The Neurotransmitters: Clinical Neurology Education
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The Neurotransmitters: Clinical Neurology Education
Art and Humanity in Behavioral Neurology with Dr. Michael P.H. Stanley
Join us as Dr. Michael P.H. Stanley, our distinguished guest from Brigham and Women's Hospital, shares an intimate portrait of his fascination with cognitive and behavioral neurology.
We discuss the philosophical terrains of the mind-brain dichotomy and cognitive phenomenology, revealing the profound importance of context in the evaluation of symptoms. We touch upon the challenges of managing cognitive impairment and the need for compassionate care.
Finally, we celebrate the fusion of behavioral neurology with the humanities, highlighting the unexpected insights gained from this interdisciplinary inquiry. We reflect on the influence of literature and non-medical fields on neurological innovation, underscoring the importance of compiling diverse perspectives.
You can find Dr. Michael P.H. Stanley on Twitter/X at @MphStanley
A podcast decoding young brains and behavior in a digital world.
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Hello and welcome back to The Neurotransmitters. Once again I am very pleased to introduce a new guest, but first I should probably introduce myself. I'm Dr Michael Kentris, Neurologist in Ohio, and we are here to talk about everything related to clinical neurology, and perhaps beyond, today. So I want to thank and introduce Dr Michael P. H. Stanley.
Dr. Michael P.H. Stanley:Thank you very much for coming on talk today. It's a sort of Mike and Mike recording. It sounds like.
Dr. Michael Kentris:Right, like those old radio shows, Mike and Mike in the morning, right, exactly. So tell us a little bit about yourself, your background and your role in the greater neurology sphere.
Dr. Michael P.H. Stanley:Sure, absolutely so. Currently I am a behavioral neurology fellow at the Brigham and Women's Hospital. And how did I get there? From there, I guess, rather than there from here? So I started out in Maine. I went to school in Maine, then went to Harvard for my undergrad and then went back actually to Maine. I split the difference. I was at medical school at Tufts in what was called the Maine Track Program, so my two preclinical years were in Boston and Chinatown and my two clinical years were up in the great state of Maine. And then I came back to Boston to do the National Brigham Neurology Adult Neurology Residency. And that is the kind of the immediate, or I should say the goalposts. And then you tell me where you want to talk about something else.
Dr. Michael Kentris:Now you know you're our first kind of cognitive, behavioral neurologist that we've had on. So neurology, brain, nerves, everything in between. But this particular emphasis is probably more of the more, as it says, on the tin, behavioral aspect. So how does one wind up being, let's say, attracted to that and then pursuing that as a subspecialty within the field that's?
Dr. Michael P.H. Stanley:a great question, very, very good question. So firstly, one way to look at it is that you're always speaking to the organ in question, right, I mean, it's the only field that allows that or asks that. Right, you get a kidney problem. You're talking to Mike and to find out if it was kidney, but you got a brain problem talking to the organ in question. So that alone is very seductive for many people. They think, wow, this is kind of a complicated situation to begin with and that's intriguing. And then, furthermore, because the nature of the questions in cognitive neurology are depth of consciousness, content of consciousness and the expressions of those which are largely behavioral, personality, language, the things that come together to make us us, that is, it's a humanistic discipline by its very nature. So I think that's the other way to be kind of seduced into the subspecialty.
Dr. Michael P.H. Stanley:It's also an area of incredible research opportunities. We've just seen in the past few years the first real disease modifying treatments for some of the diseases of cognition, like Alzheimer's. So it's available or amenable to people that are actually still kind of bench researchers or clinical trial researchers, where it is the cutting edge of neuroscience. There's still enough white whales that are out there, as opposed to just putting yet another drug out there. I don't know, this is the first one, so that's the other way to be kind of attracted to the field.
Dr. Michael P.H. Stanley:And then, of course, from there there's a lot of ways to define oneself within it. So, unlike subspecialties, where they are disease specific and that's what you study, that's what you learn, or that are diseases of a particular part of the neuro access, by definition One could consider oneself a behavioral neurologist or a cognitive neurologist or a neurocognitive specialist. If you come to this field through psychiatry, it's neuropsychiatry, and each one of those labels, splitting the semantics, actually does place emphasis on how you view this relationship between the being and the brain, and so that's another way. Once you're even there, training aside, there comes the how do you view yourself and what kinds of what are you treating? And that has a lot to do with what label you decide to use.
Dr. Michael Kentris:Yeah, that's an excellent point and this is something I don't think we kind of mentioned in our pre-show talk, but I'm curious for your take on it. There's been a lot of pushback in recent years in the concept of dualism and I see your eyes light enough there, and it's one of these things. That so my background. I'm an epileptologist, although I'm doing mostly general neurology these days, and so we see a lot of these functional neurologic disorders which I'm sure show up on your radar not infrequently, and this pushback like the mind versus the brain. Is there really any substantive difference? What's your kind of take?
Dr. Michael P.H. Stanley:on that. That is, there's a long answer and there's a short answer. The long answer is probably for its own, not just podcast or episode, but probably series or life's work. The short answer to that is to think about situations in which because you've wrapped up the functional question and so those are two separate functional neurological disorder or functional symptoms are often explained to patients by using this concept of hardware and software that's often kind of employed.
Dr. Michael P.H. Stanley:You say well, if this was a hardware problem, you'd see a stroke or you'd see multiple sclerosis lesion or you'd see something like that. But this is not a problem with the hardware. It is often how it's explained to patients. You say, well, this is a problem with the software. But if you actually press those neurologists or the psychiatrists about their understanding fundamentally about what is hardware and what is software, it becomes very clear that this is a veneer of a metaphor. It's not a well thought out model and because it gets immediately back to the questions that you're asking about, it's like what do you think? Is it all in one? Are there kind of separate situations? And this of course leads to many examples where neurology is in this in-between zone and should have more to say. Neurologists could have more to say about it, but usually don't. A good example of this is in language. When we think about either a connectionist or a connectionism approach to language, which I think in the most recent continuum issue for behavioral neurology, the section on language, the introduction does kind of state as a matter of fact from on high, as if it's a revealed truth, that connectionism is the way it works. Now, if you ask a number of prominent linguists and neurolinguists about that there are severe issues with accepting that to the degree that it's accepted in that continuum article. So these questions are open.
Dr. Michael P.H. Stanley:The best way that I would like to think about it is a nice line by Hugh who goes tell me that a lover's touch is more than nature-changing genes. So on the one hand we are biologically constrained, on the other hand we are kind of culturally liberated as creatures, as species, and if you begin to think about what that means in terms of what cognition does for us, even something like language is, it allows us to really escape fundamentals of a purely sensory, motor, concrete world. I can come up with things like the concept of or either or Either. Or has no representation in the real world. It's purely a product of language.
Dr. Michael P.H. Stanley:Another would be thinking about Austin, the philosopher, who has this notion of performative verbs, verbs where they take a word like promise to. I promise to be on the show. It doesn't exist anywhere else other than in the language. You could say well, michael, I could write it on a piece of paper. It's a promissory note. That's different, right? The sense of it is even different. So what's very intriguing about cognitive neurology is that these problems and their difficulties and these dogmas that are kind of well the schools of thought that people die on hills from, they all fall apart when you're in your clinic. That's my point, to slowly but surely work my way around not answering this question.
Dr. Michael Kentris:Right, and I think that's kind of the other thing right. We're in the process of trying to find a lot of these answers. Still To your earlier point. It is that research element of it where a lot of people talk about the Star Trek fans out there, the Final Frontier being out there, but I think you could just as easily make the argument that you can turn that same microscope inwards, because there's still so much we don't know about how our own cell is functioned.
Dr. Michael P.H. Stanley:As far as we know, for our species there is no access to mind without a brain. So that's one statement that you could make. That's pretty good, stable and a very weak statement actually. But that's about as far as we can actually go. As far as I know, in our species there is no access to mind without a brain. The next thing, which of course immediately troubles that and then pulls the rug right out of it right from under you is to say, but what about a book? Now I've got information for the first time where, yeah, I've got evidence of mind. Right, there it is. It has language, it has ideas, a figure that's drawn, a symbol that indicates stop or danger, same sort of thing. There's evidence outside of the brain, but it took a brain to make it right. So you get into those situations.
Dr. Michael P.H. Stanley:I think Fran Liebwood says that line closest thing to a person is a book. Right, it's got mind, it's got language, it's got these features. It looks terrifying to her to see a book in a trash. Can I think she has this line? It's like seeing a severed head. It's an awful thing to do that to a book.
Dr. Michael P.H. Stanley:What she's getting at comically, but it is a serious point is how extraordinary this thing called cognition, the processing of information, external and internal within the brain is, what a profound faculty that, as we were saying in our prequel to the recording, there are fundamentals like the brain. Then there are these firmamentals, the thing that it's drawn to, or Victor Frankel's lines about being pushed by drives, pulled by goals. In many ways you could say well, the metaphor of that is between your brainstem and your basal ganglia, up into your limbic system on the one hand right, and then these like incredibly noble properties that come abstractly from the neocortex. Just to make that kind of metaphor is something you get to do when you're in neurology that you don't get to do in other fields. That's to me kind of interesting. To your point about external intro, there are astronauts, but I think we should think about ourselves as neuronauts. What do we do in our clinics as cognitive neurologists?
Dr. Michael Kentris:exploring stuff, yes, no, that's a very interesting take and I'm going to bring us back down to earth for a moment. I know I took us off the rails quite quickly, but for those who might be, let's say, newer to the neurosciences or the practice of clinical neurology a word that you see thrown around very often in communication pieces, like you were saying about these drugs that came out in the last few years dementia right, dementia is a word that's thrown around very often in the public discourse and a lot of people I'm sure you encountered this as well last, like you know what we say dementia. What do we actually mean when we say that?
Dr. Michael P.H. Stanley:Oh yes. So dementia here again, this theme will keep coming back and forth of avoiding questions of, you know, being identity, personhood on the one end, and driving it into things that feel more familiar to us or feel more comfortable to us, which are the biology. So one way to look at this is with this term, dementia. So dementia has a history and a context all on its own right. Which is to say, we've heard Alzheimer's dementia, frontal temporal lobe dementia, dementia with lewy bodies, those sorts of things on the one hand, and then on the other hand is well, but what is dementia? Okay, if we use Alzheimer's as the adjective or frontal temporal lobe as the adjective, then okay, thank you. But what is dementia?
Dr. Michael P.H. Stanley:And if you look at the current definitions for it, it's actually, it's a functional definition. By then I mean it has to do with how well a person is doing right, but it's actually agnostic to what is the origin or the source, so how it probably makes the most sense to explain it in the context of the progression. So if a person has a memory problem and they say I have a memory problem but it doesn't interfere with any of my instrumental activities of daily living, then I call it subjective cognitive impairment. If I say, well, I do have a memory problem and it is, I catch it on my testing. I go ahead and get a mocha or a mental status or a slums or any number of these things, now it's mild cognitive impairment. And if I experience a memory problem and your doctor finds evidence of the memory problem on testing and you lose one instrumental activity of daily living, now you qualify as having dementia. It's not a mild stage of dementia but it's a dementia in the less.
