Hitting a Nerve

I was surprised when the name came up on my hospital census as a new consult.

andresr/Getty Images

Many years ago he’d been one of my attendings in residency. Someone I’d trained under. He’d been patient, almost grandfatherly, in the way he taught residents on his service. Never angry or impatient. I’d genuinely liked him as a person and respected him as a teacher.

And here he was now, a new consult on my daily hospital patient list.

A quick look at his chart brought the irony that I’m the same age now that he was when I worked under him. Time flies.

He didn’t remember me, nor did I expect him to. In my training from 1993 to 1997, I’d only dealt with him directly for a few months here and there. He’d seen a lot of residents come and go over his career.

He was, like me, older now. I wouldn’t have recognized him if I didn’t know the name in advance. He was frail now, seemingly smaller than I remembered, his mind and health damaged by his own neurologic issues.

Like all of us, I’ve taken care of other physicians, but this was the first time I’d encountered one of my former teachers in that role, and felt bad that he was in a situation I really couldn’t do much about.

I wrote some orders and moved on to the next consult, but haven’t stopped thinking about him.

Time comes for all of us sooner or later, though it’s never easy to reflect on. I’d certainly do what I could to help him, but was well aware (as I’m sure he was) that there was only so much I could.

When I came back the next day he’d left. At his own insistence, he wanted us to stop what we were doing and opted to be kept comfortable. It was certainly not an easy choice to make for any of us, but in character with the person and physician I still liked and respected.
 

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

I was surprised when the name came up on my hospital census as a new consult.

andresr/Getty Images

Many years ago he’d been one of my attendings in residency. Someone I’d trained under. He’d been patient, almost grandfatherly, in the way he taught residents on his service. Never angry or impatient. I’d genuinely liked him as a person and respected him as a teacher.

And here he was now, a new consult on my daily hospital patient list.

A quick look at his chart brought the irony that I’m the same age now that he was when I worked under him. Time flies.

He didn’t remember me, nor did I expect him to. In my training from 1993 to 1997, I’d only dealt with him directly for a few months here and there. He’d seen a lot of residents come and go over his career.

He was, like me, older now. I wouldn’t have recognized him if I didn’t know the name in advance. He was frail now, seemingly smaller than I remembered, his mind and health damaged by his own neurologic issues.

Like all of us, I’ve taken care of other physicians, but this was the first time I’d encountered one of my former teachers in that role, and felt bad that he was in a situation I really couldn’t do much about.

I wrote some orders and moved on to the next consult, but haven’t stopped thinking about him.

Time comes for all of us sooner or later, though it’s never easy to reflect on. I’d certainly do what I could to help him, but was well aware (as I’m sure he was) that there was only so much I could.

When I came back the next day he’d left. At his own insistence, he wanted us to stop what we were doing and opted to be kept comfortable. It was certainly not an easy choice to make for any of us, but in character with the person and physician I still liked and respected.
 

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

I was surprised when the name came up on my hospital census as a new consult.

andresr/Getty Images

Many years ago he’d been one of my attendings in residency. Someone I’d trained under. He’d been patient, almost grandfatherly, in the way he taught residents on his service. Never angry or impatient. I’d genuinely liked him as a person and respected him as a teacher.

And here he was now, a new consult on my daily hospital patient list.

A quick look at his chart brought the irony that I’m the same age now that he was when I worked under him. Time flies.

He didn’t remember me, nor did I expect him to. In my training from 1993 to 1997, I’d only dealt with him directly for a few months here and there. He’d seen a lot of residents come and go over his career.

He was, like me, older now. I wouldn’t have recognized him if I didn’t know the name in advance. He was frail now, seemingly smaller than I remembered, his mind and health damaged by his own neurologic issues.

Like all of us, I’ve taken care of other physicians, but this was the first time I’d encountered one of my former teachers in that role, and felt bad that he was in a situation I really couldn’t do much about.

I wrote some orders and moved on to the next consult, but haven’t stopped thinking about him.

Time comes for all of us sooner or later, though it’s never easy to reflect on. I’d certainly do what I could to help him, but was well aware (as I’m sure he was) that there was only so much I could.

When I came back the next day he’d left. At his own insistence, he wanted us to stop what we were doing and opted to be kept comfortable. It was certainly not an easy choice to make for any of us, but in character with the person and physician I still liked and respected.
 

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

In 1982, I went to my first concert. It was Rush, on their “Signals” tour, and I loved it. In fact, I went back and saw them again about a year later. I bought a concert T-shirt at the first one. I still have it somewhere, though I am pretty sure it hasn’t fit me in years.

Weatherman90/Wikimedia Commons/CC BY 3.0

I loved their music before the concert, enjoyed it even more afterwards, and still do. Their albums are all on my computer and phone, and part of the daily soundtrack of my life when working at my desk, driving, and walking (I’m trying to fit back in the shirt).

On Jan. 7, 2020, Neil Peart, the trio’s remarkably gifted drummer, died of a neurologic disease.

According to the news, he had a glioblastoma multiforme, a tumor terrifying for its aggressiveness, difficulty of treatment, and lack of preventable risk factors.

The cost of neurologic disease is terrible. Glioblastoma multiforme, unfortunately, is far from rare, nor is it the only one. In recent times, entertainers afflicted with neurologic disease have included Neil Diamond, Linda Ronstadt, Peter Falk, Glen Campbell, Charlton Heston, Gene Siskel, Michael J. Fox, Stephen Hillenburg, Teri Garr, Annette Funicello, Robin Williams, Dudley Moore, and most recently Ozzy Osbourne.

That’s a pretty short list, too, far from all-encompassing. The majority of people with these disorders won’t be in the news. Their everyday struggles, stories, and losses are known only to family, friends, and the medical team doing its best to help.

Medical technology advances every year. In the 22 years since I began practicing, we’ve made remarkable strides in some areas – multiple sclerosis, for example. But our work in so many other areas is nowhere close. The increasing knowledge as to the mechanisms and causes of Alzheimer’s disease have, to date, failed to translate into treatment success.

That’s not to say we should give up. Far from it. Our species has gotten where we are by always wanting to get over the next hill. Initial failures will always outnumber successes. But when you’re a doctor dealing with the very real human cost of neurologic disease, that’s not much consolation. And it’s far less so for the patients and families affected who come to us for help.

We use terms like “burden” or “cost” to discuss the financial aspects of illness, but they often don’t seem adequate to describe the real effects. The emotional damages. The gifted musicians and loved family members lost. Family members struggling with the difficult role of being care givers.

Neurologic disease doesn’t discriminate against anyone, regardless of age, fame, or talent. I’ll stay here and do my best for all of them who come to me. I’m certainly not on the front line of research. That’s incredibly important, but I’ll leave it to others. My work is where the patients are every day.

Thank you for the music, Neil.

