What Was in Frank Forster’s Bag?

Dr. Forster was a renowned epileptologist, former chair at Georgetown and the University of Wisconsin, and one of the “Four Horsemen” who founded the AAN. At the annual meeting in Philly a few months ago, I happened upon this display case with the (surprisingly large number of) objects found in his neurology bag. A little card in the case lists some other items that were found in his bag but not included in the display case, and these included a stoppered glass vial of morphine sulfate and ampules of phenobarbital . . .

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Interesting Reads

Some random tidbits:

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Do Wellness Programs Work?

“Wellness” is a buzzword these days, but recent evidence suggests that workplace wellness programs may not improve health. Here’s a recent JAMA article and here’s a New York Times piece commenting on it.

I’ve always been a bit skeptical about efforts to promote personal resilience through yoga and other exercise classes, mindfulness sessions, etc. I don’t doubt that these can be very healthful practices, but different people are interested in and respond to different things. Maybe you like spinning classes but I like swimming laps. Another person relaxes by knitting and another by playing a musical instrument. It follows that the necessarily limited workplace options for “wellness” activities will benefit a limited number of employees.

In the context of residency training, I think it’s more important to focus on removing sources of annoyance and dissatisfaction. Are there enough call rooms? Are they clean? Is the cafeteria open off-hours? Is parking affordable and convenient? Does the institution provide sufficient ancillary support, or are residents transporting patients, obtaining EKGs, and performing other services that don’t require an MD? If programs (mostly, the institutions that sponsor them) could address those issues, I think morale would benefit greatly and then residents could go do yoga or whatever they find most beneficial on their own.

Once in practice, the physician confronts different, but related, problems of exceedingly high expectations and insufficient time and support to ideally care for patients. That’s the subject of this NYT opinion piece. A close friend and colleague of mine identified this problem long ago as “an asymmetry of moral obligation”. Again, the solution to this problem lies not in yoga but in addressing the workplace structures and processes that impede the provision of medical care.

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July 1!

Welcome to all new neurology residents, and congratulations to those moving up a notch! For the start of the year, I’ve updated the menus above with some new resources, which are highlighted below in no particular order:

  • The AAN website has some pretty good webinars on the transition from neurology training to actual practice. They include the basics of searching for a job, negotiating your first contract, billing, coding, and the business side of running a neurology practice. I’ve added the link in the Fellowships and Jobs menu. This menu also has links to various fellowship and job boards, and the City-Data sites. City-Data.com has lots of data about a large number of U.S. cities (population, climate, etc.), whereas their forums have posts where users ask and answer more detailed questions about each place (Which neighborhoods are more walkable / bikeable? Which elementary schools might I consider?, etc.)
  • The University of Iowa has an ophthalmology website called EyeRounds, which includes neuro-ophthalmological case reports, photos, videos, and tutorials. For just one example, here’s a primer on anterior ischemic optic neuropathy. The link to the main website can be found under Neurological Disorders–>Neuro-ophthalmology.
  • More RITE / board prep courses and question banks are becoming available online. I’ve put a few links in General Neurology–>RITE / Board Prep.
    • The full AAN board prep course, which includes content and questions, is offered at a discounted fee for AAN members.
    • The AAN’s self-assessment exams are free for members. These include a few exams on general neurology and also some that are specific to epilepsy, vascular, child neurology, etc. Although the questions are a bit easier than those on the RITE or ABPN exams I still think they’re very good for test preparation.
    • The other sites listed are “third party” and require subscriptions.
    • You may also want to check out the online neuropathology course and the neuroradiology resources I’ve linked to in the Neurological Disorders menu.
  • I found another EMG-related website, called EMG whiz. The link can be found under Neurological Disorders–>EMG / Neuromuscular, along with a few older online resources. I particularly like Wash U.’s neuromuscular site.
  • Those who are international medical graduates, or interested in international perspectives on residency training, there is an ECFMG blog called Journeys in Medicine. I just emailed them to see if they have an RSS feed; if they do (or if they create one), I’ll add it to the collection over on the right side of the page.
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Please Rally for One of Our Own

One of the great pleasures of being part of a diverse residency is in learning about people and places all over the globe. But sadly, this occasionally means learning about the misfortunes that befall them. Last month, heavy rains brought destructive flooding to Iran; hundreds of thousands of people have been affected. One of my own resident colleagues is from the town of Poldokhtar, which was essentially washed away, rendering homeless 17,000 families. If you’re able to help out a fellow neurologist, please follow this link to a funding page and share it around with others who may also be inclined to help. Thank you.

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Gait Disorders

Quick question: What’s depicted above, and what does it mean? Answer below.

The most recent blog post on Dr. Johnson’s Raven Neurology Review is on the equine gait. Also called a steppage gait, it results from weakness of foot dorsiflexion (“foot drop”), which in turn has a few different causes–usually peroneal neuropathy or L5 radiculopathy.

What caught my attention was that the post includes photos from Eadweard Muybridge’s high-speed photographic analysis of a true equine gait–a horse in motion! This reminded me that Dr. Doug Lanska gives a superb lecture on the topic of gaits in neurologic disease. His talks include the very interesting history of the late 19th century collaboration between Muybridge, a photographer, and Dr. Francis Dercum, a Philadelphia neurologist. A University of Pittsburgh-affiliated website has a free video of one of Dr. Lanska’s talks, and it is a highly worthwhile video for the student of neurology. Dr. Lanska also authored a paper on the Dercum-Muybridge collaboration.

