Hitting a Nerve

Any other docs out there have patients on what I call the migraine-go-round?

I first discovered this ride when I started in practice, though back then it was with triptans. You know the game, you’d start someone on one drug because you had samples, or a coupon, or both. A few months later the coupon had run out, and their insurance wouldn’t cover it, so you’d move them to another drug. Maxalt to Imitrex to Zomig to Relpax to Axert to Maxalt.

The ride continued until the majority had gone generic, and I’d almost forgotten about it. You can’t do it with seizure patients or Parkinson’s disease.

But with the advent of the CGRP era, it seems to have started again. Coverage coupons have a limited number of refills, or the deal changes, or a pharmacy stops taking them, or an insurance company changes their mind, or whatever. So we go from Aimovig to Emgality to Qulipta to Ajovy to Nurtec to Aimovig (not necessarily in that order).

It’s annoying (not just for the patients, but for me and my staff as we try to keep up with it), and obviously it doesn’t work for everyone because each patient responds differently. But, if it works, it at least gets some degree of coverage until an insurance company finally approves a given drug for that person. And even then a patient’s own financial circumstances or changing job situation can keep things spinning.

When you finally step off the ride you have to pore back through the chart to figure out which, if any, worked best, or had side effects, or whatever.

A good part of modern medicine is adapting to these sorts of things. Patient care isn’t always as simple as “take this and call me in the morning.” Sometimes we have to play the game to get things done.

The trick is learning the rules on the fly – for all involved.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Any other docs out there have patients on what I call the migraine-go-round?

I first discovered this ride when I started in practice, though back then it was with triptans. You know the game, you’d start someone on one drug because you had samples, or a coupon, or both. A few months later the coupon had run out, and their insurance wouldn’t cover it, so you’d move them to another drug. Maxalt to Imitrex to Zomig to Relpax to Axert to Maxalt.

The ride continued until the majority had gone generic, and I’d almost forgotten about it. You can’t do it with seizure patients or Parkinson’s disease.

But with the advent of the CGRP era, it seems to have started again. Coverage coupons have a limited number of refills, or the deal changes, or a pharmacy stops taking them, or an insurance company changes their mind, or whatever. So we go from Aimovig to Emgality to Qulipta to Ajovy to Nurtec to Aimovig (not necessarily in that order).

It’s annoying (not just for the patients, but for me and my staff as we try to keep up with it), and obviously it doesn’t work for everyone because each patient responds differently. But, if it works, it at least gets some degree of coverage until an insurance company finally approves a given drug for that person. And even then a patient’s own financial circumstances or changing job situation can keep things spinning.

When you finally step off the ride you have to pore back through the chart to figure out which, if any, worked best, or had side effects, or whatever.

A good part of modern medicine is adapting to these sorts of things. Patient care isn’t always as simple as “take this and call me in the morning.” Sometimes we have to play the game to get things done.

The trick is learning the rules on the fly – for all involved.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Any other docs out there have patients on what I call the migraine-go-round?

I first discovered this ride when I started in practice, though back then it was with triptans. You know the game, you’d start someone on one drug because you had samples, or a coupon, or both. A few months later the coupon had run out, and their insurance wouldn’t cover it, so you’d move them to another drug. Maxalt to Imitrex to Zomig to Relpax to Axert to Maxalt.

The ride continued until the majority had gone generic, and I’d almost forgotten about it. You can’t do it with seizure patients or Parkinson’s disease.

But with the advent of the CGRP era, it seems to have started again. Coverage coupons have a limited number of refills, or the deal changes, or a pharmacy stops taking them, or an insurance company changes their mind, or whatever. So we go from Aimovig to Emgality to Qulipta to Ajovy to Nurtec to Aimovig (not necessarily in that order).

It’s annoying (not just for the patients, but for me and my staff as we try to keep up with it), and obviously it doesn’t work for everyone because each patient responds differently. But, if it works, it at least gets some degree of coverage until an insurance company finally approves a given drug for that person. And even then a patient’s own financial circumstances or changing job situation can keep things spinning.

When you finally step off the ride you have to pore back through the chart to figure out which, if any, worked best, or had side effects, or whatever.

A good part of modern medicine is adapting to these sorts of things. Patient care isn’t always as simple as “take this and call me in the morning.” Sometimes we have to play the game to get things done.

The trick is learning the rules on the fly – for all involved.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m not fanatical about dragging stable patients in. If someone is doing fine, having them come in once a year is all I ask. They have better things to do, and I have patients who need my attention more.

Of course, there will always be those who abuse this. They try to drag it out to 18 months, sometimes 2 years. I don’t think having patients drop in for 10-15 minutes once a year to make sure they’re still alive is unreasonable, but maybe that’s just me. Admittedly, during the last 2 years I’ve kind of let it slide a bit, but I think everyone has.

Last week a lady I see for an annual check-in called to make an appointment. She’d been dodging my secretary’s reminders for a few months, so I cut her migraine refill from a 90-day supply to 30 days to encourage her. She called, made an appointment for the following morning, and asked that I send in a refill for 90 days because otherwise her insurance won’t cover it. So, trying to be nice, I did, figuring she was on the schedule now.

Of course, she didn’t show up the next morning. She didn’t cancel, or call in with “I’m sick” or “sorry, I spaced on it” or some other issue. She just no-showed. One of the many banes of outpatient medicine.

Normally I avoid looking at my patients’ online presence, but I got curious. This lady has often suggested I check out her social media account for financial and real estate tips. I never had, until that morning.

Her Twitter account for the last several days was full of reminders to her followers for an in-person seminar on real estate flipping that she was hosting, which, surprisingly, started at the exact time as her appointment with me was supposed to.

I’m pretty sure she ain’t that stupid. She knew exactly what she was doing, and never planned on keeping the appointment. Now she had a 90-day supply of meds and no incentive to follow up with me before then.

Certainly, it’s not the worst thing. The drug involved isn’t controlled, and in 24 years I’ve had patients do far worse.

But it still changes the trust factor in the medical relationship. She isn’t getting another 90-day refill without coming in, and if she has to pay cash for 30 days that’s her problem, not mine. She can avoid that by calling in to schedule before then. Though I doubt she will.

I try to work with my patients. I really do. Her behavior is rude and inconsiderate, but (at least to me) doesn’t cross the line to firing her from the practice.

But it does make it trickier to be her doctor, since I now know that she isn’t always truthful with me and my staff.

And that sort of thing is important in this field.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m not fanatical about dragging stable patients in. If someone is doing fine, having them come in once a year is all I ask. They have better things to do, and I have patients who need my attention more.

Of course, there will always be those who abuse this. They try to drag it out to 18 months, sometimes 2 years. I don’t think having patients drop in for 10-15 minutes once a year to make sure they’re still alive is unreasonable, but maybe that’s just me. Admittedly, during the last 2 years I’ve kind of let it slide a bit, but I think everyone has.

Last week a lady I see for an annual check-in called to make an appointment. She’d been dodging my secretary’s reminders for a few months, so I cut her migraine refill from a 90-day supply to 30 days to encourage her. She called, made an appointment for the following morning, and asked that I send in a refill for 90 days because otherwise her insurance won’t cover it. So, trying to be nice, I did, figuring she was on the schedule now.

Of course, she didn’t show up the next morning. She didn’t cancel, or call in with “I’m sick” or “sorry, I spaced on it” or some other issue. She just no-showed. One of the many banes of outpatient medicine.

Normally I avoid looking at my patients’ online presence, but I got curious. This lady has often suggested I check out her social media account for financial and real estate tips. I never had, until that morning.

Her Twitter account for the last several days was full of reminders to her followers for an in-person seminar on real estate flipping that she was hosting, which, surprisingly, started at the exact time as her appointment with me was supposed to.

I’m pretty sure she ain’t that stupid. She knew exactly what she was doing, and never planned on keeping the appointment. Now she had a 90-day supply of meds and no incentive to follow up with me before then.

Certainly, it’s not the worst thing. The drug involved isn’t controlled, and in 24 years I’ve had patients do far worse.

