I was fairly sure I had failed my final Bachelor of Medicine, Bachelor of Surgery (MBChB) exams.
Out of my four long cases, two were patients with neurological conditions. And not only did I have two neurology cases, but waiting for me – in a stiff white coat, steel spectacles and clutching a tendon hammer – was Dr Jones.* She was one of the few female consultants at the Infirmary and, at first, I had wanted to like her, maybe even be like her. But that changed after she admonished me in year three for comforting a crying patient, and in year four told me to remember that ‘most patients have an IQ of three’.
Now, I needed her to like me – or at least pass me. This seemed unlikely as she asked me to describe the knee reflexes I had managed to elicit with shaking fingers.
‘Brisk?’ I ventured, grasping at one of the two adjectives my textbook had offered.
She snatched the tendon hammer, unsmiling, and swung it. ‘No.’
Back and forth the tendon hammer went.
‘Remind you of anything?’ she asked, rolling her eyes at the other examiner – an orthopaedic surgeon, as silent and, possibly, as confused as I was. ‘Tick, tock?’ she drawled. ‘Tick, tock.’
All I could think of (this was 2002) was Hannibal Lecter, though I’m sure today’s final-year medical students would have a different reference point.
‘A clock pendulum?’ the patient finally suggested, breaking the silence.
Dr Jones, seemingly oblivious to the irony of her own derogatory comments about patients, spun around and glared at the tiny lady in her hospital gown.
‘Yes. Pendular is the word you are looking for, candidate. Thank your patient ...’
I was probably never destined for a specialist interest in neurology – even before that encounter – but neurological conditions frequently present in general practice, and I still find them challenging. Perhaps it is the time required for a thorough neurological exam and the complexities of interpreting neurological signs. Or maybe it is the anxiety of missed diagnoses or the harms of over investigation. Maybe it is the long hospital waiting lists and the dilemma of what to do in the interim. Or the difficulties in diagnosing, explaining and managing functional neurological disorders. Disorders that were alarmingly dismissed as ‘malingering time-wasting’ by another of my dubious role models from the early 2000s – let us call him Dr Smith.*
This Focus issue of the Australian Journal of General Practice (AJGP) explores some of these challenges. Stuart, Burnett and Webster1 offer a concise framework for assessing patients with low back pain and radiculopathy, including updated recommendations such as the redundancy of assessing anal tone in primary care. Soon and Foden2 provide an update on the assessment and management of sudden sensorineural hearing loss – a topic that was completely absent from my own medical school curriculum. Singh et al3 acknowledge the difficulties of caring for people with suspected Parkinson’s disease in an imperfect healthcare system, offering guidelines for general practitioners (GPs) who wish to trial levodopa while their patients await a neurology appointment. They also highlight the Cochrane review recommending exercise as an important intervention for Parkinson’s disease. Rolfe et al4 present a case of giant cell arteritis (GCA) manifesting as diplopia and discuss the role of steroid-sparing agents such as tocilizumab in GCA management. Finally, Thomson et al5 present a compassionate, evidence-based and holistic approach to managing a woman with a functional gait disorder – an approach vastly different from the outdated attitudes of Dr Smith (who, hopefully, has long since retired).
And my final exams? I passed the neurology long cases. It turns out the silent orthopaedic consultant, like the patient, was on my side. With my pass came a resolve to scrutinise my ‘role models’ more closely and to treat my future medical students with kindness and mutual respect. Though I still can’t watch The Silence of the Lambs without hearing Dr Jones’s voice.
As for Dr Jones, I wonder if time has softened her as she has aged. Has she gained compassion and empathy from her own experiences as a patient? Perhaps she has come to realise that, inevitably, we all ‘become’ patients. And that, in our final exams and beyond, we have much to learn from them.
*Names have been changed.