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

In 1982, I went to my first concert. It was Rush, on their “Signals” tour, and I loved it. In fact, I went back and saw them again about a year later. I bought a concert T-shirt at the first one. I still have it somewhere, though I am pretty sure it hasn’t fit me in years.

Weatherman90/Wikimedia Commons/CC BY 3.0

I loved their music before the concert, enjoyed it even more afterwards, and still do. Their albums are all on my computer and phone, and part of the daily soundtrack of my life when working at my desk, driving, and walking (I’m trying to fit back in the shirt).

On Jan. 7, 2020, Neil Peart, the trio’s remarkably gifted drummer, died of a neurologic disease.

According to the news, he had a glioblastoma multiforme, a tumor terrifying for its aggressiveness, difficulty of treatment, and lack of preventable risk factors.

The cost of neurologic disease is terrible. Glioblastoma multiforme, unfortunately, is far from rare, nor is it the only one. In recent times, entertainers afflicted with neurologic disease have included Neil Diamond, Linda Ronstadt, Peter Falk, Glen Campbell, Charlton Heston, Gene Siskel, Michael J. Fox, Stephen Hillenburg, Teri Garr, Annette Funicello, Robin Williams, Dudley Moore, and most recently Ozzy Osbourne.

That’s a pretty short list, too, far from all-encompassing. The majority of people with these disorders won’t be in the news. Their everyday struggles, stories, and losses are known only to family, friends, and the medical team doing its best to help.

Medical technology advances every year. In the 22 years since I began practicing, we’ve made remarkable strides in some areas – multiple sclerosis, for example. But our work in so many other areas is nowhere close. The increasing knowledge as to the mechanisms and causes of Alzheimer’s disease have, to date, failed to translate into treatment success.

That’s not to say we should give up. Far from it. Our species has gotten where we are by always wanting to get over the next hill. Initial failures will always outnumber successes. But when you’re a doctor dealing with the very real human cost of neurologic disease, that’s not much consolation. And it’s far less so for the patients and families affected who come to us for help.

We use terms like “burden” or “cost” to discuss the financial aspects of illness, but they often don’t seem adequate to describe the real effects. The emotional damages. The gifted musicians and loved family members lost. Family members struggling with the difficult role of being care givers.

Neurologic disease doesn’t discriminate against anyone, regardless of age, fame, or talent. I’ll stay here and do my best for all of them who come to me. I’m certainly not on the front line of research. That’s incredibly important, but I’ll leave it to others. My work is where the patients are every day.

Thank you for the music, Neil.

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

In 1982, I went to my first concert. It was Rush, on their “Signals” tour, and I loved it. In fact, I went back and saw them again about a year later. I bought a concert T-shirt at the first one. I still have it somewhere, though I am pretty sure it hasn’t fit me in years.

Weatherman90/Wikimedia Commons/CC BY 3.0

I loved their music before the concert, enjoyed it even more afterwards, and still do. Their albums are all on my computer and phone, and part of the daily soundtrack of my life when working at my desk, driving, and walking (I’m trying to fit back in the shirt).

On Jan. 7, 2020, Neil Peart, the trio’s remarkably gifted drummer, died of a neurologic disease.

According to the news, he had a glioblastoma multiforme, a tumor terrifying for its aggressiveness, difficulty of treatment, and lack of preventable risk factors.

The cost of neurologic disease is terrible. Glioblastoma multiforme, unfortunately, is far from rare, nor is it the only one. In recent times, entertainers afflicted with neurologic disease have included Neil Diamond, Linda Ronstadt, Peter Falk, Glen Campbell, Charlton Heston, Gene Siskel, Michael J. Fox, Stephen Hillenburg, Teri Garr, Annette Funicello, Robin Williams, Dudley Moore, and most recently Ozzy Osbourne.

That’s a pretty short list, too, far from all-encompassing. The majority of people with these disorders won’t be in the news. Their everyday struggles, stories, and losses are known only to family, friends, and the medical team doing its best to help.

Medical technology advances every year. In the 22 years since I began practicing, we’ve made remarkable strides in some areas – multiple sclerosis, for example. But our work in so many other areas is nowhere close. The increasing knowledge as to the mechanisms and causes of Alzheimer’s disease have, to date, failed to translate into treatment success.

That’s not to say we should give up. Far from it. Our species has gotten where we are by always wanting to get over the next hill. Initial failures will always outnumber successes. But when you’re a doctor dealing with the very real human cost of neurologic disease, that’s not much consolation. And it’s far less so for the patients and families affected who come to us for help.

We use terms like “burden” or “cost” to discuss the financial aspects of illness, but they often don’t seem adequate to describe the real effects. The emotional damages. The gifted musicians and loved family members lost. Family members struggling with the difficult role of being care givers.

Neurologic disease doesn’t discriminate against anyone, regardless of age, fame, or talent. I’ll stay here and do my best for all of them who come to me. I’m certainly not on the front line of research. That’s incredibly important, but I’ll leave it to others. My work is where the patients are every day.

Thank you for the music, Neil.

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

Three months is how long I’ll leave a magazine out in my waiting room. When its lobby lifespan is up, I’ll usually recycle it, though sometimes will take it home to read myself when I have down time.

pinkomelet/Thinkstock

Leafing through an accumulated pile of them over the recent holiday break, I was struck by how many carry ads for questionable “cures”: magnetic bracelets for headaches, copper-based topical creams that claim to cure diabetic neuropathy. Another was from a company with something that looks like a standard tanning bed advertising that it has special lights to “alternatively treat cancer.”

How on Earth is this legal?

Seriously. Since college I’ve been through 4 years of medical school, another 5 combined of residency and fellowship, and now 21 years of frontline neurology experience. And if, after all that, I were to start marketing such horse hockey as a cure for anything (besides my wallet), I’d be hounded by the Food and Drug Administration and state board and probably driven out of practice.

Yet, people with no “real” (science-based) medical treatment experience are free to market this stuff to a public who, for the most part, don’t have the training, knowledge, or experience to know it’s a crock.

I’m sure some of the people selling this stuff really believe they’re helping. Admittedly, there are a lot of things we don’t know in medicine. But anything that’s making such claims should have real evidence – like a large double-blind, placebo-controlled trial – behind it. Not anecdotal reports, small uncontrolled trials, and patient testimonials. The placebo effect is remarkably strong.

There are also some selling this stuff who are less than scrupulous. They’ll claim to have good intentions, but are well aware they’re bilking people – often desperate – out of their savings. They’re no better than the doctors who make headlines for Medicare and insurance fraud by performing unnecessary surgeries and billing for medications that weren’t given.

Either way, the point is the same. Unproven treatments are just that – unproven – and shouldn’t be marketed as effective ones. If it works, let the evidence prove it. But if it doesn’t, no one should be promoting it to anyone, regardless of how long (and where) they went to school.