But it still changes the trust factor in the medical relationship. She isn’t getting another 90-day refill without coming in, and if she has to pay cash for 30 days that’s her problem, not mine. She can avoid that by calling in to schedule before then. Though I doubt she will.

I try to work with my patients. I really do. Her behavior is rude and inconsiderate, but (at least to me) doesn’t cross the line to firing her from the practice.

But it does make it trickier to be her doctor, since I now know that she isn’t always truthful with me and my staff.

And that sort of thing is important in this field.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m not fanatical about dragging stable patients in. If someone is doing fine, having them come in once a year is all I ask. They have better things to do, and I have patients who need my attention more.

Of course, there will always be those who abuse this. They try to drag it out to 18 months, sometimes 2 years. I don’t think having patients drop in for 10-15 minutes once a year to make sure they’re still alive is unreasonable, but maybe that’s just me. Admittedly, during the last 2 years I’ve kind of let it slide a bit, but I think everyone has.

Last week a lady I see for an annual check-in called to make an appointment. She’d been dodging my secretary’s reminders for a few months, so I cut her migraine refill from a 90-day supply to 30 days to encourage her. She called, made an appointment for the following morning, and asked that I send in a refill for 90 days because otherwise her insurance won’t cover it. So, trying to be nice, I did, figuring she was on the schedule now.

Of course, she didn’t show up the next morning. She didn’t cancel, or call in with “I’m sick” or “sorry, I spaced on it” or some other issue. She just no-showed. One of the many banes of outpatient medicine.

Normally I avoid looking at my patients’ online presence, but I got curious. This lady has often suggested I check out her social media account for financial and real estate tips. I never had, until that morning.

Her Twitter account for the last several days was full of reminders to her followers for an in-person seminar on real estate flipping that she was hosting, which, surprisingly, started at the exact time as her appointment with me was supposed to.

I’m pretty sure she ain’t that stupid. She knew exactly what she was doing, and never planned on keeping the appointment. Now she had a 90-day supply of meds and no incentive to follow up with me before then.

Certainly, it’s not the worst thing. The drug involved isn’t controlled, and in 24 years I’ve had patients do far worse.

But it still changes the trust factor in the medical relationship. She isn’t getting another 90-day refill without coming in, and if she has to pay cash for 30 days that’s her problem, not mine. She can avoid that by calling in to schedule before then. Though I doubt she will.

I try to work with my patients. I really do. Her behavior is rude and inconsiderate, but (at least to me) doesn’t cross the line to firing her from the practice.

But it does make it trickier to be her doctor, since I now know that she isn’t always truthful with me and my staff.

And that sort of thing is important in this field.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

She was a 20-year-old barista when we first met, working her way through college.

I was a newly minted attending physician. I’d stopped at the place she worked for coffee on the way to my office. When I got up to the front she was wearing sunglasses and apologized for them. She said she was having bad headaches, and couldn’t get into a doctor she’d been referred to. Feeling bad for her, and needing patients, I handed her my card.

She showed up a few days later, a little nervous as she’d never met a “regular” outside the coffee place before, and had brought her sister along for support.

She was back last week. Now she’s head of human resources for the same chain of local coffee shops. She’s married, with kids, a mortgage, and a minivan.

We were talking about our chance meeting and reminiscing. Her migraines had taken a few medication trials to control, but after a year or 2 we’d found the right one for her and she’s been on it since.

Like many of my longtime patients, she moved past calling me “doctor” long ago. Our one to two visits a year are now more social than medical, chatting about our kids, dogs, and lives.

The same passage of time that brings us from grade school, to medical school, to medical practice takes others along with it. We may not see the changes of days, but when they drop by only once a year it’s obvious. Just like the way we don’t see daily changes in family and friends, but when we look at old pictures we’re shocked by how different they (not to mention ourselves) look.

We all follow the same course around the sun, usually facing the same milestones and similar memories on the trip. Our long-term patients, like distant relatives, may only come by infrequently, so the changes are greater. I’m sure they say the same things about me. “I saw Dr. Block today; boy, he’s really gone gray.”

I don’t mind that (too much) anymore. My thinning, graying, hair (I hope) makes me look a little more distinguished, although my complete lack of fashion sense more than goes the other way.

The river only goes in one direction, carrying us, our patients, and our families, all along with it. We often lose track of time’s effects on us until we see the changes it has brought to another.

It’s always a good reminder to pause and remember to enjoy the ride.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

She was a 20-year-old barista when we first met, working her way through college.

I was a newly minted attending physician. I’d stopped at the place she worked for coffee on the way to my office. When I got up to the front she was wearing sunglasses and apologized for them. She said she was having bad headaches, and couldn’t get into a doctor she’d been referred to. Feeling bad for her, and needing patients, I handed her my card.

She showed up a few days later, a little nervous as she’d never met a “regular” outside the coffee place before, and had brought her sister along for support.

She was back last week. Now she’s head of human resources for the same chain of local coffee shops. She’s married, with kids, a mortgage, and a minivan.

We were talking about our chance meeting and reminiscing. Her migraines had taken a few medication trials to control, but after a year or 2 we’d found the right one for her and she’s been on it since.

Like many of my longtime patients, she moved past calling me “doctor” long ago. Our one to two visits a year are now more social than medical, chatting about our kids, dogs, and lives.

The same passage of time that brings us from grade school, to medical school, to medical practice takes others along with it. We may not see the changes of days, but when they drop by only once a year it’s obvious. Just like the way we don’t see daily changes in family and friends, but when we look at old pictures we’re shocked by how different they (not to mention ourselves) look.

We all follow the same course around the sun, usually facing the same milestones and similar memories on the trip. Our long-term patients, like distant relatives, may only come by infrequently, so the changes are greater. I’m sure they say the same things about me. “I saw Dr. Block today; boy, he’s really gone gray.”

I don’t mind that (too much) anymore. My thinning, graying, hair (I hope) makes me look a little more distinguished, although my complete lack of fashion sense more than goes the other way.

The river only goes in one direction, carrying us, our patients, and our families, all along with it. We often lose track of time’s effects on us until we see the changes it has brought to another.

It’s always a good reminder to pause and remember to enjoy the ride.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

She was a 20-year-old barista when we first met, working her way through college.

I was a newly minted attending physician. I’d stopped at the place she worked for coffee on the way to my office. When I got up to the front she was wearing sunglasses and apologized for them. She said she was having bad headaches, and couldn’t get into a doctor she’d been referred to. Feeling bad for her, and needing patients, I handed her my card.

She showed up a few days later, a little nervous as she’d never met a “regular” outside the coffee place before, and had brought her sister along for support.

She was back last week. Now she’s head of human resources for the same chain of local coffee shops. She’s married, with kids, a mortgage, and a minivan.

We were talking about our chance meeting and reminiscing. Her migraines had taken a few medication trials to control, but after a year or 2 we’d found the right one for her and she’s been on it since.

Like many of my longtime patients, she moved past calling me “doctor” long ago. Our one to two visits a year are now more social than medical, chatting about our kids, dogs, and lives.

The same passage of time that brings us from grade school, to medical school, to medical practice takes others along with it. We may not see the changes of days, but when they drop by only once a year it’s obvious. Just like the way we don’t see daily changes in family and friends, but when we look at old pictures we’re shocked by how different they (not to mention ourselves) look.

We all follow the same course around the sun, usually facing the same milestones and similar memories on the trip. Our long-term patients, like distant relatives, may only come by infrequently, so the changes are greater. I’m sure they say the same things about me. “I saw Dr. Block today; boy, he’s really gone gray.”

I don’t mind that (too much) anymore. My thinning, graying, hair (I hope) makes me look a little more distinguished, although my complete lack of fashion sense more than goes the other way.

The river only goes in one direction, carrying us, our patients, and our families, all along with it. We often lose track of time’s effects on us until we see the changes it has brought to another.

It’s always a good reminder to pause and remember to enjoy the ride.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Fifteen years ago, Mrs. Smith was hospitalized for a dural sinus thrombosis.

