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The Neurotransmitters: Clinical Neurology Education
New Year's reflections with Dr. Ashley Paul
It's New Year and January is the month for reflections! That's where my conversation with Dr. Ashley Paul begins, as we navigate the importance of introspection in the field of neurology. Using New Year prompts, we reflect on some of our big takeaways from 2023.
From discussing challenging patient cases to understanding our cognitive biases to highlighting the importance of humility and clinical reasoning, this episode offers valuable reflections for both medical professionals and enthusiasts.
Tune in as we navigate through the nuances of neurology and explore the unexpected surprises in the field.
Find Dr. Ashley Paul on X at @ShakingPaulsy
A bi-monthly podcast where we share the stories of our Caregivers, patients and...
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Hello and welcome back to The Neurotransmitters. I am Dr. Michael Kentris and I'm so glad that you're joining us today. I am joined again by my good friend, Dr. Ashley Paul. How are you doing today, Ashley?
Dr. Ashley Paul:I'm great. How are you?
Dr. Michael Kentris :Also great I am sitting we're recording this on, at least where I am a snowy January morning, so I get to look out my window and see all the pine trees dusted with snow. It's very, very relaxing.
Dr. Ashley Paul:I have a similar view in Baltimore, maryland, so a good day for reflection.
Dr. Michael Kentris :Yes, and I was very intrigued when you suggested this a few weeks ago. So a lot of times, right it's. I know we're a little into the new year at this point, but it's still January and a lot of people take time for New Year's resolutions. Looking back at the past year and you had this interesting idea of looking back and professionally, as neurologists, what are some of our big takeaways from this past year? So, kind of lead us down this a little bit here. What was your thought process?
Dr. Ashley Paul:Well, I do like using January not actually to make resolutions, because those are always easily broken. We have this like shot of motivation in January, and so everyone joins a gym and does all these things in the beginning. But I think January is a great time to actually reflect and think about what we learned and how we're going to use that to pivot and maybe make new habits or new strategies and or new pathways for the year going forward, and so and I try to actually use the whole month of January to do this, because it's really hard to just, you know, do that all in one day, right. So I think of January as sort of like a test month where I'll try ideas.
Dr. Michael Kentris :No, I think that's that's really important and we were talking before we hit record and you know I said that I started a journaling habit and the last two, three months and similarly to what you said about New Year's resolutions I tend to start my resolutions like one to two months in advance of the New Year's was like I don't know, it's my anti bandwagon sentiments. I tend to be stubborn by nature so I want to start something at a different time. So I started more regular exercise program and journaling and the reflection part is, I think, if you look at anyone who talks about journaling online or any books on the subject, the reflection part like it's one thing to write your thoughts down to have available to future you, but to look back at them and take stock of them and kind of think like what does this mean now to me in the present context? I think is where the true value tends to come through.
Dr. Ashley Paul:on that, yes, exactly as humans, we tend to live a lot in the past or the future, right, and this is sort of bringing both of those elements, I think, to your present self. Yeah, so I think it's a nice thing to do, and as I was doing this with my husband and just our personal lives, I started thinking about it in the context of my life as a neurologist, and so I was thinking about some of the prompts that we were using, and this is just something we Googled and we found some prompts online that we were going through and it was a nice exercise and I just immediately thought about how we can use these same prompts really to think about neurology. So I don't want to put you on the spot, but if you want to try, a question.
Dr. Michael Kentris :This is happening, live. All right, lay it on me.
Dr. Ashley Paul:All right. So in 2023, as a neurologist, what is one of the wisest decisions you've made?
Dr. Michael Kentris :So I always hesitate to use the word wise when applying it to anything I am thinking or doing. That way lies madness, but things that perhaps, let's say were less foolish If I reframe it in that fashion. So one of the things and I don't know that this is necessarily new, but it's something that I feel is continually re-emphasized to me is the need, professionally, we get a. I work mostly in the hospital doing inpatient neurology and a lot of times I will get a consult that at first blush appears frivolous and we all tend to by default, I assume think the worst of this consult Like ah, why are they consult? To me this seems like a waste of time.
Dr. Ashley Paul:Thank you for this consult.
Dr. Michael Kentris :Right and ultimately, while there are those there, I often find that if I don't do the consult, I do end up regretting it, which is to say I will say that is very, very, very rare, but I will moan and groan and beat my breast, complaining to the heavens, as I trudge my way there. And I get there and I'm talking to the person and I'm like, oh, this is not what was advertised in the initial consult. So if I were to say one thing is to remain humble, I would say that is a constant, daily battle against my own hubris and pride, because I am wrong so often, either whether I am just getting a story from somebody else or going and making my own impression that taking shortcuts in medicine is always a way that will lead you to ruin.
Dr. Michael Kentris :In some fashion or another. Ruin might be a bit of a strong word, but it will lead you to mistakes and it's always important to avoid the if we were to put on our cognitive biases, that premature closure for our differential diagnosis. So that premature closure, if you will, is definitely something that I think I am susceptible to, and being aware of my own biases and my flaws and my thinking processes is definitely something that it's constantly reiterated to me and I think the challenge is, like so many of us, in medicine, when patient volumes are higher, you're getting bombarded by phone calls from every angle.
Dr. Michael Kentris :It's a lot of this task switching and literal, bodily and cognitive fatigue, so juggling these things and managing patients in an appropriate yet efficient manner is definitely a skill that I am still struggling to develop, at least to my own desired level, and it's probably a process that will continue my entire career, if not life.
Dr. Ashley Paul:Yes, and it's human nature, right? Our brains like to take shortcuts and the heuristics and I was thinking for our colleagues who are consulting a neurologist sometimes I know people struggle to frame the question in a way that makes sense to us, right? And which is why you get to the bedside and you're like, oh okay, this is actually something different. Maybe it's actually something even more interesting than what was advertised, or maybe they just didn't ask the right question and I sort of changed the console to the question that should have been asked.
Dr. Michael Kentris :Right.