Dr. Michael P.H. Stanley:Now that is purely a definition based on function, right, how well somebody is doing. It doesn't actually give any insight into what the underlying disease is, right, whether it is the origin from Alzheimer's, from Sorrento Temporal Loan, from Louis Vaudev, you name it. That being said, the kind of tradition or the underlying current or the theme is to say if I am using that spectrum to begin with, if your doctor is already saying subjective cognitive impairment or mild cognitive impairment or dementia slash, major neurocognitive disorder, that doctor is already thinking about a degenerative disease. That in some ways applying it to a stroke or applying it to a traumatic brain injury on its own almost feels like a nozological incompatibility to many people. They go well, you should be using a different term. But if you are going to use SCI or MCI or dementia, you are kind of token that the origin and question is going to be degenerative. Now, that's not an absolute truth, but the way that it is thought, the way that it is used and the way that it is researched is usually with that in mind.
Dr. Michael Kentris:There is a certain connotation to it.
Dr. Michael P.H. Stanley:At least a connotation. I think it is a denotation that is little thought of, as opposed to a. It is more than implied and it is certainly more than inferred.
Dr. Michael Kentris:Got you. No, that's a great point. That is certainly one of the challenging parts that we see like a deficit To your point where we are talking about these declines in abilities of daily life. Everyone starts from a different functional level. We are saying that this is different than normal. We wind up well, what is normal for a certain person? Everyone has different intellectual capacity, that they start with different levels of education. I know that is something that they try to account for in some of the more in-depth batteries of neuropsychologic testing. But in your experience, how much of a role does that starting point play in making a diagnosis or a delay of diagnosis?
Dr. Michael P.H. Stanley:It's a huge issue If you think about it. Take something very basic like orientation With the medical students, when I do different little lectures or little chalk talks about cognitive domains or cognitive elements, I usually ask them what does it mean? We could take this, for example what does orientation mean? What does it mean to be oriented? Usually the answer that you get and you get this answer from cognitive neurologists or behavioral neurologists as well it's about knowing the date or it's about knowing where you are in space. That's orientation. That's not orientation explicitly.
Dr. Michael P.H. Stanley:If you're looking at a mocha or a mini-mental status or a slums they all have as an element of it very specifically, with points assigned to it, does he know the day of the week? Does he know the year? Does he know the month? Does he know the specific location? Does he know the county?
Dr. Michael P.H. Stanley:Counties are a very interesting thing to look about for orientation. There are some regions of the countries where counties are extraordinarily important. They have salience where the mini-mental status was developed. Counties did have a lot to say, whereas parishes in some parts of Louisiana might have more to say, or awards in certain parts of Massachusetts. So you get my idea that actually what orientation is is not very discreet things like does he know the date or does he know the location? What does he have command of? The whereabouts and whenabouts that are sufficient for him to act as an actor in a world of meaningful decisions? So, if you are so now to grind this back down into earthly matters, if a guy is retired and he spends most of his time fishing, what need has he for the month or the day of the week, right, correct?
Dr. Michael Kentris:Before. I feel that same way Right.
Dr. Michael P.H. Stanley:And how many of us have looked to double check. When we say, oh, what's the day of the month? And they say it's the 27th and you're looking like, hold on, let me look and see if it is Now, what makes it? Why should we take a point off of them? But not a point off for us, right, because it goes to this fundamental question is this beyond what we would consider normal? So now we're in a world of judgements, value exeology, value judgments.
Dr. Michael P.H. Stanley:Is this what is sufficient for this patient in front of me to go about the world in which they've told me they go about it? That's actually much more useful than finding out if they know if it's the 21st of November. So what do you do if the guy doesn't know what month it is? But he can tell you about what's going on in the news and he can right. So those are the things that don't get captured on basic screens and might even not get captured in terms of formal batteries on more intensive screens, but they do involve an interpretation and a synthesis and an analysis in the context of. I think that's actually another feature of what cognitive neurology provides. That is interesting is that we are very context dependent in a way that other fields aren't, because other fields it's either there or it's not there. Again, going back to your sort of troublesome dualistic thing that you decided to knock me off my perch with as an intro question, right, which is sort of just to say, well.
Dr. Michael P.H. Stanley:I don't know, I don't really want to say.
Dr. Michael Kentris:Yeah, and I remember one of my instructions and I think that's like, as we keep saying, a very fundamental aspect of neurologic assessment, just in general, is the context. I always remember one of my instructors would always tell me what is the company that it keeps in terms of the symptoms or, in her case, different EEG findings? Is it in the setting of an otherwise abnormal background or a normal background? Are we seeing, like if we see one isolated abnormal reflex but everything else is fine? How hard do we go into that workup? And it really is one of those things where it's like what's the sensitivity and specificity of what I'm doing?
Dr. Michael P.H. Stanley:What makes a seizure a seizure Right? Oh my goodness.
Dr. Michael P.H. Stanley:Well, I mean, but that's my point is there are what seem like obvious infirmities in my subspecialty, because of the sort of squishy nature of some of the questions that are asked are present in pretty much every other part of the neuro axis as well, or the other so especially. It's just much more cleverly conceived, right, because you'd say, well, it's a seizure, but it's not a convulsive seizure. Okay, so it's a nonconvulsive seizure? Okay, well, but it doesn't have an epileptic correlate. Okay, what do you mean by an epileptic correlate? Well, it has this particular. And then all of a sudden you start to realize that what you're dealing with is just as hard now as it was for Hippocrates, right, you know.
Dr. Michael Kentris:Right, yeah, some of those writings, some of the descriptions are very, very similar to what we elicit in our histories like 2000 years later, and it is uncanny how unchanged in general the human is over what we would consider in our brief lives, right.
Dr. Michael P.H. Stanley:Well, you make an extraordinary spanner, a very astute point, which is that there are only so many ways it can go wrong in terms of output, right, so there are many, many inputs that are faulty.
Dr. Michael P.H. Stanley:There are enormous amounts of genetic reasons why somebody could end up with this particular tremor, or there are enormous number of structural lesions a person would have that would lead to this particular tremor. But isn't it a funny thing that there are only so many frequencies we see of tremor. There are only so many kinds of movements. There are many, many. We have a hard time binning certain movements, like God, is that Korea? Or is that? You know what is it? But there's only so many.
Dr. Michael P.H. Stanley:In other words, there are load-bearing walls of phenomenology that become useful. And the same can be said as we just talked about for movement, or as one might think about for how something might propagate as an epileptic potential or a spreading depression in a migrant phenomenon. But there are only so many ways. It doesn't. And that's actually a very useful anchor for an astute scientific clinician, supposed to a clinician scientist, that they look at the world around them. And so I see this cognitively in my clinic where, if you take a disease like you know, what is called Alzheimer's disease, which has all of these different subtypes as defined you know, you can have a posterior cortical variant where they lose vision in the back. There's a dis-executive variant, right, but that's also. It's defined by its amyloid.
Dr. Michael Kentris:No, I think that's a great point and I think we've seen numerous studies in different subspecialties within neurology, like epilepsy or movement or dementia, where if you look at the clinical diagnosis that was made and then in those who underwent autopsy down the road, there's very often a lot of disparity between the phenotype and the underlying pathophysiology.
Dr. Michael P.H. Stanley:that we ultimately developed. So again circling back to your initial question, your profound one, which I still don't wish to answer right, is to say, okay, there are a billion different genetic reasons, and pathologically, is it a proteomic reasons? And et cetera, et cetera, et cetera. That could look like this one thing you know, an amnestic syndrome. So that's one direction. You could also say that this protein, same protein, could look like many other things, so you could have. So you have amyloid diseases that can be amnestic, or anything else you have. And then you have the reverse.
Dr. Michael P.H. Stanley:So you either get to say I'm only going to believe in proteins and I'm going to ignore the phenomenology, or you could say, well, I'm going to keep looking at the phenomenology, which is what, for example, like Marcel Messelon did, where he took a thing like aphasia, a progressive aphasia, and they said wait a second.
Dr. Michael P.H. Stanley:If we actually dope out the ways in which their language is impaired, if we take a truly phenomenological, semiological approach to the language impairments themselves, we actually see subcategories and, lo and behold, some of those subcategories are very specific in terms of which proteins go wrong, which diseases relate to that subtype. So all of a sudden, we salvage this idea, which is what neurology came out of right, which is that if I localize really well, it tells me not just where but what. And as we've gotten to sort of drill down deeper into biology and biochemistry, we start to question that, oh, maybe it doesn't really matter at all. And you go, no lo and behold, still works. Still good, you know, but it took. What it took was a very profound and thoughtful approach to what is a phenomenon, what is a semiology, and then the right kind of research apparatus to then uncover the relationship between these kind of protein etiologies and the cognitive domain. That's effective, the way that it's effective.
Dr. Michael Kentris:Yeah, I think no, those are. Those are all great thoughts and I find when I'm working with trainees whether they're, you know, residents from other specialties who are rotating through, or medical students, as you said earlier, with our different like mochas and MMSC, is our different kind of cognitive batteries that we do at the bedside, that you know they'll come back and like, oh, the patient got a, you know a 25 out of 30 or what have you, and I'm just like, okay, well, in what domains or what were their deficits within that? Like, how does that translate into, like, what they're presenting with? You know, very often, you know, I'll get a call from the emergency department. Let's say, the patient's aphasic and very often maybe they're just really disart right or an arthric, even to the point where they cannot produce speech, or you know. So I find a lot of it is translating Like I've observed this phenomenon but I don't recognize what I'm observing.
Dr. Michael P.H. Stanley:Oh, yeah, or your point about. So let us take a screening test, you know, like a mocha or an MMSC or a slump, and I mean I would bless it. I mean there are many, many, many, and the only reason I'm bringing these up is because they're common. This applies to most, all of them. But you know, when most of these tests were done, they were normed on less than 200 people, and they were normed I mean. Now we've got many more decades and they've been applied to different things. If you think about it, many of these were normed on, like less than 200 people. They were usually as a whole, right. So let's take the mocha, for example.
Dr. Michael P.H. Stanley:Early on and initially, as it was produced, the fact that you got all of the points wrong on memory as the result of getting you below the threshold of what would be considered abnormal did not have statistical power to say that you had a memory problem any greater than you know. Pick three random words, right. So its statistical power was that you had less than you know 26 or less than 25, less than that. That's the cutoff where there's some statistical power, not on the subset of the sections of the mocha, right? That's similar to many of the other screening tests.
Dr. Michael P.H. Stanley:So it's funny though, because we've got numbers, because we do like numbers, we love numbers, you know. I mean people forget what's the line for that Neil Young song numbers add up to nothing. This is true. You have to know what you're adding, you know. So here's a good example where you're looking at that mocha and you're asking your student the right question, which is well, where are the deficits, what are the deficits? But you're not asking intriguingly and I don't think you've ever asked this, for example well, how much deficit based on that mocha? Right, and has that those words ever left your mouth? Where you look to the training on how much, how much, how bad is it based on that mocha?
Dr. Michael Kentris:Well, I do tend to be a little flicked, so I might have said something that I effect, but not expecting an answer.