This is a scary enough diagnosis as it is, but with the miracle of modern medicine she did great. She still checks in with me every year or so, but hasn’t had any recurrence.

Three years ago she tripped over her dog (amazing how often that seems to happen) and broke her arm. She landed in the hospital and needed orthopedic surgery, so they consulted me about the safety of getting her off the antiplatelet agent she was taking since stopping Coumadin.

When I arrived someone had already written an admitting note, which included a past history of “subdural hematoma, maintained on daily aspirin.”

Where this error came from, I don’t know. When I asked Mrs. Smith, she was quite clear on her correct diagnosis, and said she’d given it to the person who admitted her. So I dictated a consult, and typed it into my progress note each day. My notes made it clear that she’d had a dural sinus thrombosis and not a subdural hematoma.

This isn’t just nitpicking, obviously. They’re entirely different disorders. While the point may not be critical to her needing wrist surgery, these are medical records, and medical records need to be as accurate as possible for this, and future hospital stays and for physicians to be aware of.

I signed off after a few days and didn’t think much of it until I was faxed a copy of her discharge summary. Which listed “subdural hematoma, maintained on daily aspirin.”

Apparently no one read my notes. Not that I’m really surprised.

We’re now 3 years later. As do many patients of her age, Mrs. Smith has landed in the hospital a few times since then. COVID, syncope, another fall. In each one of them the “subdural hematoma, maintained on daily aspirin” shows up.

At the most recent incident, the hospital’s neurologist called and asked me why I was treating a subdural hematoma with aspirin, then said Mrs. Smith had told him it was a dural sinus thrombosis. I said she was right, and he said “that makes more sense” and that he’d put it in his note.

He did, but it didn’t change anything. The discharge summary still listed “subdural hematoma, maintained on daily aspirin.”

At some point resistance is futile.

The stupidity of the whole thing is frustrating, as is knowing that it’s not just Mrs. Smith. The same scenario of incorrect history and medications is propagated from visit to visit. Taking a history is too time consuming for some. It’s easier to just read off, or cut and paste, a previous note. In cases where the patient can’t give a history I understand this. But when they can it’s just being too rushed – or lazy – to care.

It’s easy to blame EMRs as the culprits. Bashing them is fashionable. But in this case I can’t. They make it easier, but it’s nothing new. I remember a night almost 30 years ago when I was doing an admission at the Phoenix VA. When I picked up the most recent volume of the patient’s old chart to look at labs, the previous H&P said “see old chart.”

The problem is human nature. Not the computer.

But in this field the fallout can be serious – the wrong precautions taken, or medication given, based on a nonexistent contraindication. In medicine the stakes are high. Our decisions are only as good as the information we base them on, and if that information is wrong ...

Shortcuts have consequences.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Fifteen years ago, Mrs. Smith was hospitalized for a dural sinus thrombosis.

This is a scary enough diagnosis as it is, but with the miracle of modern medicine she did great. She still checks in with me every year or so, but hasn’t had any recurrence.

Three years ago she tripped over her dog (amazing how often that seems to happen) and broke her arm. She landed in the hospital and needed orthopedic surgery, so they consulted me about the safety of getting her off the antiplatelet agent she was taking since stopping Coumadin.

When I arrived someone had already written an admitting note, which included a past history of “subdural hematoma, maintained on daily aspirin.”

Where this error came from, I don’t know. When I asked Mrs. Smith, she was quite clear on her correct diagnosis, and said she’d given it to the person who admitted her. So I dictated a consult, and typed it into my progress note each day. My notes made it clear that she’d had a dural sinus thrombosis and not a subdural hematoma.

This isn’t just nitpicking, obviously. They’re entirely different disorders. While the point may not be critical to her needing wrist surgery, these are medical records, and medical records need to be as accurate as possible for this, and future hospital stays and for physicians to be aware of.

I signed off after a few days and didn’t think much of it until I was faxed a copy of her discharge summary. Which listed “subdural hematoma, maintained on daily aspirin.”

Apparently no one read my notes. Not that I’m really surprised.

We’re now 3 years later. As do many patients of her age, Mrs. Smith has landed in the hospital a few times since then. COVID, syncope, another fall. In each one of them the “subdural hematoma, maintained on daily aspirin” shows up.

At the most recent incident, the hospital’s neurologist called and asked me why I was treating a subdural hematoma with aspirin, then said Mrs. Smith had told him it was a dural sinus thrombosis. I said she was right, and he said “that makes more sense” and that he’d put it in his note.

He did, but it didn’t change anything. The discharge summary still listed “subdural hematoma, maintained on daily aspirin.”

At some point resistance is futile.

The stupidity of the whole thing is frustrating, as is knowing that it’s not just Mrs. Smith. The same scenario of incorrect history and medications is propagated from visit to visit. Taking a history is too time consuming for some. It’s easier to just read off, or cut and paste, a previous note. In cases where the patient can’t give a history I understand this. But when they can it’s just being too rushed – or lazy – to care.

It’s easy to blame EMRs as the culprits. Bashing them is fashionable. But in this case I can’t. They make it easier, but it’s nothing new. I remember a night almost 30 years ago when I was doing an admission at the Phoenix VA. When I picked up the most recent volume of the patient’s old chart to look at labs, the previous H&P said “see old chart.”

The problem is human nature. Not the computer.

But in this field the fallout can be serious – the wrong precautions taken, or medication given, based on a nonexistent contraindication. In medicine the stakes are high. Our decisions are only as good as the information we base them on, and if that information is wrong ...

Shortcuts have consequences.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Fifteen years ago, Mrs. Smith was hospitalized for a dural sinus thrombosis.

This is a scary enough diagnosis as it is, but with the miracle of modern medicine she did great. She still checks in with me every year or so, but hasn’t had any recurrence.

Three years ago she tripped over her dog (amazing how often that seems to happen) and broke her arm. She landed in the hospital and needed orthopedic surgery, so they consulted me about the safety of getting her off the antiplatelet agent she was taking since stopping Coumadin.

When I arrived someone had already written an admitting note, which included a past history of “subdural hematoma, maintained on daily aspirin.”

Where this error came from, I don’t know. When I asked Mrs. Smith, she was quite clear on her correct diagnosis, and said she’d given it to the person who admitted her. So I dictated a consult, and typed it into my progress note each day. My notes made it clear that she’d had a dural sinus thrombosis and not a subdural hematoma.

This isn’t just nitpicking, obviously. They’re entirely different disorders. While the point may not be critical to her needing wrist surgery, these are medical records, and medical records need to be as accurate as possible for this, and future hospital stays and for physicians to be aware of.

I signed off after a few days and didn’t think much of it until I was faxed a copy of her discharge summary. Which listed “subdural hematoma, maintained on daily aspirin.”

Apparently no one read my notes. Not that I’m really surprised.

We’re now 3 years later. As do many patients of her age, Mrs. Smith has landed in the hospital a few times since then. COVID, syncope, another fall. In each one of them the “subdural hematoma, maintained on daily aspirin” shows up.

At the most recent incident, the hospital’s neurologist called and asked me why I was treating a subdural hematoma with aspirin, then said Mrs. Smith had told him it was a dural sinus thrombosis. I said she was right, and he said “that makes more sense” and that he’d put it in his note.

He did, but it didn’t change anything. The discharge summary still listed “subdural hematoma, maintained on daily aspirin.”

At some point resistance is futile.

The stupidity of the whole thing is frustrating, as is knowing that it’s not just Mrs. Smith. The same scenario of incorrect history and medications is propagated from visit to visit. Taking a history is too time consuming for some. It’s easier to just read off, or cut and paste, a previous note. In cases where the patient can’t give a history I understand this. But when they can it’s just being too rushed – or lazy – to care.

It’s easy to blame EMRs as the culprits. Bashing them is fashionable. But in this case I can’t. They make it easier, but it’s nothing new. I remember a night almost 30 years ago when I was doing an admission at the Phoenix VA. When I picked up the most recent volume of the patient’s old chart to look at labs, the previous H&P said “see old chart.”

The problem is human nature. Not the computer.

