What Is Your Chief Concern?

We launch a new mini-series with Dr. Galina Gheihman that turns common neurological complaints into clear, usable frameworks for non-neurologists and neurologists alike. We talk about neurophobia, access gaps, and set the stage for earlier clinical action starting with a solid history, focused exams, and smart safety netting.

• why most neuro complaints start outside neurology
• neurophobia as a root-cause problem in teaching
• history-first and hypothesis-driven exam over reflexive testing
• common chief complaints we will cover in depth
• red flags that should speed care and green flags that buy time
• acting early while waiting months for specialist visits
• preventing incidental imaging from derailing diagnosis
• structured two-part episodes on diagnosis and treatment
• learning from diverse experts to refine approaches
• how to share cases and what to include

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Chapters

• 0:00 A New Mini-Series Begins
• 0:19 Meet The Co-Host
• 0:48 Why Focus Beyond Neurologists
• 2:52 Symptoms Versus Diseases
• 3:52 Neurophobia And Its Roots
• 5:19 Access, Shortages, And Telemedicine Limits
• 6:08 Acting Early While Patients Wait
• 7:31 History And Exam Over Tests
• 9:11 Common Diagnoses And Disease Burden
• 11:12 What Referrals Actually Look Like
• 12:19 Chief Complaints We’ll Tackle
• 13:23 Red Flags, Green Flags, And Risk
• 15:12 Building Instincts And Safety Netting
• 16:02 Empowering New Neurology Providers
• 17:35 The Two-Part Episode Structure
• 18:59 Living With Uncertainty
• 20:17 Learning From Diverse Voices
• 22:04 How To Send Cases And Feedback
• 23:20 Closing And Ways To Follow

Transcript

Michael Kentris: 0:01

Hello and welcome back to another episode of the Neurotransmitters. I'm your host, Dr. Michael Kentris, and today we are introducing a new mini-series within the neurotransmitters universe. So I am joined today by a co-host for this new venture. Would you care to introduce yourself?

SPEAKER_02: 0:19

Hi, Michael. I'm really excited to be back. My name is Dr. Galena Gaichman, and I am a general neurologist at Mass General Brigham and assistant professor of neurology at Harvard Medical School. And I'm really excited to be able to join you as co-host for this new mini-series.

Michael Kentris: 0:36

I am very excited. We've been talking on and off ever since we kind of did our previous recording together, and we run in a lot of the same medical education circles to greater or lesser degrees. And one of the things that we keep coming across is there's a lot of information out there that's intended to educate neurologists and uh neurologists in training, but less so those things that are focused for people who are not specifically going into neurology. And you know, when we were doing some background research for this project, both of us, you know, you maybe a bit more than myself, found a number of articles looking into this question. And one of the things that I thought, and obviously, you know, you and I, as neurologists, have a little bit of a bias here, uh, but most neurologic complaints are not assessed by neurologists. They are assessed by general practitioners, whether that is in the primary care, hospital, outpatient settings. And so we need our medical colleagues in general to be well equipped for these patients.

SPEAKER_02: 1:40

No, I agree with you. I think what we're talking about is the difference between, you know, a neurological disease and a neurological symptom. And often when we think about our pool of patients that we're caring for as neurologists, they've sort of crossed a threshold, right? They've entered into the neurological practice by having either a neurological symptom or a neurological disease. And at that point, they sort of become our patient. But when you think of the larger pool of patients out there with neurological complaints or symptoms, they're often not being seen by neurologists first. And so I do think it's exciting to think about how do we actually equip that larger pool of potential learners to become more confident in assessing neurological chief complaints and potentially making first steps towards diagnosis, first steps towards management. I kind of think as a neurologist, I have a duty to all the potential neurological patients out there. And so I see as part of my role as an educator is to equip those who might be making those first steps for those patients. So hopefully this series, we can kind of provoke that sense of excitement and opportunity in our colleagues and think about how we can reach our neurological patients even sooner.