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

Three months is how long I’ll leave a magazine out in my waiting room. When its lobby lifespan is up, I’ll usually recycle it, though sometimes will take it home to read myself when I have down time.

pinkomelet/Thinkstock

Leafing through an accumulated pile of them over the recent holiday break, I was struck by how many carry ads for questionable “cures”: magnetic bracelets for headaches, copper-based topical creams that claim to cure diabetic neuropathy. Another was from a company with something that looks like a standard tanning bed advertising that it has special lights to “alternatively treat cancer.”

How on Earth is this legal?

Seriously. Since college I’ve been through 4 years of medical school, another 5 combined of residency and fellowship, and now 21 years of frontline neurology experience. And if, after all that, I were to start marketing such horse hockey as a cure for anything (besides my wallet), I’d be hounded by the Food and Drug Administration and state board and probably driven out of practice.

Yet, people with no “real” (science-based) medical treatment experience are free to market this stuff to a public who, for the most part, don’t have the training, knowledge, or experience to know it’s a crock.

I’m sure some of the people selling this stuff really believe they’re helping. Admittedly, there are a lot of things we don’t know in medicine. But anything that’s making such claims should have real evidence – like a large double-blind, placebo-controlled trial – behind it. Not anecdotal reports, small uncontrolled trials, and patient testimonials. The placebo effect is remarkably strong.

There are also some selling this stuff who are less than scrupulous. They’ll claim to have good intentions, but are well aware they’re bilking people – often desperate – out of their savings. They’re no better than the doctors who make headlines for Medicare and insurance fraud by performing unnecessary surgeries and billing for medications that weren’t given.

Either way, the point is the same. Unproven treatments are just that – unproven – and shouldn’t be marketed as effective ones. If it works, let the evidence prove it. But if it doesn’t, no one should be promoting it to anyone, regardless of how long (and where) they went to school.

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

Three months is how long I’ll leave a magazine out in my waiting room. When its lobby lifespan is up, I’ll usually recycle it, though sometimes will take it home to read myself when I have down time.

pinkomelet/Thinkstock

Leafing through an accumulated pile of them over the recent holiday break, I was struck by how many carry ads for questionable “cures”: magnetic bracelets for headaches, copper-based topical creams that claim to cure diabetic neuropathy. Another was from a company with something that looks like a standard tanning bed advertising that it has special lights to “alternatively treat cancer.”

How on Earth is this legal?

Seriously. Since college I’ve been through 4 years of medical school, another 5 combined of residency and fellowship, and now 21 years of frontline neurology experience. And if, after all that, I were to start marketing such horse hockey as a cure for anything (besides my wallet), I’d be hounded by the Food and Drug Administration and state board and probably driven out of practice.

Yet, people with no “real” (science-based) medical treatment experience are free to market this stuff to a public who, for the most part, don’t have the training, knowledge, or experience to know it’s a crock.

I’m sure some of the people selling this stuff really believe they’re helping. Admittedly, there are a lot of things we don’t know in medicine. But anything that’s making such claims should have real evidence – like a large double-blind, placebo-controlled trial – behind it. Not anecdotal reports, small uncontrolled trials, and patient testimonials. The placebo effect is remarkably strong.

There are also some selling this stuff who are less than scrupulous. They’ll claim to have good intentions, but are well aware they’re bilking people – often desperate – out of their savings. They’re no better than the doctors who make headlines for Medicare and insurance fraud by performing unnecessary surgeries and billing for medications that weren’t given.

Either way, the point is the same. Unproven treatments are just that – unproven – and shouldn’t be marketed as effective ones. If it works, let the evidence prove it. But if it doesn’t, no one should be promoting it to anyone, regardless of how long (and where) they went to school.

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

Years ago, I wrote about patient poaching – the practice of stealing another practice’s patients without the patient or other physician realizing what’s going on.

©moodboard/Fotolia.com

This is high on the dirty tricks list of some practices. It’s certainly not illegal, but seems pretty unethical. Fortunately, it’s infrequent (at least where I work), but still occurs.

Recently, I encountered a particularly egregious example.

One of my patients, a nice lady in her 70s, had a syncopal event and landed in a hospital I don’t cover. A neurologist who saw her there did a brain MRI and head/neck MR angiogram, which were fine. A cardiology evaluation was also fine, so she was sent home. The neurologist there told her to follow-up with him at his office.

As my nurse says, “some people just do whatever they’re told, they don’t want to make a doctor angry.” So my patient did, and at the other doctor’s office had a four-limb electromyogram test and nerve conduction study, carotid Dopplers, transcranial Dopplers, and an EEG. He also made changes in her medications.

The first time I found out about it was when the patient scheduled an unrelated procedure, and I got a clearance request to take her off a medication in advance of it. Since I hadn’t started her on the medication (or was even aware she was on it) I refused, saying they’d have to contact the physician who prescribed it.

This got back to the patient, who was under the impression I’d been aware of all this the whole time, and she called the other neurologist to have his records sent to me.

When I got them, I was surprised to find he’d documented that I’d asked him to assume her outpatient care and do these studies for me. I have no recollection of such a conversation, and I would not have agreed to such a thing unless the patient had informed me she was transferring care to him (in which case it’s no longer my concern). Unless I was in a coma at the time this conversation occurred, I’m pretty sure it didn’t happen.

Basically, what the other doctor did was perform a walletectomy (or, in this case insurance-ectomy) on the patient under the guise (to her) that he was doing this as a favor to me.

How do you look yourself in mirror each day when you do stuff like this? Apparently, it’s easier for some doctors than it is for me.

I’ll do my best to keep it that way, too. I can’t change others, but I can do my best to take the high road.
 

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

Years ago, I wrote about patient poaching – the practice of stealing another practice’s patients without the patient or other physician realizing what’s going on.

©moodboard/Fotolia.com

This is high on the dirty tricks list of some practices. It’s certainly not illegal, but seems pretty unethical. Fortunately, it’s infrequent (at least where I work), but still occurs.

Recently, I encountered a particularly egregious example.

One of my patients, a nice lady in her 70s, had a syncopal event and landed in a hospital I don’t cover. A neurologist who saw her there did a brain MRI and head/neck MR angiogram, which were fine. A cardiology evaluation was also fine, so she was sent home. The neurologist there told her to follow-up with him at his office.

As my nurse says, “some people just do whatever they’re told, they don’t want to make a doctor angry.” So my patient did, and at the other doctor’s office had a four-limb electromyogram test and nerve conduction study, carotid Dopplers, transcranial Dopplers, and an EEG. He also made changes in her medications.

The first time I found out about it was when the patient scheduled an unrelated procedure, and I got a clearance request to take her off a medication in advance of it. Since I hadn’t started her on the medication (or was even aware she was on it) I refused, saying they’d have to contact the physician who prescribed it.

