Fillers A golden rule

Looking first

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7242.1111 (Published 22 April 2000) Cite this as: BMJ 2000;320:1111
  1. Martin Turner MRCP, research registrar in neurology
  1. London

    “It's a game, and you have to know the rules,” they said about the membership examination. Tricks of the trade were explained in great detail by ranks of registrars and senior house officers on the other side of this impossibly high fence I had to jump. One consultant, however, simply advised me to “just stop and look before you dive in.”

    She was clearly very elderly, sitting there in the chair—that is all I remember thinking on the approach.

    “Examine this lady's fundi please.”

    I leapt in, introduced myself, and put out my hand—got to look confident, got to look like the registrar. Bilateral optic atrophy. I had never seen it more obviously. Now, causes, causes, got to have the causes. I turned to face the examiner and looked him in the eye.

    “This lady has bilateral optic atrophy.” I was on a roll now; picking up the signs—this was “the game” and I had all the aces at the moment.

    “What is her acuity?” the examiner asked. The “roll” came to an abrupt halt. There was no Snellen chart to hand, what could he mean? He hadn't asked for that in the original instruction. Where was the catch? I struggled and blurted out the first thing I could think of.

    “Well, she fumbled slightly for my hand when I went to shake hers, so I suppose the acuity is reduced, but I would need to test it formally of course.” It sounded lame. He just stared at me.

    “Are there any other clues that this lady has poor acuity, doctor?”

    Now he had the look, the “smiling death” I had been told about. What had I missed? I turned back to face the patient and allowed myself for the first time to “just stop and look.”

    From under her chair, and only visible when I stood back from the patient, her guide dog seemed to be grinning at me.

    I didn't fail simply because of that—there were other more fundamental errors to come—but it was a simple lesson that I have tried to apply since—to “just stop and look before diving in.”

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