Dr. Ashley Paul:And I remember being an intern and having to make a console and it was, like you know, my first month of residency and I was kind of terrified, and I forget who I was calling I think it was a cardiologist and I could hear the annoyance on the other end Like, why are you calling about this? And I simply said something to the effect of you know, I don't actually understand all the concepts behind this and I am eager to learn more if you could teach me. And suddenly that just melted that barrier and this person I was speaking to was like, oh okay, yes, I'd be happy to teach you and go over and like I'll meet you at the bedside. And that made it much more of a collaborative experience where I also learned from the consultant and the patient got the care that they needed and you know. So keeping humility on all ends, I think, is important.
Dr. Michael Kentris :Right and that I think there was a study that came out in the last one to two years where it was looking at like the perceived quote unquote appropriateness of consults for neurology versus internal medicine residents and like who thinks they should know more about neurology versus general medicine and their perceptions amongst those two groups of individuals, and it kind of mirrors what we've been talking about, where you know the person, the consulted usually thinks the person consulting should know more. But that, yeah, it is one of those things where having humility is like they're asking a question because they don't know or they're concerned about something, and being generous of spirit is always it's never the wrong way to go.
Dr. Ashley Paul:Right, it's hard to do at times, though.
Dr. Michael Kentris :I think the perceived problem comes in when you perceive this as a someone dumping work on you, when they when you believe that they have the ability to handle this, but perhaps they don't have that same self-perception, and so that discordance amongst perceived abilities is probably where some of this potential resentment comes in. And it is challenging, right, especially if we're talking like resource-limited settings, things like that, but we should always try and approach things with a generous heart, if you will.
Dr. Ashley Paul:Yeah, absolutely. And when I was thinking about this question for myself one of the wisest decisions I actually thought about a specific case and I have a I forget how old she is, I think she's in our late 70s a woman with Parkinson's disease for well over 20 years and I've been taking care of her for the past couple of years and in one of our follow-ups she told me about how she had such severe constipation that she had nausea and vomiting. She had to be hospitalized for it and now things are a little more regular, but she still didn't gain back the weight. I mean, she lost tremendous amount of weight in this whole ordeal and unfortunately she also seemed to develop this paranoia about processed or packaged food and otherwise she was pretty much herself, but it was just. It was a little unsettling and at this point I've known her for a couple of years and it was just.
Dr. Ashley Paul:She was just a little bit off and I know she was always someone who tried to trend on the healthier side of things, like she's baked things for me and it's like oh, it's only four ingredients. So I know that she has a leaning towards that. But to be completely paranoid about food when she's lost this much weight is not like her and her husband thought, well, she just needs counseling or something Like I don't know why she's acting this way. And then in my mind there was this thought that well, what if this is something more organic? Maybe I should just check, right.
Dr. Ashley Paul:And so I ordered all the metabolic panels and be 12 and be one, and it turned out that she had actually pretty profound thiamine deficiency, which how many times you might have ordered that and it's normal, right, and thiamine levels are actually not a great marker anyway of whether someone's deficient, as I dove into the literature about this, but yeah, so she was beginning to develop a Warnikies encephalopathy, right, but she didn't have a full classic triad, right, so the triad of abdominal plegia, ataxia right, being off balance or lose, lost coordination, and then the confusion, and when I read about it, I mean even the mental status changes could be so variable, right, it could be delirium, it could be something like what she presented with, which was just kind of this weird paranoia and really nothing else. So she's fully oriented. Otherwise, she knows all about her Parkinson's disease days. I will say that was the one time she did not bring me treats, because she's always worried that I'm not eating lunch.
Dr. Ashley Paul:She's such a sweet woman. She's, that's right. Yeah, yeah, I think there was this one time where I was running late and instead of being upset that I was running late, she was more worried about that. I must have skipped lunch to try to catch up on time.
Dr. Michael Kentris :Was she right.
Dr. Ashley Paul:Yeah, she was, but Since then she would bring me little snacks, and this was the one time she did it, which was also a little unusual.
Dr. Michael Kentris :And yeah. Yeah, to your point. I've run into that kind of situation, not as longitudinally, but only it's. I think it's around 20% or so. Have the full triad right, it's a pretty low percentage overall of these patients.
Dr. Ashley Paul:It is.
Dr. Michael Kentris :I think a lot of us we forget, we always think of it as association with alcohol abuse, but weight loss of any kind I would say I've seen it just as much in those patients as I have with people who have a history with alcohol.
Dr. Ashley Paul:Right, exactly, and she was in the hospital. Not she wasn't at my hospital, she lives in a different state but at her local hospital. I mean, she was there for like three weeks and no one had checked. Oh, my. Yeah, and it's no one had thought to because she wasn't quirky enough. Right, Right, right, right. And of course she's off balance she has Parkinson's disease.
Dr. Michael Kentris :Yeah right, that diagnostic anchoring.
Dr. Ashley Paul:Yeah, exactly. So as soon as I saw that, I actually ordered her intramuscular thymine and I told them, if they couldn't get it, to go to the hospital and get IV because parenteral is not actually recommended. I mean, parenteral is recommended, oral is not recommended. Right, right, right, because you just won't repeat quickly enough or reliably.
Dr. Michael Kentris :And yeah, that's basically like anyone again, more of an inpatient practice. But anyone who comes in with a history of alcohol abuse or weight loss who's confused at all, I load them up with IV thymine. It's like you know it could be. And even if we send out the labs as you suggested, it takes sometimes like close to two weeks at least for us here to get those results back. Right, I'm going to sit around. I mean, it's B1. It ain't going to hurt nobody.
Dr. Ashley Paul:Exactly, yeah, and that's another thing. You know, as an outpatient neurologist right this is so much easier inpatient right I would have just probably just given her IV thymine, if I was even thinking about it. I didn't actually right away, you know, I just ordered the labs because it was in the back of my mind and I told them what I was thinking about and then when it came back, actually like nearly undetectable- Wow, that is quite low.
