The Neurotransmitters: Clinical Neurology Education

How to Think Like a Neurologist with Dr. Ethan Meltzer

September 19, 2022 Episode 12
The Neurotransmitters: Clinical Neurology Education
How to Think Like a Neurologist with Dr. Ethan Meltzer
Show Notes Transcript

Dr. Ethan Meltzer joins me to discuss his new book "How to Think Like a Neurologist," his thoughts on neurology education, and other musings on neurology.

Find his excellent new book  "How to Think Like a Neurologist" here:
https://amzn.to/3drFyYD

Find the artist for the cover art here:
https://www.aarondegruyter.com/shop/bifurcation-v-the-beginning-is-the-end

You can find Dr. Meltzer online at:
Twitter: @emeltzermd
https://uthealthaustin.org/directory/ethan-meltzer

Find me on Twitter @DrKentris or send me an email at theneurotransmitterspodcast@gmail.com

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The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.

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The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.

Dr. Michael Kentris [00:00:02]:

Hello, and welcome to the neurotransmitters, a podcast about everything related to clinical neurology. With the goal of reducing your neurophobia. I'm fortunate to be joined today by doctor Ethan Meltzer, a neurologist at the University of Texas. Thank you so much for joining me today. I really appreciate it. So the reason I asked you on was you had this book come out earlier this year called, very appropriately, How to Think Like a Neurologist, which I I really love that title. It's very on the nose, and it has just enough cheekiness. But tell me a little bit about kind of how you got started in neurology and then what what the path was that led you to kind of publishing this book.

Dr. Ethan Meltzer [00:00:50]:

Yeah. So, you know, my path to neurology, I guess it it goes pretty far back you know, as a child, I was always in interested in science and eventually found my way to medicine. And, you know, the brain just fascinates me. You know, as people say, it's the last frontier of medicine in the sense of, you know, there's so much that we don't yet know. And you know, it it's just something that that I think is very easy for me to see and to get it excited about. You know, there's someone know, I don't know if it's insane or someone just told this to me once, but I really like it, which is that, you know, neurology, and I guess psychiatry as well. It's the only specialty in medicine where the organ actually tells you what's wrong, you know, which I really like. You know , the liver can't speak to you, the heart can't speak to you. But you can actually ask that the organ that is having the disease what it's experiencing.

Dr. Michael Kentris [00:01:50]:

Which I think is just wild. I'm going to steal that one.

Dr. Ethan Meltzer [00:01:55]:

Yeah. Yeah. Yeah. I still look from someone. I I can't remember who the other 1 that would give the credit.

Dr. Michael Kentris [00:02:01]:

So so you've been obviously, you know, gone through training, fellowship, etcetera. And, you know, now you're you're teaching neurology yourself. And, you know, what What was it that you saw when you're when you're teaching new trainees about neurology that that kind of led you to write an entire book on the subject.

Dr. Ethan Meltzer [00:02:26]:

Yeah. You know, so the book, How to Think Like a Neurologist, is, you know, it was really inspired by, you know, what I think of as trying to to really tap into what is really the challenge of neurology, or what is the skill that neurologists have? And, you know, it it doesn't exist in isolation. And and, you know, obviously, it's inspired by my own training in people that I learned from. And I'll, you know, give a quick anecdote. You know? So I got the privilege of attending 1 of the New England Journal CPC's Grand Rounds when I was a resident, where doctor Marty Samuels was presented a case, and it was this case that was incredibly complex guy with a very complex medical history, and he's having essentially every known neurologic symptom the you know, that that can be described, and it's progressing very quickly over the course of about 3 weeks, and then he dies. Oh, jeez. And the only other information that was really relevant is there was an inflammatory spinal fluid, and you had some fever, but it's just this very, very, very quickly progressing syndrome.  And I remember sitting in the audience and they're and, you know, they're reading this history. You know, they're presenting him this history, you know, like what you would read in the you know, what the paper actually looks like when it ends up getting published. And there's so much information, and at the end of it, you know, he puts up a single slide where he's taking all of this and he says, This is a rapidly progressive, fatal meningle encephalitis. And, you know, it was, you know, basically that, what, you know, 5 or words. He's taken about a thousand words made in a 5 or 6 words, and he says, this really probably can't be much else besides Amiibo. And it was amoebic encephalitis. And, you know, it's it's 1 of these things that that looks like magic. If you don't really know what he's doing. And so that was really kind of the basis of the book is that that shouldn't be magic. It should be something that seems attainable to trainees to even to non neurologists, which is how does someone get this, you know, 2 pages of information to fill it to 5 words and then say and then formulate a differential diagnosis based off of that. And I think that that's really you know, when I think back about my training in residency and, you know, I learned lumbar punctures. You know, you learn how to do Botox. You know, you do learn discrete skills, but probably the most important skill I think I learned was how to good at history, get an exam, and then translate that into meaningful data -- Yeah. -- that defines a clinical syndrome and then I can make a differential diagnosis. And it's something that really is not taught, I think, for the most part in earlier parts of medical training. You know, students are given, you know, the exam question, and it already has distilled it. It's already defined the syndrome in the exam question. And then when they come to the wards, You know, they struggle because they aren't presented with that information already that and, you know, so being able to generate that. You know, I think that's that was really the impetus for the book. Yeah. And 1 of the things I I really like

Dr. Michael Kentris [00:05:38]:

is is your emphasis on and I I think this you referenced his book a couple times, doctor Aaron Berkowitz's clinical neurology and neuroanatomy, which actually came out just before the a year or 2 before I took my boards. I used it for my anatomy review for for board exams. Yeah. Which was great. But he talks about imaging negative neurology, which, I know there's let's just say, neuro haters out there.  And, like, what do we need to, you know, do that? We can just get an MRI. Right? But but there are so many things in neurology where the MRI, you know, maybe it's red herring or it doesn't tell you anything useful at all. Yep. And, you know, really drilling down on, like, the thought process. And if you would be so kind as to talk a little bit about kind of your approach to to generating your neurologic differential diagnosis?

