A day in the countryBMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7455.1573-a (Published 24 June 2004) Cite this as: BMJ 2004;328:1573
A picture window faces north east. Through the morning, skyscapes come and go: dark rain-clouds, uncertain cumulus, sudden clear blue. Far from the bustle of the city, we sit at ease. When I was a houseman, my colleague for today was our senior student: a diffident, kindly young man. I ask after his father: “A bit sore from running for a bus. Probably shouldn't have. Of course he's 92.” And now we too talk of retirement.
Outside, seagulls, starlings, and sparrows appear and disappear. But we are not here for bird watching. We are examining: in the Practical Assessment of Clinical Examination Skills for the Membership of the Royal College of Physicians. The candidates appear and disappear. This morning we have history taking skills, which in some cases we have not got.
We observe, take notes, take turns to cross examine a little, and come to judgment. In some cases we disagree. Outside, seagulls, starlings, and sparrows, and the occasional blackbird, come and go. Inside, there are hawks and doves.
And this afternoon we are assessing cardiological and neurological skills, which clearly also in some cases we have not got. Clever, pleasant young doctors who have worked and studied hard forget themselves and miss things, or parade obscurities we are not interested in. We are not impressed.
The game has rules but they are not much required. When a clumsy toiler is revealed in the first minute and spends the other nine getting things wrong we do not need them. When an intuitive, informed intellect succeeds in charming both us and the patient with her skill, knowledge, and kindliness, again there is no need for rules.
The devil is in the middle. A sudden access of common sense rescues a decent doctor from the follies of the smallest print; we feel relief, but wonder if that is enough. And we may disagree again when a hitherto coherent train of clinical logic is derailed by the frankly surreal. Good and bad starts, good and bad endings: in exams or in life, which count for more?
Long ago, before I sat the exam, I learned all about Quincke's capillary pulsation, an obscure manifestation of aortic valve disease. That day in the country, I think for the first time ever, I saw it. It was—and remains—quite unimportant. But the exam is fair. Half the candidates fail.