fellowship · neuro

Doctor on board

I just got back from a family vacation, which was perfectly lovely. What was not lovely, was the air travel involved. Is it just me, or has air travel become increasingly unpredictable in the last 5 years or so? I’ve been taking cross country and transatlantic flights since I was a babe in arms, and I never remember significant delays, missed connections, being rerouted. Whereas looking over the last few years, I can count on one hand the number of times I’ve made it to my destination on time.

Our outbound flight, for instance, was a transatlantic jet. We were delayed five hours due to “mechanical issues,” whatever that means. When we finally got airborne, they served “dinner” immediately (at like midnight) and then turned off the lights so everyone could get to sleep.

In the middle of the flight, somewhere over the Atlantic, I was jarred awake by a loud thump/shudder. What was that? In the aisle, a fellow passenger has collapsed. Like, totally out cold. Holy shit. I’m in the window seat, my mother’s by the aisle (also awake), I climb over her and kneel down next to the woman on the floor.

“Ma’am? Are you ok? I’m a doctor, can I help you?”

She groans and struggles to her knees. I give her my hand and try to help her stand, but she cannot bear her own weight. I ask her a few more questions, she grunts and can’t answer. There’s something dark on her lower face, but I can’t see properly because all the plane lights are off. Seems totally dazed, but tries to crawl to her seat, just a couple rows ahead. Because the flight is so empty, she has the entire row of 3 to herself, so I help her back into her seat and she tries to lie down to sleep… and promptly falls off the seats again.

At this point, I’m legit worried about her cognitive status and apparent aphasia. This is not just a simple mechanical stumble-and-fall. She seems concussed. Maybe hypoglycemic. Maybe post-ictal. Stroke unlikely, as she’s young, but we’ve all been sitting for a long time with lots of opportunity for venous thrombosis, and if she’d been walking back from the bathroom where she’d Valsalva’ed….

One of the other passengers has pressed the call bell for the flight attendant, and between the two of us, we are able to lift the ill passenger back into her seat. A couple other flight attendants hover nearby, nervously. One is holding the Green Sheet, the medical assessment summary, which I’ve filled out before on other passengers for much less. By this time she’s a little more alert, says she’s fine, says she’s sleepy. I want to take her back to the galley, where there is some light, and examine her properly. The flight attendant refuses, saying “She looks ok now. Maybe she just fell asleep.” I think of Natasha Richardson but bite my tongue.

“Ok,” I say. “I’m a doctor. I’m just a couple rows behind, in that seat right there.”

The flight attendant thanks me. The Green Sheet disappears. I climb back over my mother into my seat, my eye still on the ill passenger. She sits up a little while longer, talking to the person in front of her, then lies down again.

I check on her once more later in the flight, surreptitiously, when walking to the bathroom. She’s lying Roman-style across the seats, watching a movie. She looks alert. Later, as we’re waiting to deplane, I overhear her talking to some other passengers, explaining that she’s passed out before inexplicably, she must have been tired and/or dehydrated, she feels much better now. She says she has only a hazy recollection of what happened.  There’s some dried blood along the vermilion of her lower lip; she must have split it on an armrest. But other than that, she looks quite normal.

Was I over-reacting, friends, to be thinking of life-threatening things like untreated (undiagnosed?) epilepsy or stroke or epidural hematoma? Maybe. I’m glad she did well, and that my original suspicion of concussion was likely correct. But I don’t think I was wrong to consider those more serious, if statistically less likely (but still biologically plausible) possibilities. This is how doctors generate a differential: what’s the most likely? what’s the most serious? As one of my attendings loved to say, don’t anchor on something (patient said she’s sleepy, therefore she must have fallen asleep… while walking after sitting in a relatively brightly-lit airplane bathroom) without considering evidence for and against all the other possibilities.

I’m still a little annoyed at myself that I didn’t insist on examining her properly though. I’m a neurologist. Of all the possible inflight medical emergencies, this is what I do. I’ve been consulted for far less by the ED back on terra firma. And to defer to a flight attendant, whose medical qualifications include … CPR? Why on earth did I do that, unless it was because he was in a uniform and I was in jeans?

If this ever happens again — and I hope it doesn’t, but I bet it will because I’ve been the “doctor on board” at least once a year since I was in medical school — I’m not going to back down. If someone ever had a bad outcome because I didn’t examine them properly, I really don’t know what I’d do with myself. To be honest, there’s not much I could have done, if I’d diagnosed stroke or epidural hematoma over the Atlantic. But to go against my own better medical judgment because of some perverse sense of not wanting to cause a scene…. ugh. I need to be better than that.


What’s a little dementia between friends?

Clinic appointment request: “URGENT MOVEMENT DISORDERS. Pt needs to be seen in 1-2 days!!!” No additional information provided (like, what’s the consult question, why is this urgent, what’s the relevant history).

Patient shows up on time, but no records, no idea why he’s here. He is nearly blind and very hard of hearing but he can’t see his hearing aids to put them in. Wife, who drove him to the appointment, also is not sure why they are there. I spend 20 minutes going through every possible movement disorder symptom I can think of — too much movement, too little movement, acting out of dreams, loss of sense of smell, trouble walking, tremor, falls, balance, clumsiness, memory — nope, nope, nope, nope, oh wait, memory problems yeah doc I got memory problems.