Dr. Ashley Paul:Yeah, it was very. I don't know if I've ever seen it that low, yeah, so I'm glad she's back to normal now.
Dr. Michael Kentris :That's awesome, that's great.
Dr. Ashley Paul:Yeah, and there was no, you know, changes on our MRI, which is a good thing, right? Because if we're starting to see signal changes, right, and the mammary bodies are in the thalamus, well then we might be a little bit late in the game and some of these changes could then become permanent. So I was just thinking the universe that we caught it in time. Yeah.
Dr. Michael Kentris :And I think that's great. I think that's probably the best thing out of your story is that change in someone. When you're seeing something that doesn't fit like the illness script of like what is natural progression in someone with Parkinson's disease, right, it's like something else is going on. Yeah, and I think that's a great takeaway is to having that longitudinal relationship with somebody so you can pick up those very subtle changes. That's a great part of outpatient practice.
Dr. Ashley Paul:Yeah, and we were talking a lot about metacognition, right, of sort of zooming out and thinking about how we think about clinical reasoning, and I've been thinking about that more as I've been trying to figure out how to teach this to medical students and because that medical student had to ask me one time because he kind of saw it in action. I was sitting with a patient and I thought this was going to be straightforward Parkinson's disease and I had the student do the neurological exam and they were trying to do finger to nose and the way this patient was following the exam maneuver, you could see you was struggling to even understand finger goes to nose and then turn around and then goes to the outstretched finger. Right, yeah, you're struggling to just follow that sequence Like more executive kind of stuff.
Dr. Ashley Paul:And so then I pivoted and started doing checking for cortical sensory loss and wondering if this was more of like a cortical basal syndrome phenotype. And yeah, I mean, I think he's actually has Alpha's and nucleon as the underlying pathology, but the phenotype looks more cortical basal syndrome. Anyway, the student afterwards, you know, after we got out of the room, was like wait, what made you do that? Right, because as a student you're learning top to bottom neuro exam, right, and you're sort of just learning that pattern. And as you become more advanced in these skills, you start actually thinking about what is these things mean? Right, and what does this translate to? Where does it localize?
Dr. Ashley Paul:And so as the information starts come flying at you, right, that's a different as more analytical thinking, right, so you're going from illness grips to more of that analytical process of taking in new information as it comes at you, and so it's helpful to think about how we think about it, because that keeps you humble and it does actually help you kind of take a step back and try to look at the larger picture and not anchor on like one particular diagnosis or another. Yeah, so that actually was sort of an answer to my one of the second questions I had on this list. So, like, one of the biggest lessons I learned was to make sure you don't anchor. Yeah, I have another story that goes with that, but I'll let you go first because I've been talking for a bit.
Dr. Michael Kentris :So so, yeah, so anchoring right Always a problem, especially when we're kind of dealing with things like I think we get, we get the initial story from someone else right, because as we're all just were often consulted by somebody else.
Dr. Michael Kentris :it's it's rare that we're the first person to see somebody, but at least in my experience, but, I remember one woman that I saw in the emergency department a number of months ago and I get the story from the the emergency department residents and it's like, oh, this, this woman's had, you know, gradually progressive numbness and weakness over the last week and she's been having increasing difficulty walking. And I'm like, oh, and you know, I didn't ask what the reflexes were because I know that they didn't check. Yeah, you know, I mean that's, it's fine, I just have you know you got to work with the framework that exists.
Dr. Ashley Paul:Yes.
Dr. Michael Kentris :But I'm still in my back in my mind I'm going to buy, like you know, break in you know a reflex, hammer in like a breaking case of suspected Guillain-Marais. But that was my suspicion. Going down there right, and I'm talking to this patient and I mean to be fair, she gives the exact same story that that I got. And so I'm thinking in my head like well, this sounds a lot like Guillain-Marais and I'm examining her right. We kind of do, like you know, our typical like seven, seven part exam. So you know not that mental status, totally fine she's. You know all that good stuff criminal nerves, nothing involved String into strength. Arms are fine legs. We started seeing a bit of weakness creeping in. And on sensory exam, you know she does have a slight kind of like a length dependent sensory involvement in her lower extremities, kind of up to like the mid thigh or so, to all modalities and like, well, okay, so so far, so far, so good. But then I go to do her reflexes and they're brisk, like very brisk, three pluses throughout.
Dr. Ashley Paul:Okay.
Dr. Michael Kentris :All right, something, something going on now, yeah. And I'm like, well, and I'm in my head. I'm like you know it's early, you can have preserved reflexes in Guillain-Marais, but I don't like it. So we ended up getting MRIs before we initiated treatment and it did show a spinal cord lesion, ultimately ended up being multiple sclerosis.
Dr. Ashley Paul:I was wondering about going down that path.
Dr. Michael Kentris :Yeah, that's exactly what it was, and it was one of those things where, yeah, it's like everything, right up until that single exam change was very suggestive of Guillain-Barre, but then it all fell apart, right you get this new piece of information and it just kind of throws your whole expectation off kilter, and so you have to be adaptable to that. If something doesn't fit, you can't force the square peg into the round hole.
Dr. Ashley Paul:It doesn't work, but people try that all the time.
Dr. Michael Kentris :I know. I mean, I'm not going to lie right, I've been guilty of it. It's like, well, it's a spectrum, blah, blah, blah. Sometimes it's like this, sometimes like that. Maybe it's still that, sometimes it is, sometimes it isn't. So I think and again, this is not new to this last year, but I think it's just been a lesson that is continually reemphasized is the again I think I can tie this a little bit together with your previous question is it's that humility aspect of saying like I don't know what this is? Here are a few things I think it could be.
Dr. Michael Kentris :Here's what we're going to do to start paring it down and being logical and methodical in our approach, to like this is what the history suggests, this is what the exam suggests. These are, as you said, potential localizations, and working our way through these in a stepwise fashion so that we don't skip over potential diagnoses end up with premature anchoring end up committing to a course of treatment which may be ineffective or potentially harmful, all these kinds of things that have these downstream sequelae for the person.