This got back to the patient, who was under the impression I’d been aware of all this the whole time, and she called the other neurologist to have his records sent to me.

When I got them, I was surprised to find he’d documented that I’d asked him to assume her outpatient care and do these studies for me. I have no recollection of such a conversation, and I would not have agreed to such a thing unless the patient had informed me she was transferring care to him (in which case it’s no longer my concern). Unless I was in a coma at the time this conversation occurred, I’m pretty sure it didn’t happen.

Basically, what the other doctor did was perform a walletectomy (or, in this case insurance-ectomy) on the patient under the guise (to her) that he was doing this as a favor to me.

How do you look yourself in mirror each day when you do stuff like this? Apparently, it’s easier for some doctors than it is for me.

I’ll do my best to keep it that way, too. I can’t change others, but I can do my best to take the high road.
 

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

Years ago, I wrote about patient poaching – the practice of stealing another practice’s patients without the patient or other physician realizing what’s going on.

©moodboard/Fotolia.com

This is high on the dirty tricks list of some practices. It’s certainly not illegal, but seems pretty unethical. Fortunately, it’s infrequent (at least where I work), but still occurs.

Recently, I encountered a particularly egregious example.

One of my patients, a nice lady in her 70s, had a syncopal event and landed in a hospital I don’t cover. A neurologist who saw her there did a brain MRI and head/neck MR angiogram, which were fine. A cardiology evaluation was also fine, so she was sent home. The neurologist there told her to follow-up with him at his office.

As my nurse says, “some people just do whatever they’re told, they don’t want to make a doctor angry.” So my patient did, and at the other doctor’s office had a four-limb electromyogram test and nerve conduction study, carotid Dopplers, transcranial Dopplers, and an EEG. He also made changes in her medications.

The first time I found out about it was when the patient scheduled an unrelated procedure, and I got a clearance request to take her off a medication in advance of it. Since I hadn’t started her on the medication (or was even aware she was on it) I refused, saying they’d have to contact the physician who prescribed it.

This got back to the patient, who was under the impression I’d been aware of all this the whole time, and she called the other neurologist to have his records sent to me.

When I got them, I was surprised to find he’d documented that I’d asked him to assume her outpatient care and do these studies for me. I have no recollection of such a conversation, and I would not have agreed to such a thing unless the patient had informed me she was transferring care to him (in which case it’s no longer my concern). Unless I was in a coma at the time this conversation occurred, I’m pretty sure it didn’t happen.

Basically, what the other doctor did was perform a walletectomy (or, in this case insurance-ectomy) on the patient under the guise (to her) that he was doing this as a favor to me.

How do you look yourself in mirror each day when you do stuff like this? Apparently, it’s easier for some doctors than it is for me.

I’ll do my best to keep it that way, too. I can’t change others, but I can do my best to take the high road.
 

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

In the Nov. 1, 2019, issue of JAMA Neurology, an editorial argues that it’s time for neurologists to start managing high blood pressure.

GlobalStock/Getty Images

It makes some very valid points: that targeting a systolic blood pressure of less than 120 mm Hg results in lower rates of cardiovascular events and all causes of mortality, that poorly controlled hypertension leads to debilitating neurologic conditions, and that high blood pressure is the most common modifiable risk factor for stroke.

All are strong points. I agree with them and definitely believe that more can and should be done to control hypertension.

The editorial then goes on to say that “first and foremost we are charging neurologists with actively diagnosing hypertension and prescribing medications when appropriate.”

Uh, no. I’m not going to be the one managing hypertension, nor should any outpatient neurologist.

Outpatient hypertension treatment has historically been, and should remain, the province of general practitioners, cardiologists, and nephrologists. Too many cooks, as they say, spoils the broth. I don’t want to be in a situation where two (or more) doctors are simultaneously trying to treat the same condition. On that path lies danger.

This doesn’t mean I ignore blood pressure. On the contrary, I take it (myself) at every patient visit, and put it in my note. In most cases I do nothing further, as nothing further needs to be done. On occasion, though, if it’s concerningly high, I’ll write it down for the patient and direct them to call the physician handling it. I also fax a note about it to that office, and if it’s dangerously high will call the doctor myself.

But try to manage it? No. Elevated readings definitely overlap with my world, but treating them shouldn’t.

The article says that, for some chronic patients, neurologists are their de facto internist. Perhaps for a few, but when a patient calls with concerns about a respiratory ailment, gastrointestinal problem, or other nonneurologic issue, I tell them to call their general practitioner. If they don’t have one I’m happy to give them the names and phone numbers of colleagues who practice that field, or even urgent care and emergency department information if needed. Just because I see them for their neurologic problems doesn’t qualify me to practice another branch of medicine.

Beyond the dangers of having more than one doctor involved, as a specialist it’s not practical for me to know the antihypertensive medications – possibly the largest group of agents on the market, – in detail, with their mechanisms of action, side effects, and contraindications. Yes, I do keep a handful in mind, since they’re needed off label for migraines and tremors, but not in the kind of detail a cardiologist would. I have to keep track of enough medications in my specialty as it is.

I wouldn’t try to handle blood pressure any more than I’d expect a nephrologist to treat epilepsy. It’s just looking for trouble.

Even when covering the hospital, I’ll stay out of that arena. This doesn’t mean I ignore blood pressure in such serious conditions as stroke or posterior reversible encephalopathy syndrome. I’m more than happy to provide guidelines and parameters. But as far as choosing the medications and doses? No.

Like driving, we all have to share the road. We may even be focused on the same journey (or patient). But part of practicing medicine and handling traffic is knowing when to stay in your lane.

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

In the Nov. 1, 2019, issue of JAMA Neurology, an editorial argues that it’s time for neurologists to start managing high blood pressure.

GlobalStock/Getty Images

It makes some very valid points: that targeting a systolic blood pressure of less than 120 mm Hg results in lower rates of cardiovascular events and all causes of mortality, that poorly controlled hypertension leads to debilitating neurologic conditions, and that high blood pressure is the most common modifiable risk factor for stroke.

All are strong points. I agree with them and definitely believe that more can and should be done to control hypertension.

The editorial then goes on to say that “first and foremost we are charging neurologists with actively diagnosing hypertension and prescribing medications when appropriate.”

Uh, no. I’m not going to be the one managing hypertension, nor should any outpatient neurologist.

Outpatient hypertension treatment has historically been, and should remain, the province of general practitioners, cardiologists, and nephrologists. Too many cooks, as they say, spoils the broth. I don’t want to be in a situation where two (or more) doctors are simultaneously trying to treat the same condition. On that path lies danger.

This doesn’t mean I ignore blood pressure. On the contrary, I take it (myself) at every patient visit, and put it in my note. In most cases I do nothing further, as nothing further needs to be done. On occasion, though, if it’s concerningly high, I’ll write it down for the patient and direct them to call the physician handling it. I also fax a note about it to that office, and if it’s dangerously high will call the doctor myself.