Michael Kentris: 2:52

Absolutely. And now this is something that I know on this podcast and in other neurology podcasts as well, whether that's formal channels like the American Academy of Neurology or our good friends over at the Neurophilia Podcast have talked about the phenomenon of neurophobia, right? So these fear of neurologic symptoms and neurologic diagnosis as a common thing encountered in medical students and even at residents and attending level, where people are just like, no, get me away from that stuff. And it's it's funny, anecdotally, I we're opening a neuroICU in our my neck of the woods in the near future, and we have to recruit, you know, uh neurocritical care APPs and neuro-ICU nurses. And a lot of people that I've encountered just in passing are like, oh no, neuro, no thanks, hard pass. And so it is, right? It's this very common phenomenon. So I think uh I think a concerted effort from us in the neurology field to help with making people more comfortable with the diagnostic and treatment processes for some of these very common problems, I think is in the interests of both us as consultants, them as the primary treating practitioner, and the patient population in general.

SPEAKER_02: 4:06

It's so interesting that you say that. I think the phenomenon of neurophobia is well recognized at a kind of a superficial level by all neurologists. I mean, we know it, we like walk into the room, people are nervous, you know, neurology makes people nervous, as you said in one of our conversations. And it's interesting to me because I almost see it, you know, like a quality improvement problem. You know, if you identify a quality improvement problem, you really want to ask for what the root causes are. Like you want to ask, you know, five whys or it'll get down. And I think if we continue to teach the way we've always taught, it may not necessarily address the neurophobia. And so I think in this, these couple of episodes, I think it will be pushing ourselves and others to really think around how we not just the knowledge that we know, but how we communicate that knowledge and how we teach it maybe in a different way. Because I don't think that the non-neurologist has to be a neurologist, right? I think that there may be a slightly different way that they could approach these issues. So we may or may not get to this, but just as you share that, I it makes me wonder like, you know, can we get better, can we get a better sense of what those root causes are and maybe actually move the dial on this in the future.

Michael Kentris: 5:19

Yeah, I think I think that behooves us all because as as you and I both know, and again, kind of borne out by some of these studies, is that there is a massive shortage of neurologists, and the distribution of those neurologists across the country is very uneven. A lot of clusters in major metropolitan areas, and in particular a lot of like uh the states out west, very, very few neurologists. So access and wait times are also uh very big challenges. I mean, we're seeing some amelioration of that with things like telemedicine and kind of uh remote consultations and things of that nature to help a little bit, but it's you know, there are some uh complaints and diseases that aren't as uh easily evaluated in a remote fashion.

SPEAKER_02: 6:07

Absolutely. My own experience as a general is I'm often the first to you know meet a patient who's been referred to neurology. And it's sad to see that many of them have been waiting months, sometimes four months, nine months for an evaluation. And what think what's often hardest for me to see is when they've sort of been waiting in this non, you know, non-progressive state, meaning they've been told, hey, I think the next person you need to see is neurology, but there hasn't been uh the ability or the effort to to maybe even try to say manage the condition, maybe there's pain involved, you know. And so there's sort of this idea of can we can we start the process a little bit earlier, help our patients so that when they get to us, they, you know, that maybe it's valid that they've tried the first, second line things and now we can kind of jump to something different, something maybe the primary provider isn't comfortable with. But I do see a lot of patients who, and again, this is as you said, we're gonna reveal our own biases here, right? Like because for me, maybe I think that first line treatment is a simple thing, and maybe that another who's first seeing the patient is not comfortable with that first line approach. Uh, but hopefully we can simplify a few of these things, demystify a few of these things, and actually make a difference and reach those patients earlier.

Michael Kentris: 7:24

I think that's 100% accurate. And one of the things, right, because you and I know, right? Neurology is full of weird things, weird and rare diagnoses. But that's wonderful. Yes. Weird in as much as like, you know, you get that consult and you're you've taken the history, you've looked through all the data so far, and you're like, huh, I'm gonna have to think about this for a few minutes and maybe for a few days uh before I uh decide what we're gonna do next. And, you know, those those are the cases, right? That, you know, I certainly never fault the primary care physician for having trouble with, because I'm struggling, right? But we're our goal is to talk about common things, right? Common things are common, right? I love a good tautology. And so we were kind of kicking around names for this miniseries, you know, as we were saying earlier, right? We don't want to sacrifice clarity for cleverness. So we're just gonna call it chief complaints. And so we want to focus on what are those most common chief complaints that wind up in the neurology referral queue and what can people do while they're waiting for those lead times, which can be quite long. I know, again, anecdotally, in my own area, wait time to see a neurologist is about four months, and to see one of our nurse practitioners in the practice group is still two months. So, you know, that's not nothing. So, what can we do in the interim to kind of keep that ball moving forward in terms of diagnosis or and or treatment? So I think we need to focus on what are those things that will benefit the most number of people and help both our colleagues and their patients so that they're not just left in the lurch while they're waiting for us to get around to it.

