One of the things I never really had to deal with in residency, was supplements.

The patient population where I trained was largely rural, minimally educated, and had, for the most part, a paternalistic view of doctors. In other words, what the attending said, went. That’s not to say that adherence wasn’t a problem — the number of patients who presented in status because they didn’t take their meds, or had yet another stroke because they wouldn’t stop smoking, definitely attests to the education and public health challenges we faced as residents.

But until today, I never had a patient refuse treatment in favor of an online supplement.

The supplement in question *seems* pretty harmless. The list of ingredients, posted on the organization’s website, is just a bunch of amino acids. Protein, if you will. I have no idea of the actual doses, but unless they are insane, or unless this guy has terrible kidney disease, he’ll be fine.

But part of me also wants to be like: Why the hell are you buying this crap? You might as well start flushing dollar bills down the toilet. I didn’t say that, of course. I did ask him what he thought the supplement was doing for him, and he said, “I feel less anxious.” Which… I am frankly more willing to attribute to his taking up meditation and Qigong in response to receiving his diagnosis a few months ago. I had some downtime this afternoon so I took a look at the website he mentioned… it’s falling all over itself to state that This Supplement Is Proven By Science! Accept No Substitutes!

So I searched for the Science in question. It took a while, because all the links on the site were for non-scientific lay press articles extolling the benefit of one of the seven amino acids included in this pill (7 for the price of 1! fantastic!). I finally found the study. I’m not going to link to it because it appears to be terrible, and I don’t want to give this supplement any more business. It appears to have been an open-label comparison of oral+IV compound vs. “waitlisted control” whatever that means. A dozen patients in each arm. The results section shows NO STATISTICAL SIGNIFICANCE aside from gender. (Which, wtf, gender? Someone screwed up the “randomization.”) I’m not a statistician or an epidemiologist, but how did this get published anywhere???

Look, friends, I’m a huge believer in non-pharmacologic therapy for PD, and lots of other neurologic diseases too! Diet! (Coffee appears to be neuroprotective, which is excellent for junkies like me Exercise! Tai Chi (shown in multiple RCTs, summarized in a recent meta-analysis [open-access, PLOS One]) is one of the best therapies for PD.  Bring it on, dude.

But if you’re going to be spending hundreds of dollars a month for a pill, why not take levodopa which we actually know WORKS, by both decades of experience and, crucially, actual randomized trials, and also, which your insurance company will pay for?


Post-boards brain dump

Without getting into too many exam-related (and score-voiding) specifics….

That test was … weird. I’ve taken a LOT of medically-oriented standardized tests in the last decade: the MCAT, monthly shelf exams, USMLE Steps 1, 2CS, 2CK, 3, yearly RITE x3. So therefore, I’ve come to expect a certain level of difficulty, a level of uniformity, to the questions at any given test level.

Not on the certification exam! Questions ranged from premed level (what is the rate limiting step in this enzyme pathway I learned in college biochemistry) to incredibly esoteric (what is the best drug to prescribe this rare condition? Five answer choices I’ve never heard of.) Some questions had incredibly limited information, such that every answer choice was correct. Who writes these things, anyway? Probably the same attendings who love to pimp on rounds. There was actually very little on the test that was relevant to clinical practice. Again, having taken so many of these tests over the years, that’s not a surprise.

There were also video vignettes, which I was not really expecting, but were not difficult. As a movement fellow, videos are my bread and butter! They were mostly just patients relating their history. So people reading this before taking the neurology boards in the future: watch some videos!

Now, to promptly dump all those factoids out of my brain for the next ten years. It’s a beautiful weekend! I plan to be outdoors as much as possible.


Overheard in Clinic

Patient: How much levodopa am I taking? I heard you shouldn’t take more than 4 grams a day.

Me: Grams? No, definitely you aren’t there. You’re taking…[mental math] 800 mg a day.

Patient: How much is that in grams?

Me:  0.8 grams. It’s a thousand to one.

Patient: 0.8? That’s almost nothing! What about ounces? I can’t do this metric thing, it’s too hard.

Me: ….


[Yes, I’m alive! And thriving in fellowship. Boards tomorrow, though. Eep!]



