A case of mistaken muscles

BMJ 2002; 324 doi: (Published 20 April 2002) Cite this as: BMJ 2002;324:962
  1. Hashim Uddin Ahmed, final year clinical student,
  2. Sarah Ali
  1. Oxford Clinical School, John Radcliffe Hospital, Oxford

    Oxford Clinical School recently piloted a scheme in which final year students serve as mentors to first-year clinical students. The assumption is that these near qualified students are not too far advanced to have forgotten those first anxious steps on the wards and can therefore provide a type of support that qualified doctors could not. Equally important, they have sufficient experience to teach the basic clinical skills of history taking and physical examination.

    During a teaching session given by HUA (a finalist) to SA (a first year student) on the dreaded neurological examination, we both gained valuable lessons beyond those simply related to the intricacies of the nervous system. While HA confidently presented the innervation and actions of the various extraocular muscles, SA patiently listened. After HA had finished, SA shook her head and proclaimed, “But that's wrong.” Having recently left the confines of the dissection room, SA recalled that the superior oblique and inferior oblique muscles did not adduct (medially rotate) the eye, as HA had explained. These two muscles, as well as depressing and elevating the eye, abducted (laterally rotated) it. The superior rectus and inferior rectus muscles served to adduct.

    Having acquired a certain degree of arrogance during his two years of clinical experience, HA was having none of this. His clinical examination textbook, recommended and used by countless students around the country, was on his side. However, SA quickly produced an equally respected anatomy textbook supporting her viewpoint.

    Which book was right? With HA soon to sit finals and SA having just embarked on her clinical career, it was understandable that paranoia should set in: after all, such flaws in knowledge could be fatal in clinical exams. So, armed with a determined intellectual curiosity (and fear of failure), we scrutinised a selection of popular and respectable anatomy and clinical textbooks to discover the truth.

    The result was odd. All four clinical textbooks we surveyed supported the view that the superior oblique and inferior oblique muscles adduct the eye, while the superior rectus and inferior rectus muscles abduct the eye. In all five anatomy textbooks we consulted the reverse was demonstrated. Could the meticulous anatomists be wrong? Had the clinicians inadvertently embroiled themselves in an institutionalised error, passed down from one generation of doctor to the next? Such was the reputation of the books in the two opposing camps, that we had no choice but to (reluctantly) perform a first in our medical studies—we opened Gray's Anatomy. The answer, though revealing, was hardly surprising—the clinicians were wrong. Gray's Anatomy supported its less voluminous siblings.

    What lessons did we learn from this brief investigation of muscular minutiae? Firstly, clinicians do forget their anatomy, whether they are students or great professors of medicine. Secondly, if you are to teach, make sure you have learnt the subject correctly. At the very least, do not be arrogant and inflexible: prepare to be proved wrong, and hence enlightened. Thirdly, regardless of how authoritative your books and superiors in medicine seem to be, if in doubt be brave and challenge. If we are to reach the truth many of today's supposed facts must be made tomorrow's errors.

    And most important of all, the superior oblique and inferior oblique muscles abduct the eye, while the superior rectus and inferior rectus muscles adduct it.

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