SPEAKER_02: 9:13

Absolutely. In fact, I love what you said about, you know, that there's those cases where you have to sit down and think. Because the fact is most of our reference literature starts kind of post, you know, kind of almost like post-diagnostically, in the sense that you've already identified what you think the syndrome is. And then you're like, okay, so the further, you know, work up, the further analysis. It's rare that textbooks or reference resources are organized by like the chief complaint, right? It's, you know, you as the patient, the patient tells you, hey doctor, I'm falling or I'm dizzy, or I can't see, or I have sensory changes. They don't say, like, you know, I you may not even say I have a sensory atax. Yeah, they're definitely not gonna say that. They're gonna say, you know, I can't walk. And so I think for us, we always start at that level of what the the complaint is, what's the history? I think in these episodes, we're gonna spend so much time on the history. How do you obtain the history? How do they say it? You know, what is it? And then you kind of put something into a bucket. I think what's challenging is that when people think about neurology, they're like, oh yeah, okay, here's how you treat seizures, here's how you treat stroke, here's how you treat um, you know, even for example, um, you know, or or identifying, for example, syncope versus a seizure, but we don't talk enough about how to actually get to that stage that you've persuaded yourself as a seizure, or you're convinced this is a TAA, which is entirely a clinical diagnosis, right? So so much of this is how you obtain the history, how your exam informs and reassures or disreassures you. And so I think really pulling the curtain back on how we transition from the chief complaint, which is going to be the focus, to basically bucketing it so that you know your approach. Your approach is to kind of narrow down on what you think the phenomenon is and then go from there. Too often the reference textbooks are starting with or maybe falsifying in a way that process that kind of makes it seem like it's so simple that the patient's gonna come in, you know, to your seizure clinic and say, I have seizures. But no, no. They're they may, as you said, they may come in. The reference may be for a tremor. And the very first question is, is this even a tremor?

Michael Kentris: 11:36

Exactly. And that's, you know, it's it's the way you phrase that is exactly when I'm working with students in residence. Like when I, you know, we'll see someone with like a seizure. It's like, is it a seizure? How do you know? What kind of workup was done? Who took the history? You know, and it's like all these little things, right? You kind of have to you you do have to pick it apart and uh really drill down because a lot of times the the referring chief complaint is not an accurate diagnosis very often. And that's what we would kind of want to focus on, right? I know the stereotype of neurologists in years past was the diagnose and adiose. And I don't think that most was practiced that way any longer, but the diagnose part is still very much at the forefront, right? It's almost like uh, you know, it's the way that like neurologists like to flex on other neurologists. It's like, oh man, what a what a keen diagnostic mind they have, right? It's like as a neurologist, someone comes up to you and says, like, oh, what a good diagnosis.

SPEAKER_02: 12:37

You feel like that's gonna carry me for like a well, one of my mentors, and probably the case for many people listening, is um Marty A. Samuels. And he used to say this line, which I just loved because it both emphasized the point you made, but also I think in it had a sort of a tongue-in-cheek humility. But he said, if by the end of the history and the exam you don't know what it is, you'll never know what it is. And it was just this really, I think, kind of humble, but also I think important reminder to us that it is worth spending the time on the history, spending the time asking the right questions, spending the time on the exam with a hypothesis-driven exam, right? Adding information to your history and then using that to guide your diagnostics. I can't tell you the number of times that I get a referral for we're not gonna do this on this series, but you know, abnormal MRI. And my question is like, would I have even ordered the MRI? And that's actually the question I usually ask myself and really move, you know, the patient back to, well, what were the actual symptoms in the first place? Because they may have a chronic stroke there, but that may be incidental to the problem that brings them in. And maybe, okay, let's simplify like maybe we do need, you know, a secondary stroke prevention if they're not on it. But the point being that often people are referred actually because of abnormal studies, and you have to ask, would you have ordered them? Or you may find yourself in a situation where you're facing uncertainty and you're a little bit keen to order diagnostics, but they may not be helpful. They may be further confusing rather than clarifying. And so, you know, as we think about equipping our colleagues broadly defined, joining us in neurology and joining us in caring for the neurological patient, broadly defined, we actually want to equip them with some of the skill sets that we have, which include careful history taking and uh a careful focus targeted exam.