But in this field the fallout can be serious – the wrong precautions taken, or medication given, based on a nonexistent contraindication. In medicine the stakes are high. Our decisions are only as good as the information we base them on, and if that information is wrong ...

Shortcuts have consequences.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“Why did the other doctor say that?”

I get that question here and there, and it’s always irritating. How should I know?

Generally it’s referring to something they say their family doctor told them: A scan that showed normal pressure hydrocephalus or multiple sclerosis, but when I actually get the neuroradiologist’s report it was normal. Sometimes it’s an alleged side effect from a drug for which I can find nothing in the literature or something that requires urgent surgery in spite of all objective evidence to the contrary.

These appointments are always frustrating. The patient is upset that what they’ve been told (or at least think they’ve been told) is incorrect. They’ve spent a few weeks doing medical research on Google for a condition they don’t have. They’re angry at me for shooting them down. They’re angry at the person who referred them for not being right. They’re angry that they wasted their time coming to me.

And then they ask me why the other doctor said that. I wasn’t there. I don’t know. Medicine is a less-than-perfect science. Maybe they were looking at the wrong report. Maybe they’d gotten an incorrect “wet read” by phone. (How many doctors today even know where the term came from?) Maybe they were having a bad day, were overwhelmed, and misread something.

There’s also the possibility that the other doctor didn’t say it at all. Many people will only hear what they want to hear. Or they’ve already decided what they have and are claiming “the other doctor” told them just to give credence to it, even if it’s not true.

Such visits often end on an ugly note. The patient doesn’t want to be billed because I didn’t say what they wanted me to say. Or pay a copay. Or just get up and leave.

I try, very hard, to be polite when this happens. I don’t know what really went on at the other office – if what’s claimed even happened at all. Even if the patient is telling the truth, all doctors, like all people, make mistakes. It’s not like they were trying to be wrong or deceptive. I don’t fault my colleagues if they make an error, and hope they feel the same way about me.

But it’s still frustrating when it occurs. In many cases I’m left dictating a polite note back to the referring physician, explaining what happened. I chalk it up to a communication error, or experience, or even just a difficult patient. I never really know for sure.

I don’t think any of us are here to willfully deceive patients. We want to do our best for them. It’s frustrating when something happens to lead them to believe otherwise.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“Why did the other doctor say that?”

I get that question here and there, and it’s always irritating. How should I know?

Generally it’s referring to something they say their family doctor told them: A scan that showed normal pressure hydrocephalus or multiple sclerosis, but when I actually get the neuroradiologist’s report it was normal. Sometimes it’s an alleged side effect from a drug for which I can find nothing in the literature or something that requires urgent surgery in spite of all objective evidence to the contrary.

These appointments are always frustrating. The patient is upset that what they’ve been told (or at least think they’ve been told) is incorrect. They’ve spent a few weeks doing medical research on Google for a condition they don’t have. They’re angry at me for shooting them down. They’re angry at the person who referred them for not being right. They’re angry that they wasted their time coming to me.

And then they ask me why the other doctor said that. I wasn’t there. I don’t know. Medicine is a less-than-perfect science. Maybe they were looking at the wrong report. Maybe they’d gotten an incorrect “wet read” by phone. (How many doctors today even know where the term came from?) Maybe they were having a bad day, were overwhelmed, and misread something.

There’s also the possibility that the other doctor didn’t say it at all. Many people will only hear what they want to hear. Or they’ve already decided what they have and are claiming “the other doctor” told them just to give credence to it, even if it’s not true.

Such visits often end on an ugly note. The patient doesn’t want to be billed because I didn’t say what they wanted me to say. Or pay a copay. Or just get up and leave.

I try, very hard, to be polite when this happens. I don’t know what really went on at the other office – if what’s claimed even happened at all. Even if the patient is telling the truth, all doctors, like all people, make mistakes. It’s not like they were trying to be wrong or deceptive. I don’t fault my colleagues if they make an error, and hope they feel the same way about me.

But it’s still frustrating when it occurs. In many cases I’m left dictating a polite note back to the referring physician, explaining what happened. I chalk it up to a communication error, or experience, or even just a difficult patient. I never really know for sure.

I don’t think any of us are here to willfully deceive patients. We want to do our best for them. It’s frustrating when something happens to lead them to believe otherwise.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“Why did the other doctor say that?”

I get that question here and there, and it’s always irritating. How should I know?

Generally it’s referring to something they say their family doctor told them: A scan that showed normal pressure hydrocephalus or multiple sclerosis, but when I actually get the neuroradiologist’s report it was normal. Sometimes it’s an alleged side effect from a drug for which I can find nothing in the literature or something that requires urgent surgery in spite of all objective evidence to the contrary.

These appointments are always frustrating. The patient is upset that what they’ve been told (or at least think they’ve been told) is incorrect. They’ve spent a few weeks doing medical research on Google for a condition they don’t have. They’re angry at me for shooting them down. They’re angry at the person who referred them for not being right. They’re angry that they wasted their time coming to me.

And then they ask me why the other doctor said that. I wasn’t there. I don’t know. Medicine is a less-than-perfect science. Maybe they were looking at the wrong report. Maybe they’d gotten an incorrect “wet read” by phone. (How many doctors today even know where the term came from?) Maybe they were having a bad day, were overwhelmed, and misread something.

There’s also the possibility that the other doctor didn’t say it at all. Many people will only hear what they want to hear. Or they’ve already decided what they have and are claiming “the other doctor” told them just to give credence to it, even if it’s not true.

Such visits often end on an ugly note. The patient doesn’t want to be billed because I didn’t say what they wanted me to say. Or pay a copay. Or just get up and leave.

I try, very hard, to be polite when this happens. I don’t know what really went on at the other office – if what’s claimed even happened at all. Even if the patient is telling the truth, all doctors, like all people, make mistakes. It’s not like they were trying to be wrong or deceptive. I don’t fault my colleagues if they make an error, and hope they feel the same way about me.

But it’s still frustrating when it occurs. In many cases I’m left dictating a polite note back to the referring physician, explaining what happened. I chalk it up to a communication error, or experience, or even just a difficult patient. I never really know for sure.

I don’t think any of us are here to willfully deceive patients. We want to do our best for them. It’s frustrating when something happens to lead them to believe otherwise.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

There’s another doctor with whom I’ve referred patients, back and forth, for the last 20 years. I think he’s good at his job and assume he feels the same way about me. We aren’t social friends, but chat briefly when we run into each other at the hospital, or store, or local restaurants.

Last week I was at the hospital to read EEGs, and happened to see him in the doctor’s parking lot. We wished each other a happy new year, talked briefly about a few mutual patients, and then went our separate ways.

As he pulled out, I noticed his car had a bumper sticker for a cause I strongly disagree with. I mean, 180 degrees opposed.

Suddenly, I didn’t want to ever refer to him again. Why should I support him? He’s the enemy.

Why should I help him out by referring patients?

But then I had to stop. Isn’t this 2022? Aren’t we supposed to be in a civilized world? This isn’t my tribe versus your tribe, my cave versus your cave. The closest we’re supposed to come to direct conflict with others is the “us versus them” world of professional and college sports.

I hope.

Aren’t I supposed to be better than this? Isn’t learning to coexist the whole point of the playground as a kid (besides burning off energy and giving the teacher a break)? Isn’t the idea behind civilization to get along with each other, accept our differences as “agreeing to disagree,” and work together? Like Hamilton and Jefferson, or Ronald Reagan and Tip O’Neill?

Refusing to work with another competent physician because I disagree with their personal, religious, or political beliefs is just plain stupid.

Politicians and pundits try to convince us that people who disagree with us are the enemy, but that’s horse hockey. The truth is that the majority of people out there, regardless of personal beliefs, are decent, hardworking, and just trying to support their families like I am mine.

Later that week I had a patient who clearly needed the other doctor’s expertise, and I gave her his name and phone number. She asked if I’d send my own family to him, and I said, unequivocally, “yes” (actually I have).

Because, at the end of the day, we’re all people, along on the same ride. To not send a patient to him wouldn’t be in their best interest, which is what I’m supposed to be watching out for.

