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An Imagination and a Reflex Hammer: Losing and Finding My Ground on the Neurology Wards

Open AccessPublished:April 08, 2011DOI:https://doi.org/10.1016/j.jpainsymman.2011.03.001
      If a dancer dances—which is not the same as having theories about dancing or wishing to dance or trying to dance or remembering in his body someone else’s dance—but if the dancer dances, everything is there. The meaning is there, if that’s what you want.Merce Cunningham, choreographer (1919–2009)
      • Cunningham M.
      The impermanent art (1952).
      I wanted to love neurology. But it was January of my major clinical year of medical school, and I felt miserable. This was different from the good tiredness that came after a busy night of fevers and split open chins in the pediatric emergency room; different from my physical exhaustion during the surgery clerkship, rising daily at 4:00 am, and retracting for hours in the operating room; different, even, from the emotional fatigue that arose during psychiatry, after spending weeks dissecting my own countertransference reactions to psychotic patients.
      This was new. I had just begun my neurology clerkship, and I was assigned to the stroke service. I had looked forward to it with the same mix of eagerness and anxiety with which I had approached every rotation thus far. But the stakes were slightly higher for me now, as neurology is one of the specialties I had been strongly considering. I wanted to excel; but unlike some of the other students contemplating a career in neurology, I had no background at all in the neural sciences, let alone a PhD. Instead of working in a brain lab, I spent my undergraduate years in a dance studio, and after college, I danced and choreographed for 10 years. Although this might make me interesting, it did not help me remember which cranial nerves exit at the pontine-medullary junction, and why that piece of information was vital to understanding my stroke patient.
      And now I felt lost, as we rounded all morning from bed to bed, seeing patient after patient with variations on the same story. Chronic hypertension, diabetes, smoker, noncompliant with medications; but perfectly fine, thank you, until a few days ago, when the bell finally tolled. There is a reason we call it a stroke. In the space of just a few hours, these patients had lost their ability to walk, speak, or comprehend. One man, unable to communicate except in single words, became upset and angry at the slightest provocation. The attending neurologist pointed out to us afterward that the patient was exhibiting “emotional incontinence” because of a lesion in his frontal lobe. This was likely true. But I began to wonder if I needed an MRI for my own frontal lobe. I found myself needing to walk out of a patient’s room in the neurologic intensive care unit (ICU), overcome with tears; or I felt anger rise up in my throat at the comment, “Great case!” after another presentation of a new patient with a massive debilitating stroke.
      My neurology rotation came exactly halfway through my clinical year, a critical turning point in the development of physicians in training. Our preceptors love to tell us that we must develop our clinical decision-making skills, turn from mere “medical students” to “student doctors,” make that magical leap from simply reporting lab results to being able to interpret them and “manage” our patients. And certainly we must. But research confirms that during this clinical year, most medical students experience a significant decrease in idealism and empathy for patients, and a corresponding increase in cynicism.
      • Hojat M.
      • Vergare M.J.
      • Maxwell K.
      • et al.
      The devil is in the third year: a longitudinal study of erosion of empathy in medical school.
      This emotional hardening has been attributed to a number of factors, including a lack of positive role models, an overwhelming amount of material to learn, and what has been termed a “gradual overreliance on computer-based diagnostic and therapeutic technology” at the expense of direct physician-patient encounters.
      • Hojat M.
      • Vergare M.J.
      • Maxwell K.
      • et al.
      The devil is in the third year: a longitudinal study of erosion of empathy in medical school.
      Furthermore, much attention has focused on the “hidden curriculum” in medical education: the subtle messages that we receive as we attempt to assimilate into the bizarre subculture of the hospital. One revealing study looked at reflective essays written by third-year students at Harvard Medical School, finding a number of recurrent themes, including submission to the rigid hierarchy of medicine at all costs (even at the expense of proper patient care), dehumanization of patients, and the suppression of emotional responses.
      • Gaufberg E.H.
      • Batalden M.
      • Sands R.
      • Bell S.K.
      The hidden curriculum: what can we learn from third-year medical student narrative reflections?.