Dr. Michael P.H. Stanley:But you do ask where and what, and that's which means that's actually where the, where the doctoring comes in right and in the, the thinking the thoughtful nature is is to look at the spread of the deficits, except from right. Right, at that moment I am now going off of empirical, I've left the empirical world. You know, I am no lie, I am in the data free zone as soon as I start to say, well, yeah, but the, that first top section was all wrong and they don't, statistically speaking, they have no, not statistically speaking. You are now making qualitative assessments. You know, I mean, I've got this bag, this toolbox, filled with all sorts of things that have no norms whatsoever to them, right, but a lot of things don't have norms to them but are nevertheless entirely use, very useful. They just don't have a number.
Dr. Michael P.H. Stanley:I think we get very caught up with numbers. We like numbers. But if you start to push and pull and you say, well, is this really a phenomenon that can be quantitative? And if so, is it on a discreet? Is it discreet, is it a discreet? And you start to ask those questions of people, and again, you, you, you find out pretty quickly how shallow those principles are, and it's another reason why cognitive neurology is fascinating, because you get to, you get to sort of, you figure out quickly where are your weak spots, like you were where you decided that you thought this was, this was stable ground, and your eyes it is not stable ground, and so it's very much like you and your patient out on the moors, you know, trying to figure out how do I not step in something and sink. You know the goal is to try to map out for them what's what's real about their disease, because they want to know not just what's happening now but what's happening later.
Dr. Michael P.H. Stanley:You know, if you have a, let's say, your mocha has no orientation, the guy has no history of a driving problem, do you say, well, I'm going to take your license, like those, those kinds of fundamental questions we don't have great answers to, and so a lot of it is this judgment where you go. Well, I can see visual spatial distortion, I don't have a number of effects to it and we're starting to get numbers. I mean, there's some, there's some, there's some good neuropsych testing that shows essentially a correlation between a trails be of longer than three minutes or more than three errors, seems to be, seems to be a naughty point. People do well. People do well driving perhaps.
Dr. Michael P.H. Stanley:But things get really bad when you look at more than three minutes for a trails be or more than three, three errors. So like that's a useful test. But you'd have to, as a cognitive neurologist, know that, know that's what you're after and stick to those guns and sort of say I'm going to use this even if they look great. So again, you figure out which principles you let go and which principles you hold on to for them home. And you know in this field, yeah, that's.
Dr. Michael Kentris:That's a really challenging thing, because every every person's constellation of symptoms can be very varied and it will change over time. Right, that's a great point, right. A lot of these dementias are are progressive, you know, neurodegenerative conditions, and so from one year to the next, it is a moving target in terms of counseling and safety and all that. So how do you tend to grapple with that with with your patients who are, let's say, in the earlier stages and maybe have more insight into the condition?
Dr. Michael P.H. Stanley:I? I always start asking you know why? Why have you come? How can I be helpful? What are your concerns? You know what. What are the what? What do you need to know to go about your business?
Dr. Michael P.H. Stanley:Because then, in the course of doing the, the work up, you start to figure out okay, I know now what this is, or I think I know what it is. I'm going to tell you what. If you want, what the name of it is, I can tell you, based on what I think it is, how this is going to go in terms of months, years or or so, and what one might see or expect to see sooner rather than later. So you can sort of limb out a rough cartography of, of the clinical progression, but you have no idea if that's going to actually match that person or not, and so a lot of it requires close communication, asking questions that you think they may have but feel too embarrassed to talk about, and or ask questions that really try to discern. Is that in the same with a neuromuscular doctor? It doesn't take it for granted that the person says they're numb right, they go well, numb or tingly or weak, and they get examples. Neurologists are so in that zone of questioning and qualifying everything. And imagine doing that in a field that's mostly subjective, right, like, is it a memory problem? Well, actually it's an attention problem. Well, what do you mean? It's an attention problem. I can't remember something. Well, if the flashlight's off, you can't see anything. To begin with, right, if your attention's off, you got nothing to look at you.
Dr. Michael P.H. Stanley:Or, and it's a lot of it is metaphor making, because you're you're trying to give the person in front of you a model to understand what's going on, because, again, you're asking them the brain to question itself. So you know, a lot of it is saying, well, memory is like a well, and I'm going through the reasons of like, why that could be, and like which parts of the well are busted, and and then seeing if that works and listening. If that doesn't work, picking a different one. You know, because a lot of what I do which cannot change fundamentally the, the origin, you know the ideology, is a lot of tuning up. It's a lot of tuning up and like asking about sleep and why the CPAP might be important Really, and then you know having to try to come up with a metaphor that will make sense, like, oh, you got to recharge your battery.
Dr. Michael P.H. Stanley:I mean, have you ever had a laptop? You know those kinds of things. So it's, it's always a moving target, not just in terms of the disease but the person's understanding of the advice that you're giving. You know, the metaphor is change, even if the, as the disease changes, in order to get something that makes sense to them, because the, the apparatus that is the sense maker, is what's going bad over time. And then there's always the toggling between what makes sense to the patient, as best you can, and what makes sense to the, the other people in the room, the other people at home.
Dr. Michael P.H. Stanley:You know, oftentimes it's, it's they're much more distressed or bothered by than the patient, depending on what the, the impairment is.
Dr. Michael P.H. Stanley:So you have to negotiate that situation where, well, even if the patient isn't bothered by this, if the loved one is, it's going to lead to an agitated milieu. So in some ways I have to also treat that patient's loved one, because whatever bad vibes that loved one's going to give off is going to make that milieu uncomfortable for the patient. And so, which I think is a fairer way or a more honest way than saying like, and I treat the family too. I think, I think I think I get you get to do that if you're in family medicine. That's the glory of family medicine, I think. I think it's a it's it's unfair annexation for a neurologist to say and I treat the family too, because we don't have that training. I think it's fair to say. But I can look at what the impact of this relationship is going to be on the, on the patient, and therefore try to treat or alleviate the, the environment that that patient's in.
Dr. Michael Kentris:Right, yeah, we know no caregiver. Burnout is especially in those, those long term conditions, yeah, very huge impact.
Dr. Michael P.H. Stanley:And, and there's a lot of internal turmoil, there's a lot of self blame. Unfortunately, a lot of time is spent not on himming and harming over this or that pill, but in trying to reconcile a loved one's experience to the patient and what these behaviors are, what they mean, what the loved one's responses to those behaviors, which is often a very natural response or even correct response, but nevertheless feels bad, carries, guilt, and so then you have to sort of do this thing of reconciling. Going back to your initial question, uncomfortable as it is, how does me relate to my brain, right, and all those troublesome philosophical principles of agency and volition and insight, and those, those are the, those, those linchpins start to get separated, and it's really that's where the bulk of that's where the heavy lifting is for, for I think a clinician in this field is is is reconciling those features of you know the who and when the who goes awry.
Dr. Michael Kentris:No, that's. That's a well put Anecdotally in your your own clinical experience. What do you find are the most disruptive symptoms to to a stable home life and someone remaining in a home as opposed to moving more towards kind of an institutional setting?
Dr. Michael P.H. Stanley:Lack of insight is the thing that leads more than anything else, because lack of insight or poor judgment is what precedes unsafe behaviors. Right. So so, although early on, for many, many people the short term memory problems or some trouble in coding or registering information is distressing. Right, because you go. I should have remembered that or I should have written those things are very distressing. Ultimately, you can build a lot into your schedule and routine and regiment and you know, with very little memory, go about a lot of activities and still do things and enjoy and you know, be functional. Right. But but when the executive components or those kind of higher level executive components of insight and judgment, when they start to go wrong, that's where unsafe behaviors set in or that's where there's risk to self or others and that's where this question of independence really starts to go to rear its ugly head. So a lot of it is is a lot of it is spent on trying to understand not just where there are holes in a person's cognition, but but actually figure out like do they notice it, do they recognize it, how do they feel about it, what do they do around it?
Dr. Michael P.H. Stanley:One of the earliest signs you see in memory problems, of course, a patient comes in with his wife and you know they sit down and you're having a conversation and you say, so, well, you got any pets, you know, mr Smith. And Mr Smith says, yeah, I got a dog, you know. And you say, well, what's the dog's name? He looks to his wife right Now. The first order clinical is you go, aha, I'm every problem because he's looked to his wife, he's has an amnestic problem. A second order clinical point is to go, but what strategy he has employed? He knows that his wife is a source of information and he turns and defers to her.
Dr. Michael P.H. Stanley:Okay, right, that's very different than somebody who gives an answer that is incorrect and you see the wife correct and say no, that's not the dog's name, you know, confabulation or things like that or can be troublesome or can be dangerous, whereas that kind of turning and learning is good and they learned that. I mean, you think of this as a disease. That is all regression, but there's, you know, learning and development go hand in hand. So if there's a sign of learning or accommodation, that is to some extent a sign, cognitively, of development and so that's a good sign. I take that as a bad memory, but good sign right. Bad memory, but good insight. They learn that.
Dr. Michael Kentris:Right? No, that's a great point, and I know agitation as the disease progresses is often frequently a troublesome thing for keeping people at home as well. What role? Obviously counseling is a huge element of this, in terms of you know whether people are having hallucinations or delusions or things of that nature. I've heard different schools of thought on how much family should engage with these thoughts. What's your perspective on that?
Dr. Michael P.H. Stanley:Embedded in that question are two things. So one of the words that you use is agitation, and then kind of beneath or within that you sort of already were talking about. Well, that might be a source of agitation, which I think is what you're if I dope this out right is like hallucinations and delusions.
Dr. Michael Kentris:Yes, Well, but they might be treated differently, yeah, right.
Dr. Michael P.H. Stanley:So, for example, the most common form of agitation, right, which we don't necessarily think about as agitation outright, but it is is the frustration one gets with the failure as a result of the cognitive issue. So, memory, right, and then you know it starts as, just, you know, shocks, right, and then it becomes losing your cool, sweating the small stuff, and then you know, then it's a full blown tantrum. That's that progression, right? Well, that, if you think about it, is nothing more than not being able to put a lid or a regulator on what is a very reasonable response, right, it's. It's so.
Dr. Michael P.H. Stanley:The way that one deals with that could either be with the person themselves and thinking well, what is, do they have enough wherewithal to count and talk to five? You know, count, stop and talk to five. Count to five Is it the ability to say, step away from the problem, think about it and come back. Then you get to a point where those aren't, those are not abilities one has, and then you can say, well, can I use a medicine to regulate the autonomic system, to put a governor on that? So you know, there may be certain kinds of blood pressure medicine, pills, but actually actually, rather than the antisecotic and putting a governor on it, or am I using antidepressant or anti anxiety medicine to kind of get put a regulator on those reactivities?
Dr. Michael P.H. Stanley:That's one approach. Now you raise a separate issue, which is the question of what does one do about a delusion or a hallucination, and a lot of that again has to deal with what is the interaction that the patient has with said delusion or interaction. Have you seen? There's a nice little meme out there. The person says something like I just heard a rumor the other day that the Loch Ness monster might just be a ghost of a dinosaur and then as a dot dot dot and says as this idea causes no harm to anyone, I'm going to believe it as a little treat to myself.
Dr. Michael Kentris:Right, Well, I like that yeah.