Dr. Michael Kentris :So, yeah, that's. I mean, as I said, it's not necessarily new in 2023, but it is one of those things where I think it's a continual churn of humility.
Dr. Ashley Paul:Yeah, Well, while it's not new, it's still something important to remind people of because, it again, it's just human tendency to want the brown peg to fit in the square hole and we're always susceptible to it. But it can lead to harm and it can lead to delays and diagnosis. And as we're talking about this, I keep thinking about this one elderly gentleman who I was actually on the consult service and he had come in because he was getting a workup for some type of atypical migraine and they had ordered blood vessel imaging and, to be honest, I don't recall the exact results of the imaging, but it was something enough to. Oh, you know, I think he had an incidental dissection or you know, but it's neither here nor there at the end of the story, because when I met the patient, he kept telling me it's not pain, like I don't have a headache, and he just had such a hard time describing what he feels. But it was, you know, it was up here in its head that he would feel it, but it's not painful.
Dr. Ashley Paul:So I'm like so you don't have a headache. He's like no, I've been trying to tell people this, it's not a headache, right, but he's had this whole headache workup and he's been offered, you know migraine treatments and of course none of those things were working because it wasn't a migraine and I asked him more questions about you know what brings it on, you know the various basic questions that were all taught in medical school. And it turns out that every time he stands, whenever he stands up, that's what triggers it, right, and it feels better when he lies down. And then I started putting this all together with other features on his exam, so I also noticed some Parkinsonian features.
Dr. Michael Kentris :Of course I did I can't help it.
Dr. Ashley Paul:And it was just, you know, fortunate that I happen to be the consult attending on service that day. So I checked his blood pressure lying down and standing up and he had a 90 point drop in systolic blood pressure.
Dr. Michael Kentris :Oh, that's quite remarkable.
Dr. Ashley Paul:Yes, right, like unignorable, Like this is not like, oh, maybe this is a possibility, right, this is definitely causing his symptoms and so, yeah, so he ended up having atypical Parkinsonism and with severe dysautonomia, and the dysautonomia that dropped in blood pressure was causing this funny sensation. And a lot of my patients do have a hard time describing what that feels like, you know, unless they're passing out, right, which I don't know how he did not pass that with a 90 point drop, but you know, it probably doesn't feel good Like I can only imagine yeah, but I you know, to see this poor elderly man and he had gone months trying to figure out what's going on and that anchoring right, that anchoring towards headache, steered him completely down the wrong pathway for months.
Dr. Michael Kentris :Yeah. Yeah so that is always the challenging part. Right is getting someone to describe a subjective experience in their own words and then being able to you, as the healthcare professional, parsing that and fitting that into again. Right, like our schemas for like. How do I understand these things in terms of like? It's not headache, it's not head pain, it's like a discomfort or a sensation, right? I mean, the classic example is like dizziness, right? What is dizziness?
Dr. Michael Kentris :mean to you, yeah right, which we won't go into today, but but it looks like I think that's probably the most common thing that a lot of us like run into. When we kind of run into these subjective descriptions of things and it's really hard to nail people down in terms of what do they mean precisely by that, and sometimes it just isn't precise and that's. That's just kind of lends itself to a little diagnostic uncertainty.
Dr. Ashley Paul:Exactly, and that is one of the biggest lessons for me is being okay with a degree of uncertainty, because we tend to anchor because on some level we're not okay with it. Right, we don't want to feel uncertain, we don't want to tell the patient well, we're not sure what's going on with you. These are the possibilities, but we're not 100% sure because we feel like they want answers. That's why they came to us and I actually found that patients appreciate the honesty and, as long as you're committed to figuring it out right, that's what they want. They want someone committed to be on the journey with them. And you know it's not satisfying to not have an immediate answer, but I think it's less satisfying when you're given an immediate answer. That's totally off the mark, yeah.
Dr. Michael Kentris :I think, I think that's that's very true and you know you can probably speak to this as well. It's like, how many times have you gone in and you're, you're sitting down with somebody and you're like, and you're like, just, I need you to explain this to me as best like and like really getting into like the nitty gritty about someone's constellation of symptoms, and you know that, in my experience, is where the majority of these kind of aha moments do come from. It's like oh, oh, it's like now you get this little, this little grain of information that you're able to, you know, grow into into, hopefully, a proper diagnosis over time.
Dr. Ashley Paul:It really is.
Dr. Michael Kentris :Yeah.
Dr. Ashley Paul:Yeah, like, for me it was him saying it's not a headache, right Like, okay, if it's not a headache, why are you being evaluated for a headache, you know?
Dr. Michael Kentris :because someone else said it was a headache, right.
Dr. Ashley Paul:Yeah, and it's all over the chart.
Dr. Michael Kentris :Yes, that's. That's always the problem. Right and again right. If we talk about anchoring, just reading the chart can be anchoring sometimes.
Dr. Ashley Paul:Yeah.
Dr. Michael Kentris :And I definitely went through a phase where, for better or worse, I don't do this quite as much anymore, where I would just I would just get the chief complaint, I would just go see the patient and I wouldn't look at anything. And you know, sometimes people will get mad at me because, like why don't you know this? It's in my chart. Like well, you know, I want, I just wanted a clean slate. Some people are okay with that explanation, some not so much. So I tend to temper it a little bit in, as much as you know, looking at what kind of testing they've had done and like the general outline of either here. But a lot of times, you know to your point, it's like you know I'll say like oh, I'm here from the neurology department. They asked me to see you because someone said you were confused yesterday. And I get responses from like like yeah, I really was confused yesterday, but I feel better now, or like I wasn't confused.
Dr. Ashley Paul:They're confused.
Dr. Michael Kentris :No, I mean, I literally had a guy. It was like episodes of unresponsiveness and he's kind of this, you know crusty, old, contankerous sort of fella. And right and he was like yeah, I was awake, I heard him talking to me, I just didn't want to respond to it.