But try to manage it? No. Elevated readings definitely overlap with my world, but treating them shouldn’t.

The article says that, for some chronic patients, neurologists are their de facto internist. Perhaps for a few, but when a patient calls with concerns about a respiratory ailment, gastrointestinal problem, or other nonneurologic issue, I tell them to call their general practitioner. If they don’t have one I’m happy to give them the names and phone numbers of colleagues who practice that field, or even urgent care and emergency department information if needed. Just because I see them for their neurologic problems doesn’t qualify me to practice another branch of medicine.

Beyond the dangers of having more than one doctor involved, as a specialist it’s not practical for me to know the antihypertensive medications – possibly the largest group of agents on the market, – in detail, with their mechanisms of action, side effects, and contraindications. Yes, I do keep a handful in mind, since they’re needed off label for migraines and tremors, but not in the kind of detail a cardiologist would. I have to keep track of enough medications in my specialty as it is.

I wouldn’t try to handle blood pressure any more than I’d expect a nephrologist to treat epilepsy. It’s just looking for trouble.

Even when covering the hospital, I’ll stay out of that arena. This doesn’t mean I ignore blood pressure in such serious conditions as stroke or posterior reversible encephalopathy syndrome. I’m more than happy to provide guidelines and parameters. But as far as choosing the medications and doses? No.

Like driving, we all have to share the road. We may even be focused on the same journey (or patient). But part of practicing medicine and handling traffic is knowing when to stay in your lane.

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

In the Nov. 1, 2019, issue of JAMA Neurology, an editorial argues that it’s time for neurologists to start managing high blood pressure.

GlobalStock/Getty Images

It makes some very valid points: that targeting a systolic blood pressure of less than 120 mm Hg results in lower rates of cardiovascular events and all causes of mortality, that poorly controlled hypertension leads to debilitating neurologic conditions, and that high blood pressure is the most common modifiable risk factor for stroke.

All are strong points. I agree with them and definitely believe that more can and should be done to control hypertension.

The editorial then goes on to say that “first and foremost we are charging neurologists with actively diagnosing hypertension and prescribing medications when appropriate.”

Uh, no. I’m not going to be the one managing hypertension, nor should any outpatient neurologist.

Outpatient hypertension treatment has historically been, and should remain, the province of general practitioners, cardiologists, and nephrologists. Too many cooks, as they say, spoils the broth. I don’t want to be in a situation where two (or more) doctors are simultaneously trying to treat the same condition. On that path lies danger.

This doesn’t mean I ignore blood pressure. On the contrary, I take it (myself) at every patient visit, and put it in my note. In most cases I do nothing further, as nothing further needs to be done. On occasion, though, if it’s concerningly high, I’ll write it down for the patient and direct them to call the physician handling it. I also fax a note about it to that office, and if it’s dangerously high will call the doctor myself.

But try to manage it? No. Elevated readings definitely overlap with my world, but treating them shouldn’t.

The article says that, for some chronic patients, neurologists are their de facto internist. Perhaps for a few, but when a patient calls with concerns about a respiratory ailment, gastrointestinal problem, or other nonneurologic issue, I tell them to call their general practitioner. If they don’t have one I’m happy to give them the names and phone numbers of colleagues who practice that field, or even urgent care and emergency department information if needed. Just because I see them for their neurologic problems doesn’t qualify me to practice another branch of medicine.

Beyond the dangers of having more than one doctor involved, as a specialist it’s not practical for me to know the antihypertensive medications – possibly the largest group of agents on the market, – in detail, with their mechanisms of action, side effects, and contraindications. Yes, I do keep a handful in mind, since they’re needed off label for migraines and tremors, but not in the kind of detail a cardiologist would. I have to keep track of enough medications in my specialty as it is.

I wouldn’t try to handle blood pressure any more than I’d expect a nephrologist to treat epilepsy. It’s just looking for trouble.

Even when covering the hospital, I’ll stay out of that arena. This doesn’t mean I ignore blood pressure in such serious conditions as stroke or posterior reversible encephalopathy syndrome. I’m more than happy to provide guidelines and parameters. But as far as choosing the medications and doses? No.

Like driving, we all have to share the road. We may even be focused on the same journey (or patient). But part of practicing medicine and handling traffic is knowing when to stay in your lane.

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

I recently had an unusual patient call. A woman I’ve seen for many years for migraines called to tell me her son was being hospitalized for appendicitis. He was scheduled for surgery in the morning.

pinkomelet/Thinkstock

She called because she’d recently seen a news report about how people without an appendix may have a higher rate of Parkinson’s disease as they age. She was, understandably, concerned about the long-term risks the procedure could pose.

On the surface, as a medical professional, the call sounds frivolous and silly. The risks of untreated acute appendicitis, such as peritonitis and death, are pretty well documented. Surgery offers the best possibility for a cure without recurrence. Compared with the long-term, uncertain, risk of Parkinson’s disease, the benefit-to-risk ratio and options are pretty obvious.

The question of the GI tract’s involvement in neurologic diseases is a legitimate one that needs to be answered. It may provide new insight into their causes and potential treatments. The research she brought up raises some interesting points.

But that doesn’t mean there should be any delay in treating something as easily cured – and potentially serious – as acute appendicitis.

My patient called to ask questions, and I have no issue with that. To someone with no medical training, it’s a legitimate concern. But not everyone will call to ask.

This is a hazard of early stages of medical research making it into the lay press. It may be right, it may be wrong, but it’s too early to tell either way. We have years of training to help us recognize the uncertainties of preliminary data, but the general public doesn’t. Stories like this create interest and raise questions in the medical literature and fear and anxiety in the lay press.

I’m a strong supporter of freedom of the press, and certainly they have every right to air or publish such stories. But they should also be put in perspective at the beginning, not the bottom, and make it clear the findings are far from proven.
 

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

I recently had an unusual patient call. A woman I’ve seen for many years for migraines called to tell me her son was being hospitalized for appendicitis. He was scheduled for surgery in the morning.

pinkomelet/Thinkstock

She called because she’d recently seen a news report about how people without an appendix may have a higher rate of Parkinson’s disease as they age. She was, understandably, concerned about the long-term risks the procedure could pose.

On the surface, as a medical professional, the call sounds frivolous and silly. The risks of untreated acute appendicitis, such as peritonitis and death, are pretty well documented. Surgery offers the best possibility for a cure without recurrence. Compared with the long-term, uncertain, risk of Parkinson’s disease, the benefit-to-risk ratio and options are pretty obvious.

The question of the GI tract’s involvement in neurologic diseases is a legitimate one that needs to be answered. It may provide new insight into their causes and potential treatments. The research she brought up raises some interesting points.

