When the Dust Settles

I have moved back home to Cincinnati to take a job working in a large private practice neurology group. On my first day I was greeted by a gift on my desk which included a picnic basket, picnic blanket, bottle opener, and chocolate bar. I have a medical assistant with 30 plus years of experience in neurology who works hard for me but harder for her patients. In fact, after my appointments, I tell her to order whatever labs I want, write any prescriptions, and then it magically happens and I sign off on them. I no longer spend hours each week talking to patients about medication refills, filling out DMV paperwork, or discussing normal test results, because my medical assistant does that for me. I have been welcomed with open arms into a group that is aging and needs to pass the torch to young doctors so the practice sustains in to the future. Tomorrow I take my first inpatient call week at a local private Christian hospital. I'm nervous.

I was given two pieces of advice by some of the senior neurologists in the group when I started.

1) You eat what you kill. This basically means that the more patients you see and the more patients you see, the more money you make. On the flip side, I have also been told to learn to find the right balance between work and personal life.

2) If someone asks you if you want to see a certain type of patient, the answer is always YES. Starting out, my schedule is not busy so I need to see patients to make a living. It's very early in my career so it's still too soon for me to know exactly what my subspecialty interests are in neurology. So I've been told to see everything. Down the road as I become more established, I can filter out what I do and don't want to see. If a patient calls and wants to be added on at 5PM on a Friday, the answer is YES. If one of my partners asks me to take their weekend call, the answer is YES, because you eat what you kill. At least for now.

I have been fortunate to inherit a lot of multiple sclerosis patients from my predecessor who recently retired from the group at age 72. He is currently traveling the world, but he has kindly offered to meet with me weekly for breakfast at 7AM to mentor me and give me advice.

I get asked a lot by my patients why I like to focus on MS. The truth is the need is there and it just happened to be the subset of patients I inherited when I came in to the group. There is no magical story or enthusiasm I have toward MS. However, I like to think that every patient I see becomes a reflection of myself. If I deliver good care, they tell their friends. Their friends then tell their friends. And then I enjoy a good reputation. If I deliver poor care to just one patient, it's like adding a tablespoon of egg nog to an otherwise delicious cold root beer. My reputation becomes muddied. But being a good doctor is not the same as being liked by your patients. Ideally I would like to do both. Of course expectations don't always align with reality.

I saw a young college student with migraines two weeks ago. This is something I've seen many times before. I offered her various preventative medications. Propranolol, topiramate, amitriptyline. I explained the side effects of each medication and she did not want to take them. I discussed a very safe alternative of magnesium and riboflavin, but I also discussed that it often takes months for that to work even though it is basically completely safe without dangerous side effects. She chose the magnesium and riboflavin which I told her she could purchase over the counter. 1 minute later after I walked out the door she was in tears. "I expected more from a neurologist." I asked my medical assistant to prescribe her some amitriptyline. I hope this helps...

Last week I saw a woman who had a roux-en-y gastric bypass procedure 10 months ago and had lost 80 lbs. Now she developed left foot drop (weakness in raising her left foot). I examined the patient carefully. She could barely left her left foot, and now she was subtly weak in her right foot too. I told her she had common fibular nerve damage. I told her I did not know the exact reason, but that she may improve with physical therapy. We discussed that I could offer her an extensive workup which would include EMG/Nerve conduction studies, lab work to check for autoimmune processes, and maybe even an MRI of the brain if things still remained unclear. I told her that I think it is unlikely that she had MS, ALS, or that her weakness was related to her gastric bypass.

She was worried, but preferred to avoid a timely and costly workup. She opted to try physical therapy and an ankle foot orthotic first and see if things got better. 2 days later she called to let us know things were worse. She was so weak that she couldn't move her foot to drive. We obtained many labs and one of my partners did her EMG and nerve conduction study. The EMG/NCS report was equivocal and apparently it was somewhat limited by artifact. There were no sensory or motor potentials in the lower extremities is what I heard. Some fasciculations were found which can be an ominous finding suggestive of ALS. But when I examined her, it didn't seem to fit ALS. I had localized her lesion to the common fibular nerve, but the EMG and NCS in no way supported this and was equivocal, and of course muddied the waters. This is why I try to limit ordering EMGs...

I spent about 1 hour thinking harder. Maybe she has multifocal motor neuropathy, charcot marie tooth with hereditary neuropathy with liability to pressure palsy, mononeuritis multiplex from an undiagnosed autoimmune or neoplastic condition... These were all conditions I've read about but almost never diagnosed previously.

I reviewed the literature and saw at least 7 case reports of fibular neuropathy after gastric bypass. The mechanism is unclear but it is related to rapid weight loss. I think she probably has this now in retrospect, but I told her something completely contradictory earlier...

Ultimately, I accept my limitations. I am a general neurologist, and not a neuromuscular specialist. My partner who performed the EMG is also not a neuromuscular specialist and I bet that the quality of the EMG will be better at an academic health center. It's not as simple as calling Dr. Chahin who did 3 neuromuscular fellowships at Mayo Clinic (neuromuscular disease, peripheral nerve, and myopathy) and having him do a quality EMG and benefiting from his expertise which is what I would have done in residency. I'm probably going to refer her to the University of Cincinnati, where the wait list will be at least 4 months. I may try to talk with some other neuromuscular specialists I know.

In the mean time, I have a patient who is getting weaker faster than I anticipated, and her problems are compounded by the fact that I am swimming in diagnostic uncertainty and there is a chance that the specter of ALS has reared its ugly head...

I can't defer to my attending physician anymore, because I'm the attending physician. Maybe I should have done another year of fellowship an learned how to do EMGs myself. Maybe I should have worked harder in residency. I've also been told you learn more during your first year on the job than in any other period of your life. I'll figure this all out, and when the dust settles, maybe it will all make sense some day.