Michael Kentris: 14:33

Absolutely. So moving forward a little bit, what are these most common complaints, if you would indulge us?

SPEAKER_02: 14:41

Yeah, well, as we were preparing for this, I think we were just making a list from our own minds. You know, we were like, these are the common things I see. These are the common things I get asked about. And it was kind of cool to see that there's actually been some studies out there. People have looked at the common complaints that sort of the most common neurological diagnoses, the most common referrals to neurology clinics, and also the most common complaints seen in neurology clinics. So maybe we can step through some of those papers. But one of the ones that I think a good place to start on is just the burden of neurological disease, kind of globally within the US, and then kind of thinking how you know that pairs down in terms of is that what we're seeing in our clinics or not. I think it's probably not surprising when I list these out, but the most common in general outpatient diagnoses, and this doesn't say whether they're coming to neurology or not, but just to get a sense of what kind of neurological disease burden is out there is the highest is actually migraine, estimated to be 20 million people in the US. Chronic low back pain, which again, as you can imagine, may or may not come to neurology, stroke, probably coming to neurology, not necessarily. A lot of secondary stroke prevention is managed in a non-neurological setting. Epilepsy. Not sure how they classify that, probably epilepsy, maybe seizure-like events would be included there. Parkinson's disease, and then multiple sclerosis. Uh so Parkinson's disease is still about a million people, and then multiple sclerosis is less 400,000. And I'd argue that probably is uh in in seen by a neurologist. So if we kind of simplify the earlier ones, it's migraine, back pain, stroke seizures, and Parkinson's, or I guess gait and movement abnormalities. Did you find that surprising, Michael? What did you think of that?

Michael Kentris: 16:34

Not at all. I I think the only one that was slightly surprising to me was the chronic low back pain. And I will say somewhat, not entirely, because a lot of times I end up seeing the folks who kind of had like that failed back syndrome. So people who have had back surgery and they're still having like neuropathic or ridiculopathic type pain. And so maybe they've kind of seen pain management. Maybe the medication regimen was a dialed in, maybe it wasn't. So a lot of times we're doing some neuropathic pain medication management for these people. So there is some, I think, uh utility to bring a neurologist into some of these cases, but it's not what we tend to think of for ourselves as neurologists, is low back pain. So it I think it kind of depends on like what kind of low back pain do you mean? And is it something that we have anything in our armamentarium for?

SPEAKER_02: 17:27

That's a good point that we do sometimes intersect with other fields, right? Like, for example, I have a lot of shared patients for rheumatology where they have kind of like a rheumatological neuropathic pain is a little different than, you know, what what we might see otherwise in the case of, say, a diabetic polyneuropathy. And so I think low back pain is similar. And even gait abnormalities sometimes can be musculoskeletal. And I'll admit, maybe us in neurology are not as strong in the musculoskeletal system as we are in the nervous system. But sometimes we can make that confirmation that, you know, it's it's of the localization or the confirmation that this is a really a pain management situation at this point. Um, and then I think people vary in their practice and how their how their level of comfort and how much they they do that versus how much they have support from a pain management team.

SPEAKER_00: 18:16

Absolutely.

SPEAKER_02: 18:18

But what about the referrals, right? Because these are the diagnoses, and that is a little bit different than what people are being referred to for neurology for that kind of when you're still at the question mark phase.