Dr. Michael P.H. Stanley:Delusions for some are fantasies, for others, the question is about harm in many ways. So you could look and you could say is the delusion that the person has harmful? They just talk about it a lot and so it's annoying. And then again, how you're asking am I treating the, who am I treating and how my verse versus? Is there a quality to the delusion, right, is it? Is it an ego dystonic thing, something paranoid, something hurtful, something scary? Well, that needs to be addressed in a way that you know an idea that the neighbors have a lot of parties, okay, well, is that? Is it bothering you? Is it just a thing that you know, or an idea that you have? And so that could be the difference between an antisecotic and minding it or playing around with it or, you know, ignoring it. Where are the challenges? Again, now I'm getting kind of airy, so I'll ground it.
Dr. Michael P.H. Stanley:Think about think about a Lewy Body Disease, where they have a lot of visual phenomenon right, visual hallucinations and or posterior cortical atrophies in general, which are at a greater risk of a thing called Capgrass Syndrome right, where you look at a familiar person but find them to be an imposter. So I have a number of patients which are in this, in this situation, and what we've been able to do early on in some of these diseases or some of these syndromes rather, is use a different sensory modality to provide the positive feedback they need to check themselves, right. So that could be something like having the person presumed an imposter, leave the room and start talking or singing or some sense that oh yeah, that's their voice. It could only be Michael Kentress' voice. I know that voice anywhere. It could only be Michael's voice and have them continue to talk as they reenter the room, right, so that's one option. Another is to say well, I know what his hand feels like, right, so closing me, or I know what his cologne smells like, or those sorts of things, and trying to get around what otherwise is a, at that point in time, just one modality that's screwed up as opposed to later. So that's one way to do it. So that's one way. Another is, again, by manipulating or trying to give a little bit of cognitive power through, like a colonesteroids inhibitor. There is some evidence to suggest that capgrass and certain peridolic phenomenon get better with a little bit of a cortical tone. You know what you get with a colonesteroids inhibitor.
Dr. Michael P.H. Stanley:Or again, some of these things happen because a person is subtly anxious. And so, therefore, the error checking that we have, like you know, when you're in the store and you're like three aisles over from somebody and you say, oh yeah, that's Jeff, right. So you wave and then, as Jeff approaches, you realize it's not Jeff, In fact it's Jane. You know. Well, that's because we do have an error checker and we have a maker or a matcher function. You know that's going on, and we had enough information to feel pretty good about what we thought this was. Similarly, they've got enough information to feel pretty good about what it is. They're wrong, right as far as we're concerned. But so the question is oh well, are they pretty sure, because the anxiety or fear is heightened enough that they've chosen the wrong, they've made the wrong match, you know. And so if I give them a lexapro, if I give them an anti anxiety medicine, it'll calm it down, it'll give them a larger repertoire of options to choose from. And maybe it's not an angry thing or a scary thing or you know paranoid thing. So that's another option.
Dr. Michael P.H. Stanley:And then there are people that have had figured out some very clever things to do with Frank hallucinations. There's somebody, for example, that the hallucinations are annoying, but they don't really interact with them, they don't name call, they don't do bad things, they're just annoying. And what's very annoying is just that initial sense of is this real or not Right? Because if this is a real stranger in my house I got a problem Right, whereas if it's not a real stranger, I can ignore it. So they've got like a what do you call it? Infrared thermometer. You know the long distance thermometers and it's like you know it's on their TV dinner tray and basically when they're watching TV and they look in the corner and they see there's something they're like I don't know. It looks like a person Wonder if they're real. They just put the you know, turn, turn the infrared thermometer on them. They look and they go nope, temperature of the wall, not real Right.
Dr. Michael P.H. Stanley:Now, why does that work? Well, the reason it works is because they still have insight. You lose insight Right, and now there's no explaining away. Right Now it's a delusion, fixed idea, right, as opposed to a perceptual experience without an extra, extra personal stimulus. You know, it's a hallucination, as currently defined.
Dr. Michael P.H. Stanley:And so those are the kinds of tricks that are patients figure out on their own, and then it because you ask about them, they tell you, and then you, then you have the ability to say to somebody who is going through something well, I thought what about this?
Dr. Michael P.H. Stanley:You know, and when they look at you, like you're crazy, but I have a patient who this works for, and now they believe it, right, because it's been tried out there in the world, and so so those, those are the kinds of ways that you're, you know, you, you're working around these, these, these issues, so the person can remain functional, can remain themselves, can keep that sense of identity. And it's only when you start to realize that what they've, what they're thinking or what they're seeing, is tipping into unsafe, or you know that's where or could or could start to be unsafe is is where you start to say, okay, now how do I him in the perimeter of their ability to act on said thing? And maybe that's, maybe that's what I meant. Maybe it's with supervision, maybe you know who knows it depends. It depends on the person.
Dr. Michael Kentris:No, that's. That's a great point, and I love the integration of like those, those intact sensory modalities, especially like the very outside the box kind of strategies that you're.
Dr. Michael P.H. Stanley:Well, it came to me from. I had a. Well, she wasn't a patient, she was. She was somebody I was introduced to. I've written about her and one of she had.
Dr. Michael P.H. Stanley:She had a synucleinopathy, she had a sort of Parkinson's and then did all Parkinson's disease with dementia, and but one of her heralding signs was she had come back home and she had opened the closet door, like you know, coats and that kind of stuff and there was a man hanging in there, you know, which is terrifying. So she fled. And then again something which tells you, she told, she told us all something was up. She went back, yeah, she, like you know, looks at it again and yeah, it looks like a guy hanging in the closet. But then she reached out to touch him, which already tells you that something, something in the analyzer, lets you know that it probably wasn't legit, you know. In other words, she quite literally was testing reality, Right, and she was right, because when she touched it and felt it, this thing, this man, the image of this man in the closet, it no longer looked like a man hanging in the closet, you know.
Dr. Michael P.H. Stanley:And you'd ask, you'd say, well, what does it look like, what did it look like? A coach is well felt like a coat. You know, I could feel the coat, I could feel it was on a hanger and it looked different. Now, it didn't look like a man, but it also didn't look like a coat either, you know. But it but it felt like a coat on a hanger and that was what gave me the idea of saying I wonder if I can bust up some of these, these perceptual errors, by providing some alternative. You know feedback, either haptically through your fingertips, or automatic, with smell, or you know you name it, and that's been relatively successful for a number of cases. But that's because a patient told me something which which you then sat and thought about, you know.
Dr. Michael Kentris:That's very interesting. Now that makes me curious about if you have any thoughts about like pseudo hallucinations or something like Charles Benet syndrome or both, you know, acquired hearing loss. You might hear snatches of music or things like that. How do you think that that kind of like sensory release phenomenon relates to kind of these perceptual changes in dementia, or do you think it's totally different mechanisms?
Dr. Michael P.H. Stanley:I like to, I like to believe in lumping rather than splitting, you know. So I like to think about how, you know, I did very early, very early apparatus, very early apparatus get kind of exapted into higher and higher cortical or cultural needs. And so, you know, one thing to look about is to say, in the same way that you would take a number and you would factor it out to figure out, you know, if the number is 24, okay, the factors are somewhere between one and 24, can't be less than, can't be more than right. So, similarly, on the one hand, we have a thing that's called a hallucination, which, again, that current definition is like there's not a stimulus out there in the world, but I have a perception on the inside.
Dr. Michael P.H. Stanley:And then you brought up this point about sort of Charles Bernay, which we which is described, as you know, quote unquote a release phenomenon, you know. And then we have these things that are paradox, cloud gate. We all do this as cloud gazing, right, you look at something and you make meaning, that of an otherwise meaningless pattern, right, and so you can see it. And patients with a weak body disease have a lot of will, have a lot of pareidolia. They'll see faces and things, or writings and things, and so I like to think about it like factoring that number. So now let me take these phenomena and let me organize them. On the one hand, I have a thing called hallucination. That's maybe 24, right, that's the thing. That's just we. We, we allege that there is no external stimulus and that it's all internal perception.
Dr. Michael P.H. Stanley:And then, on the side of the lowest side. The number one is there's absolutely stimulus out there, but I'm misperceiving it and I'm making a. You know, I'm parsing in the local and global features in a way that make you see a face and something that isn't a face, and then you'd say, well, maybe Charles Bernay sits right in between. So now you get to ask yourself, well, does that really mean that there's nothing out there in space that those people with hallucinations aren't responding to, that it's totally internally derived. Then what makes that any different than a Charles Bernay hallucination? Right, which is quote unquote a release, because in theory, what do we say? What is release phenomenon? So what releases? It's in there, right, if you start to get poking fraud people on this as well, it's in there, but it comes out as if you know, your skull is like a little Pandora's box and there's stuff in there, right, it just comes out, right. So that doesn't make sense. I mean, when you, right, when you start to really peel it away, you go. This doesn't make any sense at all. This is a complete fabrication. This is, this is a metaphor of, this is a myth, right, and it's a myth that helps us explain certain phenomenon that where we don't really know, but we apprehend them, but we don't comprehend them right.
Dr. Michael P.H. Stanley:So what I would say is probably going back to like big art historians, like Ernst Gombrich, who said that the how aesthetic movements, moments work as we. You know, we make a thing in our head and we match it. You know what am I looking at? Well, it could be this, it could be that, and then I look and I try to fit some features on that and get some insight and draw some conclusions. I do it very fast, right, it doesn't take long to make this, but I do that. And so you would say, all right, so if that's kind of exactly what's happening in a paratheolic phenomenon, who's to say that?
Dr. Michael P.H. Stanley:What the hallucination is, whether it's an auditory hallucination or a visual hallucination is there's something out there in the environment, however small, that is leading to conclusion, jumping, making and matching erently. And then you know the brain is amplifying that that would. And then the question is okay, if that's a true construct, michael Stanley, what does it mean to amplify? And then you'd have to say, okay, well, how would that work in the brain? But now I have something testable, I have something I can look out in space, as opposed to saying it gets released. You know, we get into the whole n-gram problem when we start to talk about release. You know like well, okay, well, where is there just a little librarian card thing that I pull out and I find that work.
Dr. Michael P.H. Stanley:What that doesn't make that starting to not make any sense. Right Now, that starts to feel like we've left the world of hardware and software and we're you know so, or in fact we're exactly in that point. My point is, I think, what the actual examples that patients have given me of working around their hallucinations or their delusions or their optical illusions, mirages, mr Magooisms would tell me that it's probably a continuum rather than that they're separate things. And that's where my head is in terms of thinking about this as a construct, which puts me in the camp of a smaller group of people. But it's still a camp. I'm not the only one out there in space who thinks that.
Dr. Michael Kentris:Yeah, and I've only in the last couple of years, started reading a little bit more about the neuroscience of some of these things, like you said, like ideational construction, linguistic construction, all these kinds of phenomenon that you know when we're in medical school we're trying to like oh, you know, your expressive language is in focus.