Dr. Ethan Meltzer [00:06:33]:

Yeah. Yeah. No. It's, you know, very apt to bring up Aaron's book You know, I know him well. And and, you know, you know, I you know, he was 1 of my attendees. Yeah. And so, again, you know, these ideas aren't in isolation, and And so, you know, really, the idea of the book was to try and codify in a way that at least I hadn't seen before. And, you know, I think, you know, 1 of the little blurbs for the book is really trying to flip kind of the case narrative on its head where it's you know, the case is not the that's not what we're focused on. We're not, you know, the you know, I I tell the the readers, you know, this is not a book where you're you're going to be learning clinical diseases, you know, hopefully not because it's a lot of Zebras, a lot of weird things going on. Aren't too relevant for most of medical training. And so the end payout is not necessarily getting it right. The end payout is the, you know, is the journey. It's the way to get there. And so unlike a a typical case book where the focus is on the actual pathology, You know, if if you've looked at the book, you know, the the pathology, it's not necessarily a throwaway, but it's a small little paragraph for the most part at the end of any case, and really the meat of it is trying to define the clinical syndrome. And so, you know, kinda going back to that and defining that term a little bit here, You know, I think about it, it's the 1 liner in the assessment for neurology. You know, that's that's what I tell medical students when I'm rotating is -- Yeah. -- you know, your neurology assessment you know, shouldn't be, you know, 25 year old comes in with a MCA stroke. You know, the you know, that first line is, you know, a 25 year old comes on with an abrupt or acute or hyper acute, whatever term you want to use. You know, acute onset of aphasia, and right sided weakness. You know? And then the differential stems from that in terms of what the actual pathology is. And so A lot of the book talks about using the history and particularly what I've used of the term as the pace. Other people would use the word tempo, but essentially how quickly something comes on. And then also the localization, where within the Neuro-axis is it? And combining those 2 things, is what I think of when I think of as the clinical syndrome. So yeah. And, you know, that's what, you know, Marty did in, you know, in that Grand Rounds is you know, rapidly progressive, meningoencephalitis. And, you know, it's you know, that's the syndrome. And there's no you know, you don't necessarily need any sort of book knowledge. Now you need neuro anatomy, of course. You need to go to get a history. You know, so it's it's not that there are any skills that are needed, but you don't necessarily need to have an encyclopedic knowledge of every disease that's out there. If you can get the syndrome, you're probably about 95 percent of the way there in terms of the diagnosis.

Dr. Michael Kentris [00:09:18]:

Right. I I think that's yeah. A lot of the workup that sometimes you'll see, you know, if if there has been a workup before you are asked to see a patient. It seems almost haphazard in terms of, like, imaging obtained. Like, I can't I can't count how many times I've been asked to see someone who's been having, like, you know, difficulty walking or leg weakness or, you know, quote unquote, lake weakness. And there's a lumbar MRI on file. Like, well, that doesn't that doesn't fit this presentation at all. Like, that's just a wasted test. Yep. And so, you know, I I somewhat ingest with the with the residents and students who were with me. It's like, you know, sometimes part of the job is just telling people where to point the scanner.

Dr. Ethan Meltzer [00:10:03]:

Right. But and and, you know, to that point, I'll I'll get 1 a unique note. But, you know, to that point, when I think of value based care, especially in neurology. Oh, yeah. And it's interesting, you know, because, you know, we have these discussions often in our morning reports. You know, value you know, there's a lot of value based here there. Right? Because it is, you know, getting unnecessary tests, you know, lab tests, MRIs, has a huge cost, you know, to the patient. You know, you have the potential for false diagnosis. And so, you know, think about how many MRIs of the lumbar spine for difficulty walking could be avoided. Right. You know, with, you know, a simple you know, what's the pace? What's the localization? Oh, you know, that you know, that seems like Parkinsonism. Okay. Well, there's no need to look in, you know, at the lumbar spine. And I have to make the comment just because I'm You know, it it just happened this week, but I was you know, 1 of my proudest moments so far in morning report is 1 of our new PTY twos was presenting this case of of this person who came you know, this woman who came in. And and, you know, the ER had called him after they had ordered a, you know, MRI of the brain cervical thoracic fine. And he sees a patient, and he says, well, has this kind of ascending paresthesia and hyporeflexia, a little bit of minor hip flexor weakness. And he said, you know, III told him, no. Just, you know, we don't need to look there. Yeah. You know, I really thought that this was a highly radiculopathy, and I thought, you know, you know, the, you know -- Nice. -- the future is bright. I mean, you know, they're they're, you know -- It makes your heart as well. -- the neurologist is still there, and and and And so, you know, that sort of thing is, you know, makes me so proud when I hear our students thinking like that. Because they're they're generating hypotheses you know, in the room, and then they're testing it with an MRI. And that's where the case may be.