Michael Kentris: 18:31

Right. So that's right. That's kind of that's kind of where we're looking to focus in is like what is the question that is being sent our way? And so there were a couple of these different things here. So who is sent, whether that was a neurology residency clinic or neurology clinic in general, and they they overlap pretty closely with the relative incidence. You know, topping the list again is headaches, headache disorders broadly. And then again, not surprising probably to anyone in neurology practice, uh, are functional and psychological symptoms. So kind of a functional neurologic disorder spectrum, right, with a kind of an umbrella term. So that could be functional movements, functional seizures, a functional cognitive decline, all those kinds of things are kind of lumped together as far as I'm aware in these studies. And we also saw things like neuromuscular disorders, which I assume is going to include things like probably neuropathy, myasthenia gravis, uh, ALS, etc., movement disorders, which again would include like our tremors and Parkinson's patients, cerebrovascular disorders, so strokes, and then epilepsy. And you know, these these vary a little bit percentile-wise. The other one goes a little bit more down the chain here and includes like demyelinating disease, spinal disorders, and syncope, which, you know, again, can it be related to neurologic phenomena? Yes. Is it usually? No. But we'll dive into that in one of our later episodes, right? The chief complaints are not just the reason for referral, but I'm sure that we will be indulging And some of our own chief complaints as well.

SPEAKER_02: 20:02

So what's what's interesting, Michael? What's interesting is you were naming, you know, the ultimate diagnoses that came out of this. And I think it's interesting that these papers, they kind of like give the two sides of the coin, right? They give like what the person came in with and then what the ultimate diagnosis was. So you named the ultimate diagnoses, but I think what people came in with, and this will very much guide what we're gonna focus on in about five or six episodes, is seizure-like events, which we're gonna maybe broaden even further and say, you know, episodic spells. Spells, though the term seizure-like events mostly here. Sensory symptoms, which I think is actually an important word because so many times patients come in and they come to me and they say, I have neuropathy. And I'm like, Wait, who told you that? Like, like, what does that mean? Um, so really sensory complaint, pain, headache, and then some kind of motor symptoms where something is moving, too much, too little, yeah, and you know, which part is moving and how is it moving? And so I think that that these very much mirror our experience in clinic. They very much mirror what we think we want to focus on in this series. And what we're gonna hopefully do is actually over a series of episodes, help our listeners, and and the series is really for everyone, to gain like a mental framework for how you approach the first steps of a neurological chief complaint. So the first steps towards even kind of parsing out what the differential diagnosis might be, then determining the first steps in diagnosis, which I think we arbitrarily create this step one, step two, step three, when really this happens in parallel, most often we're figuring out the differential, we're starting first steps to diagnosis. And often the patient is not wanting to leave the room without some kind of management plan. So we're often starting management in parallel, but we'll gain a framework for how to do that for common neurological chief complaints seen in the outpatient setting. And I think an important thing to that we're gonna hopefully emphasize is really what you might call like green and red flags. Like that's something that I it's always on my mind as a neurologist, is as I'm doing this and I'm creating this differential hierarchy, I'm also looking for things that either would concern me, raise my level of concern, raise my need to act quickly, or green flags, things that are really consistent with the you know the diagnosis. I'm considering things that give me pause, that give me reassurance that, hey, I may not know what it is, but you know, it's been here for six years. So like I think I get through another three months to get, you know, work up before I jump to jump to some kind of conclusion. So I'm excited because I think what we're gonna do is in a way demystify the most common complaints and hopefully give people a step forward to how to act when they when they encounter them.

Michael Kentris: 22:52

Yeah. And I totally agree with that thought process. A lot of times I'm asking myself, but when I'm getting this history of like, does this make sense? Does this fit with what I know? And if it's not, then I'm usually asking myself, well, I'm missing something. What is it? And hopefully I can figure that out. Um and then the second question is, do I need to be worried right now? As you said, right? Do I have time to do a, you know, a measured workup, or do I need to get them, you know, more expedited and you know, get things really cooking fast? So those are kind of, I think, the the two biggest questions that I I ask myself on a very regular basis is does this make sense and should I be worried right now?

