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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Meta

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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A Match Week Take on LORs

First, good luck to everyone out there involved in the match–students, program directors, even junior residents, since the match will determine the quality of your senior resident life in a couple of years 🙂

I have in my personal RSS feed a blog called Fake Nous, and really liked a recent post by author Michael Huemer on letters of recommendation. The gist of his argument is that one solicits these from people likely to write nice things about you, possibly even somewhat embellished things. At the same time, employers are scouring them for any hint of a coded message that the applicant may pose a risk. All in all, it’s a time-consuming exercise that adds little of value to the vetting process.

His argument is very applicable to the residency application process. Most letters are glowing and therefore uninformative because they all read pretty much the same. They come from attending physicians, who likely have a limited view of how the students work in the trenches, so to speak. This actually has two aspects. First, we don’t give much responsibility to medical students anymore and so it’s arguable that no one really knows how they’re going to function “in the trenches” until they get there as interns. Second, even if there was something knowable about the student’s real-world performance, it would probably be other students and residents who would know it–not the attending physician writing the letter.

More than the LORs, I rely on the Dean’s letters (Medical Student Performance Evaluations, or MSPEs), since they at least have verbatim comments from each rotation. But those also suffer from the same two weaknesses just mentioned. I would love an MSPE that had comments from fellow students, interns and residents, and nurses and other members of the inter-professional teams too, in addition to the faculty comments. Of course, no one wants to risk derailing a student’s career over something that might just be a one-off matter–a bad day or a bad judgment call or a miscommunication rather than an indicator of future potential. But if all comments were included, then it would be pretty easy for reviewers to identify and ignore the outlier ones and perhaps stand a chance of reliably identifying the best vs. the riskiest candidates.

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Quick Tips on PD Management

A few posts back, I mentioned that there are some really good neurological YouTube videos. Our own Dr. Jones recommended that I relay this quick (10 minute) primer on managing Parkinson’s disease by Dr. Eric Ahlskog, a movement disorders specialist at Mayo. His bottom line: use levodopa / carbidopa and don’t bother with the dopamine agonists! He has some tips on dosing and managing dyskinesias. By searching his name, one can find other, more comprehensive, videos as well.

Update: Please see Dr. Shannon’s comment below regarding the proper titration of levodopa / carbidopa.

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Forgiveness

Some readers are probably aware that the Green Journal recently retracted a Neurology and the Humanities submission by Dr. William Campbell, titled Lucky and the Root Doctor. Dr. Campbell wrote about a former patient, a Southern Black man, who chose a traditional healer called a root doctor over his own ministrations for polymyositis. Had the article focused on this choice and educated readers about root doctors, perhaps with reference to the larger history of nineteenth century medicine, it might not have generated much controversy. But the piece contained characterizations of this patient, his family, and other Black people Dr. Campbell encountered during his time living and practicing in the South that many considered racist. For example, there is an extended discussion of the patient’s “nature” as a euphemism for his sexual function. His wife’s adiposity is described as having “jiggled when she giggled”. Another person is reported “individually salting each French fry”.

The episode is regrettable beyond the racial stereotyping. As someone who has helped select the AAN’s Creative Expression Award recipient for the last few years, I’ll offer that the piece does not, as required by the award for which several of Dr. Campbell’s other submissions have been considered, “artistically express human values in the practice of neurology, including compassion for persons with neurological disorders and reflection by physicians involved in their care.” Rather, this piece arguably takes on a judgmental and not a compassionate tone, especially with respect to diet and obesity.

Take care of all your memories, said Mick
For you cannot relive them
And remember when you’re out there
Tryin’ to heal the sick
That you must always first forgive them

Bob Dylan

Certainly, unhealthful dietary patterns, metabolic syndrome, and the resulting diseases are major public health problems, especially in the South. But there are good arguments that these stem as much from social and political factors as from personal failings. As Dr. Robert Lustig puts it, are we to blame rising obesity among 6 month-old infants on their gluttony and sloth? People suffering from these diseases, like all patients, deserve compassion and not ridicule.


In response, Neurology has not only removed the article from its website, but also invoked its copyrights to force Medscape to delete a PDF linkage. They’ve suspended the Neurology and the Humanities section of the Journal and fired accepted the resignation of its editor, Dr. Anne W. McCammon. The AAN’s website describes a number of other steps being taken to improve their editorial and other processes as regards equity, diversity, and inclusion.

