The Neurological Method

Today’s morning report was a very challenging and interesting case of headache with unusual MRI findings. I thought that, with some redirection, we had a very robust discussion that was well worth the hour spent. It was a great example of how not all headaches are chronic migraine with analgesic overuse.

I do want to address, however, the sub-optimal framing of the case (meta-framing, if you will). The meta-framing of the case was “We need to decide whether to discharge this patient or work him up further, so I’d like to show you his MRI real quick and make a decision before moving on to the case actually scheduled for discussion”.

But this is just the same undisciplined thinking that we often bemoan when exhibited by our non-neurology colleagues. Think of all the patients we’ve seen who have undergone head CT for the complaint of paraparesis. Or carotid ultrasound for syncope or posterior circulation ischemia. Or ANA and Lyme titers because a brain MRI (often ordered for dubious reasons) showed a few non-specific foci of high T2 signal. We too should not jump to review imaging, or make treatment decisions based on such, without first considering in detail the clinical history and exam.

As I mentioned this morning, it is common for people to try to insist on framing a case for you. Here are some examples I’ve heard over the years:

  • “I’ve got this woman here with a numb face and headache and just want to transfer her down to you.” (Diagnosis: vertebrobasilar dissection with acute brainstem infarction)
  • (While in the ED finishing up a consult) “Can you just examine this other patient real quick for me and make sure he didn’t have a stroke? You don’t need to interview him or really do a consult.”
  • (Clinic patient) “I don’t want to answer your questions on go through your silly exam–just tell me what my MRI shows!”

Of course, we can’t make neurologists out of everyone, and I think it’s actually quite satisfying to help get a case back on track by applying rigorous thinking–even if we don’t end up making some brilliant, obscure diagnosis. The one we can do quite commonly; the other only rarely. But the key point is that while referring physicians are free to say whatever they want to say and frame the case however they like, we are free–obligated, in fact–to independently review the history and the exam and re-frame the case in the way we feel is most proper. Only then are we truly adding to the patient’s care.

It follows that the meta-framing of a case should not be “let’s just look at this MRI real quick” but rather “I was going to go over this case, but a more pressing one just came to light and I’d like to do that one instead”. The former is only really appropriate when the primary purpose of the conference is to review interesting scans–not to make clinical decisions. So what I did at morning report today was to insist on a re-meta-framing of the case, and it turned out to be a great one!

About Justin A. Sattin

I'm a vascular neurologist and residency program director. I created this blog in order to share some thoughts with my resident and other colleagues, and to foster my own learning as well.
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