I wrote a post about two years ago discussing some of my struggles from my neuroscience course. That post was subtly titled “I Don’t Know Anything About Brains”. Fast forward two years. I am now struggling through my neurology clerkship, and I have come to the realization that I know even less about brains now than when I took the course as a first year.
About that course…..I’m still not sure I passed it. I took the first test (the “midterm”) and did poorly. By “poorly” I am really saying that it was the single worst test grade I have ever received in my academic career. I buckled down and studied really hard for the remaining month, then proceeded to get a worse score on the final. In my gradebook it says “Pass”, but the math says I probably didn’t pass, and at this point I’m just scared to ask questions and suffer recurrent nightmares about having to retake that class. We did a portion of the exam where we sat in a giant lecture hall while they displayed images of brains on the screen, with little arrows pointing at stuff that we needed to identify. It was basically two hours of people cursing under their breath and staring hopelessly at the front.
Now that you have some context, let me tell you a little bit about the Neurology clerkship so far. First of all, it’s just not that interesting. We see mostly strokes, seizures, altered mental status, and a handful of other conditions that require hospitalization periodically (Myasthenia, MS, etc). I know that there are doctors and medical students who love this stuff, but it just doesn’t do anything for me. I struggle to pay attention in lectures, can’t find motivation to study after work, and surf Reddit a lot on my phone. This has been easy for the last few weeks, as the residents and attendings I have been working with have set ridiculously low expectations for us and they have been easy to meet and exceed.
The funny thing about this is that I can really appreciate the way neurologists practice medicine. I have spent the last six months on teams that look at patients who develop an altered mental status (AMS) for about thirty seconds before saying, “Well he’s altered. Better call neuro.” Neurology and psych notice subtle details in history and exam, pay close attention to their findings, and usually do a thorough exam on patients that the surgical team won’t even see during rounds. Further, neuro has an intimate understanding of neurologic anatomy and pathways. Our residents have been able to localize lesions in the brain in less than a minute. At that point, I’m still reasonably confident that they have an injury affecting their brain area. You know, the one in the head. So while I appreciate the practice of neurology, I can’t see myself doing it at all.
My favorite phrase in neurology is “back to baseline”. We use this phrase for patients who undergo strokes or seizures, then have a period of altered mental status or decreased awareness. We talk to the patients, their families, and caregivers to determine whether or not this patient is “at their baseline”. Sometimes, our exam shows that this person is full alert and awake, they are just really dumb. If they are stupid at baseline, well……we can’t fix stupid. For example, a hillbilly from way out in the country didn’t know who the President was. Not because he was confused, just because he didn’t know. He even votes, he just forgot who it was. I gave hints and it didn’t help this guy. To evaluate peoples reasoning we will often ask them to do basic tasks, like “serial 7’s”. We will have patients start at 100 and count backward by 7, so “100,93,86,79,72,…” etc. This guy had no hope. He started out wrong and it got worse. He actually ended up adding 10’s, so he ended up at 134. We spent over an hour in another room trying to explain medication dosing and intervals to a family whose brother had just had a seizure. It was not hard. One new med, and two changes in doses to existing meds. We went over it about 15 times before we realized that their combined IQ was about 60 and that they literally could not remember what we were telling them. I think we could have admitted all of them for altered mental status, but instead we let them drive home!
Some patients have neurologic injury and exhibit neurocognitive defects as a part of their injury. For example, I saw a patient who had a stroke, and the only words he said to me all week were “Jose” and “ouch”. He also had perseverance of speech, which means that once he said a word, he kept repeating it over and over. Another patient was a very nice old man who was 75. He had severe memory loss, and legitimately thought that he was 50, it was 1990, and that his dad was alive and 78 years old. He was so nice and polite, and no matter how many times you informed him that it was actually 2016, he would forget within a few minutes of you telling him.
I’ve learned a lot so far on neuro. I feel like I am much better equipped to handle patients that are not responsive or have altered mental status. I have learned some great tips for examining and interviewing difficult patients that I will use for the rest of my life and practice. But I still don’t know anything about the brains!