Oxford Clinical School recently piloted a scheme in which final year students serve as mentors to first year clinical students. The assumption is that 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 cannot. Equally important, they have sufficient experience to teach the basic clinical skills of history taking and physical examination.

During a teaching session given by Hashim Uddin Ahmed (a finalist) to Sarah Ali (a first year student) on the dreaded neurological examination, we both gained valuable lessons beyond those related to the intricacies of the nervous system.

While Hashim confidently presented the innervation and actions of the various extraocular muscles, Sarah listened patiently. After Hashim had finished, Sarah shook her head, “But thats wrong.” Having recently left the confines of the dissection room, she recalled that the superior oblique and inferior oblique muscles did not adduct (medially rotate) the eye, as Hashim 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.

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

Which book was right? With Hashim soon to sit finals and Sarah 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 looked at supported the view that the superior oblique and inferior oblique muscles adduct the eye, and the superior rectus and inferior rectus muscles abduct the eye. In all five anatomy textbooks we consulted, the reverse was shown. 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 perform (reluctantly) a first in our medical studies—we opened Grays Anatomy. The answer, though revealing, was hardly surprising—the clinicians were wrong. Grays 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 todays supposed facts must be made tomorrows 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.



Hashim Uddin Ahmed, final year clinical student
Email: email

Sarah Ali, final year medical student University of Oxford Clinical School, John Radcliffe Hospital, Oxford, OX3 9DU
Email: sarah.ali@balliol.ox.ac.uk

First published in http://www.studentbmj.com/issues/02/07/editorials/219.php

Thanks Sarah for your interesting piece in the studentBMJ(july2002,vol10,246) regarding fallacies of ocular muscle testing and rekindling my confusion and curiosity I too had experienced during my 3rd year days when I stepped into medicine from anatomy. I had suppressed my confusion at that time and found your piece extremely helpful in resolving it this time.I read up Gray's as you had advised also topped it with Parson's Eye(both of which confirmed your assertion regarding the function of the muscles and then I went to Hutchison and found that he too was correct.Hutchison never said that SO and IO adduct the eye, it says,(pg291--20th edition), SO and IO act as elevators and depressors when the eye is in adduction. Which is quite true and so to test them we have to keep the eye in adduction.I suppose by this time you yourself would have realised it or somebody else might have pointed it out. Anyway I for one was helped by your original and diligent observation.

http://www.studentbmj.com/response/02/nov02.php#res10

Rakesh Biswas