      Moreover, although “professionalism” is held up as a core value for all physicians and addressed at many levels throughout the medical education curriculum, the culture of the large teaching hospitals in which we receive most of our training tends to be, as one author put it, “diametrically opposed to the virtues that we explicitly teach.”
      • Coulehan J.
      Today’s professionalism: engaging the mind but not the heart.
      My weeks in the inpatient neurology wards represented a personal crisis, as I struggled to come to terms with my own emotions, and at the same time, assimilate into the culture in such a way as to avoid criticism. The practice of neurology requires a certain facility with logic, and neurologists have acquired a perhaps undeserved reputation in other fields for being cool diagnosticians with little to offer in the way of treatment (“diagnose and adios,” as one internist put it to me). This characterization is unfair, I feel. Overall, the neurologists I encountered were a group of dedicated, hardworking, and intellectually curious physicians. I came to appreciate that the unruffled detachment with which they appeared to approach their patients was often merely a veneer. One resident reacted touchingly in the outpatient clinic when a patient for whom she had cared six months earlier in the ICU walked in for a follow-up visit. “I can’t believe I am seeing you walk,” she said. “You don’t know what this means to me.” The patient’s children remembered her well, and the entire encounter had the tone of a reunion between long-lost family members. Another resident found me hiding in a corner at a computer, pretending to write a note but actually trying to recover from one of my emotionally incontinent episodes. “This floor can get to you,” he said. “Just go outside, get a cup of tea. Look at the snow falling. Be good to yourself.”
      However, despite these moments of poignant humanity, there were many instances where the hidden curriculum was only too visible. For example, the way that students were assigned patients to follow made clear which patients were the “good” ones. In general, students were not assigned patients who had a “poor prognosis” (translation: dying) or had languished in the hospital for more than a few weeks. “That’s not a great patient for you,” we would be told. Many patients were suffering from delirium and/or dementia in addition to their strokes, infections, or subarachnoid hemorrhages; everybody avoided these patients in favor of the more “interesting” ones with whom communication was easier.
      I do not wish to paint an unflattering picture of the neurology wards. Indeed, this hidden curriculum was only too familiar: I had encountered it on every rotation, from primary care to general surgery. On the contrary, I write about this clerkship in particular because of the unique timing—exactly halfway through my alleged descent from idealist to hardened subintern—and because, out of all my clerkships, neurology was the one that seemed to offer me a path back up. It is this “reascent” that I want to discuss, and it came through the teaching of the most basic skill we were required to master during the clerkship: the detailed physical examination that is the foundation of neurologic practice and the subsequent interpretation of this examination.
      The neurologic examination is a beast of a physical examination, which may take anywhere from 10 minutes to three hours, depending on the level of detail into which the physician wishes to delve. It consists of six parts: mental status, cranial nerves, motor, sensory, reflexes, and gait/coordination. On my other rotations, I am ashamed to admit that my neurologic examination had most often consisted of a cursory glance, “squeeze my hands,” and the ever present “no focal deficits” in my note. Moreover, physicians in other specialties love to hold up the neurologic examination as the example of what not to do in a so-called “focused physical examination.” “Please don’t let me come in and find you testing every reflex,” I was told during one clerkship. “Just get in and get out.”
      After my initial week on the stroke service, I moved to a new inpatient team. This one, termed the “graduate service,” managed the patients who had recently “graduated” from the neurologic ICU but continued to need more intensive care than could be provided on the regular inpatient ward. The patients were quite sick. Many of them had suffered subarachnoid hemorrhages, devastating strokes complicated by brain swelling, and the repeated infections that haunt ICU beds: pneumonia, urinary tract infections, and pressure ulcers. Some were on ventilators. The idea of performing a complete neurologic examination on patients who could barely open their eyes, let alone respond, seemed to border on the absurd.
      Our attending physician, “Dr. N.,” was not a talkative person. Unlike some of the attendings I had encountered in various settings, she did not tend to lecture or “pimp” students about facts that she knew we would be unlikely to know. Instead, she would appear by the nursing station each morning at 9 am, elegantly dressed, staring vaguely into the distance, and spinning her impressively weighty reflex hammer absentmindedly in one hand: a neurologic gunslinger.