Not only that, but if I don’t refer just because I disagree with him as a person, then I’ve become the problem and not the solution.

Because I, and everyone else, have to try to be better than that.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

There’s another doctor with whom I’ve referred patients, back and forth, for the last 20 years. I think he’s good at his job and assume he feels the same way about me. We aren’t social friends, but chat briefly when we run into each other at the hospital, or store, or local restaurants.

Last week I was at the hospital to read EEGs, and happened to see him in the doctor’s parking lot. We wished each other a happy new year, talked briefly about a few mutual patients, and then went our separate ways.

As he pulled out, I noticed his car had a bumper sticker for a cause I strongly disagree with. I mean, 180 degrees opposed.

Suddenly, I didn’t want to ever refer to him again. Why should I support him? He’s the enemy.

Why should I help him out by referring patients?

But then I had to stop. Isn’t this 2022? Aren’t we supposed to be in a civilized world? This isn’t my tribe versus your tribe, my cave versus your cave. The closest we’re supposed to come to direct conflict with others is the “us versus them” world of professional and college sports.

I hope.

Aren’t I supposed to be better than this? Isn’t learning to coexist the whole point of the playground as a kid (besides burning off energy and giving the teacher a break)? Isn’t the idea behind civilization to get along with each other, accept our differences as “agreeing to disagree,” and work together? Like Hamilton and Jefferson, or Ronald Reagan and Tip O’Neill?

Refusing to work with another competent physician because I disagree with their personal, religious, or political beliefs is just plain stupid.

Politicians and pundits try to convince us that people who disagree with us are the enemy, but that’s horse hockey. The truth is that the majority of people out there, regardless of personal beliefs, are decent, hardworking, and just trying to support their families like I am mine.

Later that week I had a patient who clearly needed the other doctor’s expertise, and I gave her his name and phone number. She asked if I’d send my own family to him, and I said, unequivocally, “yes” (actually I have).

Because, at the end of the day, we’re all people, along on the same ride. To not send a patient to him wouldn’t be in their best interest, which is what I’m supposed to be watching out for.

Not only that, but if I don’t refer just because I disagree with him as a person, then I’ve become the problem and not the solution.

Because I, and everyone else, have to try to be better than that.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

There’s another doctor with whom I’ve referred patients, back and forth, for the last 20 years. I think he’s good at his job and assume he feels the same way about me. We aren’t social friends, but chat briefly when we run into each other at the hospital, or store, or local restaurants.

Last week I was at the hospital to read EEGs, and happened to see him in the doctor’s parking lot. We wished each other a happy new year, talked briefly about a few mutual patients, and then went our separate ways.

As he pulled out, I noticed his car had a bumper sticker for a cause I strongly disagree with. I mean, 180 degrees opposed.

Suddenly, I didn’t want to ever refer to him again. Why should I support him? He’s the enemy.

Why should I help him out by referring patients?

But then I had to stop. Isn’t this 2022? Aren’t we supposed to be in a civilized world? This isn’t my tribe versus your tribe, my cave versus your cave. The closest we’re supposed to come to direct conflict with others is the “us versus them” world of professional and college sports.

I hope.

Aren’t I supposed to be better than this? Isn’t learning to coexist the whole point of the playground as a kid (besides burning off energy and giving the teacher a break)? Isn’t the idea behind civilization to get along with each other, accept our differences as “agreeing to disagree,” and work together? Like Hamilton and Jefferson, or Ronald Reagan and Tip O’Neill?

Refusing to work with another competent physician because I disagree with their personal, religious, or political beliefs is just plain stupid.

Politicians and pundits try to convince us that people who disagree with us are the enemy, but that’s horse hockey. The truth is that the majority of people out there, regardless of personal beliefs, are decent, hardworking, and just trying to support their families like I am mine.

Later that week I had a patient who clearly needed the other doctor’s expertise, and I gave her his name and phone number. She asked if I’d send my own family to him, and I said, unequivocally, “yes” (actually I have).

Because, at the end of the day, we’re all people, along on the same ride. To not send a patient to him wouldn’t be in their best interest, which is what I’m supposed to be watching out for.

Not only that, but if I don’t refer just because I disagree with him as a person, then I’ve become the problem and not the solution.

Because I, and everyone else, have to try to be better than that.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

During my usual 2 weeks off over the holidays I did my usual stuff – taxes, read journals, do CME, review legal cases that have come in, hang out with my family, nap with my dogs.

Somewhere in that stretch of time off. I run out of things to do, and that’s when I have to confront an odd truth: I’ve forgotten how to relax.

In medical school and residency I certainly could enjoy the rare weekend time off. I’d watch sports, go running, do things with friends.

But now it’s a different world. My friends, while still people I enjoy, are on the other end of a computer, far away. My interest in sports and movies waned years ago, and I avoid televisions as part of my aversion to the news. Even the books I used to enjoy, such as the late Clive Cussler’s, don’t hold my attention anymore. If I’m going to read anything it’s going to be humor, because the medical field is serious enough as it is.

The bottom line is that it’s hard for me to relax and “do nothing” anymore. I don’t know if that’s just me, or if it’s part of the personality of being a doctor, or both.

If I’m not at my desk working, I feel like I’m not doing anything. Do other doctors feel that way? Have I become a workaholic in my middle age?

Is this a bad thing?

It probably is, and I should look to the beginning of a new year to make some changes. Maybe I should go back to running (or, at this point in my life, walking) or finding some humor books I enjoy and reading them. The old standby of going on a vacation is kind of limited right now.

I’ve been an attending physician for 24 years now, which is still hard to believe. My retirement isn’t (hopefully) anytime soon, but is coming up faster than it seems. If I don’t relearn to relax by then, when will I?
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

During my usual 2 weeks off over the holidays I did my usual stuff – taxes, read journals, do CME, review legal cases that have come in, hang out with my family, nap with my dogs.

Somewhere in that stretch of time off. I run out of things to do, and that’s when I have to confront an odd truth: I’ve forgotten how to relax.

In medical school and residency I certainly could enjoy the rare weekend time off. I’d watch sports, go running, do things with friends.

But now it’s a different world. My friends, while still people I enjoy, are on the other end of a computer, far away. My interest in sports and movies waned years ago, and I avoid televisions as part of my aversion to the news. Even the books I used to enjoy, such as the late Clive Cussler’s, don’t hold my attention anymore. If I’m going to read anything it’s going to be humor, because the medical field is serious enough as it is.

The bottom line is that it’s hard for me to relax and “do nothing” anymore. I don’t know if that’s just me, or if it’s part of the personality of being a doctor, or both.

If I’m not at my desk working, I feel like I’m not doing anything. Do other doctors feel that way? Have I become a workaholic in my middle age?

Is this a bad thing?

It probably is, and I should look to the beginning of a new year to make some changes. Maybe I should go back to running (or, at this point in my life, walking) or finding some humor books I enjoy and reading them. The old standby of going on a vacation is kind of limited right now.

I’ve been an attending physician for 24 years now, which is still hard to believe. My retirement isn’t (hopefully) anytime soon, but is coming up faster than it seems. If I don’t relearn to relax by then, when will I?
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

During my usual 2 weeks off over the holidays I did my usual stuff – taxes, read journals, do CME, review legal cases that have come in, hang out with my family, nap with my dogs.

Somewhere in that stretch of time off. I run out of things to do, and that’s when I have to confront an odd truth: I’ve forgotten how to relax.

In medical school and residency I certainly could enjoy the rare weekend time off. I’d watch sports, go running, do things with friends.

But now it’s a different world. My friends, while still people I enjoy, are on the other end of a computer, far away. My interest in sports and movies waned years ago, and I avoid televisions as part of my aversion to the news. Even the books I used to enjoy, such as the late Clive Cussler’s, don’t hold my attention anymore. If I’m going to read anything it’s going to be humor, because the medical field is serious enough as it is.

The bottom line is that it’s hard for me to relax and “do nothing” anymore. I don’t know if that’s just me, or if it’s part of the personality of being a doctor, or both.

