Leaving AMA

I have had three patients leave AMA (against medical advice) this week. Though it significantly lightened my patient load, I still have been a little irked by it. If I have patients that insist on leaving, I at least try to give them prescriptions for medicines they will need before they go, but all three of these patients left abruptly at night. By the time I had heard about it, they were gone.

One was a lady with COPD and pneumonia who left because I wouldn't let her go outside and smoke. Two were alcoholics being treated for various alcohol-related disorders who left to resume drinking. Maybe I should start ordering beer and cigarettes for my patients so they will stay for treatment. But wait, those are the things that got them there in the first place. Imagine what ER's around the country would be like if there was no smoking and no drinking. Most would have to shut down for lack of business.

Or, as I heard from an ER attending, we could do what one large hospital in Chicago did. They added a one dollar charge at the entrance gate for their ER's parking garage. This small change led to car after car pulling up to the gate and then backing out and driving away. Their patient volume literally fell by 50%. It's scary the abuse of ER's in this country. People go to the ER to get out of going to jail, to get med refills, to have a place to sleep, to get some food...almost everything but to get medical care for a real medical emergency. I guess we still have those too, but it's still a problem. Whew, I guess I had to get that off my chest.

Not a mammogram

Frequently, I order tests for my patients, and it may take a day or two for them to get done. Thus, when my patient goes for a test, I don't always know what test it was until the results come back.

This brings me to a visit I had with one of my patients today. Bear in mind that the patient is a sweet 70 year old man. I went in to ask him how he was doing, and he said that things were fine.
"Did my test come out okay, doc?"
"Which test?" I asked.
"The test I had last night."
"Well, I'm not sure which one that was, but I'll check on the results."
"Come on, doc, it was that mammogram that they did on me," as he gestured towards his pelvic area.
"Well, I'm still not sure which test it was, but I think I can safely say that it was not a mammogram."

Why neurology

Sorry for not blogging in a while. I've been working on this one, and it has taken me a while, as you'll see...

I’d like to respond to a recent blog of a friend of mine about a subject close to my heart, which you can find here:

First, I’d like to say thanks to Phil for giving such nice consideration to the field of neurology.

Phil also expresses some of his reservations about the field, which I think are common misperceptions about neurology. I’d like to respond to some of these if I can, though bear in mind that I am definitely biased as a neurologist-to-be. At the very least, maybe you can get an idea of why I chose neurology.

The criticism: In neurology, you can diagnose things, but don’t have many treatment options.
This is probably the most common misperception about neurology. In Texas, I’ve often heard it referred to as the “Diagnose and Adios” field. While that’s funny, I still don’t think it’s completely accurate. The total number of treatment options for most areas of neurology is quite limited when compared to the rest of general internal medicine, but I think the key is comparing apples to apples. In diseases like ALS, there is virtually nothing in the way of treatment, but it would be unfair to compare this to the treatment of hypertension. ALS is a degenerative disease, so how about comparing it to another degenerative disease like an inherited dilated cardiomyopathy. How much is there to do for that? The difference is, unfortunately, that neurology has a disproportionately high number of degenerative diseases, which are very difficult to treat across the board. For diseases like epilepsy, there are many antiepileptics available, and this would be fair to compare with hypertension, though it is still true that there are more antihypertensives available. So the criticism of limited total number of therapeutic options is valid, though how good or bad this truly is in choosing a career will be debated further below.

However, if by not having many treatment options, there is the implication that there are not EFFECTIVE treatment options, then I would beg to differ. Consider an autoinflammatory neurologic disease like MS. There are MS-specific immunosuppressive therapies available that are quite effective. Compare that to therapeutic options for lupus or RA. At best there are “disease-modifying” agents that still have a fair bit of systemic toxicity and aren’t altogether effective. How many times have you had a patient with SLE or RA living a relatively symptom-free life. I've actually had well-controlled MS patients who report almost no symptoms on meds. It is the same with Parkinson's, where I've had a number of asymptomatic patients on medications. The bottom line is that most therapy in neurology is focused on symptom control, but so is most medical therapy in the rest of internal medicine. So we don't cure MS or cure Parkinson's. But when is the last time you cured hypertension or diabetes? Meds in those cases ALSO just control the symptoms, as we certainly see when our hypertensive and diabetic patients stop taking their meds.

So if you equate a person with normal blood pressure on anti-hypertensives with a person with no tremor/bradykinesia on a dopamine agonist, where does the misperception that there are no good neurologic therapeutic options come from? Most residents/students encounter neurologic diseases like Parkinson’s or MS in the ER/hospital setting, where they are either being diagnosed for the first time or are poorly controlled at home. The same is true for hypertensive urgency or new onset diabetes. The difference is that all residents/students also rotate in outpatient clinics where they have the opportunity to see well-controlled diabetes and hypertension. Most do not rotate through outpatient neurology clinics where they can see well-controlled MS, Parkinson’s, migraines, epilepsy, and more.

Then, is it even so bad if we can't cure all these diseases? For me, it helps me to keep a healthy humble approach to medicine instead of thinking that I'm out there saving everyone’s life, since even if I do, it's not through any power of my own anyway. Also, for me neurology is MORE exciting since less is known. It means there is lots of work to be done, and I honestly think that in my lifetime the major breakthroughs in all of medicine will be in neurology. Just look at the percentage of grants and new studies that are in neurological fields of study. I think that many older doctors who have been in practice a while tend to fall back on all the therapies they’ve been using forever instead of keeping up with all the newest, most innovative treatments. If there are constantly new treatments becoming available (like in neurology), it forces you to keep up, and I like that. But I’m even comfortable in acknowledging that we will likely never know all that there is to know about how the brain works. For me, there is a certain beautiful mystery to the human brain that reminds me of its creator. To me, it is God’s most intricate and amazing creation, and I am humbled just to be able to study it and to serve others who have problems with it. That’s why I chose neurology.