SPEAKER_02: 23:32

I think that's so important to emphasize because this is has a little bit of overlap with the idea of facing uncertainty in medicine and in our practice. And the more I think about this topic and the more I talk to others about it, the more it seems that it is these sort of parallel questions that we're asking. Less what is it, and more what's the risk of not knowing what it is in the next day, week, month? And what's the risk to the patient? What's the risk to potential reversibility versus not? And kind of taking that for each complaint and having in your back pocket almost like a follow-up plan, a safety netting plan, you know, letting the patient know what to look out for, what would be the next change, what would be inconsistent with the diagnosis that you're you're thinking about. And to be fair, in a way, maybe what we're asking is a little bit of like an impossible task in the sense that what we're saying is we're leaning on, you know, some of the spidey senses and instincts that we've built as neurologists through our training. And so I completely always, at the end of any kind of teaching, I do say, okay, listen, low threshold to reach out for help, right? Like if it doesn't make sense, it doesn't make sense because often what does make sense is the fact is a spidey, as I said, it's an instinct that we have based on the volume and the the cases that we've seen and built up an experience over. However, I do think that if we get these frameworks right from the beginning, then we can really empower our colleagues to start to have uh a little bit of that same society. Since I would say there's a neurologist in every one of us, so we just have to, you know, build them out and let them uh reveal themselves. But it's an important point because we have new providers joining us in neurology. You know, in an unprecedented way. I think there was one statistic that there's been 170% increase in the number of PAs who have joined neurology. Maybe sounds like not the neuroICU, but at least neurology. Right. And so what we want to do is we want to get their instincts right from the start.

Michael Kentris: 25:42

Yeah. And I would right, we don't know where in neurology practice they are, if that's in a subspecialty clinic and a general neurology setting. And I mean, I would argue that jumping straight into general neurology is probably the hardest thing to do because there is such a multitude of ways that patients present, which, you know, it's kind of what we're trying to address is to take some of them with these uh different complaints and what are the most likely things these are going to be, and how do we kind of approach these? And it's really like I couldn't imagine being like a fresh graduate with, you know, two or four years of training and no residency, and then jumping straight into practice with some oversight, little oversight. Um, you know, it depends on where you're practicing. And that could be uh a lot.

SPEAKER_02: 26:31

So, Michael, take us through what are these episodes gonna be like? Like what's gonna happen in the next couple of weeks.

Michael Kentris: 26:38

So we are reaching out to some of our friends and colleagues working in some of these different fields who we, you know, whose opinions we respect. And, you know, we're kind of be doing this. I always think of those uh YouTube series that was, you know, explain this at five, you know, explain black holes at five different levels, you know. So you go all the way from like a you know grade school up to like a PhD colleague, and you know, we're gonna be trying to, you know, drop as much neurospeak as we can, and because I know it infuriates people. And uh and bringing it down to a something more practical, applicable, and kind of have a how how do people who see these patients day in and day out think about their approach and what do they think, like when they get patients who are referred into their clinic, what do they wish that had been done or had how they'd been thought of the patients themselves and their symptoms prior to them getting there? If there was something that should have been done, could have been done, and kind of take that diagnostic approach in the first episode on each of these chief complaints. And then the second half, for each of these common diagnoses that may come from those evaluations, what can we do as far as treatments that might be appropriate again while we're waiting for that next evaluation? And I kind of thought what you were saying earlier, you know, two things, like a lot of times we are operating. I was thinking, you know, whenever I say the word idiopathic, I'm doing air quotes here. But when I'm talking to patients, and the cause will ask me, like, you know, why am I having seizures or why do I have neuropathy? And I was like, well, it's idiopathic, quote unquote. And I can uh I had I had one attending who he told me an anecdote about a patient of his. He was like, is that something you know or is that swag? And as a neurologist, most of us do not have swag in the conventional sense. And he's like, What is that? And he's like uh a scientific, wild ass guess. And he said, Yes, in that case, it is swag. Um right? So we can always theorize as to why these things are happening, but you know, in a fair number of cases, we don't have like the ultimate underlying, underpinning pathology for some of these processes. And in some cases, that doesn't necessarily matter so much to the treatment outcomes. As you were saying, right, patients want an answer, right? So sometimes saying, like, oh, this is seizures or epilepsy, that's okay for some people. Some people want more than that. And I'll be like, well, you know, there's a lot of reasons why, blah, blah, blah. Right? You got your whole spiel. But there's still that layer of uncertainty, even after you come to a diagnosis. Like, why does that diagnosis there can still be a question mark, whether that's stroke, neuropathy, seizures, et cetera, right? And so even in the midst of our diagnostic certainty, quote unquote, there is still a layer of uncertainty. And so it really does just come with the field, unfortunately. There's so many things in medicine just at large that kind of get lumped under idiopathic that, you know, as time goes on, we identify antibodies, genes, et cetera, et cetera. There's probably, I usually like to say it's multifactorial. Uh, that's my cop-out usually. But it's usually true. So I think that going through these things and kind of uh, as you said, structuring these episodes in a diagnostic and therapeutic pairing is going to be hopefully helpful to our listeners and kind of get some outside opinions, right? Uh a lot of times, if it's just me or uh just the two of us, we can kind of get into a little bit of an echo chamber. So we want to get some other people who have experiences and uh maybe some different perspectives on these common chief complaints and uh, you know, kind of open the floor to some of these people from you know different parts of the country, different training programs, et cetera, et cetera.