If I’m not at my desk working, I feel like I’m not doing anything. Do other doctors feel that way? Have I become a workaholic in my middle age?

Is this a bad thing?

It probably is, and I should look to the beginning of a new year to make some changes. Maybe I should go back to running (or, at this point in my life, walking) or finding some humor books I enjoy and reading them. The old standby of going on a vacation is kind of limited right now.

I’ve been an attending physician for 24 years now, which is still hard to believe. My retirement isn’t (hopefully) anytime soon, but is coming up faster than it seems. If I don’t relearn to relax by then, when will I?
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“I am capable and ready to begin.”

Sounds trite, doesn’t it? What slush pile did that come from?

Actually, it was the closing sentence of the 1988 “personal statement” I wrote for my medical school applications. (I applied to something like 25 schools, maybe more.) Come to think of it, I suspect my father came up with that line.

Have you read your personal statement since you became an attending? It’s like a letter from an alternate universe, where you weren’t a doctor, weren’t sure you’d ever be one, and were trying very hard to sound confident in the face of an uncertain future.

Mine began in a melodramatic way, emphasizing what I’d seen as an emergency department volunteer. When I wrote it I thought I’d be an ED doc, and never imagined that years later I’d be doing something entirely different – and loving it.

Having the opportunity to go back and talk to our younger selves is a common trope in movies, but in real life reading something like this is as close as it gets. But it’s still neat. It brings back not who you are, but who you were. Reminds you why you wanted to be a doctor, when you were younger, probably more naive, and felt medicine was a calling, not a job.

Do you still feel that way, after years of paperwork, insurance games, a mortgage, a family, defensive medicine, your own health changes, and all the other things life and the often-jaded medical field bring?

I hope the answer is still yes.

On my first day at Creighton Medical School, our dean – the late William L. Pancoe, PhD – gave us a “go get ‘em!” speech. His main theme was that we should “wear sneakers and hit the ground running” on day 1, because otherwise we’d never catch up. But he also told us to remember and hold on to the feeling we had when we got our first medical school acceptance letter. That feeling of relief, joy, the realization that we’d been given a chance to make our dream come true. He told us that feeling might be all that would get us through the long nights of studying, the occasional failures, the self-doubts, and all the other things in the 4 years to come.

Dean Pancoe, you were absolutely right. Today I’m older than you were when you gave us that speech. My only additions would be:

1. Don’t just hold onto that feeling for medical school, but for life.

2. Always keep one copy of your personal statement (even if in your picture you were wearing hideous 1980s-style glasses, like mine). Keep it in your work desk, not in the bottom of a filing cabinet or scrapbook. Read it at least once a year. It’ll take maybe 2 minutes. You have that much time to spare.

Because it’s not just the young who can learn from the wisdom of the old. The older can learn, and be reminded of, many good things from the young. Even if that younger person is you.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“I am capable and ready to begin.”

Sounds trite, doesn’t it? What slush pile did that come from?

Actually, it was the closing sentence of the 1988 “personal statement” I wrote for my medical school applications. (I applied to something like 25 schools, maybe more.) Come to think of it, I suspect my father came up with that line.

Have you read your personal statement since you became an attending? It’s like a letter from an alternate universe, where you weren’t a doctor, weren’t sure you’d ever be one, and were trying very hard to sound confident in the face of an uncertain future.

Mine began in a melodramatic way, emphasizing what I’d seen as an emergency department volunteer. When I wrote it I thought I’d be an ED doc, and never imagined that years later I’d be doing something entirely different – and loving it.

Having the opportunity to go back and talk to our younger selves is a common trope in movies, but in real life reading something like this is as close as it gets. But it’s still neat. It brings back not who you are, but who you were. Reminds you why you wanted to be a doctor, when you were younger, probably more naive, and felt medicine was a calling, not a job.

Do you still feel that way, after years of paperwork, insurance games, a mortgage, a family, defensive medicine, your own health changes, and all the other things life and the often-jaded medical field bring?

I hope the answer is still yes.

On my first day at Creighton Medical School, our dean – the late William L. Pancoe, PhD – gave us a “go get ‘em!” speech. His main theme was that we should “wear sneakers and hit the ground running” on day 1, because otherwise we’d never catch up. But he also told us to remember and hold on to the feeling we had when we got our first medical school acceptance letter. That feeling of relief, joy, the realization that we’d been given a chance to make our dream come true. He told us that feeling might be all that would get us through the long nights of studying, the occasional failures, the self-doubts, and all the other things in the 4 years to come.

Dean Pancoe, you were absolutely right. Today I’m older than you were when you gave us that speech. My only additions would be:

1. Don’t just hold onto that feeling for medical school, but for life.

2. Always keep one copy of your personal statement (even if in your picture you were wearing hideous 1980s-style glasses, like mine). Keep it in your work desk, not in the bottom of a filing cabinet or scrapbook. Read it at least once a year. It’ll take maybe 2 minutes. You have that much time to spare.

Because it’s not just the young who can learn from the wisdom of the old. The older can learn, and be reminded of, many good things from the young. Even if that younger person is you.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“I am capable and ready to begin.”

Sounds trite, doesn’t it? What slush pile did that come from?

Actually, it was the closing sentence of the 1988 “personal statement” I wrote for my medical school applications. (I applied to something like 25 schools, maybe more.) Come to think of it, I suspect my father came up with that line.

Have you read your personal statement since you became an attending? It’s like a letter from an alternate universe, where you weren’t a doctor, weren’t sure you’d ever be one, and were trying very hard to sound confident in the face of an uncertain future.

Mine began in a melodramatic way, emphasizing what I’d seen as an emergency department volunteer. When I wrote it I thought I’d be an ED doc, and never imagined that years later I’d be doing something entirely different – and loving it.

Having the opportunity to go back and talk to our younger selves is a common trope in movies, but in real life reading something like this is as close as it gets. But it’s still neat. It brings back not who you are, but who you were. Reminds you why you wanted to be a doctor, when you were younger, probably more naive, and felt medicine was a calling, not a job.

Do you still feel that way, after years of paperwork, insurance games, a mortgage, a family, defensive medicine, your own health changes, and all the other things life and the often-jaded medical field bring?

I hope the answer is still yes.

On my first day at Creighton Medical School, our dean – the late William L. Pancoe, PhD – gave us a “go get ‘em!” speech. His main theme was that we should “wear sneakers and hit the ground running” on day 1, because otherwise we’d never catch up. But he also told us to remember and hold on to the feeling we had when we got our first medical school acceptance letter. That feeling of relief, joy, the realization that we’d been given a chance to make our dream come true. He told us that feeling might be all that would get us through the long nights of studying, the occasional failures, the self-doubts, and all the other things in the 4 years to come.

Dean Pancoe, you were absolutely right. Today I’m older than you were when you gave us that speech. My only additions would be:

1. Don’t just hold onto that feeling for medical school, but for life.

2. Always keep one copy of your personal statement (even if in your picture you were wearing hideous 1980s-style glasses, like mine). Keep it in your work desk, not in the bottom of a filing cabinet or scrapbook. Read it at least once a year. It’ll take maybe 2 minutes. You have that much time to spare.

Because it’s not just the young who can learn from the wisdom of the old. The older can learn, and be reminded of, many good things from the young. Even if that younger person is you.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Phoenix has only a few months each year to use my hot tub, so winter is when I catch up on a lot of my reading. Recently I was reading the November Lancet, which had some interesting statistics about migraine.

• It’s the second leading cause (behind back pain) of years lived with disability.
• There are 10 million people with migraines in the United Kingdom (population roughly 70 million).
• In the last 5 years, migraine use of emergency rooms has increased 14%.
• According to the U.K. National Health Service, over 16,000 ER visits for migraine could be avoided.

These are compelling statistics, and probably (taking into account population differences) similar to numbers here in the United States or Canada.

Like all neurologists, I see my share of migraine.

Like many neurologists, I also get migraines. Not many, maybe 2-3 per month, effectively treated with a triptan. So I have a decent understanding that they aren’t pleasant.