Also, in the “General Medicine” part of the menu above is a link to the Stanford Medicine 25–a series of short videos on physical examination. Among the neurology videos is one on gaits.

And what’s pictured above? Gower’s sign. Due to proximal leg weakness, the child with muscular dystrophy needs to push off with his hands in order to rise from the floor or the bent-over position.

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Raven Neurology Review

I recently learned of another neurology education resource worth sharing. It’s called Raven Neurology Review–a website created by Dr. Paul D. Johnson, a stroke neurologist in the mountain west. The site includes:

  • Links to free e-books on neuroimaging and stroke.
  • A signup form for Neurons, a few-times-per-week email newsletter that addresses high-yield neurology topics.
  • Information about his neurology review books for medical students, RITE review, and APPs.
  • A neurology blog! I added the RSS feed to his blog over on the right side of this page.
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Because the question came up recently, I want to remind everyone that everything written in this blog is either my own personal opinion or those of the other authors and commentators. I pay out of pocket to maintain the website, and the opinions expressed herein are not those of any university, hospital, government agency, or professional organization.

If another website links here, it doesn’t imply an official relationship or endorsement. Likewise, my posts contain many quotations and links to other websites, articles, and the like, and there are a few RSS feeds in the sidebar. I think these serve to illustrate or reinforce specific points, and enhance the value of the site generally. However, their inclusion here doesn’t imply my endorsement of everything the referenced people ever did or said.

If you’d like to contribute to the discussions, there is a commenting feature. To keep it civil, you must input your name an email address before commenting, and I do review each one before publication. Alternatively, you may send your comments to justin@ghostofcharcot.net. If warranted, I’ll post them and respond in a follow-up entry, preserving your anonymity if you so desire. If you’re someone I know well, you might consider being a guest author!

While we’re at it, here are the rest of the disclaimers that I’ve updated on the “About the Blog” page and in the footer:

  • The website is for general educational purposes only; it is not an authoritative source of information for treating individual patients, and the accuracy of the content, whether original or linked, is not guaranteed. Medical science is continually progressing, and the blog posts and other information contained or linked to may quickly become out of date. If you are a physician, please consult the appropriate texts and consultants for patient-level advice. If you are a patient, please consult with your physician and do not rely on the information herein to diagnose or treat your condition.
  • All clinical vignettes discussed herein are composites designed to highlight certain medical, ethical, and other issues pertinent to neurology and neurological education. There is no protected health information on the website and any details resembling actual patients are coincidental.
  • All original content may be freely used and shared for non-profit educational purposes, with attribution. Note that some content is not original and may be copyrighted; it appears here either with permission or under fair use doctrine, but reuse may be subject to copyright.
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Longform Read on the EHR Mess

Hat tip to Dr. Shannon for this one: A Fortune article titled, Death by a Thousand Clicks: Where Electronic Health Records Went Wrong. It’s a long exposé on the problems with electronic health records and specifically how they can lead to medical error and physician burnout. I’ve linked to other pieces on this topic before, including here and here.

I think the best treatment of this topic is Dr. Robert Wachter’s book, The digital doctor : hope, hype, and harm at the dawn of medicine’s computer age. I really like this book because it puts the EHR in the larger context of medical practice and systems of care. He compares the design of EHRs, and ICU and other technologies, to airline cockpits and how the relationship between, say Boeing pilots and engineers is so much different than the relationship between physicians and EHR programmers. Another very interesting part of the book explores the ethnographic changes wrought by electronic health systems. For example, we used to walk down to the radiology reading room more often, because that was the only way to view the films. We’d thereby have face-to-face interactions with our colleagues who could help us refine our differential diagnoses and provide better care to the patients. Now, we mostly look at our scans on PACS (although in academic neurology, especially at my institution, I think the relationship with our neuroradiology colleagues is still pretty tight).

I’ve mentioned this before, but one thought I keep coming back to is that the EHR has put physicians in the business of note construction, which is a very different task than note writing. Note construction is a chore aimed at satisfying various billing and regulatory requirements. Note writing is a part of the patient’s care aimed at documenting and communicating our findings and assessments. It seems to me that the physician burnout related to EHRs derives in large part from this shift.

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Palliative Care Resources

In our recent grand rounds on palliative care in neurology, Dr. Tauck referenced some online resources for education in this discipline. I’ve added two of these to the menu, under the “General Medicine” heading. These are sites that have at least some free content:

  • Palliative Care Network of Wisconsin. Among other resources, their web page has a litany of “Fast Facts” on topics ranging from communication skills to ethics, opioid prescribing to prognosis. There are also specialty-specific ones, including one for neurology that has tips on brain death, neoplastic meningitis, the care of patients with Huntington’s disease, ALS, locked-in syndrome, and other conditions.
  • VitalTalk is a non-profit who mission is to improve communication skills. Under the Resources menu heading, there are links to many good videos on topics titled: Disclose Serious News, Address Goals of Care, Conduct a Family Conference, etc.
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