But that doesn’t mean there should be any delay in treating something as easily cured – and potentially serious – as acute appendicitis.

My patient called to ask questions, and I have no issue with that. To someone with no medical training, it’s a legitimate concern. But not everyone will call to ask.

This is a hazard of early stages of medical research making it into the lay press. It may be right, it may be wrong, but it’s too early to tell either way. We have years of training to help us recognize the uncertainties of preliminary data, but the general public doesn’t. Stories like this create interest and raise questions in the medical literature and fear and anxiety in the lay press.

I’m a strong supporter of freedom of the press, and certainly they have every right to air or publish such stories. But they should also be put in perspective at the beginning, not the bottom, and make it clear the findings are far from proven.
 

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

I recently had an unusual patient call. A woman I’ve seen for many years for migraines called to tell me her son was being hospitalized for appendicitis. He was scheduled for surgery in the morning.

pinkomelet/Thinkstock

She called because she’d recently seen a news report about how people without an appendix may have a higher rate of Parkinson’s disease as they age. She was, understandably, concerned about the long-term risks the procedure could pose.

On the surface, as a medical professional, the call sounds frivolous and silly. The risks of untreated acute appendicitis, such as peritonitis and death, are pretty well documented. Surgery offers the best possibility for a cure without recurrence. Compared with the long-term, uncertain, risk of Parkinson’s disease, the benefit-to-risk ratio and options are pretty obvious.

The question of the GI tract’s involvement in neurologic diseases is a legitimate one that needs to be answered. It may provide new insight into their causes and potential treatments. The research she brought up raises some interesting points.

But that doesn’t mean there should be any delay in treating something as easily cured – and potentially serious – as acute appendicitis.

My patient called to ask questions, and I have no issue with that. To someone with no medical training, it’s a legitimate concern. But not everyone will call to ask.

This is a hazard of early stages of medical research making it into the lay press. It may be right, it may be wrong, but it’s too early to tell either way. We have years of training to help us recognize the uncertainties of preliminary data, but the general public doesn’t. Stories like this create interest and raise questions in the medical literature and fear and anxiety in the lay press.

I’m a strong supporter of freedom of the press, and certainly they have every right to air or publish such stories. But they should also be put in perspective at the beginning, not the bottom, and make it clear the findings are far from proven.
 

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

“Why didn’t you see that patient?”

TongRo Images/Thinkstock

The hospitalist on the phone was angry. He’d wanted the patient seen by neurology and cleared for discharge. Apparently, I hadn’t complied.

Actually, that isn’t true. I was on call, so I had dutifully dragged myself in (with the help of some coffee), reviewed the chart, and gone in to see the fellow.

The patient, however, had other ideas. He said he was sick of doctors, didn’t like them, didn’t want to see me, and asked me to leave. So I did.

This threw off the hospitalist’s well-choreographed day of admissions and discharges. Without me seeing the patient, he had to either discharge him on his own decision or find another neurologist who would do it.

Sorry, but I’m not going to force this issue. If a patient doesn’t want to see me, it’s not worth fighting over. Believe me, I get paid to see patients, so I don’t have much incentive to just walk away.

But at the same time I have to respect patients’ decisions. While a neurology consult is pretty noninvasive, it’s still a part of medicine. If a patient doesn’t want to see me, I’m not going to force them to.

Granted, there are exceptions. Obviously, if the patient is fairly demented or otherwise not mentally competent to make such a decision, I’ll see them. In those cases, their deteriorating mental status is likely the reason for the consult.

But the fellow that day seemed alert and reasonable, and there was nothing in the chart about confusion. So I’m going to assume he knew what he was doing when he told me to go away.

The hospitalist didn’t see this as an issue, but I did. Doing a consult on a patient who doesn’t want one seems, at least to me, like harassment. I’m sorry if it messes up the discharge planning, but that’s not my fault. It’s the patient’s decision.

While I may disagree at times with patients’ decisions, their autonomy is still central to medicine. I respect and believe in that, even if it makes things more difficult for those around them.

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

“Why didn’t you see that patient?”

TongRo Images/Thinkstock

The hospitalist on the phone was angry. He’d wanted the patient seen by neurology and cleared for discharge. Apparently, I hadn’t complied.

Actually, that isn’t true. I was on call, so I had dutifully dragged myself in (with the help of some coffee), reviewed the chart, and gone in to see the fellow.

The patient, however, had other ideas. He said he was sick of doctors, didn’t like them, didn’t want to see me, and asked me to leave. So I did.

This threw off the hospitalist’s well-choreographed day of admissions and discharges. Without me seeing the patient, he had to either discharge him on his own decision or find another neurologist who would do it.

Sorry, but I’m not going to force this issue. If a patient doesn’t want to see me, it’s not worth fighting over. Believe me, I get paid to see patients, so I don’t have much incentive to just walk away.

But at the same time I have to respect patients’ decisions. While a neurology consult is pretty noninvasive, it’s still a part of medicine. If a patient doesn’t want to see me, I’m not going to force them to.

Granted, there are exceptions. Obviously, if the patient is fairly demented or otherwise not mentally competent to make such a decision, I’ll see them. In those cases, their deteriorating mental status is likely the reason for the consult.

But the fellow that day seemed alert and reasonable, and there was nothing in the chart about confusion. So I’m going to assume he knew what he was doing when he told me to go away.

The hospitalist didn’t see this as an issue, but I did. Doing a consult on a patient who doesn’t want one seems, at least to me, like harassment. I’m sorry if it messes up the discharge planning, but that’s not my fault. It’s the patient’s decision.

While I may disagree at times with patients’ decisions, their autonomy is still central to medicine. I respect and believe in that, even if it makes things more difficult for those around them.

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

“Why didn’t you see that patient?”

TongRo Images/Thinkstock

The hospitalist on the phone was angry. He’d wanted the patient seen by neurology and cleared for discharge. Apparently, I hadn’t complied.

Actually, that isn’t true. I was on call, so I had dutifully dragged myself in (with the help of some coffee), reviewed the chart, and gone in to see the fellow.

The patient, however, had other ideas. He said he was sick of doctors, didn’t like them, didn’t want to see me, and asked me to leave. So I did.

This threw off the hospitalist’s well-choreographed day of admissions and discharges. Without me seeing the patient, he had to either discharge him on his own decision or find another neurologist who would do it.

Sorry, but I’m not going to force this issue. If a patient doesn’t want to see me, it’s not worth fighting over. Believe me, I get paid to see patients, so I don’t have much incentive to just walk away.

But at the same time I have to respect patients’ decisions. While a neurology consult is pretty noninvasive, it’s still a part of medicine. If a patient doesn’t want to see me, I’m not going to force them to.

Granted, there are exceptions. Obviously, if the patient is fairly demented or otherwise not mentally competent to make such a decision, I’ll see them. In those cases, their deteriorating mental status is likely the reason for the consult.