Dr. Michael Kentris [00:11:50]:

That's awesome. Yeah. Yes. So so to your to your point, in terms of, like, you know, like you said, it almost seems like magic when, like, these experienced attendees with decades of of experience coming and see these patients. And You know, there are a lot of medical schools out there that, you know, maybe their neuroscience courses are taught by more PhDs or non nonclinical staff. So they don't necessarily get that exposure to clinical neurology. And, you know, I I happen to work in an in area that there's not you know, let's just say, a dearth of neurologists as there are in many parts of the country. So for the the trainees out there, other than just buying a copy of your book and using that with their neuroanatomy text. What's what's the best way for them to to try and get exposure to to that, to to get better feelings for that? What kind of resources would you recommend or just calling local clinicians, which I know can be a little slow as well. I mean, it's a, I mean, it's a huge challenge,

Dr. Ethan Meltzer [00:13:00]:

I don't know if I have a great answer for you. Yeah. Right? I mean I mean I mean, this is a problem everywhere is and correct me if I'm wrong, you might know the the data. At least I I think what the data is, it's about 1 in 50 medical students go into neurology.

Dr. Michael Kentris [00:13:12]:

Yeah. So, actually, I just saw a paper earlier this week, and it was 2 percent. So you are right on the money. Okay. Okay. Okay.

Dr. Ethan Meltzer [00:13:19]:

You know, which I think, you know, that's that's kind of my observation as well. Yeah. And and what's what's interesting to me is, you know, I've historically, I've been in places where there are you know, there you know, neurologists are are bountiful. You know, they're everywhere. Even then, the ratio is not that different than -- Right. -- 2 percent, you know, or 1 in 50. Right. And so I guess, you know, that really begs the question I mean, you you asked a specific question, which I I I'm not answering just yet. No. I haven't answered just yet. Answer any question. But what I would say is, you know, even when there are neurologists around -- Yeah. Still that ratio, you know, maybe it changes a little bit, but at least in my anecdotal experience, it's it's not too different. You know, it's still close to 1 in 50. And so, theoretically, those students are also seeing neurologists, you know, from getting that clinical exposure having to go out of their way, it's actually being put right in front of them. It's a core clerkship rotation. Yeah. And so that's still being missed. And so, you know, I think you know, and people have written about that as well -- Right. -- in terms of why and that goes back to, you know, some of those, you know, original article on neurophobia back in, you know, the, you know, 19 94. Yeah. Yeah. I think. But it it's still a prob you know, I guess it's a problem that's been discussed for decades and doesn't have a solution yet.

Dr. Michael Kentris [00:14:42]:

Yeah. And it, you know, it it's I think it's becoming a more and more pressing issue just in terms of, you know, there are treatments being developed for neurologic issues And if there's no 1 to recognize the problem in a timely fashion and administer the appropriate treatments, then we're now we're really missing the boat.

Dr. Ethan Meltzer [00:15:02]:

Yeah. Yeah. No. No. It's absolutely true. I mean, the the percentage of the population that has neurologic diseases is only increasing. Right. You know, just as we have an aging population, Yeah. It's simple math. Right.

Dr. Michael Kentris [00:15:14]:

But yeah. At well, you know, I guess I just raised more questions that we don't have answers to.

Dr. Ethan Meltzer [00:15:20]:

Yeah. Yeah. I mean, I'm I'm trying to think of a good answer back to your original question, which is, you know, without it, you know, without it in front of. You know, how do you improve that? And I think, you know, that's the challenges because when I think of, you know, how to get students interested. To me, it's all about stimulating curiosity. And I think, you know, that's the shame about maybe neurology is that, you know, that should be it is objectively interesting. You know, I have plenty of friends that are not neurologists. They would never wanna be a neurologist in practice, and that's okay. And, you know, I wouldn't wanna do what what they do, and that's okay. You know, neither of us is wrong. Yes. But you know, neurology is objectively fascinating. And and I think that that's 1 of the challenges I see sometimes is you know, when the focus at least for for some students coming in is, you know, I have to memorize some of the, you know, the brainstem stroke syndromes or the neuroanatomy seems very dense. It's hard to then see the relevance of that. You know, the you know, see that in practice see how powerful that knowledge is. And so, you know, when I have students on service, even the ones who don't wanna be neurologists, and they see a patient and they have this, you know, opportunity to practice imaging negative neurology, which -- Yeah. -- I love that term. Right? Where they go in the room, and there's something unexpected. They come out and they say, you know, that person you know, that that was clonus. Yeah. You know? And it said, yeah. And you and they had weak And, you know, I thought that that was gonna be a trapner, but it's okay. You know? So where is the clone? You know? And they kinda get there and say you know, you know, is this a You know, a spinal cord injury? And and, you know, and and to see that connection happen even for someone who, you know, may wanna do something very far removed from neurology and practice. And I think everybody is you know, I think everyone finds that fascinating. And I get you know, I think maybe that's you know, it's not really the answer, but, you know, the quest you know, that's what I think of I think of the medical school curriculum is we have to be showing students, you know, what's really cool about neurology. And -- Yeah. They may not become neurologists. That's okay. But it'll at least make them more willing to think about neurology because they're gonna see patients with neurologic diseases. Right? And and that's, you know, that's the big Right. Is there so much overlap with other specialties and people throw up their hands because they don't wanna -- Right. -- try. And, you know, you used a phrase, actually, 1 of my my attendees, used as well, the the black box of the brain.