Dr. Michael P.H. Stanley:Well, like, take Charles Bernay, for example, because you brought that up as like okay, charles Bernay suggests that this is a hallucination. It's a form to hallucination, usually sometimes abstract, but mostly form to hallucinations, and that the person has, a person knows that they're not real, right? Well, do they? Do they know it right from the get go, or is it after like a second or two? They go, wait a second. This person is too small and they're floating in space and that doesn't make sense, right as opposed to well, the exact same I mean, I've heard this too the exact same hallucination in one patient we call Charles Bernay, because they recognize it to not be real when they tell it to you, versus a different patient has the exact same hallucination and we say, oh no, it's an organic hallucination and it's a hallucination out of Charles Bernay and it's not real when, because they don't recognize it's real. Now, what that would suggest is that the difference is really not of a visual perceptive, but of the insight into it, and therefore it raises a funny rule of thumb that many old timers will tell you but again troubles the, the gravitational field of the academic world. When you go it's kind of a funny thing you don't see Charles Bernay in the very young Right and a surrogate right. We don't know. It's true, I take it to be that it's true, but I am not sure that it's true, Right, I've not seen, I've not seen to the and therefore you could say, well, it's probably nothing about being young. I mean, there's a lot of good points about being young, but that's probably not one. It's probably that what we mean is there's some degree of cognitive impairment already at work in those with Charles Bernay, right, there's already something at work, it's just that it's not bad enough that they've lost the insight into it. And it's very interesting that if you do a literature search on this, the Charles Bernay, they either haven't lived long enough to develop dementia, right, or it's a funny thing that they usually transform into something like Parkinson's, or they transform, you know, it's probably in the way it's on the way to getting somewhere. So, so that's really cool.
Dr. Michael P.H. Stanley:Because now it goes back to thinking about a sort of tried and true in medicine of like the two hit phenomenon. And so we say, well, what are the two hits? One of Charles Bernay is, as you mentioned, always something in the periphery I've got hearing loss, or I've got some optic, I've got some retinal stuff or I've got, you know, glaucoma. That's the peripheral, and then there's something central, and the thing that's central is what leads to that Charles Bernay phenomenon. So it's not released. In other words, now that you've teed it up that way, now you go well, it isn't necessarily released, right, because that would suggest that there's always some little grotesque man in my head that just is constantly being repressed. And then you go what does that mean? What would? What would right, right? If you say release phenomenon, what's repressed phenomenon, right, nobody wants to right. So either. If you say, well, there's no such thing, then I go well, there's probably no such thing as release phenomenon, right?
Dr. Michael Kentris:So yeah, and I do wonder, sometimes, you know, we kind of think like, for, say, someone who has, you know, like developed complex regional pain syndrome after a peripheral limb injury of some sort, right, we get this centralization of pain over time. You know, very likely, if we're talking about like a peripheral hit to the eyes and we lose that sensory input, you know, is this the centralization of that lack of input.
Dr. Michael P.H. Stanley:And now what you're doing is exactly what we should be doing as neurologists, right, which is, you know we're, which you're starting to think about as you? Well, hmm, I, I, I have a well trod metaphor and model for one kind of phenomenon out there, and then I say, well, wait a second, there's a peripheral and a central thing. And what if I applied that to a different modality and a different one? You go, well, this one checks out this one checks out this one. And now you actually be able to then really boost, now you get to really actually abstract from those separate metaphors, a true kind of, you know, syn-topic analysis, where you get to say, wait a second, maybe what's going on is just a step before we get into the, the, the modal, right, it's actually, maybe this is an A modal prop, this is an A modal phenomenon, it's, it's, it's independent. In other words, it doesn't matter that the thing that's going on, the actual mechanism that's going on, doesn't matter if it is haptic, nociceptive, visual, you know, gustatory. So the mechanism therefore can't be in the, in the very specific modality, right, it's not buried there, it's something one above right. It just happens to be that, you know, the downstream effect is that, you know, on the Plinko game of of sensorium, it's, it's ending up in the visual rather than but that's. And then now you've got a cool model. Now you've got something to really think about, not not what are the functions of the brain, but again, now you're what you were doing by building that model, michael, was you were talking about what is the brain's function? What does the very fact of having a brain do for us as an organism? And then once you and this would be one of those things would you say hmm, I have a peripheral portion of my apparatus, a central portion of my apparatus, and this is the. This is what the central does for the peripheral. And you've noticed that when the central goes wrong and it's nearby this modality, I get chronic pain when it goes wrong on this one. So, so now you get to, now you get to test this out, which is you go. Isn't it a funny thing that I can use certain anti ASMs? Now, right, anti-seizure medicines for central pain, and I could use. And so then you say, well, how well could I use it for another thing? So well could I use that for? Could I use that for these Charles Benet phenomenon? Is that a thing? Well, now you have a reason for trying it out, as opposed to just blindly trying it out. You're trying to fit a model.
Dr. Michael P.H. Stanley:Another way to look at this is that there was a thing that was called olfactory reference syndrome. It's a, it's a psych. Technically speaking, it lives in the psychiatric world, although to me it just feels like like a chronic pain disorder of the nose, like you've got horrible, horrible smells that have no particular source or origin. You know, you, you, they get their sinuses worked up and everything and it's empty and, and importantly, they get EEGs, right to note that they're not having, like you know, metatemporal of seizures and they go. Nope, as far as we know, they're not seizing. But if you put these people in carbamazepine, it goes away. You know, just like with chronic pain stuff, you know, or or or deserene, you put them on ASMs and sometimes it helps and go.
Dr. Michael P.H. Stanley:What's that about? You go because I'm probably modulating something centrally, in the same way that I'm modulating those, and you go low and behold, as we just mentioned earlier in our in your podcast, that there are only so many ways the thing goes wrong. Right, cause it's only cause there's only so many ways to have built it in the first place, there's certain load bearing walls, of how these structures work. Surely, then I can probably use the same solution over and over and it'll probably work, as long as I'm correct about the load bearing wall. You know, and that's exactly what you're pointing out, and so now we're again. We're now we're being scientific clinicians about it. You know, which is cool. That's what's great about neurology we get to do that, you know it is.
Dr. Michael Kentris:I always tell students that that's it's both one of the most interesting but also potentially, depending on your temperament the most frustrating things about neurology is we don't have these robust, high number of studies but you get to play around with a lot of abstractions, like, like you said, if this principle is true and this treatment is working, works in this situation, maybe it'll work in this situation as well, and we certainly see that exact thing done for a lot of, like you know, in rare situations, like using levatoracetam for different kinds of tremors and things like this right, things for which it was definitely not ever developed, but someone tried it based on some example, and found that it works sometimes, and so we wind up with another potential branch in the treatment. Yeah, thinking about well, why is?
Dr. Michael P.H. Stanley:that Is it? Because the receptor that is tickling is also in a different place? That's one way of looking at it. That would tell you that it's. It's a drug specific phenomenon, you know, or a receptor, but it goes through. Or you say, wait a second, these two phenomenon have a have a shared mechanism. That's another way to look at it. You know, a little higher up, you as the neurologist who hopefully has a good sense of neuroanatomy, gets to sit down and go well, wait, no, I can't possibly be. You just cannot possibly be a shared mechanism. It's got to be. The receptors are in two different places, you know.
Dr. Michael P.H. Stanley:But that's what's great, as you, you know, you sit down and you think about I, I, I like cognitive and you know neurology in general and cognitive neurology specifically, because it really is a lot of it's testing out your principles. You know, against the practice. You know your, your philosophy against the reality. You know just as much as my patients are often attempting to test their realities. I'm testing their realities right along with it, but we're just doing it in a with slightly different lenses, that you know. They're doing it for their own functional independence and I'm doing it to understand not just them but the diseases that are, you know, uh, uh, beleaguering them, um so, uh, but. But yeah, it's a great field for starting to think about. Well, how does it work that way? Why does it work that way?
Dr. Michael Kentris:Um, yeah, I find a lot of physicians do fall down a little bit on the why uh, which is, you know, sad, because I think that's a lot of the the most fascinating parts of practice Absolutely.
Dr. Michael P.H. Stanley:Um, you, you. I think the other element of it is um, a lot of what and this is true for for for cognitive neurology, I'm sure it's true for for the other um sub specialties as well which is, we ask these extraordinarily good questions and we see some incredible instances and cases in our clinic and because of the nature of the practice of medicine. Now, the literature that we read and the information that we read, how vast it is, how much it is, it's all we can do just to stay on top of the, the, the trade, uh papers, if you will, um, but actually the really good things come from connections outside of our field, you know so, where you get to use that skill set somewhere else. So what do I mean by that? I mean, um, there are a number of very good insights that were made by Luria and made by Jonathan Miller and made by Oliver Sacks, because they took and brought to bear their neurological and neuropsychological tools and applied them to people's lives outside of the clinic, you know, back in their environments, back in their ecosystems, back in their functions. Or, similarly, you know, if you are going along reading in, you know, harper's Weekly or some some other magazine that has no relevance in theory to to our own. And you hear a story and you go I have a neurological answer to that story or I have a neurological question in that story. That's, I think, where a lot of really good um insights come from. You know, if you, if you keep pressing out into um other fields, either because they gift you with different um analogies that you get to work with, different models you get to work with, or they provide um you know, they provide to you data you otherwise weren't going to get in your clinic.
Dr. Michael P.H. Stanley:You know, I've had a couple articles which have been like that, where I was reading something in you know Washington Post or is reading something in the Atlantic or whatever, and I I went oh, this person has provided me what happens before they come into my clinic. Let me write a letter to the editor explaining what happens after their article. You know, but I never would have the idea, never would have occurred to me, if I hadn't have read their article. You know which means I would have had, which means I had to be reading something that was non neurological. You know, in order to have this neurological epiphany, I had to be reading something non-neurological. And so, again, it's a clarion call to say that you do have to square away. You know, as Osler said, 30 minutes a day to consult the saints of humanity, you know, in order to get those insights into medicine. Because, you know, medicine ultimately is a normative science, it's a moral science, and so it requires you to be reading that literature as well.
Dr. Michael Kentris:I think that's well said and of course I would be remiss as people may have gathered from your passion about the humanities that you are yourself quite prolific in the neuro-humanities. If you will, but tell me a little bit about how you found yourself in that arena. Did that come after the fellowship training or was it kind of on route?
Dr. Michael P.H. Stanley:I came in response. Well, the neuro-humanities thing is a or that term or whatever. That's a later development. But the general concept of the sort of vialondongra, this okay, he's doing the medical thing and he does this thing as non-medical. Where does that come from? That's largely responsive or reactive. So, as you recall and I'm sure people listening who either are experiencing it or shortly will or medicine is a very jealous mistress, takes all of your time. You know all of it, and so you get to choose which things you let go. And you know I had let go in the pursuit of medicine a lot of things that were really important to me, which was a bad idea.
Dr. Michael P.H. Stanley:And it wasn't until I had gone to Maine, actually my third year of medical school, when in Rockport, maine, at Penn Bay Hospital, which is where I did my training, richie Kahn Dr Richie Kahn, who was an internist and an incredible medical historian, sort of took me under his wing and sort of pointed out he says well, if you like history or you like literature or you like those sorts of things, you may just have to tweak the subject matter right so that it gets counted and it gets considered as relevant to whatever medical academic overlord you happen to be working for, right, like, if I do this incredible thing about, if I want to write about Keats, people go, okay, you do that on your own time. I don't see how that's relevant. Don't even put that on your CV. If you write about, well, actually I'm going to write about how Keats' medical training influences poetry, and they go, oh, you can probably put that on the CV, right? So what Richie taught me was two things A, there's nothing wrong about being a doctor who wants to learn about and read about and write about and teach about humanities topics. That's actually probably the right thing to be doing, and it was a thing that we were doing for many, many years. And then two, with a little bit of augmentation or twisting, you can do it. Then you aren't necessarily having to live two totally separate lives. I mean, I pretty much do live two totally separate lives, but there's a little at least. There's a doorway or a window in between, more like an elevator maybe, but that's one thing.
