It's sad that the clinical part of the MRCPath (Haematology) exam has all but departed. It enabled examiner and examinee to engage in an enjoyable competition of exposing each other's ignorance. It was perhaps unfair of us to put up a case with cerebellar secondaries, but, in truth, the signs were so gross that even a haematologist could spot them. The intention tremor as she undid the buttons on her cardigan fair shook the building. I asked the candidate what tests he knew for demonstrating cerebellar dysfunction. He volunteered Romberg and dysdiadokokinesis. One tip for examiners is always to ask what the candidate does not suggest, so I requested a demonstration of the finger nose test. The idea here is to see if teh patient can move his finger back and forth between the doctors finger and his own nose. At first he did this very well, getting the patient to follow his moving finger with increasing inaccuracy and overshoot.
“Anything else?” I asked.
“Would you close your eyes, please?” The patient complied. “Now, touch your nose and then my finger.”
But instead of keeping his finger in the same place he proceeded to make it wander in a wide arc in front of the patient’s face. Of course with his eyes closed the patient had no idea wher the finger was.
“And what precisely are you testing now?” I enquired. “Extrasensory perception?”
In the same year my co-examiner introduced a patient as “one of our colleagues”. He was, in fact a local general practitioner with polycythaemia.
“Would you examine the abdomen?”
Now this candidate was behind on points, I had already asked her to exmine a patient's armpits. Shee had taken a very long time feeling for what she expected to be enlarged lymph nodes and found none, but she had forgotten to look before she felt and so had missed the black velvety rash of acanthosis nigricans. This time she was determined to leave nothing out. She drew back the sheet and stood staring at the man’s belly for fully sixty seconds. Then, with a sudden lunge, like an eagle swooping on its prey, she leaned forwards, grabbed the GP’s testicles and squeezed. Hard.