Dr. Michael Kentris [00:17:46]:

And, you know, as soon as it's a neurologic issue, you know, that's exactly what happens. Right? It's like, oh, you know, that's probably gonna be complicated. I better just, you know, send it in raws. But then, you know, we run into that same problem again, right, where it's a weight of, like, 3 plus months, months, depending on what part of the country you're in. And,  we need internists and family physicians who are well versed in neurology because they are the frontline people. So so, yeah, how do you think like, let's say we have a, like, a practicing physician out there, like an internist or a family doc. How could they best best utilize this information here to to guide their practice?

Dr. Ethan Meltzer [00:18:28]:

Yeah. You know, that that is a question I think I can answer. You know, 1 thing I like to tell students and rotators when they're on service with me, you know, as an example in terms of what I want them to get out of our time spent together, which is usually too brief -- Right. -- is I'll give them the example of you know, if they're in the hospital and they have a patient and they think that patient has an acute abdomen, And I asked them, would you ever call the surgeon without ever having pushed on the belly? Or if you did call the surgeon without having pushed on the belly, what do you their response would be on the, you know, on the other end of the phone. It would that you know, they wouldn't be acceptable not to try. And I think that that to me is what I think about, you know, for the book and what I think about when I work with them is what I want them to do is I want them to focus -- less on can they get the answer right.  But more, can they go in the room and the can they obtain the language, you know, really be able to speak the language and be able to describe what they're seeing. You know, if someone's coming in and, you know, and they're altered, Right. You know, we all you know, as in Robert, we all get these questions. Oh, patient is altered. I don't need them to tell me what it is. You know, I need them to say, you know you know, miss Jones, was you know, she was -- Yeah. -- you know, out playing bridge with her friends this morning. Right. And now she's lying in bed, and I'm you know, she's asleep unless I'm constantly stimulating her. Right. Perfect. You know, you know, yeah, really giving me a lot of information about the acuity. And so I think, you know, the book, you know, is trying to get a little bit to which is to empower the reader -- Yeah. -- to say that even with just observation and being curious -- Right. -- and asking those questions, you actually get a ton of information that, you know, that you should feel empowered to try and act on. You know? That that would be the simple to try and get the diagnosis. But even getting that information makes you a better physician and makes you someone who will be more informed when you are asking for help.

Dr. Michael Kentris [00:20:25]:

Yeah. I I think it's identifying what you're observing is is a -- Yes. -- big piece of it. And, you know, like like you said, we we don't necessarily get trained in that on the on, like, the behavioral side of things as much as we probably should be. And, you know, That that's exactly right. Like, I I always tell people on rounds. Like, well, you know, you don't have to, like, you know, spell world backwards for their mental status exams. Like, are we like, exactly like you're saying, like, do they fall asleep while you're talking to them? Like, do you have to keep shaking their shoulder the whole time? Just describe what you see. And, yeah, it's it's really a struggle sometimes to get people to kind of break out of that, you know, sort of mental rut that they're in.

Dr. Ethan Meltzer [00:21:12]:

Yes. You know, so the book, it actually started as a lecturer I gave medical students at the beginning of the clerkship. And I was asked to talk about you know, it it wasn't, you know, it was it wasn't anatomy. It was, you know, kinda clinical. You know, it was something. And and that's where the it came from, but and it started with this disclaimer that I would get the students. You know? At least were small sessions about 8 students, and I said, look. You know, all of these are rare cases. And the likelihood is that no 1 in the room here knows the answer. Or has it you know? And most of the time, you've never even heard of the disease. And, you know, not too many spoiler words with the book, you know, but there are things like, you know, artery pressure on stroke in there that, you know, maybe some student happened to have heard in passing. But there's no way that they would to have that on their mind and they and they shouldn't. Right. But I tell them, because these are all rare and you're not going to get the answer, the intent is that it removes any sort of fear of standing up in front of the class and saying you know, and and, you know, getting it wrong. Right. And that none you know, none of you will have it, and there's no reward to quickly going through the stem looking for the, you know, kind of the red flag words, you know, buzzwords, and then trying to to make that connection. Right. And so, you know, the intent, you know, this was, again, before the book even existed, was to have this lecture where we were doing these cases and who is forcing the students to not try and guess the ultimate pathologic diagnosis based on the question stem, right, based on the case presented. And so, you know, that's that's kind of how it how it started in practice. And, you know, and then I realized, oh, actually, you know, the students were really enjoying this. You know, they were you know, it was something that was new that they really hadn't experienced yet. And, you know, often, at the beginning of the lecture, almost always, they they still try and do it. You know, you know, I'm circling around and talking to little small groups, and I hear people saying, oh, you know, aneurysm or something. No. Stop. You know, I'm not gonna ask you if you think it's an end to them. I don't care about that. I'm gonna ask you what you think the clinical syndrome was. But sure enough, within 5 or 10 minutes, you know, they're really doing it. And and I'm proving to them that they're actually essentially making the diagnosis. You know, you know, rapidly progressive fetal meningolencephalitis. You know, they're they're putting that together where they can just put it into Google and get the answer. And we often do that to prove to them that, oh, actually, they did get it right because, you know, they you know, they're medical students. They do wanna get it right. Of course. That's what we're all programmed to do from the get go anymore. Programmed to do that.