I don’t doubt the sincerity of the Neurology or AAN leadership; they seem truly saddened that our flagship publication carried an article so insulting to so many readers. However, I don’t fully agree with their responses. The copyright-enforced disappearance of the article seems akin to a book burning. We’re all adults here–we can read something controversial and even insulting and potentially benefit from the ensuing discussion. On the Synapse listserv (login required) there were people who genuinely asked to be educated about what made this piece so objectionable. Others responded eloquently about lingering racial caricatures such as that of the jolly mammy. A notice of retraction that thoughtfully critiqued this article might have done more to help extinguish such caricatures and improve our future discourse than simply expressing outrage, guilt, and renewed, but also somewhat platitudinous, expressions of commitment to diversity, equity, and inclusion.

Similarly, a thorough analysis of the piece and the editorial process that led to its publication would make Dr. McCammon a better editor. Neurology and its readership would then benefit from the ongoing efforts of someone with 8 years’ experience in the role, now much wiser after having been held accountable for this poor editorial decision.

Finally, I suggest that Dr. Campbell himself also deserves some compassion. I don’t know him personally, but do know that he’s a veteran and a long-time contributor to our field. He’s authored many papers, as well as the most recent edition of DeJong’s classic, The Neurologic Examination. He’s contributed several other, non-controversial, pieces to Neurology and the Humanities. He maintains a Wikipedia-like website of neurological signs that I think is a nice resource for learners. Medscape quoted him thus: “The retracted article described an encounter with a memorable patient that reached across the generational and ethnic divide. It is a work of creative nonfiction that describes real people and real events in a literary way. Some took offense. Certainly, none was intended.” Of course, that no offense was intended doesn’t mean that the piece wasn’t offensive, and I agree that it did not merit publication. But since it was nevertheless published, constructive responses to the article would have helped make Dr. Campbell, and perhaps other authors, into better writers.*

In comparison to these responses to Neurology’s poor editorial decision, consider how we respond to poor clinical decisions. We all make those from time to time, but assuming no malice or pervasive pattern of error, we learn from the experience; we are not banished. And if the errant physician is a resident, his or her program director is not summarily fired. In my own program, we’ve even renamed M&M to “Systems of Care” conference specifically to distance ourselves from the old-school practice of berating (but even then, generally not firing) individuals for their mistakes. We’re all ignorant about something (most things, really, thinking about the universe). It would be regrettable if, whenever people make errors of ignorance, they are banished from the arena and thus unable to make future contributions of value.


*Update #1: A relative retorted to me that those who have been subjected to historical and ongoing stereotyping and discrimination are under no obligation to educate others on these matters. Fair enough. My constructive criticism here is not of the individual readers who voiced their offense to the piece, but of the AAN’s response as an organization whose vision is to be “indispensable to its members”. The point is that our membership would benefit from a more thoughtful and, yes, educational response.


Update #2: The most common further criticism I’ve received on this commentary is that it seems I’m arrogating to myself the right to “forgive” Dr. Campbell for offending people. I didn’t mean it this way, but can see the concern. My argument is not that he should “get a pass because he’s a good guy”. It’s that we should approach a problem like this with the aim of educating people (author and readers alike) about what made it offensive to so many other readers. In this way, we gain insight into our previously unexamined beliefs and biases and thereby become better doctors, better writers, and better people. I really intend for this to be a positive message and regret not making that as clear at it could have been.

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Ownership and Generosity

I have written before about virtue in medicine and medical training. I hesitate a bit to return to the theme, because I certainly don’t manifest these virtues as consistently as I’d like. On the other hand, a few more have come to mind lately, and perhaps thinking and writing about them is a good way to reinforce them in oneself.

A former Navy SEAL named Jocko Willink writes and talks about the virtue of “Extreme ownership”. This is the principle that a team or an organization performs best when every member takes personal responsibility to the highest level. I think about this a lot in the context of medical teams, and especially residency training. I’ve noticed that programs go through cycles of morale and performance and that the two are linked. When people are always generous with each other, when they take ownership of matters that may not even strictly be their responsibility, the team functions better and morale is high. Think about the physician who always completes the consults that come in on his or her shift, maybe working late so as not to hand off work to the next person. Or the APP who steps up to put in some orders or discharge a patient when he or she sees that the patient’s main provider is swamped. Contrast this with the physician who, receiving a late consult, stalls for time by telling the primary team to get an MRI of dubious necessity, and then hands off the consult since the MRI won’t be done until after the shift change. Once a member of the team is seen to be taking advantage, everything is at risk of falling apart.

Turning and turning in the widening gyre
The falcon cannot hear the falconer;
Things fall apart; the centre cannot hold;
Mere anarchy is loosed upon the world . . .

