About the Blog


Introduction

October 4, 2012

Dear Residents:

I introduce for our mutual learning a weblog on neurological education. The genesis of this is that in the course of your training, many issues arise that pertain not just to our treatment of an individual patient, but also to the process of becoming a neurologist and working within an increasingly complex health care system generally. I believe that our current methods of addressing these issues are inadequate: A personal conversation or email exchange doesn’t allow others to share in the learning. A blast email isn’t a good way to have a discussion––no one wants their inbox filled with dozens of “reply all” messages––and historically this has been reserved for rapid communication of policies and procedures. We do (and will continue to) discuss some of these matters in our morning report and other conferences, but time constraints make it difficult to do justice to complex issues in these venues.

It will be mutually educational to have a forum in which to explore in more depth matters of wider scope or interest: A recent (de–identified) acute stroke case might lead not only to a review of the guidelines on multi–modal brain imaging, but also a discussion of the associated resource allocation issues. A misdiagnosis of conversion disorder will raise questions about our approach to such patients and the rich history of hysteria. The development of templated H&Ps and discharge summaries in the electronic medical record raises questions about the proper balance of auto–population, cut & paste, and the dying art of narrative in our medical documentation. As some of you know, I’m a (very amateur) student of the psychology of decision–making and like to analyze our decisions, biases, and errors in this light.

To help maintain the educational focus, the blog posts will be categorized according to the relevant ACGME core competencies (Medical Knowledge, Patient Care, Professionalism, Communication and Interpersonal Skills, Practice–Based Learning and Improvement, and Systems–Based Practice). I may later add tags corresponding to the additional neurology–specific competencies that will arise as part of the ACGME’s Next Accreditation System (of which there will be about 36[!]).

My hope is that at least some posts will generate robust discussion in the comments. Please feel free to pose questions, suggest topics, or even submit your own posting––my plan is to address anything that has broad relevance in the blog rather than via email.

I’ll invite the rest of our faculty to participate as well, both by commenting and also guest–authoring their own posts. If this endeavor proves successful, it might be desirable to broaden the community to include other UW departments, other medical schools, or even the wider public. Rest assured that the posts will never contain protected health information*, and I’ll omit any information that could be used to identify a specific physician in a sensitive case unless authorization is provided.

This also seems like a good time to note that anything written herein represents my own personal opinion and those of the other authors and commenters–not those of the UW, the VA, or any other employer–and that the authors retain copyrights on the work products herein.

The Ghost of Charcot

What’s the meaning of the blog’s title? The ghost of Charcot is a term that I learned from a residency colleague at the University of Virginia. It supposedly (I’ve never heard it since) refers to the phenomenon whereby the resident on call examines a patient and reports to the attending certain exam findings or usually the lack thereof. Overnight, the exam changes and when the attending makes rounds the next morning, there is now a Babinski sign or some other pertinent finding that you’re positive WAS NOT THERE the night before. The ghost of Charcot strikes again!

Kind Regards,
Justin


Joseph Škoda’s Percussion Hammer

Škoda (1805-1881) was a Czech physician renowned for his skill in physical diagnosis. He helped resurrect the lost art of percussion, and designed a hammer for this purpose. The portrait below comes from National Library of Medicine’s collection, Images from the History of Medicine and is in the public domain. Permission to use the picture of Škoda’s hammer in the blog’s header and the sketch of it below were kindly provided by Global Antiques, an eBay seller located in Bulgaria.

Joseph Škoda

 

 

 

 

 

 

 

 


Jean Martin Charcot

Charcot (1825-1893) was a French neurologist, anatomical pathologist, and one of the founders of our specialty. The photo in the blog’s header (and favicon) comes from the National Library of Medicine’s collection, Images from the History of Medicine and is in the public domain.

Charcot recommended using Škoda’s percussion hammer for eliciting deep tendon reflexes:

Source: Charcot JM. Lectures on the Pathological Anatomy of the Nervous System: Diseases of the Spinal Cord. Translated from the Reports of Dr. E. Brissaud, in the Progrés Medicale by Cornelius G. Comegys, M.D. Cincinnati: Peter G. Thomson, 1881. p.104.

The Background Pattern

The background is a tessellation of a photomicrograph of rat brain stained with glial fibrillary acidic protein (GFAP). I adjusted to hue to blue. The original photo was released to the public domain by Miles Orchinik of Arizona State University; I found it on Wikimedia Commons.

I think the GFAP staining provides a modern-looking contrast to the old-style photos in the header (and not to get all manly about it, but I really didn’t want pink H&E as my background 🙂 ). More philosophically, the design represents the marriage of classical medicine with modern technology–a marriage in which one partner is striving for dominance and to which balance must be restored. This will be one of the major themes of the blog.

On a trivial note, one of the fun things about starting a blog is that it’s given me the opportunity to play around with Adobe Photoshop. When I first tiled the photomicrograph for use as a background, the edges were unpleasingly obvious. (Come on–who among us doesn’t have at least a little OCD trait?) Following this tutorial, I used the offset filter to bring the edges into the center of the picture and then used a filter mask to blend those edges with a duplicate copy of the picture in the layer below. The result was a much more uniform background and a much better night’s sleep . . .


Legal

* Regarding the HIPAA Privacy Rule (which may or may not apply, as in this context we’re probably not “covered entities”, but which we shall follow regardless):
The following identifiers of the individual or of relatives, employers, or household members of the individual must be removed to achieve the “safe harbor” method of de-identification:(A) Names;(B) All geographic subdivisions smaller than a State, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of Census (1) the geographic units formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and (2) the initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000; (C) All elements of dates (except year) for dates directly related to the individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older; (D) Telephone numbers; (E) Fax numbers; (F) Electronic mail addresses: (G) Social security numbers; (H) Medical record numbers; (I) Health plan beneficiary numbers; (J) Account numbers; (K) Certificate/license numbers; (L) Vehicle identifiers and serial numbers, including license plate numbers; (M) Device identifiers and serial numbers; (N) Web Universal Resource Locators (URLs); (O) Internet Protocol (IP) address numbers; (P) Biometric identifiers, including finger and voice prints; (Q) Full face photographic images and any comparable images; and (R) any other unique identifying number, characteristic, or code, except as permitted for re-identification purposes provided certain conditions are met. In addition to the removal of the above-stated identifiers, the covered entity may not have actual knowledge that the remaining information could be used alone or in combination with any other information to identify an individual who is subject of the information. 45 C.F.R. § 164.514(b).