Dr. Michael Kentris [00:23:42]:

But, yeah, I I really like and the 1 of the beautiful things about about your book is that You know? There's, I think, like, 40 some cases in here. And, you know, each 1, it's it's nice and digestible, and your writing style is very very good. I I very much enjoy it. Oh, thank you. But, you know, if you even just have 10:20 minutes, you can you can get through you know, at least 1 or 2 of these cases. So it's it's a great book to just have sitting on your desk and be like, if you even if you're not actively studying neurology just, you know, want a quick diversion. It's, I think, a great text for that.

Dr. Ethan Meltzer [00:24:22]:

No. It it's not meant to be dense. It's meant to be something you can pick up. You can put down. It's meant to be you know, it's an adjunct. It's it's to know, some sort of more dense neuroanatomy studying or or disease studying. And and, you know, and and it's supposed to be approachable. And I, you know and and I think that that's really critical in neurology teaching, maybe getting a little bit back to some of the questions you asked before, which is that, you know, neurology is it's hard. Yeah. And and it's pretty humbling. You know, even as someone who, you know, now I'm in attending, I'm supposed to always know the answer. And And, you know, and I don't. You know, some you know, you know, people make mistakes or or, you know, you miss some subtle finding or you get anchored on something.  And neurology is hard at and I, you know, I have this distinct recollection as of when I was at PGY 2. You know, finished intern year. You know, I'm pretty good at being an intern. You know, obviously, I'm not, you know, very you know, I've learned some medicine -- Right. -- you know, but I'm good at my job. And then I became a PQI too, and I thought, man, I am just getting my butt kicked. And and just remembered just feeling you know, Like, you know, how I I didn't realize how much complexity there was -- Yeah. -- to really trying to do this well. And and I think that if we don't acknowledge that, you know, now someone, I guess, who's on the other side -- Right. -- we don't acknowledge that this is really a challenging field. And and it and, you know, you can be the world's best neurologist and still not always get it right. That you know, the book is supposed to be approachable and that it's supposed to say, you know and, you know, you can see in the book, especially, you know, the cases get a little bit harder as they go. You know, there are times where the diagnosis wasn't clear or the diagnosis is missed. And it's not because somebody was lazy. It's not because they bad. It's just that, you know what?

Dr. Michael Kentris [00:26:20]:

Neurologic can be challenging. Sometimes it takes a little bit of time to figure something out. I know. It's I I always feel, like, residents are frustrated when I say this. Like, you know, over time, it will likely declare itself as to as of which of these things it is. And it's like, well, that's not very satisfying, is it?

Dr. Ethan Meltzer [00:26:38]:

Yeah. I you know, I'm I say that as well. Yeah. You know, I'm I'm not too far out of training, and I think I need a few more gray hairs. You know, you know, when you have a lot of gray hairs, I think you can kinda sit back You can -- Right. -- you know, you can stroke your chin or something, and you can say that and and people don't roll their eyes as much. Right. But it's true. Right? You know? And I find myself saying that as well as, you know, I really would love to have the answer now. We might just have to see this person come back and follow-up in 3 months. And that will really tell us which way we're going. Yes.

Dr. Michael Kentris [00:27:08]:

And, you know, to your earlier point, you know, I I too have an epilepsy attending in my fellowship who he would just say, you know, it's such a humbling field because you're just wrong so often. Like, your initial impression is just wrong. Like, just this last week, another anecdote, I had a, you know, a young woman come in for spells. And, you know, they've been increasing in you know, the tempo was increasing. And -- Yep. Know, they would be last just a couple of minutes, but she had a burning smell. But she's like, I have flutter my eyes, but I don't lose consciousness. I'm like, well, you know, maybe it's something. Maybe it's not. But, you know, they're happening almost daily. So, like, alright. We'll just put you on continuous EEG and we'll cash out. And I I went into it fully expecting these to be, you know, non epileptic spells of some nature. And, you know, I will I will be danged if if they weren't epilepsy. Yeah. And so I you know, I'm glad I did the work up, and I didn't just, you know, buy into my own assumptions. But but, yeah, it just goes to show that -- Yep. -- you just wrong sometimes.

Dr. Ethan Meltzer [00:28:15]:

Yeah. Yeah. And I, you know, I think that, you know, it is something that I've noticed when students ask me about you know, how you know, why, you know, why neurology, you know, which is which is always a complicated question. But -- Right. -- 1 thing I tell them is that you know, it's a bit of a personality test. Right? You know, if you all you know, if you want to be very clear cut, you know, black and white, know, get the answer right there. So, you know, have a problem then solve it or fix it. Virology may not be free. Okay. Maybe maybe interventional or, you know, something that's more procedural. But you know, for the most part, if you're someone who who really loves, you know, the puzzle. Right? You know? Right. We I read lots of applications for neurology residency, you know, puzzle, you know, the mystery, the, you know, the logic of it.  I think it takes a certain personality to say, you know, that's really interesting, and I want to figure that out. Yeah.