SPEAKER_02: 30:36

Yeah, I'm excited to learn as well. I think whenever you you said like on, you know, a high compliment you could pay to a neurologist is their diagnostics acumen. And at the same time, a fun thing to do is to hear how other neurologists think. I don't know if it's just because we're brain doctors that we love hearing how others think, but I think it's fun to play that kind of game and to see what you can learn. I also think that the point that you made about uncertainty is probably something that's gonna come up in these episodes. The fact that oftentimes we might be able to be, for example, say, like, well, I definitely know why you know you're having trouble walking to Parkinson's. But as you said, maybe that next layer down of, well, why do I have Parkinson's is something we can't answer. And I do wonder if sometimes those who aren't neurologists maybe do have a similar level of confidence around maybe what it is, right? Like I often get a referral, referral for Parkinson's. And I'm like, oh, well, they got it right. Like, great, like good job. But then the question is like, okay, well, what, you know, what was the gap for the next step? Um, and maybe sometimes it's appropriate to send them in. We're fortunate to have a Parkinson's center at my hospital. So it's definitely appropriate for them to get that comprehensive, multi-factor, multidisciplinary care. But there may be communities where maybe that's not accessible. And so really letting people know, like, gosh, you got it right, like start the cinema, you know, or whatever it is that is the next step for that patient. So hopefully we can kind of make it so that this series feels representative and you know, send in your questions, send in your thoughts. We'd love to work through not officially, you know, hip uh like allowance, but kind of work through cases, make it conversational, make uh share our hard cases and our uh and and every case is a hard case, right? Every case is a certain case, but uh share some maybe some best practices and how to approach that.

Michael Kentris: 32:31

Absolutely. And you can either send those in uh through the fan mail button in the show notes, or you can email us at contact at the neurotransmitters.com. Again, remember keep all your questions anonymized without any identifiers in them. If you do send anything in, how should people reach you, Galina?

SPEAKER_02: 32:51

Well, they can um, I guess for this series, they can reach out to the Neurotransmitters Podcast and we'll bring their cases on the on the air.

Michael Kentris: 33:01

All right. Any final thoughts as we go forward into this brave new world?

SPEAKER_02: 33:07

I'm really excited to do this with you, Michael. I'm excited to hear what our experts think about the most common chief complaints. And I really hope that this is helpful for those of you out there, neurologists and non-neurologists alike, because we're all collectively caring for our patients with neurological complaints.

SPEAKER_00: 33:27

Absolutely.

Michael Kentris: 33:28

I, like you said, I'm also looking forward to learning new things because, as you said, every time you talk to someone, you pick up new little tips and tricks. And it is, it is always beneficial to my own practice to hear how other people approach uh their whole paradigm. So I'm looking forward to this also. This is going to be uh a nice new venture for for our podcast here, and I always enjoyed trying out uh new formats and getting new people involved. So thank you again for embarking on this with me, and I'm looking forward to it.

SPEAKER_02: 34:00

Me too. I always tell our listeners to send in your cases and your feedback, but not your complaints.

Michael Kentris: 34:06

That's right. Keep your bad opinions to yourself. With that being said, feel free to leave us five stars wherever you're listening to this podcast. And you can follow us on X at neuro underscore podcast, and you can also find our past work at theneurotransmitters.com. How to get that pitch in there.

SPEAKER_02: 34:25

No, that's perfect.

Michael Kentris: 34:27

All right, everybody. Thanks again, and we'll be getting back to you soon with some of these chief complaints.

SPEAKER_02: 34:32

Thanks, Michael. Thanks, everyone.

Michael Kentris: 34:34

Thank you.