Filler

In praise of half doing a job

To many of us, "half doing" something is quite unthinkable. We are programmed by our upbringing and medical training to believe that if a job's worth doing it must be done properly. In the real world, however, life's not quite like that. In general practice we often have to cut corners because we simply don't have time to do a full examination on every patient.

To diverge slightly, I was once told that many people with messy desks are actually very tidy. This apparent paradox arises from the fact that they prefer to live with the mess if they haven't time to do a thorough job tidying up. They feel uncomfortable just putting papers into piles, so they put off the job until there is time to file everything in its proper place.

Perhaps it's a bit like that in general practice. I suspect one or two of us don't even attempt to do a particular examination (funduscopy, for example) because we haven't the time (or the skills) to do it properly.

I returned to general practice two years ago after a career in medical journalism. One of the perks of coming back via the (excellent) "returner scheme" is to be invited to higher professional training meetings for the next two years. A couple of months ago, I attended a talk by an specialist registrar in neurosurgery entitled "So you think you've got a brain tumour." The food and company were great, but I confess to being somewhat disappointed with the talk. I had hoped to receive pearls of wisdom on how to distinguish between "benign" and serious headaches; what I learnt was that basically you can't.

But I did take home one message: always examine the fundi in any patient presenting with a headache. Nothing particularly novel about that, you might think. However, our young speaker did add one extra dimension—he gave us permission to "half do" the job. With the pragmatism of a surgeon, he stressed that the important issue was to check out the optic disc. It was not necessary for us to agonise over the state of the retina or retinal vessels through a small undilated pupil.

So, my guilt assuaged, I now look at the optic discs of every patient who presents with a headache. Imagine my surprise last week when I couldn't find any sort of edge on either disc of an 18 year old presenting with a three week history of headache. Yes, this obese young woman, who was taking antibiotics for her acne, had bilateral papilloedema.

My patient is now doing well with treatment for her benign intracranial hypertension. And, guess what? My formerly messy desk is now clear—except for three large piles of paper waiting to be filed.

London (jjrgraham{at}aol.com)

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