But the fellow that day seemed alert and reasonable, and there was nothing in the chart about confusion. So I’m going to assume he knew what he was doing when he told me to go away.

The hospitalist didn’t see this as an issue, but I did. Doing a consult on a patient who doesn’t want one seems, at least to me, like harassment. I’m sorry if it messes up the discharge planning, but that’s not my fault. It’s the patient’s decision.

While I may disagree at times with patients’ decisions, their autonomy is still central to medicine. I respect and believe in that, even if it makes things more difficult for those around them.

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

Another solo-practice neurologist and I were talking last week. He’s understandably worried about the local hospital starting construction on a new “neuroscience center” down the street from us. They have ambitious plans for it, which apparently don’t include those of us who’ve served the community for 20-30 years.

Whatever. I’ve been in a large practice before, and don’t want to be a part of one again.

His concern, which I have, too, is that the hospital center will drive us little guys out of business. This seems to be a common medical practice model these days.

I hope not. I’ve been doing this for a long time, and am happy with my little world. I also believe, perhaps naively, that there’s still a place for a small practice.

My staff and I know my patients. We’re generally tuned in to who needs what, or how much time. We return all calls within a few hours (or less) and try be on top of getting medication refills and records requests done the same day they come in.

While a large practice has some advantages, based on my time with one I’d have to say we didn’t do those things as well there. Messages often weren’t relayed, or were sent to the wrong doctor. Here there’s only me.

I may not make as much, but my appointment times and intervals aren’t dictated by an accountant. This allows me to generally spend as much time as needed with each person and not feel rushed as the day goes on. I hope patients still desire that in a physician, as opposed to a place advertising “20 neurologists, no waiting!” on a sign that would fit in on the Vegas strip.

Obviously, I can’t control what the hospital will do. I can only manage my own little world. I’ll continue doing that as best I can, as long as I’m able.

Time spent worrying about things I can’t change isn’t productive and is bad for one’s blood pressure. So I’ll focus on what I can do, and try not to worry about the rest.
 

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

Another solo-practice neurologist and I were talking last week. He’s understandably worried about the local hospital starting construction on a new “neuroscience center” down the street from us. They have ambitious plans for it, which apparently don’t include those of us who’ve served the community for 20-30 years.

Whatever. I’ve been in a large practice before, and don’t want to be a part of one again.

His concern, which I have, too, is that the hospital center will drive us little guys out of business. This seems to be a common medical practice model these days.

I hope not. I’ve been doing this for a long time, and am happy with my little world. I also believe, perhaps naively, that there’s still a place for a small practice.

My staff and I know my patients. We’re generally tuned in to who needs what, or how much time. We return all calls within a few hours (or less) and try be on top of getting medication refills and records requests done the same day they come in.

While a large practice has some advantages, based on my time with one I’d have to say we didn’t do those things as well there. Messages often weren’t relayed, or were sent to the wrong doctor. Here there’s only me.

I may not make as much, but my appointment times and intervals aren’t dictated by an accountant. This allows me to generally spend as much time as needed with each person and not feel rushed as the day goes on. I hope patients still desire that in a physician, as opposed to a place advertising “20 neurologists, no waiting!” on a sign that would fit in on the Vegas strip.

Obviously, I can’t control what the hospital will do. I can only manage my own little world. I’ll continue doing that as best I can, as long as I’m able.

Time spent worrying about things I can’t change isn’t productive and is bad for one’s blood pressure. So I’ll focus on what I can do, and try not to worry about the rest.
 

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

Another solo-practice neurologist and I were talking last week. He’s understandably worried about the local hospital starting construction on a new “neuroscience center” down the street from us. They have ambitious plans for it, which apparently don’t include those of us who’ve served the community for 20-30 years.

Whatever. I’ve been in a large practice before, and don’t want to be a part of one again.

His concern, which I have, too, is that the hospital center will drive us little guys out of business. This seems to be a common medical practice model these days.

I hope not. I’ve been doing this for a long time, and am happy with my little world. I also believe, perhaps naively, that there’s still a place for a small practice.

My staff and I know my patients. We’re generally tuned in to who needs what, or how much time. We return all calls within a few hours (or less) and try be on top of getting medication refills and records requests done the same day they come in.

While a large practice has some advantages, based on my time with one I’d have to say we didn’t do those things as well there. Messages often weren’t relayed, or were sent to the wrong doctor. Here there’s only me.

I may not make as much, but my appointment times and intervals aren’t dictated by an accountant. This allows me to generally spend as much time as needed with each person and not feel rushed as the day goes on. I hope patients still desire that in a physician, as opposed to a place advertising “20 neurologists, no waiting!” on a sign that would fit in on the Vegas strip.

Obviously, I can’t control what the hospital will do. I can only manage my own little world. I’ll continue doing that as best I can, as long as I’m able.

Time spent worrying about things I can’t change isn’t productive and is bad for one’s blood pressure. So I’ll focus on what I can do, and try not to worry about the rest.
 

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

I don’t want to rule the world.

Some doctors do, albeit in a non–Attila-the-Hun sort of way. They want to have offices on every street corner, in every suburb of a given city, sometimes more than one city. Like the Starbucks of medicine.

That’s not me. I’m happy in my little one-office world.

Maybe I just don’t have the ambition, or the business mindset, or whatever it takes to want to do that. I understand it’s all part of wanting to be successful, and obviously those doctors are more driven in that direction than I am. The more offices, the more patients can be seen, and the more money you make.

It’s not quite that simple, though. No one can be in more than one place at the same time, so to see more patients at more places you need more doctors. To pay more doctors requires more money, which in turn requires more patients.

There’s nothing wrong with taking over the world (or at least a suburb) if you like that sort of thing. But to me, more money brings more headaches. More offices to rent, more staff to hire, more people to handle billing, IT, HR, payroll, accounting, contracts, and so on.

You can have it. I’ve taken over all the world I want, in my case a 1,200-square-foot suite on the second floor of a small-to-medium-size medical building. To some that may sound unambitious, but to me, it’s perfect.

I know where my Keurig, Sodastream, and office supplies are. Except for my secretary and her cheerfully rambunctious young daughter, I don’t have to worry about sharing stuff here, or if anyone wants a different carpet color, or what’s going on at a satellite office halfway across town.

If other doctors want to try and take over the world, more power to them, but I’m happy with this. Enough is as good as a feast.
 

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

I don’t want to rule the world.

Some doctors do, albeit in a non–Attila-the-Hun sort of way. They want to have offices on every street corner, in every suburb of a given city, sometimes more than one city. Like the Starbucks of medicine.

That’s not me. I’m happy in my little one-office world.

Maybe I just don’t have the ambition, or the business mindset, or whatever it takes to want to do that. I understand it’s all part of wanting to be successful, and obviously those doctors are more driven in that direction than I am. The more offices, the more patients can be seen, and the more money you make.