Dr. Ashley Paul:Well, you know, it's actually true.
Dr. Michael Kentris :It is. I mean, you know people in the hospital. They don't feel well, Sometimes they just don't want to be bothered, right? But I mean, you know those kinds of things. Sometimes you're saying like, hey, I'm here for this reason, is that a concern to you? Yes, and sometimes they're like no but, and they give you an entirely different thing that they're worried about.
Dr. Ashley Paul:Yeah.
Dr. Michael Kentris :So it is. It is definitely weighing what are the concerns of the medical team versus what are the concerns of the patient.
Dr. Ashley Paul:Also, yes, I like that and I actually have a similar process because, you know, sometimes I'm like the ninth neurologist that someone is seeing and they'll come with a stack of papers and I actually yeah, I don't necessarily read through that entire stack because I don't want to be anchored or biased, and I do the same processes as you. I tried to just see what they're generally here for and what workup they've done, because I'm not going to repeat unnecessarily any workup, and that seems to be enough to satisfy people that I've read through their chart and I know enough about them, but also to be open minded to you, know what's going on and and not just say, okay, so someone else has already diagnosed you with Parkinson's disease. We'll just start there and I'll tell patients that well, this is a clinical diagnosis, and so I actually like to I I know you've already been through this journey and you've landed on this diagnosis, but I kind of like to confirm for myself that I agree with what's been said before and I may or may not.
Dr. Michael Kentris :Right, right, I do find that I am. I am somewhat disagreeable from a diagnostic perspective.
Dr. Ashley Paul:I am too. I am, but that's not necessarily a bad thing, I think right.
Dr. Michael Kentris :You know? Yeah, so it's. It's okay to have you know. Everyone's just like other parts of the body. Everyone has opinions, right?
Dr. Ashley Paul:Exactly, yeah, yeah. Can I ask you a harder reflection question?
Dr. Michael Kentris :All right, let's go for it.
Dr. Ashley Paul:So what is the biggest risk that you've taken as a neurologist in the past year?
Dr. Michael Kentris :So I am somewhat risk averse, just by nature. I remember one of our mutual attendings Dr Tracy Iker would often say of neurologists that quote neurologists are weenies, I think. Quote.
Dr. Ashley Paul:I hope she's listening.
Dr. Michael Kentris :Maybe she is. We'll have to send her this episode, but I don't think I'm too bad about that. But I do think that there are situations right. So we both have different practice environments. I'm in the corner of more of a community hospital situation where we don't have a particularly large neurology department, so sometimes I don't have subspecialty colleagues to call on for certain things, but in terms of I'm not going to say risky behavior but diseases that are high risk in and of themselves. So I've been working a lot with some of our intensive care unit pharmacists to develop a proper status epilepticus protocol and with our ICU nursing staff to get them comfortable with treating this. So one of the, as neurologists may know, we've got status epilepticus continuous seizure activity for five minutes.
Dr. Michael Kentris :Other sub-definitions we're not going to get into or beyond that super refractory status where we have people refractory would be where we put them on IV drips, put them into a medically induced coma high doses compared to what people are normally using for just plain sedation in the intensive care unit when someone is on a ventilator, and so when I started at this hospital, people were very uncomfortable, to say the least, with these kinds of dosing regimens.
Dr. Ashley Paul:Yes, I already had a lot of looks.
Dr. Michael Kentris :Yes, yes, definitely did, Definitely. A lot of questions directed in my direction as to is this appropriate, is this safe? What are we doing to make sure it is safe? And it has required a lot of work with the different intensivists, as well as the ICU nursing staff, and I think everyone's been very open to the idea. If we're saying this is standard of care, we're enabling patients to receive care in the community without having to transfer them 60 miles away to an academic center.
Dr. Ashley Paul:Which is a little scary if they're in status.
Dr. Michael Kentris :Right, it's not ideal in many, many ways. So, especially because we are still a level one trauma center, we still have a fairly high patient volume and so being able to provide some of these services, and I'm somewhat fortunate that I have an epileptology background to lean on, which I know not every general neurologist is going to have in their back pocket.
Dr. Ashley Paul:But these protocols are nicely written and available online. They are or there are existing protocols For people who are not epileptologists out there?
Dr. Michael Kentris :Right, the Neuro Critical Care Society, the American Epilepsy Society they all have guidelines that people can follow when we start getting into these dosing ranges.
Dr. Michael Kentris :The tricky part is the continuous EEG monitoring, which is not readily available in many hospitals, although I think that is becoming more common. But having the familiarity because this isn't something that comes up every day or even every week but knowing when it is appropriate to institute these kinds of treatments and what are the relative risks and benefits in these patients and how aggressive to treat and all those sorts of things, are things that over time I've had to work with on the different, because we have three different ICUs at our hospital, which I know some people may scoff at. It's on the smaller side, that's OK, but getting people familiar with these protocols in each of these different departments has been an ongoing process. I've been very fortunate I have some advocates for this project in the pharmacy departments. In terms of moving this forward, in terms of standardized order sets, we're on Epic, so getting those things through is like an act of God, but they've been very persistent with it and I appreciate that and so getting everyone on this same page.
Dr. Ashley Paul:And order sets does make it easier, right, if you can get them Right.
Dr. Michael Kentris :So not necessarily a risk, as much as if it doesn't work right, it can be high risk in terms of injury to people, either from the incorrect treatment or insufficient treatment also. So I think that's what I would say at present as my quote unquote riskiest endeavor in the last year.
Dr. Ashley Paul:Well, as physicians, I think we all are a little risk adverse and we all want to practice evidence-based medicine. So I've had patients come in and say that they want to do some experimental stem cell treatment in another country and I'm like, well, I can't really recommend that, so I won't say I take risks like that, but I do try to keep an open mind. One thing I told myself is that I never want to tell a patient that there's nothing I can do. It always breaks my heart a little bit when I have a patient that's come to me and said that well, everyone's told me that I can't do anything.
