The central axiom
Everything you have worked for has been for this moment. The brain lies at the center of our personal universe. It transforms a chaotic world of hurling particles into the perception of sense and stability. In addition to creating a sensory representation of reality, the brain allows us to be aware of ourselves and others. Every nervous system process can be deconstructed into sensation, movement, emotion, memory, and communication. The brain allows humans to create, explore, interact, and yearn for something better. It contains our greatest dreams and hopes, as well as our fears and nightmares. It is where life and religion originate. It is where good and evil reside. It is where life ends.
The central axiom of medicine is simple. Support and protect the brain. Everything you have learned in medical school has directly or indirectly been for this purpose. The TCA cycle, G proteins, anatomy of the heart, acid/base balance and the kidney, and oxygen transport with the blood and lungs are all critical to keep the brain alive.
Do not misinterpret this to mean that everyone should become a Neurologist. That would be foolish, and not in the brain’s best interest. We need cardiologists, nephrologists, and pulmonologists. In the game of chess, the pawns are important as well. If every piece was the king, then chaos would reign. Just as the body has divided the organs to protect and support the brain, so must the field of medicine emulate this division of labor for the greater good. So rest assured. The goal of this clerkship is not to permanently transform every medical student into a Neurologist. You will just be asked to be a Neurologist for your 4 weeks on this rotation, with no obligation to necessarily remain one at the end.
Why should we study the brain
“Hearts and kidneys are Tinkertoys! I’m talking about the central nervous system.”
Gene Wilder, Young Frankenstein
The brain is by far the most complex and fascinating organ of the body. Although some may try to argue, it is the organ most worthy of a lifetime of study. The brain can be contrasted with the heart, which undoubtedly plays a key supportive role. The heart, in all its intricacy, comes down to 4 chambers, 4 valves, and some electrical wire. Of note is that it can also be replaced, by a man-made rendition. The heart of one person can be transplanted into another person within a matter of hours. Now, how complicated can that be?
There remains much to be known about the brain. Although tremendous strides are made each year, the study of the brain remains in its infancy. This black box is intimidating for many medical students, but has also been the source of fascination for the world’s greatest scientists, writers, and philosophers. It’s true that you cannot measure pressure or volume or electrical conductance for the brain as you can with the heart.
“If the human brain were so simple
Emerson Pugh
That we could understand it,
We would be so simple
That we couldn’t.”
What makes neurology different
As you make your way through your clerkships, you will note that each field has a particular approach to patients, and also tends to attract a certain personality. You will find most neurologists are both curious and content. Primary importance continues to be placed upon a proper history in order to arrive at the correct diagnosis and course of action. Although there are pressures upon everyone in medicine to see more patients, the initial evaluation cannot be short-rift. In clinic, a new patient visit can take an hour, and a follow-up can take 30 minutes. For a complicated new patient in the hospital with an acute problem, it may take well over an hour to do the initial assessment.
We learn medicine by talking with patients. Textbooks serve as a guide, but patients translate the medical terminology into the human experience. No one is an expert by reading a book chapter and seeing a single person with a given condition. It will take many patients with a given condition and followed over years until you begin to realize how a disease presents and affects someone. The contact with your patients is invaluable and needs to be fully appreciated. If you know how to listen and make observations, it will enrich your practice and the rest of your life.
A good history takes time. With experience, you will learn to ask open-ended and non-leading questions. Neurologists from a previous generation would say that you get nothing meaningful in the history during the 1st half hour! Unfortunately, there are some time constraints, so most histories should be completed in 20-30 minutes unless they are complicated.
As you obtain the history, you start to form a hypothesis about what is going on. Additional questions will further test your hypothesis and develop concepts relating to localization. You will then ask additional questions to help refine your localization. The history is a dynamic process that does require some skill and flexibility. You need to continually scrutinize the information for further clarification to help with medical decision making. You also need the know how to phrase each open-ended question so that the patient will provide a description in their own words. Computers can ask questions, physicians elicit a history. It is also crucial to understand something about the patient’s environment, and how their illness has impacted their ability to function.
The physical exam is also a dynamic process. Every patient will get a complete examination, but you need to be flexible and scientific as well. You will carefully scrutinize key parts to test your hypotheses and convince yourself whether a sign is truly present or absent. If you are unsure, you need to repeat the exam maneuver until you are sure, or look for other corroborating sign. An Attending can spend either 10 seconds on the reflexes or 5 minutes, depending upon the clinical scenario. This need to think on-your-feet becomes very enjoyable once comfortable with the concept.
In addition to talking, Neurologists like to examine patients. The neurological exam is very important and serves many purposes. Most patients, unless they have headaches or seizures, will have many interesting neurological findings. If you come to movement disorders or multiple sclerosis clinic, then almost everyone has an abnormal physical exam. The exam can take a substantial part of the office visit. Since you spend time touching the patient, it also helps to solidify the physician-patient relationship. The physical exam in Neurology is a most necessary element of the work-up and an inextricable component of a proper assessment.