W. B. Yeats

Another way of looking at this is within the framework of organizational psychologist Adam Grant. He classifies people as givers, takers, and matchers. Givers, like Prof. Grant himself, are very generous with their time and efforts. Takers take advantage of others’ generosity. Matchers are ever-vigilant to ensure that every favor is repaid and that they are never taken advantage of. I consider myself extremely fortunate to work alongside a whole bunch of givers among faculty and residents alike. There was one taker, though. I could sense something about him when I interviewed for my first job, and my interlocutor remarked, “Yes, [that physician] will always meet you 49% of the way!” Hilarious and largely true (my own experience with that character was more like 37%). There was also one matcher–someone who would literally want to lock down 30 minutes of call coverage two Wednesdays from now in exchange for 30 minutes today.

When generosity is in short supply, when people feel that they are being taken advantage of, the sense of a shared mission dissipates. People start referring more to position descriptions, policies, and procedures to guide their actions. What poor substitutes these are for generosity and a shared purpose! So there ensues a downward spiral of bickering, avoidance, and resentment, often justified with a heavy dose of motivated reasoning: “Hey, it’s not that I didn’t want to help, but that person really needs to learn how to be more efficient . . .”

So what’s the answer when morale and generosity are low, when the shared sense of purpose is gone? I come back to the concept of extreme ownership. We can’t control other’s behavior directly. But if the best among us, instead of “lacking all conviction”, step up to do the right thing for the patients and the team, others will follow. Maybe not everyone, but enough to make all the difference. Or, as Marcus Aurelius said, “Just that you do the right thing. The rest doesn’t matter. Cold or warm. Tired or well-rested. Despised or honored.” (Hat tip to the Daily Stoic for that last quote).

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Medicine: Digital and Analog

This may sound a bit crazy at first, but YouTube turns out to have lots of hidden gems, specifically high-quality grand rounds talks. I’ve found that by watching (mostly listening, really) to some lectures, the algorithm starts recommending others and there ensues an educationally-positive feedback loop (rather than the well-known descent into cat-video oblivion).

I particularly enjoyed the following two lectures pertaining to the practice of medicine. The first is a 2015 grand rounds by Dr. Allan H. Ropper of Harvard and the Brigham. It’s titled, How to Make Mistakes; Thirty-Five Years, and Counting. It’s a good lecture because the cases are interesting and provide a great way to learn some neurology–by hearing about some pitfalls that others have discovered. On another level, Dr. Ropper takes aim both at the Institute of Medicine’s estimate of the number of patients dying via medical error, and at the propositions that computerized decision support, ACGME core competencies, and other responses to the IOM report are effective ways to reduce medical error. Rather, he argues, physicians learn to avoid error by accumulating experience, reflecting on their practices, and sharing their experiences with their colleagues both formally (e.g. M&M) and informally.

The other lecture I really enjoyed is this 1971 talk at Emory by Dr. Lawrence Weed. He was one of the earliest proponents of problem-oriented charting, the SOAP note format, and electronic medical records. In this fascinating lecture, he rails against what he characterized as a prevailing sloppiness in medical documentation and the associated difficulties in making accurate diagnoses, auditing records, and reducing errors.

One of the many things I loved about this talk was his emphasis on defining the problem. He uses a cardiac example: The problem might be cardiomyopathy or rheumatic heart disease. But if you don’t know for sure, then the problem might better be defined as heart failure. But if you’re not even sure about that, you might define the problem as shortness of breath. Whatever you can say for certain is the defined problem. You list that as a discrete item on the problem list and then proceed to outline your differential diagnosis and plan for investigation and management.

These principles apply almost everywhere. Pathologists, for example, sometimes sign out a case “descriptively”. If they can’t say for certain whether a specimen is cancerous, they might report that “the specimen consists of nests of epithelioid cells exhibiting nuclear atypia and high mitotic rate . . .” This they can say for certain. The treating physicians then need to decide whether to treat for cancer, obtain additional tissue, or take some other action. Similarly, if we’re not sure what caused someone’s unusual spell, we might assign a diagnosis of “Transient left-sided motor dysfunction”. I think this is perfectly acceptable–we say what we can say and we don’t render diagnoses we’re not confident about. Contrast this with the tendency to label every lapse in memory or awareness in an elderly patient as a TIA . . .

So I guess my conclusion from watching these two lectures is that, as with so many areas of life and medicine, there must be balance. We don’t want to return to the days of sloppy charting (“Patient doing well. Repeat chest x-ray today and continue aspirin.”) but we also don’t want the Frankenstein’s monster that is the modern electronic medical record or the fallacy that rules, regulations, and algorithms can replace reflection and discussion.

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