Dr. Ashley Paul:And even if I can't cure what they have which is very common in movement disorders if there's something I can do to improve the quality of life, I want to try it, and weighing the risk and benefits of different treatments to get to that point can sometimes be challenging, and I think I actually told you a little bit about this case that I have of a young he's somewhere in his 30s with a post-sinoxic myoclonus. So he had a cardiac arrest and he survived, but now he has these. For people who don't know what myoclonus is, it's jerky movements and it could be isolated to one part of the body or it could be diffuse. So he has generalized his whole body is involved and he has both basically action-induced myoclonus. He has negative myoclonus as well.
Dr. Michael Kentris :So that's hard.
Dr. Ashley Paul:Yeah, he has everything, basically, while he's muscarily strong because his parents, his family, has worked him out and made sure that he doesn't waste away, basically, which is great, but he still can't stand because his legs would keep giving out from the negative myoclonus. And same thing when he tries to use his hand to reach for a fork it just keeps jerking and you can only imagine how hard it is to live that way. And he's young and of course, his family is very reasonably concerned about what his future is going to look like. And he's been on many medications no-transcript.
Dr. Ashley Paul:This type of myoclonus is very classically refractory, right, and you read up on it and it's like, well, yeah, this is very hard to read and I was like, okay, thanks, right, and I never want to set expectations that I'm going to be able to fix this, of course, but I wanted to keep an open mind to trying. Maybe, if there's something he hasn't tried yet, to try it out. And so this was the case where I decided to try phenobarbital with him, which I can't say I've ever really prescribed that as an outpatient right, especially in the world of epilepsy right. We have so many better anti-epileptic drugs. The only time I really use phenobarb is for status right.
Dr. Michael Kentris :I will say that I have used it on the outpatient side, but usually in people who have already been on it for a number of years.
Dr. Ashley Paul:Like back in the day, when that's what we had and that's what they've been on, and you don't want to rock the boat and now their brains used to it, and so you keep it going right.
Dr. Michael Kentris :Absolutely.
Dr. Ashley Paul:Yeah, but it's not something you'd immediately reach towards.
Dr. Michael Kentris :No, no, it's not.
Dr. Ashley Paul:Yeah, because it does have some icky long-term side effects and it's not the kindest drug. But, as his family pointed out, his quality of life is fairly poor and is it worth trying something. And yeah, so socially this was also a complex situation too, which is kind of what made this a little bit risky too. Like are they going to be able to handle this kind of drug when he's already on four other medications that can all interact? Right? It's like.
Dr. Michael Kentris :Right, the pharmacology gets a little hairy.
Dr. Ashley Paul:Yeah, Because he was on depico paranthamol. He was also on Larazepam and I'm missing one right now, but anyway. So I was like, well, let's get the depico to offers before we put the phenobarb on. But unfortunately made his mypone is even worse. He had to go to the hospital, you know, but it did pay off. He's been hospitalized twice in this whole process. Oh geez.
Dr. Michael Kentris :I know.
Dr. Ashley Paul:But yeah, there was a point where we loaded him with phenobarb and he had no myoclonus. It just went away. Unfortunately it did not last, though, yeah, I saw him in follow up and it's kind of back to where it was. So I've now increased the phenobarb a little bit more to see, and I'm thinking about trying to wean off some of his other medications. But for me this was do I take this risk because I'm not the first person to treat him to at my institution? You know he was initially followed by my colleagues in epilepsy and he's never had any EEG correlates to these movements, and I think they've also kind of tried everything they could think of, and you know he's been on so many different combinations of medications.
Dr. Ashley Paul:It's even hard to kind of track like the changes and that were made or even why certain medications were switched Before I inherited him, before his. The last neurologist is on before me was like, well, let's get another opinion in here. And maybe this is more appropriate for a movement disorder specialist, since there is no EEG correlates, since you're not having seizures technically yeah.
Dr. Michael Kentris :Yeah, you do start to wonder, with something so medically refractory right Moving up against the edge of that evidence based medicine.
Dr. Ashley Paul:Yes.
Dr. Michael Kentris :And so you start to wonder like would DBS be appropriate? What about a posterior corpus, callosotomy?
Dr. Ashley Paul:Right.
Dr. Michael Kentris :You know, like all these kinds of things that we use for other somewhat tangentially related disorders.
Dr. Ashley Paul:Exactly.
Dr. Michael Kentris :But it is right, it's kind of the Wild West a little bit.
Dr. Ashley Paul:It is, it feels that way. There are case reports of phenobarb right and aren't there always. Yes, exactly, but you know that's, that's what I'm operating off of, and so, but, yeah, and then, yeah, do I escalate this even further to try something more radical? And it's hard to know, right, because evidence based medicine does start somewhere. Right, there is a first person who's tried this. Someone had to be the first, yeah exactly, but at the same time I don't, you don't want to cause harm.
Dr. Michael Kentris :Right.
Dr. Ashley Paul:And I worry about that too, yeah.
Dr. Michael Kentris :Yeah, that's that's very challenging.
Dr. Ashley Paul:Yeah.
Dr. Michael Kentris :So, hopefully.
Dr. Ashley Paul:you know, I don't know. I don't know what I'll do when I start running out of medications to try it, but maybe bring him up to the surgical committee and see what they think. Yeah, we do have a DBS committee, so that is something. But you know, like you said, most people are risk adverse and I don't have any data to say that. This would you know? I haven't specifically looked at if someone's tried DBS or for this condition.
Dr. Michael Kentris :Is this? Would it be accurate to say these are Lance Adams myoclonus.
Dr. Ashley Paul:Yeah.
Dr. Michael Kentris :Okay, just just making sure I was remembering correctly.
Dr. Ashley Paul:Yep, that's correct yeah.
Dr. Michael Kentris :Yeah, very challenging. I've only seen one true case myself in my career and thankfully he was fairly easily controlled.