So unsurprisingly dude ends up scoring terribly on his brief cognitive screen, even accounting for the blind-and-nearly-deaf part. No movement disorders issues at all. So I order a cognitive workup, arrange for him to see General Neurology, and send him on his merry way.

Then I’m at home, writing up his note, and in digging through the chart, I realize that dude was seen by our clinic 3 years ago (well before my time) by the now-graduated fellow, for the same URGENT MOVEMENT DISORDERS consult from the same PCP, and had the same findings. Never did his dementia workup then, either.

books · fellowship

How are the mighty fallen

Back in the dark ages of medical school, I spent a summer interning at a health policy/advocacy group in DC. The office was down the street from a Barnes and Noble, so at lunch, I would often run over and read. That B&N was my private library that summer, where I discovered Jonathan Safran Foer, a (then) young author with a brilliant debut novel, Everything Is Illuminated.


Some of the images in that book, particularly of the shtetl, have stuck with me for years. This was a time I was also reading Michael Chabon (Kavalier and Clay) and Zadie Smith (White Teeth), so the two protagonists theme was big in my literary life.

Fast forward to a decade later, JSF’s newest novel, Here I Am, arrives in my mailbox from Powell’s Indiespensable book subscription club. Yay! I think. I remember this author. I like him. So I settle down to read.

Ugh. This book. I just finished it, and it was out of a sense of duty more than interest. The story is ostensibly about a failing marriage against the backdrop of a massive earthquake in Israel, humanitarian disaster, war, etc. I usually eat that stuff up, the juxtaposition of the domestic with the epic.

Not this time. I couldn’t stand either of the partners here. Jacob is a spineless neurotic Woody Allen stereotype, and Julia is your stereotypical ice queen. No sense of why these two people got married in the first place. No sense of how they drifted apart. No sense of why they are bothering to get divorced, no sense of any pain it causes either of them, or joy at being free. They neither of them seem to have any emotions.

The Israel At War stuff was bizarre, heavy-handed, and had no bearing on the divorce plot. It was like a totally separate story that had somehow wandered into the domestic family drama and tried to take it over. Similarly, there was a random section written in the first person where everything else was written in third omniscient. WHY?

Also, dear god the philosophizing. Pro-tip, six year old children do not speak in fully articulate sentences about the nature of death. Also, the endless flashback digressions which interrupt conversations only serve to set up/explain a one-liner joke in that conversation…. ugh.

I’m really glad that book is over and done with, because my next step is to sell it on eBay. Anyone in the market for a signed first edition of JSF’s latest novel?



My residency program hosted a conference last week, and by luck, I had the day off to go down for it. It was so, so lovely to be back home. First time I’d been back since starting fellowship, and it felt like I’d never left. I got a chance to catch up with several attendings, as well as some of the junior residents who came.

I’d left in the near-pitch-black of night, a travel mug of coffee rattling along next to me. But as I left the city and suburbs behind, the sun started to rise just over my left shoulder, and the trees, still heavy with their summer leaves, started to glow. At one point, the road curved through farmland, and the mist rising up from the fields near took my breath away.

I tried, unsuccessfully, to wrangle my phone out of my purse and take a photo while zipping along at 55 mph. It came out poorly, as car window photography is wont to do, so I’ll spare you. It looked something like this:

Season of mists and mellow fruitfulness

And I can’t tell you how great it was to be back in my old space, seeing my old attendings and catching up, chatting with the junior residents, snarking in the back corner with some of my NP friends.

I do like where I work now. I feel supported at work, and like my supervisors care about my development as a neurologist. But the team of folk down where I trained, that was something special. The department here, maybe because it’s so huge, is pretty formal, standoffish … I don’t feel that I’ve gotten to know anyone, really, in a personal sense. I tried to organize a couple of smaller events among the fellows (Fourth of July picnic, free-admission day at the Art Museum, that sort of thing) but it fell flat because, I dunno, the culture is just different. Come to work, do work, go home, be home. I get that you don’t HAVE to be friends with the people you work with, but still. I miss that.

Sometimes I wonder if I have Stockholm Syndrome about residency. You know the thing … you get so brainwashed by a person or place or structure that you start to identify with it and think it is the greatest thing since sliced bread. Let’s be real, I would not go back to 30 hour calls or stroke codes, or the ICU.

But I also acknowledge that my training program was a gem. We had a wonderful role model of a chair, and a fantastically supportive program director — the sort of guy who, if you said, “hey, I want to disappear for 7 weeks to go study abroad,” he’d be like “yesss! let’s make it happen.” I’m realizing, talking to my co-fellows and seeing the day-to-day here, that not everywhere is like that.

That’s what really makes a home, I’m starting to realize. Not just “address on your tax return,” or some tchotchkes on the wall, but having a sense of belongingness. A local pub. Knowing the best place to watch the sunset; the best place to get your car inspected; the best running route through town. I’m starting, slowly, to build that here… and when I get down, I remind myself that my first year of residency was not all puppies and butterflies, that I was finding my home then, too.

But let me tell you, it was good to be home, even if just for a day.



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!]