I’m sitting here in the A terminal of Dulles Airport, putting my feet up during a rare moment of rest in the last couple weeks.


On April 8, I disconnected my Comcast connection (hooray), loaded my bags up, and drove away from home. No worries, folks, this wasn’t some manic spree, but rather, a well-calculated, if somewhat foolhardy, trip to the Pacific Northwest and Vancouver (Canada’s Pacific Southwest, maybe?), then on to la France for an away rotation.


The PNW was amazing. I hadn’t spent any time in that corner of the country, except for an interview at OHSU which was just Portland, and pretty in-and-out at that. This time, I had a whole week! Met up with my friend L in Portland and we had many adventures, including riding bikes down stairs in Portland (map reading skills), discovering the concept of an ice cream flight, which, omg, best concept ever!, hiking through muddy terrain to the most gorgeous waterfall I’ve ever seen, getting my first speeding ticket at the ripe old age of 30, and eating an expensive seafood dinner at the sort of place where the waiter puts the napkin on your lap. Personally I’ve always preferred hole in the wall digs (the more literal the better) but no denying that the food was excellent.



We also went to the AAN conference in Vancouver, while we were up there. Really good stuff, although somewhat overwhelming. I mostly went to clinician educator talks and career planning things, which means I know very little about movement disorders right now, but hey, that’s what fellowship is for, right.


And now, on to Grenoble, to study and work for a month with the neurosciences center there. What an amazing opportunity — one of my attendings knows someone there, and we just … Set it up. Remarkably easy. I’ve been to Paris once, and the rest of France never, despite taking French for a decade and at one point being fluent. My circadian rhythm is going to be all screwed up, but my brain’s gonna love it.


A bientôt, mes amis!


Anticipatory Grief

Entering the final few months of residency. It’s a really weird, mixed feeling. On one hand, being done with residency is definitely something to celebrate, even for those (like everyone in my class) going on to fellowships and further training. Residency is harder by far than anything I’ve ever done — intellectually, emotionally, physically — and I admit I’ll be glad when I sign out my pager for the last time.

But the flip side of finishing residency is the leaving of everything. Leaving my fellow trainees. Leaving the safety net of having someone else help with decision-making. Leaving my home.

After a little back and forth, I decided on a fellowship that is not offered at my home institution, meaning that I have to leave no matter what. That was a tough decision in itself; at one point I actually thought about doing a different fellowship just so I could stay. (Yes, that was silly. But that’s how much this town has got under my skin.) But now I have to find a place to live in this new city where I’ll be for the next couple years, and I kind of don’t want to? Because signing a new lease will mean I really am leaving my current place, and that I am committing to place A instead of place B.

The decision-making logic that went into my choice of where to go for fellowship was pretty convoluted, and in retrospect, not all that sound. I made the same bad choices about a decade ago and still regret it. I keep trying to pretend that it’s great! I’m excited! New adventures! in the hope that saying it enough will make it true. But here I am, on a bright Sunday morning in March, trying not to cry.


Studying for the RITE

Every February, neurology residents around the country dust off their #2 pencils in preparation for that worst of exams: the RITE. The Residency In-service Training Exam is a brutal, 8 hr scantron affair covering ALL OF NEUROLOGY. I’ve taken a lot of exams in my day; the RITE is the worst. Maybe it’s the 500+ questions written by attendings who want to show off their smarts and lack of real-world knowledge. Maybe it’s the “pictures” so blurry they must have been printed on a dot-matrix, then mimeographed several times, before being hand-copied by a horde of Egyptian scribes.

But because I don’t want my program director to realize how dumb I am, I’ve spent the last two weeks looking through old exam “discussion manuals” (i.e. answer keys; they reuse the questions) and review guides prepped by prior residents. The reviews are pretty amazing, like this gem from 2013:

2016-02-10 10.24.50

Yes, Virginia, dread of cats is a testable topic for neurology residents. And let’s not forget the one question every year that is like “What is the billing code for a 40 minute subsequent encounter? 99132, 99133, 99134, or 99135?” This is high-yield, vital information! Exactly what you NEED to know as a neurologist.

Ugh, back to the books before I fail this sucker.