It’s not quite that simple, though. No one can be in more than one place at the same time, so to see more patients at more places you need more doctors. To pay more doctors requires more money, which in turn requires more patients.

There’s nothing wrong with taking over the world (or at least a suburb) if you like that sort of thing. But to me, more money brings more headaches. More offices to rent, more staff to hire, more people to handle billing, IT, HR, payroll, accounting, contracts, and so on.

You can have it. I’ve taken over all the world I want, in my case a 1,200-square-foot suite on the second floor of a small-to-medium-size medical building. To some that may sound unambitious, but to me, it’s perfect.

I know where my Keurig, Sodastream, and office supplies are. Except for my secretary and her cheerfully rambunctious young daughter, I don’t have to worry about sharing stuff here, or if anyone wants a different carpet color, or what’s going on at a satellite office halfway across town.

If other doctors want to try and take over the world, more power to them, but I’m happy with this. Enough is as good as a feast.
 

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

I don’t want to rule the world.

Some doctors do, albeit in a non–Attila-the-Hun sort of way. They want to have offices on every street corner, in every suburb of a given city, sometimes more than one city. Like the Starbucks of medicine.

That’s not me. I’m happy in my little one-office world.

Maybe I just don’t have the ambition, or the business mindset, or whatever it takes to want to do that. I understand it’s all part of wanting to be successful, and obviously those doctors are more driven in that direction than I am. The more offices, the more patients can be seen, and the more money you make.

It’s not quite that simple, though. No one can be in more than one place at the same time, so to see more patients at more places you need more doctors. To pay more doctors requires more money, which in turn requires more patients.

There’s nothing wrong with taking over the world (or at least a suburb) if you like that sort of thing. But to me, more money brings more headaches. More offices to rent, more staff to hire, more people to handle billing, IT, HR, payroll, accounting, contracts, and so on.

You can have it. I’ve taken over all the world I want, in my case a 1,200-square-foot suite on the second floor of a small-to-medium-size medical building. To some that may sound unambitious, but to me, it’s perfect.

I know where my Keurig, Sodastream, and office supplies are. Except for my secretary and her cheerfully rambunctious young daughter, I don’t have to worry about sharing stuff here, or if anyone wants a different carpet color, or what’s going on at a satellite office halfway across town.

If other doctors want to try and take over the world, more power to them, but I’m happy with this. Enough is as good as a feast.
 

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

Kernohan’s notch false localizing sign. PPRF. The 7th nerve fascicle wraps around the 6th nerve nucleus. (Or is it the other way around?)
 

Yes, I’m studying for my 10-year boards.

It’s funny how many of these details you forget over time. I used to be able to rattle off names, syndromes, and pathways at the dreaded Thursday morning differential conference in residency. To not know them would get you a dreaded glare from the chairman. Now ... not as much.

Granted, the names of such things become less important over time. What’s important is the instinctive understanding of them that comes with experience. Remembering the specific name of a neural pathway becomes less relevant compared to recognizing where the problem is when you see that patient, and translating that into appropriate testing and treatment.

But, every 10 years, I have to go back to the books. Relearn the faded details of enzyme pathways, miscellaneous receptor actions, and courses of nerve tracts.

A lot of it is done on my iPad, a gadget I never imagined back in medical school, but it’s still the same routine I knew so well back then: Reading a page, staring blankly off to commit some point to memory, taking a practice test, and reviewing the answers. Occasionally, wandering off to get a can of soda or make tea.

Of course, today I have to work that around my family and job, concerns I didn’t have to split my time with in medical school. I had classmates who were married and had kids, and this always gives me a new respect for how they managed it.

Does knowing these details again make me a better doctor? I have no idea. I understand the idea that we need some way of showing we’re still on top of things after 20 years in the field. I’m not sure the current maintenance of certification practices are the best way to do that, but admittedly I don’t have any better ideas.
 

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

Kernohan’s notch false localizing sign. PPRF. The 7th nerve fascicle wraps around the 6th nerve nucleus. (Or is it the other way around?)
 

Yes, I’m studying for my 10-year boards.

It’s funny how many of these details you forget over time. I used to be able to rattle off names, syndromes, and pathways at the dreaded Thursday morning differential conference in residency. To not know them would get you a dreaded glare from the chairman. Now ... not as much.

Granted, the names of such things become less important over time. What’s important is the instinctive understanding of them that comes with experience. Remembering the specific name of a neural pathway becomes less relevant compared to recognizing where the problem is when you see that patient, and translating that into appropriate testing and treatment.

But, every 10 years, I have to go back to the books. Relearn the faded details of enzyme pathways, miscellaneous receptor actions, and courses of nerve tracts.

A lot of it is done on my iPad, a gadget I never imagined back in medical school, but it’s still the same routine I knew so well back then: Reading a page, staring blankly off to commit some point to memory, taking a practice test, and reviewing the answers. Occasionally, wandering off to get a can of soda or make tea.

Of course, today I have to work that around my family and job, concerns I didn’t have to split my time with in medical school. I had classmates who were married and had kids, and this always gives me a new respect for how they managed it.

Does knowing these details again make me a better doctor? I have no idea. I understand the idea that we need some way of showing we’re still on top of things after 20 years in the field. I’m not sure the current maintenance of certification practices are the best way to do that, but admittedly I don’t have any better ideas.
 

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

Kernohan’s notch false localizing sign. PPRF. The 7th nerve fascicle wraps around the 6th nerve nucleus. (Or is it the other way around?)
 

Yes, I’m studying for my 10-year boards.

It’s funny how many of these details you forget over time. I used to be able to rattle off names, syndromes, and pathways at the dreaded Thursday morning differential conference in residency. To not know them would get you a dreaded glare from the chairman. Now ... not as much.

Granted, the names of such things become less important over time. What’s important is the instinctive understanding of them that comes with experience. Remembering the specific name of a neural pathway becomes less relevant compared to recognizing where the problem is when you see that patient, and translating that into appropriate testing and treatment.

But, every 10 years, I have to go back to the books. Relearn the faded details of enzyme pathways, miscellaneous receptor actions, and courses of nerve tracts.

A lot of it is done on my iPad, a gadget I never imagined back in medical school, but it’s still the same routine I knew so well back then: Reading a page, staring blankly off to commit some point to memory, taking a practice test, and reviewing the answers. Occasionally, wandering off to get a can of soda or make tea.

Of course, today I have to work that around my family and job, concerns I didn’t have to split my time with in medical school. I had classmates who were married and had kids, and this always gives me a new respect for how they managed it.

Does knowing these details again make me a better doctor? I have no idea. I understand the idea that we need some way of showing we’re still on top of things after 20 years in the field. I’m not sure the current maintenance of certification practices are the best way to do that, but admittedly I don’t have any better ideas.
 

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