The neuro exam will not often give you an answer as to the diagnosis, because the findings are typically not that specific. However, it will give you an idea as to where to localize, how much the person is functionally affected, and also a differential diagnosis. One can really appreciate how people have difficulties in their everyday lives by examining them.
Some may find it frustrating that most neurological diseases do not have a laboratory test that gives a ‘yes’ or ‘no’ answer. Parkinson’s disease is based solely upon the clinical characteristics of a unilateral tremor with bradykinesia, rigidity, and postural instability. Despite strides in neurodiagnostic testing, it also remains true that migraines, epilepsy, M.S., and stroke remain a diagnosis based predominantly on clinical grounds. It is not like doing a cardiac catheterization to determine if they have coronary disease. Neurologists know how to spend money on tests, this is for sure. However, a test without the proper reasoning will often create more confusion than illumination.
Finally, neurologists tend to enjoy talking about their specialty. Since the brain is so interesting, it is hard not to teach and discuss. Patient rounds can be long, but hopefully you will find them both educational and enjoyable. Rounds are your opportunity to observe the experienced attending, who has been doing this for some years. Everything the attending says and does with the patient is for a particular reason. There is a lot of learning that can be accomplished on rounds, even though it may not seem like there is specific ‘teaching’.
Dispelling some myths
Neurology is depressing.Untrue. The first reason for this misconception is that 2nd year medical school courses are often taught based upon pathology. While our Pathologists do a wonderful job at explaining the basis and the structural changes associated with neurologic diseases, medical school pathology cases can be biased to those patients who did not do well. What you sometimes learn about are the large strokes that herniated and died. And the HSV-Encephalitis that herniated and died. And the end-stage Alzheimer that aspirated and died.
Second, medical school clerkships are often based on inpatient experiences. There is no doubt that inpatient neurology contains its fair share of neurological catastrophes. But that experience should not be construed as typical. When you go to outpatient clinic, you will notice strokes and MS and headaches and epilepsy and Parkinson’s disease, with people who are doing remarkably well.
Third, even some of the neurological catastrophes do remarkably well. You are seeing these patients in their darkest hour. They are comatose, paralyzed, cannot speak or understand. You don’t always get to see them in 6 or 12 months. For many, recovery can be remarkable.
Finally, this all needs to be placed into perspective. Unless you are doing well-visits in family practice, every field in medicine has its depressing side. Pediatric oncology can also be depressing. Many people with heart and lung and kidney disease are severely disabled and not doing well. Sometimes we mistake our impression of control and our ability to prescribe modest therapies as equivalent to being effective.
Diagnose, then adios.Again, false. The charge is two-fold: that Neurologists are only interested in the processes of localization and diagnosis, and that there are no treatments. As the joke goes, the neurologic therapeutic arsenal contains phenytoin, steroids, and heparin.
First, you need to understand that your power as a doctor is not just because you can prescribe medications. Listening to patients is an important therapeutic process unto itself. Patients can discuss their inner-most concerns without fear of reprisal or judgment. And they can discuss their varied symptoms with someone who understands them. Many people feel uncomfortable telling their symptoms even to their spouse, family, or close friends. Some worry that they are crazy or that their experience is unique. Conveying their experience can be cathartic.
Second, neurology does have many therapeutic agents. Whether it is MS or epilepsy or headache or movement disorders, there has been tremendous development of effective medicines.
Third, what we can do for our patients is not limited to supporting the pharmaceutical company. We teach and provide information. We serve as a liaison for support groups. We coordinate multi-disciplinary teams for dealing with serious illness. Rehabilitation medicine strives to keep people ambulating, mobile, working, and doing all those other things in their life which they care about. We can offer clinical trials that may help the patient, and will hopefully lead to new therapeutic options.
Neurology is too complicated.Wrong. The first week of the rotation might be a bit intimidating. Between remembering your neurosciences, neuroanatomy, diseases of the nervous system courses, localizing the lesion, and prioritizing a differential diagnosis, there is definitely much information to consider. However, within a week, you will be doing all these things. By the end of the 4 weeks, you should have a very good appreciation of how to recognize and communicate neurological issues to other physicians.
The MRI will replace Neurologists.Yeah. Right. They’ve been saying this since the first head CT scanner was created in the ‘70s. I’m not too worried.
Expectations for this rotation
This rotation should be challenging. You will be taking care of patients, working with your team, preparing for different rounds, and keeping-up with reading assignments. This is the type of rotation where you will get-out whatever you put in. If you take ownership and responsibility for your patients, then you should definitely feel like an important part of the team. You should be proactive about obtaining additional experiences during your brief time. Time flies when you are busy.