      As students, we were given the privilege of presenting new admissions, an undertaking that tended to send us into anguished paroxysms of nervousness. As we struggled through our presentations, Dr. N. never interrupted. Instead, she listened patiently, never betraying the slightest reaction. Only toward the end would she ask one or two questions to clarify the history we reported. Then we would enter the patient’s room.
      She began by unhurriedly washing her hands at the patient’s sink. No quick rub with an alcohol-based hand sanitizer for Dr. N.: she took a solid minute to do it in the old-fashioned way, soap and water, drying carefully with the towel, and then donning gloves. She would then turn to the patient and just look. Most of the time, they had their eyes closed. She spent at least 30 seconds observing them before she ever attempted to arouse them.
      She would then proceed to perform what I came to regard as one of the most thorough physical examinations I have ever had the privilege to observe. It was not thorough in the sense of “completeness,” for it had little relationship to a checklist approach, in which each finding is dutifully noted until the list has been exhausted. As I mentioned, the “complete” neurologic examination, if one could perform it at all, would take hours. Instead, Dr. N.’s examinations had the same quality of flexibility that one sees in a musician improvising on a theme. They flowed effortlessly from one test to the next. There was a quality of inevitability to her findings, yet often an element of surprise as well, for at times she elicited signs from patients that no one had yet thought to look for. Her conversations with the patients, when they were able to speak, had a similar characteristic. When performing the mental status examination, she would follow the initial “Tell us your name and where you are” with a conversation that sometimes ranged into the remote past and revealed her own remarkable knowledge of history and geopolitical events.
      Dr. N.’s examinations were striking in that she seemed to see each patient exactly as he or she was: no more, no less. Where I might have dismissed a patient as nonresponsive after a few shouts in the ear, Dr. N. administered a ruthless pinch with her well-groomed nails, starting lightly but progressing quickly to a pressure that made me yelp involuntarily (I asked her to give me one so I could assess for myself). Although appearing mildly cruel, it was such a pinch that aroused a woman previously deemed comatose; she opened her eyes and looked at us for the first time. “You have to give them a chance,” Dr. N. commented.
      She never hurried, yet we rarely spent more than 15 minutes in the room. When we emerged, after the obligatory pause while she repeated her handwashing ritual, she would turn expectantly back to the student who had presented the patient. It was time to localize the lesion, that time-honored neurologic tradition that nonneurologists tend to consider obsolete because of the ubiquity of high-resolution imaging techniques. Localize we did, or attempted to, after examining each new patient. Only after this ceremony would we move on to the logistics of management: which antibiotic, which test, and when to attempt to wean from the ventilator.
      It was Dr. N. who blew away the miasma of “hidden curriculum” that had begun to envelop me, threatening to sour me forever. I recognized in her interactions with patients something familiar from many years in the dance studio. Like a neurologic examination, a rigorous technique class, whether ballet or modern dance, follows a strict structure: first the pliés and tendus, then the exercises for balance and strength, and finally, the turns and jumps. But within that structure, each class is new. A dancer who enters the studio expecting to know the exercises already will be lost in a few minutes, for each one must be meticulously observed—it will usually only be demonstrated once, and it will be different from yesterday’s. Allowing for the unexpected becomes even more critical in the process of choreography, for the choreographer will not know how a movement will appear until the dancers execute it. My best moments in choreography were those times when I came to the rehearsal with no ideas at all, and simply worked with the dancers who showed up, creating dances out of what I saw.
      Merce Cunningham, arguably the most innovative choreographer of the 20th century, wrote that choreography wasa process of watching and working with people who use movement as a force of life, not as something to be explained by reference, or used as illustration, but as something, if not necessarily grave, certainly constant in life. What is fascinating and interesting in movement, is, though we are all two-legged creatures, we all move differently, in accordance with our physical proportions as well as our temperaments. It is this that interests me.