Fortunately, migraine advances have been impressive, with seven new CGRP drugs in the last 3 years, bringing successful treatment closer for many.

But the problem is far from solved, a point that was driven home yesterday.

I awoke early yesterday morning with a migraine, and took an Imitrex. But instead of feeling better in an hour, it kept worsening until I was literally disabled by it. I took some Excedrin Migraine. The last time I had a migraine this bad was in 1998, during my fellowship, and my attending had to drive me home (thanks, Joe).

It was showing no signs of letting up. I thought about going to emergency department. After all, aren’t we trained for that when we hear “worst headache of my life?” but figured it was more likely just a migraine, and didn’t want to bog down my ED colleagues in the midst of another COVID-19 wave.

I took another Imitrex. I found a sample of Ubrelvy that I’d brought home out of curiosity, and took that, too. I think I have an old, nearly empty, bottle of Norco, somewhere, from a 2014 dental surgery, but was too photophobic to go looking for it (if I still have it at all).

I lay down in bed under the ceiling fan, and somehow fell asleep.

When I woke about 90 minutes later it was gone, like a switch had been flipped. Maybe it was all, or just one of, the meds I’d taken. I’ll never know. I could now resume my regularly scheduled program.

The migraine had cost me 7 hours. Like most small business owners, I’m trying to get all the year-end paperwork wrapped up, in addition to reviewing cases, writing up reports, and spending time with my family. So none of that happened that Saturday morning. If I’d had to see patients that morning there’s no way I could have done it.

Fortunately, as I said, that’s only the second time that’s happened to me, and it’s been 25 years since the last one.

But I’m lucky. There are those who have them far more frequently, limiting their ability to work, raise families, spend time with friends. … Have a life.

Migraine is far from a deadly disease. In neurology we treat far worse conditions. But in sheer numbers migraine affects far more people, and (indirectly) an even larger group of coworkers, parents, friends, and children who have to cover unpredictably when the other person is out with one.

For all of them, improved migraine treatment approaches can’t come soon enough.

Phoenix has only a few months each year to use my hot tub, so winter is when I catch up on a lot of my reading. Recently I was reading the November Lancet, which had some interesting statistics about migraine.

• It’s the second leading cause (behind back pain) of years lived with disability.
• There are 10 million people with migraines in the United Kingdom (population roughly 70 million).
• In the last 5 years, migraine use of emergency rooms has increased 14%.
• According to the U.K. National Health Service, over 16,000 ER visits for migraine could be avoided.

These are compelling statistics, and probably (taking into account population differences) similar to numbers here in the United States or Canada.

Like all neurologists, I see my share of migraine.

Like many neurologists, I also get migraines. Not many, maybe 2-3 per month, effectively treated with a triptan. So I have a decent understanding that they aren’t pleasant.

Fortunately, migraine advances have been impressive, with seven new CGRP drugs in the last 3 years, bringing successful treatment closer for many.

But the problem is far from solved, a point that was driven home yesterday.

I awoke early yesterday morning with a migraine, and took an Imitrex. But instead of feeling better in an hour, it kept worsening until I was literally disabled by it. I took some Excedrin Migraine. The last time I had a migraine this bad was in 1998, during my fellowship, and my attending had to drive me home (thanks, Joe).

It was showing no signs of letting up. I thought about going to emergency department. After all, aren’t we trained for that when we hear “worst headache of my life?” but figured it was more likely just a migraine, and didn’t want to bog down my ED colleagues in the midst of another COVID-19 wave.

I took another Imitrex. I found a sample of Ubrelvy that I’d brought home out of curiosity, and took that, too. I think I have an old, nearly empty, bottle of Norco, somewhere, from a 2014 dental surgery, but was too photophobic to go looking for it (if I still have it at all).

I lay down in bed under the ceiling fan, and somehow fell asleep.

When I woke about 90 minutes later it was gone, like a switch had been flipped. Maybe it was all, or just one of, the meds I’d taken. I’ll never know. I could now resume my regularly scheduled program.

The migraine had cost me 7 hours. Like most small business owners, I’m trying to get all the year-end paperwork wrapped up, in addition to reviewing cases, writing up reports, and spending time with my family. So none of that happened that Saturday morning. If I’d had to see patients that morning there’s no way I could have done it.

Fortunately, as I said, that’s only the second time that’s happened to me, and it’s been 25 years since the last one.

But I’m lucky. There are those who have them far more frequently, limiting their ability to work, raise families, spend time with friends. … Have a life.

Migraine is far from a deadly disease. In neurology we treat far worse conditions. But in sheer numbers migraine affects far more people, and (indirectly) an even larger group of coworkers, parents, friends, and children who have to cover unpredictably when the other person is out with one.

For all of them, improved migraine treatment approaches can’t come soon enough.

Phoenix has only a few months each year to use my hot tub, so winter is when I catch up on a lot of my reading. Recently I was reading the November Lancet, which had some interesting statistics about migraine.

• It’s the second leading cause (behind back pain) of years lived with disability.
• There are 10 million people with migraines in the United Kingdom (population roughly 70 million).
• In the last 5 years, migraine use of emergency rooms has increased 14%.
• According to the U.K. National Health Service, over 16,000 ER visits for migraine could be avoided.

These are compelling statistics, and probably (taking into account population differences) similar to numbers here in the United States or Canada.

Like all neurologists, I see my share of migraine.

Like many neurologists, I also get migraines. Not many, maybe 2-3 per month, effectively treated with a triptan. So I have a decent understanding that they aren’t pleasant.

Fortunately, migraine advances have been impressive, with seven new CGRP drugs in the last 3 years, bringing successful treatment closer for many.

But the problem is far from solved, a point that was driven home yesterday.

I awoke early yesterday morning with a migraine, and took an Imitrex. But instead of feeling better in an hour, it kept worsening until I was literally disabled by it. I took some Excedrin Migraine. The last time I had a migraine this bad was in 1998, during my fellowship, and my attending had to drive me home (thanks, Joe).

It was showing no signs of letting up. I thought about going to emergency department. After all, aren’t we trained for that when we hear “worst headache of my life?” but figured it was more likely just a migraine, and didn’t want to bog down my ED colleagues in the midst of another COVID-19 wave.

I took another Imitrex. I found a sample of Ubrelvy that I’d brought home out of curiosity, and took that, too. I think I have an old, nearly empty, bottle of Norco, somewhere, from a 2014 dental surgery, but was too photophobic to go looking for it (if I still have it at all).

I lay down in bed under the ceiling fan, and somehow fell asleep.

When I woke about 90 minutes later it was gone, like a switch had been flipped. Maybe it was all, or just one of, the meds I’d taken. I’ll never know. I could now resume my regularly scheduled program.

The migraine had cost me 7 hours. Like most small business owners, I’m trying to get all the year-end paperwork wrapped up, in addition to reviewing cases, writing up reports, and spending time with my family. So none of that happened that Saturday morning. If I’d had to see patients that morning there’s no way I could have done it.

Fortunately, as I said, that’s only the second time that’s happened to me, and it’s been 25 years since the last one.

But I’m lucky. There are those who have them far more frequently, limiting their ability to work, raise families, spend time with friends. … Have a life.

Migraine is far from a deadly disease. In neurology we treat far worse conditions. But in sheer numbers migraine affects far more people, and (indirectly) an even larger group of coworkers, parents, friends, and children who have to cover unpredictably when the other person is out with one.

For all of them, improved migraine treatment approaches can’t come soon enough.

I still, on occasion, use Felbatol (felbamate).

Thirty years since its explosive entrance to the market, then even more explosive collapse, it remains, in my opinion, the most effective of the second generation of anti-seizure medications. Arguably, even more effective than any of the third generation, too.

That’s not to say I use a lot of it. I don’t. It’s like handling unstable dynamite. Tremendous power, but also an above-average degree of risk. Even after things hit the fan with it in the mid-90s, I remember one of my epilepsy clinic attendings telling me, “This is a home-run drug. In refractory patients you might see some benefit by adding another agent, but with this one, you could stop their seizures and hit it out of the park.”