Dr. Michael Kentris [00:29:04]:

And being okay that they may or may they may not or that it might take some time to unravel it. And there was. You know, it's it's very apropos that you said that there was a a study just in the last couple years that was looking at like, they did, like, language analysis of personal statements for neurology applicants. And the highest things that were, like, you know, most commonly seen were, like references to Sherlock Holmes and -- Yeah. -- puzzle solving. Yeah. And it it really is. Like, there there is a, you know, sometimes stereotypes exist for a reason. Right? And I think the stereotype of the neurologist does hold true in some respects.

Dr. Ethan Meltzer [00:29:42]:

No. No. It does. But, you know, that that's what makes a good neurologist. Yeah. Again, you know, you have to be curious. You know, when when somebody said something, you know, you kinda have to have that you know, that kind of prickling sensation on the back of your neck where you say, oh. Yeah. What do they mean by that? You know, I, you know, I wanna learn more. Yes. And and you know, I do that with the, you know, students you know, they have all these Oscars, you know, these, you know, standardized things. And and I try and tell them when I'm doing it in the hospital with them. I say, you know, I don't need you to do these checklists. You know, if someone says something that you think is interesting, I just want you to stop explore that. You know, spend as much you know, if if they if you think that there's something that's important or they use a word and you want them to explore more, you know, just focus on that. Yeah. Because the likelihood is that, you know, that's actually gonna be much more relevant than asking the, you know, the other parts of the review of systems. Right.

Dr. Michael Kentris [00:30:34]:

Yeah. I I hate to review systems. I think it's it's it's an artifact of billing, but Yeah. Yeah. But but yeah. And I I do find, like, you know, every once in a while, it is there's, like, almost a sixth sense where you just you're sitting down talking with somebody, and then, like like you said, the hair on the back of your neck just goes up and be like, oh, I because you're you're, like, kind of sloshing back and forth between all these, like, how can I link all these disparate symptoms together? And then, like, like, 1 key phrase falls into your lap and just, like and it just crystallizes in that I don't know. It's a rush of, like, this epiphany. Where you're like, I'm hot on the trail now.

Dr. Ethan Meltzer [00:31:16]:

Yeah. Yeah. Yeah. I mean, I guess, you know, we throw out lots of anecdotes. I'll throw out another -- Yeah. Yeah. I've seen this 1 recently in clinic, and she had come to me. You know, I'm a I guess, part of my day job is I'm a neuroimmunologist, and so I have an investment in neuroimmunology clinic. And woman with MS, but she'd also carried this diagnosis of epilepsy and had these spells. And and I saw her the first visit, and I clearly didn't pick up on something. You know, I I hadn't probed it enough. And I said, you know, she was establishing care. I said, okay. It's a long history. She had been having more spells. You know, let's get that EEG. You know, let's make sure that you're safe and you're on some anti seizure medicines, you know, so that you're not having these things. And then she came back a few months later, and it's 1 of these things that, you know, I I sat there after the visit. I thought, you know, what what was different? You know, how did I get such a different answer? And And I realized in that second visit, you know, these spells, these were all things that were happening only when she was very tired. And and, you know, and I think 1 of the differences with the husband was there to give some more, you know, information. And and we went on this whole pathway. It seemed like, you know, this was actually sound like a sleep disorder. Yeah. And there were all these features of narcolepsy with -- Yeah. -- kind of like and and it seemed you know? And it went back to this pace and localization. Actually, you know, probably criminally type of case I didn't include in the book in terms of these corrupt onset of neurologic symptoms would be sleep disorders. Hours. Yeah. So you can explain our word. There's they're not a a patient with a sleep disorder in the book, although there should be. And And I I was thinking back and I thought, you know, I completely, you know, I completely missed it because in my mind, I had closed this syndrome when I was thinking about the syndrome of, okay, nuances of rather abrupt transient neurologic symptoms. I was, you know, it's not a stroke, you know, you know, seizure, and she had had this diagnosis of epilepsy. And then when I really sat back, got a little bit more history. The husband was there to help help out a little bit. I thought, oh, I've been completely blind to other things that can cause rather sudden loss consciousness -- Yeah. -- which would be Jesus sleep. Right. And and so, you know, going back to the neurology as humbling, but also, you know, with time, you can figure it out. And so I kinda sat down and said, actually, everything we kinda spoke about Let's not, you know, let's not throw it out yet, but let's do some further investigation.

Dr. Michael Kentris [00:33:39]:

And I think that's that's a great point, especially for non neurologists. Right? We tend to think you know, obviously, from our training. People with certain types of neurologic issues, whether it's epilepsy or, like, you know, recrudescence, or, like, stroke or MS related symptoms, things like that. You know, it's very stereotyped. But if there's a change in the symptomatology or the events, you know, that that kind of, for us, raises red flags. But for other people, like you said, you know, they could say, like, oh, well, you've got the history of epilepsy. You're losing consciousness. I I need no go I don't need to go any further down that path because we already know you have epilepsy. And, you know, like, maybe they're having syncope, sleep disorders -- Right. -- the list goes on. But, yeah, I mean, that's that's a a great point is that we always have to be constantly reevaluating our diagnoses.