      • Cunningham M.
      Choreography and the dance.
      Dr. N. did not enter her patients’ rooms with expectations. She postponed her interpretation of what she saw, taking the time only to look and notice: this man, this woman, here, today. The patient who yesterday did not respond: today, his finger twitched. The woman who no longer gestured with the arm she had used the day before. The man who lay seizing in his bed, eyes deviated to the left, lips smacking, where earlier he had joked about going home.
      Forget the hierarchies, etiquette, and unwritten rules of the hospital that make the physician with the longest coat the lead character in an ongoing tragicomedy. Forget, even, the lectures on practicing “humanistic medicine” that we are constantly given, to batter us, they hope, into remembering to be polite to our patients. My aim, as physician in training, must be to learn to see each patient and reserve judgment. The nervous system, fortuitously, may be observed directly—if I pay attention. The meaning, as Cunningham said, is there, if that’s what you want.
      • Cunningham M.
      The impermanent art (1952).
      Only after this initial observation does the careful neurologist begin to interpret the examination, localize the lesion, hypothesize about a mechanism of disease, and develop a plan.
      Taking a medical history and performing a physical examination are primary, essential skills that form the underpinning of competence in almost every medical specialty. I have come to believe that these skills are, in fact, creative. They require profound levels of attention, flexibility, mindfulness, and imagination, none of which tend to be emphasized or rewarded during medical education.
      I am far from the first to suggest this, and many have proposed ways to address this deficiency in our training. The field of narrative medicine emphasizes narrative competence, defined as “the set of skills required to recognize, absorb, interpret, and be moved by the stories one hears or reads.”
      • Charon R.
      Narrative and medicine.
      These skills may be acquired through facilitated close reading of literature, reflective writing, and study of the arts and humanities. One recent article described an unusual program of “compulsory creativity” for undergraduate medical students at the University of Bristol, United Kingdom. The authors argued “creativity is not a luxury, it is an essential component of the innovation on which the future of our health services depends.”
      • Thompson T.
      • Lamont-Robinson C.
      • Younie L.
      ‘Compulsory creativity’: rationales, recipes, and results in the placement of mandatory creative endeavor in a medical undergraduate curriculum.
      Most arts- or humanities-based courses have been geared toward medical students, but it may be residents who need them even more. Innovative ideas proposed in the literature include substituting narrative medicine courses for morning reports or noon conferences on a semiregular basis, allowing time for residents to write freely or reflect on a work of literature.
      • Alcauskas M.
      • Charon R.
      Reading, writing, and reflecting: making a case for narrative medicine in neurology.
      For my final week on the neurology wards, I returned to the stroke service where I began with such trouble and approached my patients with new eyes. I recognized that the emotional reactions that had dominated my first week were more about myself than about my patients. The same study that found a decline in medical student empathy during the third year noted the difference between sympathy, which involves an intense emotional identification with the patient, and empathy, a more cognitive process that involves understanding a patient’s experience without this level of identification.
      • Hojat M.
      • Vergare M.J.
      • Maxwell K.
      • et al.
      The devil is in the third year: a longitudinal study of erosion of empathy in medical school.
      I had been sympathizing with my patients to a degree that impaired my ability to function, let alone form a connection. Now, I began to temporarily put aside my emotional reactions and simply look at and listen to my patients. Instead of fleeing and hiding in corners, I stayed in the room. What I found there was new, unexpected. An arm that flailed uncontrollably after a stroke in the globus pallidus: isolated hemiballism, a finding that medical students read about in textbooks but rarely see. And the owner of said arm, a man who after 50 years of chain-smoking, was ready to quit forever. The possibility of recovery and change.
      I have moved on from the neurology wards to my next clerkship, and am now immersed in the busy world of obstetrics and gynecology. But before I left neurology, I bought the same hefty reflex hammer that Dr. N. carried. I keep it in my short white coat as a reminder: to stop, wash my hands slowly, take a deep breath, put aside my expectations, and enter the room quietly. I may or may not become a neurologist, but I plan to carry that hammer forever.

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