Dr. Michael P.H. Stanley:And then what happened, of course, was neurology is the place for that, because neurology is where I mean it's a quote, steve Hyman, it's a three-pound universe, like right. Or going back to Fran Leibowitz with the book, right? I mean what doesn't pass through the brain for great literature, for great art, for great photography, for great, you name it. And so there is something to be said about a neurologist. It's like philosophers think about thinking and a neurologist thinks about how a philosopher thinks about thinking, right. So there's this interesting layer that we can provide, not necessarily with explanatory value, some augmented value maybe. And so that's where it started.
Dr. Michael P.H. Stanley:Basically, that was the start of it, and then what happened was I had a really interesting patient that I thought was just a phenomenally important story, as every intern thinks that anything that they do is phenomenally important, right. So they become an M1 and they realize, no, no, no, actually that's not true. But I thought it was a very good story and I couldn't get it published in any of the academic papers. But I would go around talking about the story over and over and over and people go, god, it's a great story, you should get that published. Nobody would publish it. Nobody in the academic journals would publish it, and I got very frustrated as to, fine, I'll put it in the lay press. And I sent it out to a two-plus in the lay press and the Wall Street Journal wrote me back. They said, yeah, we'll take it, these are the edits. You make those edits or whatever, and then locked out. Like four months later another incredible thing happened and you go I wonder so okay, I send that around to the academic journals? And again, nobody was interested. Nobody was interested at all in this, didn't even give you the courtesy of running back and I said, well, I'll try the lay press again. I sent it out again. Sure thing, it took it.
Dr. Michael P.H. Stanley:And so it started this situation of being a conduit to a lay audience about things that are that might be we only see in our world, but we know are out there in the world and we know have some relevance to the everyday person. We just see extreme examples of it, or we see really exacerbated phenomenon, but something that everybody really has. And so that's how it started was. I just kept writing. And then other topics. Then people write to you, other topics present themselves and they say, hey, could you write us about this? What are your thoughts on this? I don't know if I should be talking about this. I don't know, I have no thoughts on the matter. And they say, yeah, but you explain things in a way that we don't get explained to otherwise. And so you say, oh, okay, I guess that's a reasonable role to take up, and so that's what I started doing with more frequency.
Dr. Michael P.H. Stanley:And then it isn't until really the last three years that the work that I had done in societies, academic societies, finally being allowed in to some extent as sort of a tolerated, informed tourist, you know, into these academic societies for this thing that I do, and in that role I've been able to kind of advocate more strongly for this question of what are the, what are the?
Dr. Michael P.H. Stanley:This thing called the neurohumanities or this thing called romantic science, which is what Luria and Sacks said their writings were.
Dr. Michael P.H. Stanley:And that's really been a distinct pleasure and privilege is to try to support as a platform, through whatever kind of blogs or writings or conferences, other people that are really doing some serious work in this but are they're not getting the credit they deserve in their local institutions or their societies.
Dr. Michael P.H. Stanley:But because I have amassed this tiny little lens you know it's got a high luminescence but it's a tiny little dot, you know on the wall but it's enough to kind of like push that little spotlight on somebody else and go, oh my God, look at this thing they just did, you know, this wonderful seminar series they're doing or this incredible, you know, form of journalism that they're doing, and that's been. That's kind of the mode that I'm in now is trying to promote enough of a critical mass of people that want to think about the medical humanities and, specifically, in our world, the neurohumanities, not as a tool of pedagogy, you know, and not as a solve for, you know, wellness, but as a true scholarly discipline, you know, as a field of inquiry and research. And that's where I'm really pushing hard to do, because that, I think, is, I think that's what's called for now.
Dr. Michael Kentris:No, I think that's excellent and it, you know, I would say delving, dipping my toes into more of the classic philosophy side of things, more so than the modern.
Dr. Michael Kentris:But it gives me, when we talk about, like you know, epistemology and ways of knowing so many of us these days, especially with many of us having kind of more of a STEM background, you kind of right, we focus so much on the reason but if you think back to like, kind of like, like ancient spirituality, like things like the noose, if you're familiar, like the spiritual way of knowing things right, very much ties into this, this way, this qualitative aspect of knowing right. So these, not to be too touchy, feely, hand wavy about it, but different ways of knowing things, like these stories, are very much that right, there's no study, there's no data, but we know from talking with this person, from the language they use, from the way that they hold themselves and communicate right, these things that we can't necessarily even communicate to ourselves, that there is something there that we are perceiving that they are communicating to us. That is somewhat inevitable.
Dr. Michael P.H. Stanley:Yeah, what would you? How do you? Where do you want to go? It's such a broad topic. What I would, what I would say, is neurologists are in a really good position to ask questions. That, and I mean really ask questions. Ask questions from a position of humility about knowing.
Dr. Michael P.H. Stanley:Again going back to this, because it's a, it's a, it's a, it's a sore spot to me the, the notion that we have some very important institutions that have allowed it to be printed as if it is a truth, as if it is a gospel truth about connectionism and language, when it couldn't be further from proven linguistically or neurological, let alone neuro linguistically. The reason that that's allowed, I think, is because, no, there isn't enough people in the neurological community to question that fundamentally right. The metaphor is offered, or the myth is offered and you go well, that makes sense, and so that's actually where I think you are absolutely right to take this sort of Richard Onion's view. You know, the origin of origin of thought, I think is his, his book, richard Onion's classic book, talking about how do you get from? You know Suke, and what does it mean for Suke, which can become psyche for us. You know, versus Numa, right, and where were those localized and what did they mean separately? Or Fumos, right, the thymus, so you think of it, so think about that. We just take psychiatric, that world itself, neuropsychiatrically, let's, let's put it in that balance that I don't mention psychiatry, because I have nothing to speak about in psychiatry. I'm speaking at a turn. I'm talking about psychiatry, but neuropsychiatry I can maybe talk a little bit about. So there we have it. So I've got, I've got neuro and what it countenses, I've got psychiatry, psychase, so psyche, so Suke, and what did that mean over time? And then? So how does the Suke differ from Fumos, which is where we get dysthymia and euthymia, right, and what's really being, what's the connotations of those or what? And then, and then you get something like you know, numa Numa.
Dr. Michael P.H. Stanley:And so those are three different ways of looking at the soul, looking at the mind, looking at the spirit, looking at the, and if you start to take that neurologist view on it, who, luckily for us, have decided to say I will only look at this three pound bit of integrated hamburger, and now I will try to fit these, these costumes right, these metaphors, over that, and see which ones fit, which ones don't, and if they don't fit, not necessarily discard them, but ask wait, why doesn't that fit? Does that not fit? Because there's a. It's a, it's a cultural costume, and I am outside of the history and I am outside of the cultural context for that to work. And just as well, if I took the cultural costume off my three pound hamburger and I put it back, then it wouldn't fit right. In other words, is it a, is it that kind of thing, or is there something fundamentally flawed about it, you know. So those are the.
Dr. Michael P.H. Stanley:Those questions start to come in when you go. Well, wait a second. What does that metaphor mean to me? What does that model mean? What does that myth mean to me?
Dr. Michael P.H. Stanley:Why is it that certain, you know, myths might be more or less universal, you know, I mean, there's a lot of Joseph Campbell's, you know, mythology is after forge, which bears fruit, even clinically, if you take the hero's journey and you apply it to certain neuropsychiatric situations and they understand it and they go oh my god, this makes sense and it relieves a lot of tension for them and you go. Well, that's funny. Why should that thing that doesn't have any randomized, controlled trial to it, you know, have bears such fruit? Why should it be such a helpful technique and you go. Well, I don't know, it's been around a long time. Not that tenacity is proof of efficacy. I want to point that out. Right, there are a number of very tenacious ideas in medicine that I'm sure are completely flawed, and you know, either we don't know it now or we do and we don't want to talk about it.
Dr. Michael P.H. Stanley:But I think that's what makes cognitive neurology so cool. Is that again an Elliot-like way? You know, coming back where we started, seeing it for the first time, we are dealing with this situation where I am studying the brain and patients see me because they have a brain problem but their symptom is not. They don't go, my brain hurts, they do say. They do say brain fog.
Dr. Michael P.H. Stanley:The closest that you ever come to directly implicating the brain when somebody comes into it in terms of complaint, in terms of, like the hard, harsh relationship between symptom, right, and it's origin.
Dr. Michael P.H. Stanley:Somebody breaks their arm, their arm is flopping, and they point to it and you're like, aha, they say their arm hurts, I see the thing flopping, it's a broken thing, right. But it's much more like being a remote viewer in cognitive neurology, where you're listening to these symptoms and you're thinking in your head like we're somehow on some other plane, cognitive plane. I'm trying to isolate the symptom or the phenomenology, and then I then have to ground it into some part of the brain or some network or some nodal structure, or you name it, and so that's what becomes kind of cool is you're starting to look at this and you're going, oh God, this either does work or it doesn't work, you know. And when it doesn't work, you're looking at your patient and going well, you've got as it began. You say, you've got dementia. And they go oh, thank God, I was worried, I had Alzheimer's Right, see what I?
Dr. Michael P.H. Stanley:mean yes, yeah, that's a hard starting point for a conversation that is exactly the problem, right, you would say to me oh my God, this is just a matter of semantics and this has become one of the most boring things I've ever had to listen to. But it's not boring at all, in fact. This is you know what something means, right? And then the question is what is the something? And neurologist asked the next question, which is what does it mean? What does it mean? And I feel that right now, we've lived in a world where we've been relatively lucky that all the low hanging fruits since you know, charcot and now has been in the something part, and now we're getting into the means, you know, of the what something means, and the problem is I don't think we've got the tool set, or we have yet to reach back to some tools that have been left on the shelf right when it was very hard to figure out how any of this might have even remotely worked. You know, because we're almost a wash in a world of technologies and things that sort of give us an answer or a seeming answer. It's like every Wednesday, I am forced to do the images for our, like our, morning report kind of thing. I'm forced to do that and and I always start, or almost always start, with you know, this is an image or this is a picture of the brain. You know this is an MRI of the brain, but it isn't the brain, right? You know it's a, it's a, it's the treachery of images. This is not a pipe, right, and this is not a brain. And again you would look at this and say, oh, that's very cheeky and kind of Don Eschumer, michael Stanley, and you know this is really not to be this, not to be tolerated in a medical environment. But actually when you listen to, like Alan Roper give a talk about broad neurology I remember Alan was the first one to mention this and I heard it I was like, yep, that sounds true. He goes.
Dr. Michael P.H. Stanley:It's funny, when you guys think about a stroke in your heads, you see an image, you see a DWI. When I think of a stroke, say, alan Roper, because I see pathology, I see tissue, because we had a whole year of neuropath, and so you go, ok, you know, again the going back to this, like what's the layer with the deeper layer, the initial layers, you go, fine, things change. And you know, now we look at it as an image, as it was looking as a pathology slide, and it can't make that much difference. And you go? Oh, contrary, because when you are faced with a three dimensional object like the brain, and you're looking at the lesion, seeing how that lesion like works its way through, you get really good, like you were talking about it at neighborhoods, you realize you really feel what's connected to what and what becomes anatomically and therefore clinical, anatomically impossible, in a way that we just don't with images, because images are always too big and so we're always kind of thinking about it, kind of looking at us, a two dimensional image, and we it's harder to grasp. Again, going to apprehension and comprehension, it's harder to apprehend those neighborhoods and those connections when you're looking at a 2D, in the way that Alan didn't have that difficulty because he's he's got the brain in his hands, you know, and then when he slices it into a 2D thing, he's still putting it in a in his head in this 3D model. So there again, I think we're.