Dr. Ethan Meltzer [00:34:31]:

Yeah. And, you know, going on a tangent from that, but because you mentioned it -- Yeah. -- you know, 1 other thing I I think about is you know, how do we define what is neurologic and what is not neurologic? Right? You know, even in this short conversation, we've mentioned things, you know, like, you know, you know -- Yeah. -- non epileptic seizures. You know, are those neurologic or non you know, we've talked about syncope. We've talked about sleep disorders. And and I think that's 1 of the challenges in our medical education when a lot of the medical education occurs in the hospital where there's an enrichment and disproportionate amount of seizure or stroke. Right. And then, you know, as neurologists, you know, we're very quick to say, you know, to sign off. You know, this is you know, this was syncope. This was not seizure, and our work here is done and and we'll pass this back. You know? But you know, does that fall within the realm of neurology? You know, the you know, that's loss of blood, but, you know, but there is brain dysfunction and often This is related to neurologic disorders. You know? Is it autonomic failure? You know? And these are the things, and I think that that also is 1 challenge you know, I think, you know, I struggle with is you know, when I'm talking to students and and even to our own residents, you know, this idea of what we own as neurologists, you know, what what we should be experts in and what we don't need to worry about and don't need to be experts in. And if we are kind of shunning this and putting it to the side, then it it you know, I think it it makes us not as good as neurologists. I think it's harder for the patient.

Dr. Michael Kentris [00:36:01]:

But it probably exposes us to more errors. Right? Because then we're just saying, oh, it's not a seizure, so we can sign off -- Right. -- which I think is dangerous. Yeah. And, you know, you're absolutely right. Like, just, you know, to your point. Right? Just this last week, I saw a gentleman who came in with syncope. Right? But you know, he he has Parkinson's. So he needed an eds tweaked just because it just because it's syncope doesn't mean that there's not a neurologic component or someone with a severe peripheral neuropathy who's having, again, some decompensation in their autonomic. So I think that was that was a that helped me get through residency a little bit, like, when I would get a consult, like, oh, this is nonsense. And I'll be like, maybe there will be something that I can help with. And that was the only way I could make it through because otherwise, I would just be hating everything.

Dr. Ethan Meltzer [00:36:49]:

Yeah. Yeah. And yeah, it it's not that I don't under you know, it's not that I expect our residents here at at 2AM. Okay. Yeah. Yeah. You can you can be bothered. It's okay. Yes. You know, that that that human. Right. But then, you know, you know alright. Then now you're in the room. You know, there's a patient there. Right. It's time to, you know, you know, time to really, you know, ask some questions. Absolutely.

Dr. Michael Kentris [00:37:11]:

Yeah. Yeah. And I I know it, you know, it's it's easy too, especially when you are on the hospital service to to gripe and and bellyache about a lack of perceived effort on our colleagues' parts. But I think in reality, it is. And it kinda comes back to to this to emphasize the education aspect so that people are aware, like, oh, well, I should be thinking of x, y, and z. These are a few things. Screening tests I can do especially in hospitals that are short staffed on neurologists or maybe don't even have neurologists at all -- Yep. -- to kind of help you get through the the very early steps of the evaluation.

Dr. Ethan Meltzer [00:37:50]:

Yeah. And, you know, I I talk with our residents, and, you know, I know that this is not something unique to me, but, you know, when when we're getting a consult, you know, somebody that's asking for help. And I think that you know, as neurologists, we, you know, we should have a lot of pride in what we do. And and this goes back a bit to what I said at the beginning is you know, this is a it's a skill. Right? It's not doing a lumbar puncture. It's not doing botox. It's not doing a procedure. But there is a a real hard skill. And that's what I'm trying to teach in the book -- Yeah. -- that we have from our training. And to not sell ourselves short. When we go in the room and that thought process going through the history, going through exam, identifying boutiques and something that's honed over training, something that needs to be done intentionally. Right. And that was you know, maybe 1 other component to the impetus for the book was that I found that a lot of our you know, the students or a lot of our residents, they were doing this, but they didn't realize it. They weren't doing it. You know, they weren't intentionally setting out to do it. And they weren't really codifying it in their mind. And I thought, okay. If I could attempt to -- Yeah. -- you know, have people do this intentionally and with intent and practice it, then, you know, maybe that will help their training. You know, much like you would never you know, if you're a musician and, you know, I've you know, and I I play cello. And so, you know, started when I was a kid, you would never just sit down and start playing. You could. But you're not gonna be very good at it, and you're not really gonna progress very far. Yeah. But if you really focus on the methods and the process, you know, there's a reason why people do scales and, you know, do these sort of reps. Right? You know, if you're playing sports, you don't just go out and play basketball. You know, the practice isn't just, you know, 10 guys on a court going back and forth. You're practicing drills. You're practicing different components and in neurology, you know, do we really do that? You know, our is our -- you know, curriculum for medical students is our curriculum when we have internists or, you know, psychiatrists or family you know, future family medicine doctors or for our own residents. Are we intentionally trying to break that part down into different discrete components to further the training? And and, you know, it's something I think about when I'm on service. And, again, I'm not saying that the book does that for everybody, but it was a thought that I had in mind when I thought of, you know, this is a book that might be worthwhile that people might actually think helps them in their clinical practice.

Dr. Michael Kentris [00:40:40]:

I think I think it will. And I think even, you know, as a a neurologist, again, I will say all of the same, not not terribly far out of training. Although I am getting some gray. But I think that this even in just and I've read about half of it so far. And It's I think it's good, like you said, to examine our own thought processes as well even if we're, you know, somewhat experienced in neurologists. So that we can because the further you get away from that initial training part of your education, You know, it becomes 1 of those things that you you do automatically. And, you know, how how can I best communicate to this to someone who doesn't speak the same language that I do clinically? Yep. And refamiliarizing yourself with those very basic steps to get someone on the right path. So they too can reap the benefits of a of a creating this neurologic framework.