Like most neurologists, I use other epilepsy options first and second line. But sometimes you get the patient who’s failed the usual ones. Then I start to think about Felbatol. I explain the situation to the patients and their families and let them make the final decision. I worry and watch labs very closely for a while. I probably have no more than three to five patients on it in the practice. But when it works, it’s amazing stuff.

Now, let’s jump ahead to 2021. The year of Aduhelm (and several similar agents racing up behind it).

None of these drugs are even close to hitting home runs. For that matter, I’m not convinced they’re even able to get a man on base. To stretch my baseball analogy a bit, imagine watching a game by looking only at the RBI and ERA stats changing. The numbers change slightly, but you have no evidence that either team is winning. Which is, after all, the whole point.

And, to some extent, that’s the basis of Aduhelm’s approval, and likely the same standards its competitors will be held to.

Although they treat different conditions, and are chemically unrelated, the similarities between Felbatol and the currently advancing bunch of monoclonal antibody (MAB) agents for Alzheimer’s disease make an interesting contrast.

Unlike Felbatol’s proven efficacy for epilepsy, the current MABs offer minimal statistically significant clinical benefit for Alzheimer’s disease. At the same time the risk of amyloid-related imaging abnormalities (ARIA) and its complications with them is significantly higher than that of either of Felbatol’s known, potentially lethal, idiosyncratic effects.

With those odds, I’m far more willing (as are my patients) to take chances with Felbatol for epilepsy than the current MAB bunch for Alzheimer’s disease. In medicine, every day is an exercise in working through the risks and benefits of each patient’s individual situation.

As I’ve stated before, I’m not in the grandstand rooting for these Alzheimer’s drugs to fail. I’ve lost a few family members, and certainly my share of patients, to dementia. I’d be thrilled, and more than willing to prescribe it, if something truly effective came along for it.

Nor do I take any kind of pleasure in the recent news that, because of Aduhelm’s failings, around 1,000 Biogen employees will lose their jobs. I feel terrible for them, as most had nothing to do with the decision to forge ahead with the product. More may soon follow at other companies working with similar agents.

Here we are, though, going into 2022. I’m still, albeit rarely, writing for Felbatol 30 years after it came to market for one reason: It works. But it seems pretty unlikely that future neurologists in 2052 will say the same about the current crops of MABs for Alzheimer’s disease.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I still, on occasion, use Felbatol (felbamate).

Thirty years since its explosive entrance to the market, then even more explosive collapse, it remains, in my opinion, the most effective of the second generation of anti-seizure medications. Arguably, even more effective than any of the third generation, too.

That’s not to say I use a lot of it. I don’t. It’s like handling unstable dynamite. Tremendous power, but also an above-average degree of risk. Even after things hit the fan with it in the mid-90s, I remember one of my epilepsy clinic attendings telling me, “This is a home-run drug. In refractory patients you might see some benefit by adding another agent, but with this one, you could stop their seizures and hit it out of the park.”

Like most neurologists, I use other epilepsy options first and second line. But sometimes you get the patient who’s failed the usual ones. Then I start to think about Felbatol. I explain the situation to the patients and their families and let them make the final decision. I worry and watch labs very closely for a while. I probably have no more than three to five patients on it in the practice. But when it works, it’s amazing stuff.

Now, let’s jump ahead to 2021. The year of Aduhelm (and several similar agents racing up behind it).

None of these drugs are even close to hitting home runs. For that matter, I’m not convinced they’re even able to get a man on base. To stretch my baseball analogy a bit, imagine watching a game by looking only at the RBI and ERA stats changing. The numbers change slightly, but you have no evidence that either team is winning. Which is, after all, the whole point.

And, to some extent, that’s the basis of Aduhelm’s approval, and likely the same standards its competitors will be held to.

Although they treat different conditions, and are chemically unrelated, the similarities between Felbatol and the currently advancing bunch of monoclonal antibody (MAB) agents for Alzheimer’s disease make an interesting contrast.

Unlike Felbatol’s proven efficacy for epilepsy, the current MABs offer minimal statistically significant clinical benefit for Alzheimer’s disease. At the same time the risk of amyloid-related imaging abnormalities (ARIA) and its complications with them is significantly higher than that of either of Felbatol’s known, potentially lethal, idiosyncratic effects.

With those odds, I’m far more willing (as are my patients) to take chances with Felbatol for epilepsy than the current MAB bunch for Alzheimer’s disease. In medicine, every day is an exercise in working through the risks and benefits of each patient’s individual situation.

As I’ve stated before, I’m not in the grandstand rooting for these Alzheimer’s drugs to fail. I’ve lost a few family members, and certainly my share of patients, to dementia. I’d be thrilled, and more than willing to prescribe it, if something truly effective came along for it.

Nor do I take any kind of pleasure in the recent news that, because of Aduhelm’s failings, around 1,000 Biogen employees will lose their jobs. I feel terrible for them, as most had nothing to do with the decision to forge ahead with the product. More may soon follow at other companies working with similar agents.

Here we are, though, going into 2022. I’m still, albeit rarely, writing for Felbatol 30 years after it came to market for one reason: It works. But it seems pretty unlikely that future neurologists in 2052 will say the same about the current crops of MABs for Alzheimer’s disease.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I still, on occasion, use Felbatol (felbamate).

Thirty years since its explosive entrance to the market, then even more explosive collapse, it remains, in my opinion, the most effective of the second generation of anti-seizure medications. Arguably, even more effective than any of the third generation, too.

That’s not to say I use a lot of it. I don’t. It’s like handling unstable dynamite. Tremendous power, but also an above-average degree of risk. Even after things hit the fan with it in the mid-90s, I remember one of my epilepsy clinic attendings telling me, “This is a home-run drug. In refractory patients you might see some benefit by adding another agent, but with this one, you could stop their seizures and hit it out of the park.”

Like most neurologists, I use other epilepsy options first and second line. But sometimes you get the patient who’s failed the usual ones. Then I start to think about Felbatol. I explain the situation to the patients and their families and let them make the final decision. I worry and watch labs very closely for a while. I probably have no more than three to five patients on it in the practice. But when it works, it’s amazing stuff.

Now, let’s jump ahead to 2021. The year of Aduhelm (and several similar agents racing up behind it).

None of these drugs are even close to hitting home runs. For that matter, I’m not convinced they’re even able to get a man on base. To stretch my baseball analogy a bit, imagine watching a game by looking only at the RBI and ERA stats changing. The numbers change slightly, but you have no evidence that either team is winning. Which is, after all, the whole point.

And, to some extent, that’s the basis of Aduhelm’s approval, and likely the same standards its competitors will be held to.

Although they treat different conditions, and are chemically unrelated, the similarities between Felbatol and the currently advancing bunch of monoclonal antibody (MAB) agents for Alzheimer’s disease make an interesting contrast.

Unlike Felbatol’s proven efficacy for epilepsy, the current MABs offer minimal statistically significant clinical benefit for Alzheimer’s disease. At the same time the risk of amyloid-related imaging abnormalities (ARIA) and its complications with them is significantly higher than that of either of Felbatol’s known, potentially lethal, idiosyncratic effects.

With those odds, I’m far more willing (as are my patients) to take chances with Felbatol for epilepsy than the current MAB bunch for Alzheimer’s disease. In medicine, every day is an exercise in working through the risks and benefits of each patient’s individual situation.

As I’ve stated before, I’m not in the grandstand rooting for these Alzheimer’s drugs to fail. I’ve lost a few family members, and certainly my share of patients, to dementia. I’d be thrilled, and more than willing to prescribe it, if something truly effective came along for it.

Nor do I take any kind of pleasure in the recent news that, because of Aduhelm’s failings, around 1,000 Biogen employees will lose their jobs. I feel terrible for them, as most had nothing to do with the decision to forge ahead with the product. More may soon follow at other companies working with similar agents.

Here we are, though, going into 2022. I’m still, albeit rarely, writing for Felbatol 30 years after it came to market for one reason: It works. But it seems pretty unlikely that future neurologists in 2052 will say the same about the current crops of MABs for Alzheimer’s disease.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.