Dr. Michael P.H. Stanley:We're right now in that place with cognitive neurology where for many years we've been blessed with luck that most of the syndromes seem to line up with most of the pathology that we had stains for. And then new stains on new proteins and new genetic markers and new genetic things and we realize, oh, wait, a second. This syndrome can be explained by a huge array of pathologies, and while the instinct therefore, in a very reductive way, is to say well, then, the semiologies have no utility, the actual answers to say well, the semiologies are providing the semiologies are providing answers that are categorically different to what makes a disease a disease than the, than the, than the genetic screening, or then, you know, the protein screening or whatever those are. Those are actually categorically different answers to the questions. Useful question. So, for example, if a patient has posterior cortical atrophy, they have a visual spatial distortion, they have trouble navigating things, and it really doesn't matter to them at all if I determine that it is from blue bodies or from Emily's right, because the actual behaviors that result from these cognitive deficits are at the level of functionalism, right, at the level of cognition to behavior, and not pathologically. And so this, then again, trying to ground this because I could, I do, we've been up high and let's make this useful. So if we, if we look at the most cutting edge thing in my field right now, it's about these new antibody treatments for right, amyloid based antibody treatments.
Dr. Michael P.H. Stanley:For all times the trials were designed, though, specifically around amnestic presentations. But the but. The mechanism of action is about the protein, so it shouldn't matter if the presentation of the patient with Alzheimer's is a posterior cortical atrophy or a logopenic variant, primary progressive aphasia. The drug's mechanism is amyloid dependent and if I believe, and I say that the disease is caused by amyloid, and I approve that you've got amyloid in your head, it should work the same right. And so this.
Dr. Michael P.H. Stanley:What's interesting is to watch the field do that, where the, where the field did say, yeah, that's true, we developed this, we developed a study which actually excluded all these people phenomenologically, but I will include these people now in a way that we don't do that with almost any. I mean, think of the disease kinds, or we would do things in your world and seizure where you would ever have done that. We've never happened, right. And so again, what you're, what you're doping out, is huh, there's a little bit of a this is an unspoken or unacknowledged or an ideological unconscious between what do we mean by the disease pathologically and what do we mean by the disease syndromically, how they're related, how treatment is related. You know how the know how the nozology is related and the the area for something like romantic science or the area for something like the neuro humanities is to actually get right into that spot and call that, call that out and call it into question so that our science is better. You know, and that's where I think it gets misconstrued is, I think there's a lot of times where people look at it and they go well, but either I don't think this is going to be applicable or a better. I think this is just a sounding your barbaric yop on principles, as opposed to saying what's the practical value? And you go, well, the practical values right there, which is I just watched you do something with ideological unconsciousness. I watched you make a decision about that the diseases of diseases, of disease by its phenomenology, and that was inclusion criteria and exclusion criteria. And then, after its approval, I go well, actually, diseases really based solely on the protein, the protein alone, and so then I will allow them to come back in even though I technically don't have any data whatsoever to support that it would be helpful into those cognitive domains. Right, that is a. That's an extrapolation. Now, again, it's not an unfair extrapolation, because we do that in medicine all the time. Actually, medical science works in a way and we bootstrap it into into clinical practice in that way, but to be thoughtful and explicit about it.
Dr. Michael P.H. Stanley:Through these kinds of approaches, like the neuro humanities approach or romantic science approach, can be looked at as kind of hostile young turkism. You know, to some, especially some who you know do gain a lot of grant money, and so I think that's the first right, as opposed to me who, if they say, well, how do I fund you? You go, well, I need to, I need a notebook and a pencil, and they go great, here, you know, here's 10 bucks, and you go, oh, no, wait a second, maybe I should have asked for more. I have space, you know, I just lounge space, language, that kind of thing.
Dr. Michael P.H. Stanley:So but what actually becomes very vital? Because if you start to put in the, it's the, it's the complement to what you know mess along did by looking at a vague thing like primary, and then you go to Asia and realizing, wait, if I take a strong neuro linguistic approach, I actually find out that there are different diseases within it. This is the exact same thing where you're looking and saying wait a second. I'm pointing out that there is there's an inconsistency here in the pattern of thought on behalf of clinical science, and not that it's created any harm. It's not done any harm. That's not at all. We're saying right, we're saying actually. Here's an incredible opportunity, therefore, to clarify what do we mean as a field, which then immediately helps inform our patients about what we believe a disease is a disease, so that we don't have that woman that came up to me and said, oh my God, thank God, I have to mention I don't have Alzheimer's.
Dr. Michael Kentris:Right, yeah, and I think that it brings up this whole idea of, like you know, convergent versus divergent, phenomenology of the same pathophysiologic process versus disparate, like, say, genetic abnormalities or prognopathies leading to the same clinical manifestation, and I think that both are important. But, yeah, it does make it very, very difficult on the ground sometimes.
Dr. Michael P.H. Stanley:Yeah, and I think that's why there is this, this unmet need which is starting to be met around, literally just health literacy for these, not provided by by doctors in the clinic to their patients, but sort of around it. And you see this in something like the platform room, which I've done some work for right, where you know they've taken a few diseases which are, you know, complex and they've asked patients, experts, occupational therapists, you name it, the same question just to see the many different answers that they have, which either compliment or contradict. But it gives the patient two things either some useful information or be some very useful sense of wait a second. There's a lot of answers to this question. Maybe there isn't either one truth or we don't know anything about it, and that's useful to. So, again, going back to people who say well, you know, dr Stanley, I can't, I don't have the bandwidth to write a whole bunch of articles about a whole bunch of disparate topics, or I don't have a bandwidth to create a seminar series you know what you do or any of those things. What can I do to flex or scratch that itch?
Dr. Michael P.H. Stanley:In something like the neuro humanities or romantic science, you say, well, actually there's the, there's a strong tradition of physicians being involved in public education, and I would say that's a strong tradition. If you go one step further, academics have a moral obligation, if not certainly a professional one I would go so far as to moral obligation to disseminate the findings in a way that makes sense to the license, paying public, you know. And that's one way to say to yourself oh God, I've got so many competing interests, how do I ever spend, you know, 20 minutes to do this thing, which might be writing a nice little one pager about a subject and making it available at your local library or whatever, you'd say? Oh well, the reason I have to do this is that I'm obliged to Like. My hospital doesn't pay me to do it right and my medical school doesn't pay me to do it, but technically speaking, I have a professional obligation to do this and there is a sense of not just being right but doing right. That comes from that.
Dr. Michael P.H. Stanley:And I would say that I started to realize that after, at the start of and through the pandemic, when a lot of my writing shifted to really pointing out parallels between, like, for example, I had written a piece in Portland Press Herald about the first COVID wave and it had been described in terms like World War Two. And I actually point and I had been reading a lot of Paul Fussell War and Modern Memory and I was actually doesn't have anything to do with World War Two. This is much cleaner and closer to paradigms in World War One and the before and after of that. You know I wrote this piece which again you would have thought would have been too weedy and too inside baseball to have had any relevance to the lay public and that would have been much more relevant to academic medicine. But academicism wasn't interested in it, didn't want to look at itself in that way. But the lay public looked at that and went oh my God, when you put it that way, this makes sense, this is useful for us, we can kind of orient. Going back to this concept of orientation, we now know the whenabouts and whereabouts historically, we know the whenabouts and whereabouts metaphorically and based on those two things, our response to this pandemic might be different than what it was if I hadn't read the piece, because it wasn't.
Dr. Michael P.H. Stanley:This medical paradigm had not been structured appropriately in a way that was useful to the public, which is ultimately what we want to be. It's just useful in our clinics and without our clinics. So, yeah, that would be a way that you could say well, why should I write a piece or pick up a pen or go on a local podcast or somebody you know? Because of this reason, because it's important to do that, I mean, what you do is in that concert. Your podcast is a part of that approach. I don't know, you don't have to think so, I know.
Dr. Michael P.H. Stanley:So that's exactly what it's designed to do and the role that it plays, which is a very important one, because, as as the profession of medicine makes this change into the industry of health care, the ability for physicians, who sort of go from professionals to laborers, you know, from from independent practitioners to employees, actually does restrict the ability of the platform and the forum that they can do this thing that they are professionally obliged to do, and so having these kinds of forums like yours to explore for the, for everybody, what is the kind of doc, what is this kind of doctor, how do they think about their world, how do I use this doctor's services versus how do I use this doctor's approach, and how is it relevant to my life?
Dr. Michael P.H. Stanley:It's actually through through this kind of world. Again, in many ways we're going back to, or we're making use of, the sort of Lyceum tour that used to be ongoing, you know, in America, where guys would just go and lecture right, because they weren't book guys, they were writing guys. Or the notion of having these radio shows and always having interviews and always talking to people, or for a public that doesn't read long form anymore, this is the equivalent of reading, you know, instead of the 18th century gentlemen's magazine where you'd be reading about, like what is procrastination and what do I do about it? Is it a moral failing? This is the equivalent of that today. So the medium has changed, but not the message.
Dr. Michael Kentris:Although you know some people would say the medium is the message. I suppose right.
Dr. Michael P.H. Stanley:Well, yeah, some people would, Some people would. You could name them if you like. There's a theory of that in journalism. What I would say and maybe this is a fair way to kind of button this whole conversation and answer more directly your initial question, which I did not wish and still do not wish to directly engage with is there is a line which I think comes from Penfield I check my tangles, it's not working. My temporal lobes aren't working like they should, and it's.
Dr. Michael P.H. Stanley:The brain is messenger. It is not the message, and I think that, in the way that we think of, is it cognitive neurology, is it behavioral neurology or is it? You know, neurocognitivism is a, is the way to explore what, what, what a behavioral neurologist or cognitive neurologist or a neurocognitivist would say about that paradigm that Penfield lays down, which I think is also a paraphrasing of Hippocrates the brain is a message, a messenger, but it's not the message. That's actually how you sort out whether you're a behavioral neurologist, whether you're a neurocognitivist or whether you're a cognitive neurologist, and I think that's kind of where that's the gauntlet. That should be the research program. That's what we should be working for is trying to figure out valid, invalid, correct, incorrect and wrong, correct, incorrect, disprovable, you know, is it a, is it? Does this lay in the world of mystery or is this a problem? Neurology is cool because neurology both walk into your clinic. We get both mysteries and we get both problems, and it's not many fields that get to do that.
Dr. Michael Kentris:No, I think. I think this was this was a great conversation. I I have a lot of thoughts bubbling under the surface right now. Certainly, I do tend to indulgence on some of these more rare fried topics as well, especially when we start verging on the near metaphysical aspects of what it means to be a person, and I think these that's the really very interesting part of neurology. And how, like you said, these three pounds of meat in our skulls, why, why, how? You know all these kinds of fascinating things that we're still learning about, and I'm very grateful that we have someone like you working on some of these, fusion, fusing these questions together into a way that brings it to the wider public. So you know, you sent me a lot of your work that you've been doing online and, in particular, with the Boston neuroscience site. I apologize, I keep getting the name wrong.
