Mirror mirror on the wall who is the smartest neurologist of them all?

As a resident in training, I quickly came to the realization that some of my attendings were smarter than others. No matter how vexing the clinical problem these were the few who always knew the answers. I would present the history, examination findings and pertinent labs and voila these master clinicians would be able to put the pieces of the puzzle together. If they did not know the answer right away, they always knew where and how to look for it. What organ system to focus on and what tests to order. They stood out in stark contrast to my other attending, all ‘good’ neurologists but who I frequently found ordering multiple and at times random tests struggling to find answers to what plagued the patient. Eccentric with bedside manners that at times bordered on the theatrical, these master clinicians on the other hand made medicine fun and easy. It was as if they could walk into a patient’s room and smell his disease.

I frequently wondered what set these neurologists apart from others. It could not be the medical school or the residency program they graduated from. Few were from Ivy League colleges and a seldom few were known outside the corridors of the institution they served in. On the other hand a good number of the ‘good’ neurologists made it to the New York’s best doctors list time and time again. Was it their depth of knowledge? Many of the ‘good’ neurologists would quote articles and studies with ease but still came up short at the patient’s bedside. It had to be Factor E (excellence factor) coded by the M (master) gene. Only a chosen few had it.

Now when I am on the other side of the fence teaching residents and fellows in training, I still at times wonder whether master clinicians are born de novo (with copious amounts of Factor E) or whether a chosen few good neurologists become master neurologists and the rest remain good. A lot has been written about improving residency training. The goal is to produce competent neurologists at the end of the training process but can good residents be trained to become master clinicians? Is Factor E teachable and transferable? Does training under the wings of these masters automatically ensure transfer of gene M to the trainee1? The field of neurology glitters with examples of master clinicians who taught, mentored and inspired their residents and fellows to become master clinicians themselves. A closer look at these attending teacher-resident trainee relationships is worthy of our attention. The patient’s bedside is your laboratory is the central tenant that master clinicians teach their students encouraging them to spend time at the patient’s bedside hearing their stories with rapt attention for a small detail in the patient’s history may very well be the key which unlocks the whole puzzle2. Sherlock Holmes the master sleuth once told his prodigy Dr. Watson “you see but you do not observe”. Blessed with astute powers of observation and an analytical mind master clinicians similarly teach their students that the eyes do not see what the mind does not know. James Parkinson, a master clinician in his own right, in his short monograph titled “The Shaking Palsy” described 6 patients in total, three of whom he simply observed walking on the city streets. Much of the description of the longitudinal course of the illness we now know as Parkinson’s disease was derived from his observations of a single case only. Master clinicians report just not their successes but also their failures. Always remembering and learning from their failures constantly striving to become better they inspire trainees to follow in their footsteps. Knowing all too well that medicine never was nor shall ever be an exact science, they encourage their trainees not to hesitate to think out of the box when confronted with a vexing case. “When you have eliminated the impossible, whatever remains, however improbable, must be the truth” another quote attributed to Sherlock Holmes is well worth remembering. Last but not the least these lone stars of neurology teach their trainees the importance of treating patients with respect and dignity reminding them ever so gently that our patients remain our best teachers.

 

“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”

(William Osler-Canadian physician 1849-1919)

 

 

References

  1. Johnston A. Training under the wing of many masters. Pract Neurol. 2012 Jun; 12(3):144-6.
  2. Caplan LR. Fisher’s Rules. Arch Neurol. 1982 Jul; 39(7):389-90.

 

 

Nitin K Sethi, MD

A neurologist reflects…..

Nitin Sethi, MD

Assistant Professor of Neurology

New York Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

Saturday morning finds me in my favorite  coffee shop in the West Village reflecting on the week that went by.  It was a long week, even by my standards and I am happy to have the time to sit down and reflect on it. The week also saw me confronted with a moral and ethical delimma. Electroencephalogram (EEG) (this is a test to look at the brain waves) monitoring was requested for prognostication purposes on a patient in the intensive care unit. Patient had suffered multiple strokes and was on a mechanical ventilator. The purpose of getting the EEG was to get an idea of the extent of his cerebral dysfunction. His EEG showed some slowing of brain waves but otherwise surprisingly looked “good” given the extent of pathology in the brain and the fact that he was comatosed.

His wife tearfully was considering termination of care. Patient had a living will, in which he had clearly made his wishes apparent that he did not wish to live in a state where he was dependent on others, bed-bound and unable to participate in activities of daily living. Objectively as a doctor I knew he was not brain dead, my neurological examination told me that. I did know that his chances of a meaningful neurological recovery were very poor and likely he was heading to a persistent vegetative state (read more about PVS on my website http://braindiseases.info).

His wife had justifiably struggled to come to the decision of termination of care of her beloved husband. Next day when she finally made her decision to terminate care, the patient was noted to wince to pain as she walked into his room…..

There started the moral and ethical delimma for everyone, his wife as well as us doctors. Can we ever prognosticate sufficiently about the extent of someone’s neurological recovery? Can we ever be 100% sure about the extent of someone’s neurological recovery especially if we are attempting to make that decision soon after the neurological insult. Various neurological papers have attempted to answer this vexing question. We do have some leads. We know that a patient who loses brainstem reflexes such as pupillary light reflex (shine a light into the pupils and the pupils constrict) shall have a universally poor outcome. Tests like MRI brain, EEG and evoked potentials further help us in prognostication.

But what does meaningful neurological recovery  mean to the patient, his family and to us doctors? To us doctors it means being independent in activities of daily living, a patient conscious and alert and productive member of society. We have scales to help us grade this recovery. But meaningful neurological recovery might have a completely different meaning for the patient and his family. For his wife, the very fact that her husband is alive, someone she can reach out and touch may mean the world. True along with that shall come the burdens of caregiving.

Now what about the patient? True our patient made a living will, a will made when he was fully alert and in control of his senses. He made his choices known. But did he plan for a situation like this?  He is critically ill and the doctors are not certain what his chances for a meaningful neurological recovery are. Would he have liked to have his life sustanied if the answer was not black or white but a shade of grey?

The more I reflect on this, the more I realise that life is never simple and there are seldom easy answers. The struggle continues…..