Dr. Ashley Paul:Oh, that's good. Yeah, yeah. And you know, a lot of these patients probably don't even survive, right?
Dr. Michael Kentris :Well, kind of that's one of those things. How I typically understand it is that it's one of those things you kind of diagnose post-post hoc where it's like, well, if they have early myoclonus after a cardiac arrest at some point, they have a high mortality. Obviously we know that.
Dr. Ashley Paul:Yeah.
Dr. Michael Kentris :But if they don't survive, well then it wasn't Lance Adams, right? If they wake up, well then it's Lance Adams right, right, exactly yeah. So it is one of those things where who knows what the true incidence is. I think it's kind of one of those self-fulfilling prophecy types of situations that we run into in the neurocritical care literature.
Dr. Ashley Paul:Yes, and myoclonus in general, I think, is especially when we're talking about cortical, subcortical localization. I always think it's an interesting like does it belong in epilepsy or does it belong in movement disorders? Oh, like, if we put EEGs on the brain, right, would we see something Right? Right, because he's not, he's head-scarred, or something.
Dr. Michael Kentris :It is one of those things that's very interesting, right, especially if we know that they had an anoxic brain injury, right, we know that there was probably damage to both cortical and subcortical structures, right. So it is kind of interesting. It's a very challenging etiology conceptually. Anoxic brain injury, just in general, is something that I think we're still learning so much more about, and what are the appropriate acute and then more long-term measures that are going to lend themselves to the best outcomes? It's a very interesting area that's, I think, still in development.
Dr. Ashley Paul:And the whole. You know, people don't always look like they're MRIs of their brains, right?
Dr. Michael Kentris :Right, right.
Dr. Ashley Paul:Because his brain looks pretty good.
Dr. Michael Kentris :Yeah.
Dr. Ashley Paul:Yeah, but from a symptom perspective it's very challenging. So it's yeah.
Dr. Michael Kentris :Hmm.
Dr. Ashley Paul:Yeah, so one last question. All right Wait on me Biggest surprise in 2023.
Dr. Michael Kentris :Biggest surprise in 2023. Surprising things, God, I don't know. Every day is a surprise. In the wrong it often is.
Dr. Ashley Paul:We get used to being surprised, I think, and we just kind of run with it.
Dr. Michael Kentris :Yeah, I mean to an extent. Yes, I'm trying to think was there anything in the literature that was like oh my gosh, what a practice-changing thing? I mean there's a couple of things that were like somewhat surprising, but not like hugely surprising. I don't know. I'm going to give a cop-out answer.
Dr. Ashley Paul:That's fine.
Dr. Michael Kentris :I'm going to say again, working on the more acute neurology side of things that I do get I don't want to say daily, but probably multiple times per week when I'm working I do get surprised by like, oh, that's what the MRI shows, or oh, this person's getting better. Yeah, that could be good surprises too.
Dr. Ashley Paul:Yeah, it could be good surprises too.
Dr. Michael Kentris :yes, but yeah, I would say that it is kind of a nearly daily occurrence in my current practice setup.
Dr. Ashley Paul:So what keeps neurology fun?
Dr. Michael Kentris :What does keep neurology fun? I do like I don't know. It's one of those things where when I started out, I struggled a little bit with the diagnostic uncertainty, but I think to an extent it is kind of that thrill of the chase. What is this diagnosis? I want to know, I want to solve the puzzle and I do think that that is a driving force for me. Is that the intellectual curiosity that comes along with some of these? They talk a lot about challenges. When you're challenging yourself intellectually, you want it to be hard, but not too hard. That's how I like my cases to be Mostly just. I don't mind those really hard cases but in my current environment that if I know this person would be better served by a place that has better resources or better turnaround time or certain subspecialists that would be better suited to the initial diagnostic workup.
Dr. Michael Kentris :I find those a little more frustrating just because I know that they could get better served by somebody else, and so those are not surprising.
Dr. Ashley Paul:But they are frustrating.
Dr. Michael Kentris :And so I think, kind of going back to that reflective piece, it's like knowing what you don't know. There's that one quote from I think it was Donald Rumsfeld, not a political quote, but there are the known knowns, known unknowns and unknown unknowns, which I think it's kind of a pithy saying essentially that, well, I know what I know and I know some of the things that I don't know, but I need to be aware that there are things that I don't know, of which I am unaware, and so trying to be cognizant of that gap, or as one of our attendings told me, dr Ludwig, if you don't know it, you can't diagnose it.
Dr. Ashley Paul:So you have to look for it.
Dr. Michael Kentris :Right. So knowing if this looks like a disorder, but I don't know what, not being afraid to call in that second opinion right or third or fourth or however far down the chain. We happen to be at this point in time.
Dr. Ashley Paul:Or maybe read up on what you're seeing Exactly.
Dr. Michael Kentris :Yeah, doing some research, Exactly Digging deep and seeing what kind of testing do I need to do, and that's always a challenging part, right? I don't have a lot of longitudinal follow-up with a lot of these patients, although I'm looking to part of my future for 2024 is I do want to start doing some more outpatient clinic again and getting back into that longitudinal aspect of patient care. But because I do miss out on that, is that that longer term workup right. Not everything's going to be solved in just a few days on the inpatient side of care. I would say probably isn't going to be most of the time. So being able to look through that lens and reflecting on that a little bit, I think is very important.
Dr. Michael Kentris :Absolutely I don't know if that's I veered from your original question.
Dr. Ashley Paul:That's fine, but I think it's an important point to make about accepting our uncertainties and learning to be okay with it, because when we're not okay with it, that's when we make mistakes and that's when patients can be harmed.
Dr. Michael Kentris :Right, I saw someone on Twitter post this way, where they are X, I guess it is now. It's like being okay telling someone. I don't know what this is, but I'm going to find out with you, yeah. And then making a good faith effort to do that. So I think I mean right, no one's going to be right. Dr House is a fictional character for a reason.