Dr. Michael P.H. Stanley:It's a long name. It's a very long name.
Dr. Michael Kentris:But in one in particular. I mean, many of them were very excellent, but I really enjoyed the analysis from the last Halloween issue. I'm not much of a horror person by nature, but I thought the the analysis of kind of the the underlying psychology, if you will was very interesting.
Dr. Michael P.H. Stanley:Oh yeah, so kind of the position that I've been in and really enjoying now is the management of a number of blogs or newsletters or just taking a supporting role in other organizations that are neuro humanities driven or bound and helping to support them. And the pure sighting, the one on body horror for the Halloween edition, that had come from Matia Rosso and Charlie Palmer, who are two neurology residents at Medical University of South Carolina and they have really built up a critical mass of seminars that are around the neuro humanities and they keep finding more and which is really incredible, and every once in a while when I go to one of these I think, wow, this is really good. You think you could write that up for me, you know, and so so Matia and and Charlie have have kind of knocked off a few of these, and the one on body horror was really cool because a, what is it mean to be horrified Like? What does, where does that live, what, what, what is the cognitive processes of that? What is the autonomic input? What is the? You know, those are the kinds of things that you know Matia and Charlie took a serious approach to, and so those are what a thing like what Matia and Charlie have done is show that there are a wealth of questions or topics that could be questioned with a neurologist's observation or neurologist lens, and that that role I think they've been able to assume really well and and make that accessible to other neurologists, other psychiatrists, other even the lay public.
Dr. Michael P.H. Stanley:They had, they just did a seminar on Chuck Close, who's an artist who has visual perceptual difficulties, and I had invited to the seminar a couple photographers that I know that also have visual perceptive difficulties, and they loved it, you know, and these were not neurologists or medical people, but they were artists and they, what they got out of that and what they put into that seminar was really incredible. So it shows that this is not a field that lives all alone on some astral plane although we've spent most of our time today on the astral plane, but but it is an everyday, lived and embodied experience and can be reflected upon in that, and that the neurological lens does have something to say, not necessarily something to explain, but something to explore. So yeah, the body horror one is a good example that even if you're kind of creeped out about the creepies and crawlies, if you bear with it, something beautiful can be found there.
Dr. Michael Kentris:I love that phrasing not necessarily. Not necessarily to explain, but to explore. Hopefully someday to explain, but the exploration is the first step, right?
Dr. Michael P.H. Stanley:Well, all depends on the question, you know. I mean science accumulates knowledge, but that's different than understanding, and so there are hard points as far as neurology can go for some of the questions in the accumulation of its knowledge. But the real thing to be borne out in this proposition of the neurohumanities is A if we do have that idea correct, this sort of program, this method of inquiry, interdisciplinary, multidisciplinary way of inquiring, will that allow us to go from the role of knowledge accumulation, which is really the province of science, into understanding, which is the province of the humanities. Humanities are for understanding, and so that's kind of. The interesting question is to say, does the addition of neurologists in the conversation allow, through the dialogue, the kind of analysis and then later the kind of synthesis from a humanities perspective? Because neuro is the prefix on this right, it's not the noun to actually get us to some points of understanding about the human condition that would have been lacking if the neurologist had not been present? That's kind of the point.
Dr. Michael P.H. Stanley:Interesting so how does horror? And so if you go back to the Boston Society of Neuro-Surgical, neurosurgery and Psychiatry blog and you read the piece on body horror, one of the things that I think does come out of that is I do feel that there is a bit more understanding on my part about what horror is and how horror might work and what horror's role is, from having read that piece. So I do think that that is a work of neuro humanities as opposed to a work of romantic science or just some neurologists sounding a barbaric yop and sort of. Here's my essay, here's my thoughts. Right, just because you have thoughts. I mean, that's the great danger of doctors in general and I certainly am guilty of this left and right. I mean first degree of having a thought on something because I know something about something else and so therefore, my opinion must matter, and it's really good to have that checked publicly from time to time.
Dr. Michael P.H. Stanley:You know where somebody goes. You have absolutely no idea what you're talking about and you go. Oh, my God, you're right, I don't, you know. I'm very sorry. So that's what this impressive new or I should say return to a field has been about is trying to figure out who is part of this program. Who's at the table? Who's inquiring? What's the language of the inquiry? What are the tools of this enterprise?
Dr. Michael Kentris:And yeah it does. The whole endeavor does gives kind of those echoes of that classic, you know, physician, kind of echoing back to like Sharco's education programs where he would is very much about the patient, you know, at the at the center of the entire story, and I really do appreciate the work that you've been doing in terms of reintroducing that and bringing us back to you, some might say kind of again that foundation that we keep echoing around.
Dr. Michael P.H. Stanley:Yeah, and I think the what, what ultimately crippled the use of the single case study. You know, the single patient study was the very fact that when there is an ascendance of statistics which is very useful to answer certain questions, I mean is it is the most powerful way of answering a number of questions generating generating answers that can be verifiable or at least can be found to not be disproved. That's great. But that that's not the only statistics, not the only way of answering many of the questions that are that are actually still within the purview of neurology. And there are many, many questions that we can supply knowledge to that the numbers add up to nothing. You know, to quote Neil Young, that that it's actually unhelpful. They get in your way. You know they're meaningless, they are comforting because we like to have a thing that seems objective, but objective how you know. So that's actually where the single case study comes back and you start to look at the role of, like romantic science, with what you know Luria did with the mind of an M Anest or a man with a shattered world. Or you know what SACs did in a number of his papers not just his essays to the lay public, but I mean his papers is a long, long form articles that were single case studies. And you realize that the kinds of knowledge generation that can only be brought about through romantic science is because the numbers have nothing to say. It's an application of the wrong tool, you know, to a particular special field. And so now the compliment is what's kind of being tried, where we say, okay, well, we've gone only so far for our knowledge generation in neurology and for understanding, we need the humanities, we have to have the humanities, we need humanists, scholars of the humanities to help us with this. And what we can supply on the neurology side is the knowledge of the neurological to help direct that humanities inquiry. And then so that's kind of where we're at right now, and I think guys like Charlie and Matia are really pioneering that kind of second generation of this enterprise. So it's a really good thing, yeah, those so. So if you're, if you're, interested in these kinds of subjects, the places to look are, you know, at the on the BSNNP blog, because we've got a lot of them and that is that's the place for it. And then, more broadly, in the medical humanities, the American Osler Society has a very good blog which engages to some extent on the medical humanities, although it does have a stronger history focus, particularly. And then you know the, the institutions in the country that are really leading on this, like Duke has a, has a, has a neuro humanities center, gabby Starr, who's the president of Pomona out in California. I mean she's an incredible leader in the in the neuro humanities. Her book Feeling Beauty is extraordinary. I think that should be a Bible for a lot of people interested in this subject. And she's got a new one coming out on on the neuro aesthetics of time, how time is appreciated. So you know she's, she's got a program, she's running that program. It's beautiful.
Dr. Michael P.H. Stanley:David Friedberg at Columbia. David, david is sort of the continuation in the art history world of what guys like Mattia or Charlie or you know to some extent me, is on the neuroscience side, where David, really David is a human, you know human. He really is a humanities scholar. But David, because of his influence, both positively and his approach away from people like Ernst Gombrich, for example, or Ernst Christ who are interested in this from the art history side, what neurology and what psychiatry says, sorry, what neurology and what psychology has to say about art history David has, through his research program at Columbia and his fellowship program at Columbia have been able to expand that and really make meaning for work. And of course, his books Power of Images the first one and the recent one on iconoclasm drives home, going again from the astral plane and back down to concrete examples. Like, his book on iconoclasm shows how this method of inquiry and the results of it have explanatory power, not yes, but also explanatory power for the way that we do certain things, the way that we destroy certain images and not other images. And so you know it is a work that is not just meaningful but also useful. So I think David's program at Columbia is again, along with Gabby Starr's work over her end, you know, probably the biggest and the most productive.
Dr. Michael P.H. Stanley:And then, as I mentioned, vanderbilt and Duke have good medical humanities and neuro-humanities programs. They're everywhere. I mean, there are, whether it is a course, one off or, you know, a real institution or a center there. And depending on which focus is it visual arts, is it music, is it whatnot? You don't have to go to a big place, and in fact oftentimes going to a very big place is what's going to limit you, because it's extremely siloed. You are in many ways better off in a smaller place where it's easier to have a friend in the English department and a friend in the neuroscience department and say let's start something, than it is to be in a place where which neuroscience department do you want to talk with? Which English department do you want to talk with? That's when it becomes difficult. So yeah, I think there is a way for any neurologist to get involved with the neuro-humanities in some way if they want to. And then the question is you know whether that's productive for them and productive field. But you can do this.
Dr. Michael Kentris:Excellent and I know we could and have talked at length, but you've hinted at some of your work. If people want to find more, where should they look online for the projects you're working?
Dr. Michael P.H. Stanley:on? They probably shouldn't. I think they should be looking at other things. A lot of my stuff is one-offs, so like you'll find commentary in things like the Wall Street Journal or Boston Globe or National Review or Christian Science Monitor. So it's a lot of one-offs. There's no consistent home.
Dr. Michael P.H. Stanley:So I guess if you want to check in and kind of see what's happening lately what trouble have I gotten myself into this time the best way to do that would either to be to follow me on LinkedIn or follow me on Twitter. Mphstanley is the handle. Everyone says I should have a website and I know I should, but I would have to have time to do that and I'm not about to yet. So one day I will get time. So that's the way to. If I've written something and I've posted it, it'll be there. So that's where you find me. But really a lot of my efforts right now are either in talking and promoting this field, this discipline, with folks like yourself, or in one-off lectures. I mean, I've been doing my own little like Lyceum tour of lecturing to different places, so that's probably the best way is if you want to know what I think, come invite me.
Dr. Michael Kentris:And I'll tell you what I think. A dangerous offer, to be sure. Well, I really appreciate you taking the time to come and talk with me, to talk with our listeners, and I'm sure I'll be asking you back on later and assuming that you have the time and bandwidth for it. So, thank you Once again. I really do appreciate it.
Dr. Michael P.H. Stanley:Oh, thank you so very much for having me Presuming. Your listeners are satisfied with this and this was a good thing for them. Then, yes, I'll look forward to your email in my inbox, and if I never hear from you again, well, I'll understand.
Dr. Michael Kentris:All right, well, hopefully it doesn't come to that.
Dr. Michael P.H. Stanley:We'll see you. Thank you, bye.
Dr. Michael Kentris:Thank you again to Dr Michael PH Stanley and thank you, listener, for making it through this entire conversation. I hope it was interesting to you. It certainly was to me. If you want to find more of our work, you can find us online at theneurotransmitterscom. You can find me on twitter, slash X, at drkentris D-R-K-E-N-T-R-I-S. And please, if you like this, share it with your friends. Help get the word out, and if you have any ideas or you want to perhaps have something interesting to say for our audience, drop us a line on the website.