Dr. Ethan Meltzer [00:41:39]:

Yep. Yep. No. I agree a hundred percent.

Dr. Michael Kentris [00:41:42]:

Awesome. Well, I wanna thank you. Do you have any final thoughts? Anything else you wanted to share?

Dr. Ethan Meltzer [00:41:51]:

No. III think that we've, you know, we've really touched on a lot of topics you know, maybe the the end 1, although it's a bit cheesy to end on, but I you know, it's too late. I've already committed to it, is that you know, I find neurology just fun. And and I think that it can be fun if you have the tools. Right? Yeah. You know, it it's not fun if everyone else knows something or has the tools and you don't. And so you know, when I'm working with our, you know, off service rotators from medicine or our medical students, you know, it's not fun for them if you know, if I'm talking to the senior resident and the junior residency event and and we're all part of a club and they're not. Right. You know, likewise, when someone calls a consult and we dismiss it and we, you know, we kinda brush it off in the note, that's not fun to them. You know, we're not you know, we're not including them. And so, you know, what I try you know, I try and meet people where they are. I try and and see you know, for a medical student, what's their knowledge base? And then and then kinda bring them in from there. You know, consults, if they're silly, it's a time for education. You know? For the off service rotators. It's time to give them the skills they think are gonna be relevant for them to, you know, to be able to see these patients in the future. And And, you know, if we can't if we can't make neurology fun, we can't take the passion that we feel as a neurologist and then make that an enjoyable experience for others Yeah. You know, we're we're never going to increase that that 2 percent. And, you know, hopefully, the the book is supposed to it's supposed to be fun. It's supposed to, you know, be mysteries. It's supposed to feel a little bit like Sherlock Holmes where, you know, there's yeah, there's something that's happened. We need to figure it out and that we can get there together, you know, and no you know, no matter where the readers starting from. Yeah. And so, you know, maybe that that would be what I would end on. And I I will say 1 1 additional

Dr. Michael Kentris [00:43:57]:

1 final compliment if you if you can stand it.

Dr. Ethan Meltzer [00:44:01]:

Yeah. It it's your pug, so yeah. You can do whatever you want. Well, wait. I'll make it 2. First,

Dr. Michael Kentris [00:44:06]:

You know, I know everyone's listening, but the cover has this beautiful art deco inspired picture of the brain from an artist. Aaron Michael DeGruyter. Am I saying that correctly? Yeah. And I'll include a link to that in the show notes, but it it is beautiful. He has other organ systems as well. Although, obviously, I'm bummed. Missed. And then the second thing, the the chapter titles are and then the the initial vignette They give me, like, very strong Oliver Sacks vibes  which I very much it gives you, like you said, that kind of, like, a mystery is beginning. You know? And, again, it is that very Sherlock Holmesian vibe. You know? It's like the case is afoot. So I I like it's very like, they're very punchy opening. So, you know, there's it A lot of neurology, you know, especially the big door stopper techs have it you know, just looking at them, sitting on your desk is intimidating. Right? Like, I I know you mentioned Adams and Victor's in your book, which is the 1II used through most of residency, and, you know, Bradley is is even bigger. And you know, even as a neurologist, looking at those, you're just like you just have, like, an internal sigh because you flip open to a chapter and be like, These pages are so thin, so they can fit even more in here. But but no. Like, I wanna emphasize how how digestible each 1 of these case vignettes are and how quickly you can get to, like, This was a myopathy. This was a neuropathy. This was a brainstem syndrome. And, you know, it it it's it's very well put together, and it doesn't it doesn't outstay its welcome in each case so that even people who are only let's say, passing. I don't know how they could be, but passingly interested in neurology could still maintain their attention through through a case. So I I just wanna thank you again for, 1, for coming on and, 2, for for writing such an excellent textbook. I think it It has good applications for folks all the way from, med students, even in other specialties, you know, people who are working in neuroscience adjacent fields. All the way up through attending physicians. Neurologists and non neurologists alike, I think there's a a role for it in everybody's library.

Dr. Ethan Meltzer [00:46:27]:

Great. Yeah.

Dr. Michael Kentris [00:46:28]:

Thank you for the kind words, and and thank you so much for having me. Thank you. And if folks wanna reach out to you, where where should they track you down if you're wanting people to do so.

Dr. Ethan Meltzer [00:46:38]:

Oh, gosh. So, you know, I I guess I am newly on social media on Twitter. I'll I'll have to tell you. I actually I have to pull up my Twitter profile and make sure I'm giving you the right name. It's it's emelter m d. So at email to m d is probably a way to reach out. And, you know, I'm I'm always loved to talk neurology. So you can find me there, and I also have a a link to the book on my Twitter page as well. Excellent. I'll include a link to that as well in the show notes. And

Dr. Michael Kentris [00:47:10]:

Thank you again so much for coming on. I really appreciate the chance to talk with you. Thank you, everyone, for listening. If you enjoyed this podcast, please rate, review, and share it on Apple, Spotify, or wherever you get your podcasts, and please subscribe for future episodes.  We'll see you all next time.