Dr. Michael Kentris :Yes, and being able to recognize where we don't know and then being able to apply those logical diagnostic reasoning processes to someone's presentation and working through a workup to get to an answer. I think that's very helpful, even if it is, like you said, something that doesn't necessarily have a treatment or let alone a cure then, sometimes knowing what it is, what can be expected?
Dr. Michael Kentris :that prognosis can be just as important, depending on the person. Do they have children? Do they need to worry about their family providing all those kinds of things, these psychosocial aspects of life that I think a lot of times for those of us outside of the psychiatric field, we kind of focus more on the biological model of disease and not the biopsychosocial. So I do think that it's something that we all fall short of from time to time.
Dr. Ashley Paul:I'm sure yeah, and going back to that metacognitive process of thinking outside of how we thinking about thinking right, that's what it is. I do wish that we put more emphasis on this when we're teaching medical students. Right, it's one thing to learn illness scripts, but no one's going to walk in with multiple choices Right. Just written on their forehead.
Dr. Ashley Paul:Right, it's either ABC or D, but that's how we are training our students to think right, and then they have to rewire that when they are in residency. I feel like that's what happens to accept uncertainty, to work through the process of information flying at you and just doing your best right.
Dr. Michael Kentris :Yeah.
Dr. Ashley Paul:Chasing that puzzle of the unknown and also bridging the understanding to the patient, because they're also lost right and they're looking to you to be a guide, and I take a lot of satisfaction in my job of being a trying to be a good guy, even if I don't have the answer.
Dr. Michael Kentris :Right.
Dr. Ashley Paul:And yeah, so I don't have a great answer for this question either. I think I don't know why I'm surprised by this, but I'm always surprised by my patient's gratitude.
Dr. Michael Kentris :Right, and that's like that therapeutic relationship, right. It's someone is listening, someone is attending to it and I'm able to hopefully trust this person who is providing care to me. So I definitely think that there is that element to it. Right, that we want to look back at that historical patient-physician relationship. It is one that engenders trust, and this goes all the way back to Hippocrates. When you look through his manuscripts and stuff. It talks about this kind of relationship and how one should comport oneself so that you don't violate that trust that's put in you.
Dr. Ashley Paul:Exactly, and in December there was like two days before or three days before Christmas I had clinic and a lot of my patients showed up with Christmas cards and one person the care partner of the patient made me like a ceramic vase with a flower. It's nice, it's just that deep level of gratitude, and I didn't necessarily cure their illness or give them all the answers, but it was a nice reminder of how important that relationship, that trust that you build, what that is, and yeah, so it took me by surprise, though.
Dr. Michael Kentris :Right, yeah, sometimes our perspective is not the same as the other person's perspective, right? Which I mean? It sounds obvious when you say it out loud.
Dr. Ashley Paul:I know right, I feel almost silly. Saying like this is surprising, but when this person handed me this card and I was like you didn't have to give me anything and they said, well, we're just so grateful.
Dr. Michael Kentris :Yeah, and that is. I think that's something we come across over and over again. If people are out there reading different things like these ancient reflections, it's that you never know what kind of good you're. Somewhat like what you might perceive as nothing might be everything to somebody else.
Dr. Ashley Paul:Yeah, like I'm just doing my job.
Dr. Michael Kentris :Right, like I saw again. To put a little more humorous spin on it, there's another post on X where it was like some guy out there got a compliment from a woman on this shirt two years ago and you know, every time he pulls that shirt out he's still thinking about that compliment he got about how he looked nice. So it's one of those things, right, where it's like a kind word here and there and demonstrating that you care about people. It is something that is valued and I think it does go to those deeper ethical questions about what does it mean to care for someone in a society, even beyond just in a healthcare setting?
Dr. Ashley Paul:Yeah, and maybe a good reminder to listeners to show your gratitude right. A lot of us think about how, oh, this is nice or that person was nice, and we don't always tell the person how we feel about that. And it goes a long way. People really carry that.
Dr. Michael Kentris :Yeah, yes, that is something I always I try to be cognizant of that, like with my trainees as well. Right, it's like you did a really great job this week. You know I appreciate your help. Yeah, Because it is. It's one of those things where you know sometimes that little at a boy it really means something I know when I was a resident. That always meant the world to me. It's like, oh, I did a good job. You know, I'm appreciated. I appreciate being appreciated.
Dr. Ashley Paul:Yeah, you need to know that your efforts mean something, and yes it's getting that feedback that it does right is where it's just gold sometimes.
Dr. Michael Kentris :Right, right it's. It takes very little, yeah, to just demonstrate. Right, just say what you're feeling. But, yeah, any final thoughts as we close out our reflections Ashley.
Dr. Ashley Paul:Well, I'll say that I am grateful to be here on this podcast with you and to have this conversation, this reflective practice, on a Saturday, snowy morning in January. This has been fantastic.
Dr. Michael Kentris :I'm grateful that you suggested it as well. It's always fun to have a chat with you. We get to get kind of go outside of our usual neurology education boxes on the show here. So thank you as always, Although I am eventually going to pin you down and make you do your movement disorders shtick on the show eventually.
Dr. Ashley Paul:Yes, stay tuned, we can do that for sure.
Dr. Michael Kentris :All right, if people want to find you, where should they look?
Dr. Ashley Paul:Twitter or X is a good place. My Twitter handle is shaking palsy as S-H-A-K-I-N-G-P-A-U-L-S-Y, so that's my spin on palsy.
Dr. Michael Kentris :An excellent pun.
Dr. Ashley Paul:Thank you For.
Dr. Michael Kentris :Dr Paul, you can also find me on X slash Twitter at Dr Kentress. That's a D-R-K-E-N-T-R-I-S. You can also find the other projects we're working on at theneurotransmitterscom and you can subscribe to our newsletter there to get notified of future episodes and also weekly updates on interesting little neurology education tidbits from around the internet. So thank you all again for listening, if you've made it this far, and we will see you all next time.
